Recently we received a question from a reader asking us to describe what a “typical good pelvic floor physical therapy session” is like.
It’s a question I’m sure every pelvic pain patient prescribed PT has thought about. Currently, there is no standard of care for pelvic pain PT. So unfortunately, patients get PT ranging from good to mediocre to inadequate to a complete waste of time. The hope is that when patients begin to push for the best standard of care, change will occur. The problem is that the majority of patients have no idea where the bar should be set when it comes to pelvic pain PT. Going into it they get very little, if any, information from their prescribing physicians, who themselves often have little knowledge of the treatment.
This brings us back to the original question: What is a “typical good pelvic floor PT session like?” With this post, we plan to answer that question by giving a play-by-play description of both an evaluation appointment at our clinic and a typical follow-up appointment.
Before we go any further, however, you’re likely wondering who the heck we are to presume to set the standard for pelvic pain PT? Well, for one thing, over the past decade we’ve focused solely on the treatment of patients with pelvic pain, both women and men. Plus, during that time, we’ve worked extremely hard to educate the PT community and the general medical community about pelvic pain PT (click here to get to know us better). But the most important claim we have is that we know what we do works because our patients get better!
Now, back to the question at hand. Below is the reader question that sparked this post.
I’m curious as to what a typical good pelvic floor PT session is like. I went to PT for a while to treat my pelvic pain, but I’m not sure it made a difference. The PT didn’t really explain anything—the only thing I heard was that I have some tight muscles, but that seems pretty vague to me. My PT sessions consisted of about 20 minutes of conversation, then I got up on the table, was guided through a leg stretching exercise, then my belly was massaged for a bit. From there I got undressed and had about 15 minutes of vaginal massaging. This never varied.
At the evaluation appointment, the first thing we do is interview the patient. What we’re after is the patient’s full pelvic pain history. Among the questions we ask are:
When did your pain start? What does it feel like? Where is it located? What exacerbates your pain? What alleviates your pain? How does it affect these three functions: Urination? Bowel movements? Sex? What activities does your pain limit? What kind of work do you do? What doctors/other PTs have you seen? Have you had any diagnostic procedures done? What past treatments have you had? What medications are you taking?
It’s important that the interview not go over 15 minutes! That’s because we want to make sure we have enough time to get our hands on the patient. That’s how our time and their time is best spent. So after 15 minutes, whether we’ve gathered all of the info we need or not, we ask the patient to undress and hop up on the table. We leave the room to give the patient privacy and time to get situated and comfortable. If there is still info we need from the patient—and there always is—we will simply continue the conversation as we begin evaluation and treatment.
The evaluation is the actual hands-on work that we do on the patient. The goal is to begin to uncover the contributing factors of each impaired area.
We choose where to begin based on what we’ve already learned from the patient. Because we’re limited by time—the evaluation appointment is a one-hour appointment—we must prioritize. So, we’ll pick selective things to work on during that first appointment. We want to tackle the areas causing the patient the most pain first.
While every patient’s pain is its own unique puzzle, there are two areas we will always check out on evaluation day. These are a patient’s connective tissue mobility and their internal pelvic floor muscles. We’ll access the latter either vaginally with our female patients or rectally with our male patients.
During the internal exam we are on the lookout for hypertonic (tight) muscles, trigger points, and a gauge of the patient’s pelvic floor motor control and function. Plus, we will palpate the peripheral nerves to identify irritability. As for the connective tissue, it’s a rare day that connective tissue is not involved in a patient’s pelvic pain. In fact, we go through the connective explanation every single time we have a new patient.
In case you’ve never gotten an explanation for how connective tissue contributes to pelvic pain or you need a refresher, this is our schpeal: “Connective tissue becomes tight as a result of underlying dysfunction in muscles, nerves, organs, or joints. As a result, there is reduced blood flow and the tissue becomes hyper-sensitive. Therefore, it becomes difficult and painful to manipulate. If we don’t fix it, it’s going to continue to contribute to the underlying impairments in corresponding muscles, nerves, organs, or joints, and the pain cycle will continue.”
So, in the evaluation appointment, we definitely examined the patient’s connective tissue mobility and their pelvic floor, plus other areas we were able to get to that we believed were contributing factors to their pain. Ultimately, between this first appointment and the next appointment or two, all areas on the patient will be evaluated from the ribs to the knees, back and front.
One of the things that bothered us in the reader’s question was this line, “They didn’t really explain anything—the only thing I have heard is that I have some tight muscles, but that seems pretty vague to me.”
We don’t ever want our patients not knowing why we’re doing what we’re doing! Throughout the treatment session, we explain to them what we’re doing and why.
If your PT is not giving you these kinds of explanations, it’s important that you ask for them. Asking her will not only bring you up to speed, it’ll force her to develop a plan, and not just treat you in a scattered, directionless way. And do not accept a half-hearted explanation that what she’s doing “decreases muscle tightness.” Your PT needs to be able to tell you why she thinks the tightness is there, what she thinks is causing it, and what she’s doing about it.
On top of explanations throughout, at the end of every appointment we give our patients a briefing on what we did, what we found, and what our expectations are. For instance, we’ll say something like, “So I worked on such and such trigger points today, they’re still there, so basically I don’t expect your pain to change until these start to change more. For the next four weeks, I’m only going to focus on this area and if I can’t get things under control I’m sending you for trigger point injections.”
A Typical Pelvic Pain PT Session
At the beginning of a typical PT session, we walk into the room with the patient dressed. We question the patient for two minutes at the most. Just as on evaluation day, time is precious. We only have one hour, so we want to begin manual therapy on the patient as soon as possible. If we don’t get all of the info we need in two minutes, then we’ll just continue the conversation once we begin treatment.
One bit of info we want to get from the patient is a description of their symptoms after their last treatment. We especially want to know how those first two or three days were after treatment.
This is important for a few reasons. For one thing, oftentimes we will focus our treatment for the day based on what their response is and what is bothering them the most. For another thing, it allows us to educate our patients about reasonable expectations. For instance, based on their response to the question, we’ll explain why they were sore (if they were). Or why their pain was better or worse.
Also, from looking at the chart before the patient comes in, we’ll have a few very specific questions to ask. For instance, if it’s a patient who is having pain with sex, we’ll ask whether sex was possible since their last appointment.. If it was, we’ll want to know if anything was different about the experience. We’ll want to know whether the pain was less in intensity, less in duration, or in a different area.
After our two minute chat, we’ll leave the room so that the patient can change and get situated on the table. When we come back into the room, we’ll tell her or him what we’ll be doing during the appointment and why.
The first thing we’ll do during treatment is to treat the patient’s connective tissue. The reason we do the connective tissue manipulation first is that it makes it easier to treat underlying trigger points, it calms the nervous system down some; it increases blood flow to the area; and it relaxes the pelvic floor a bit.
For the most part, there are four rungs to the ladder of pelvic pain treatment. They are: working out external trigger points, working out internal trigger points and lengthening tight muscles, connective tissue manipulation, and treating at structural abnormalities. However, the last, treating structural abnormalities, is only incorporated when it applies. So during a typical appointment, we are focused on these strategies.
Typically we spend about half the appointment on connective tissue manipulation and external trigger point release (external work), and half the appointment on internal trigger point release and muscle lengthening (internal work). An appointment lasts for one hour. And patients either see us twice a week or once a week.
So that’s what we do during a typical PT appointment. What we don’t do during an appointment is: We don’t ever leave our patients alone in the room hooked up to a tens unit or to a biofeedback machine or performing exercises with an aide. When it comes to the successful treatment of pelvic pain, what works is manual, hands-on treatment, so that’s what we do.
Also, we don’t use a cookie cutter, one-size-fits-all approach to pelvic pain PT. Not only will every patient’s treatment be different, but a specific patient’s treatment will change and evolve from appointment to appointment!
And, we don’t spend precious time cheer leading our patients through stretches and strengthening exercises. While we do arm patients with therapeutic home exercises from day one, like pelvic floor drops, we don’t spend more than a few minutes teaching patients how to do them. As for stretching and strengthening exercises, they do have their place; when pain is either completely gone or way down and when trigger points are gone, and the muscles are either tight or weak. That’s the time, and the place for them is when the patient is at home.
So, now that we’ve given you a rundown of what we believe is a good pelvic pain PT session, we’d love if you’d share your experiences with us and our readers! Do your PT sessions differ from what we’ve described? If so, in what way/ways?
Please either leave any questions or comments you might have in the comment box or email us at: [email protected].
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Steph and Liz