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One Big Beautiful Bill Act: The Impact on Pelvic Health Physical and Occupational Therapy

By Stephanie Prendergast, MPT, PHRC Pasadena

In July 2025, the One Big Beautiful Bill Act (OBBBA) was signed into law, introducing transformative student-loan reform that will shape federal graduate borrowing for decades to come. Among its many sweeping policy changes, one stands out for the rehabilitation community: a recalibration – and dramatic narrowing – of what counts as a “professional degree” for the purpose of federal student loans. The ripple effects for physical and occupational therapists, Medicare beneficiaries, and the broader U.S. health-care system are profound.

For providers working in specialized, high-needs areas such as pelvic health rehabilitation – clinically managing conditions like urinary incontinence, sexual pain disorders, and bowel dysfunction – the implications feel deeply personal. But beyond personal frustration lies a structural reckoning. This law risks destabilizing our clinical pipeline, restricting educational access, and ultimately reducing care availability for the patients who need us most.

 

The Legislative Change – and who it leaves behind

The OBBBA eliminates Grad PLUS, replacing it with a bifurcated definition of post-baccalaureate borrowing:

• Students enrolled in designated “professional degree programs” may receive up to $50,000 annually, with a $200,000 lifetime cap.
• Students in all other graduate programs – classified under new policy as “non-professional degree programs” – are capped at $20,500 annually, with a $100,000 lifetime borrowing limit, representing an effective reduction of roughly 50% compared to prior borrowing norms.

The list of approved “professional degree programs” remains largely unchanged from legacy policy definitions, emphasizing physician and select medical specialties including: physicians, pharmacists, and attorneys.

 

Notably excluded from this designation, and therefore reclassified as “non-professional degrees”, are: physical and occupational therapists, nurse practitioners, physician’s assistants, certain mental health professionals, and speech-language and audiology doctorates. 

 

This reclassification was confirmed in recent rulemaking commentary, which explicitly noted that rehabilitation professions and graduate therapy degrees are no longer eligible for the professional borrowing limits afforded to medical degrees.

The real-world cost of a semantic downgrade

Language drives policy. Policy drives financing. And financing drives workforce behavior.

Physical and occupational therapists follow a training pathway that rivals many degree tracks deemed “professional” under the new rule. The process includes:

• Four years of undergraduate education
• Three years of clinical doctorate graduate training, including full-time clinical clerkships
• Passing difficult federal and state licensing boards
• Maintaining licensure with required continuing education hours and mandatory clinical competencies

And for those committed to pelvic health rehabilitation – a specialty serving patients with severe, complex, often disabling symptoms – the financial burden climbs even higher. Post-graduate pelvic-health training programs often cost thousands to tens of thousands of dollars, typically paid out-of-pocket, including advanced fellowships, certifications, and residencies.

Impact on pelvic health patients

The pelvic health patient population is often in dire need. Therapists in this area commonly treat conditions such as:

• Pelvic Floor Dysfunction
• Diagnoses such as Endometriosis, Vulvodynia, Vestibulodynia, Interstitial Cystitis, Chronic Pelvic Pain Syndrome, Pudendal Neuralgia
• Neuroplastic pain syndromes
• Urinary and fecal incontinence

Interdisciplinary pelvic pain requiring both rehab and medical management.

Crucially, evidence consistently shows that medical management alone is rarely sufficient for treating chronic pelvic pain and dysfunction – a fact that underscores the need for interdisciplinary rehabilitation. Pelvic-health therapists do not “replace” medicine – we partner with it, addressing neuromuscular impairments, functional disability, tissue sensitivity, behavioral pain-science education, and return-to-life outcomes that pharmaceuticals alone cannot restore.

If therapist numbers decline, so does the patient’s ability to achieve continence, sexual function, and pain reduction, all of which directly influence psychosocial participation, mobility independence, sleep, emotional health, and societal productivity.

Medicare: coverage vs capacity vs reality

The OBBBA does not directly amend Medicare coverage rules for therapy – but its indirect impact on the coverage landscape may be even more powerful.

Therapy reimbursement under Medicare is governed largely by:

• The Centers for Medicare & Medicaid Services
• Budget-neutrality requirements
• Therapy caps historically imposed and intermittently removed
• Relative Value Unit (RVU) classifications that often undervalue rehabilitative care

Even before OBBBA, rehab providers have weathered perennial reimbursement erosion despite rising overhead costs – supplies, clinic leases, documentation compliance systems, liability insurance, and salary competitiveness.

If clinician supply drops, payors are likely to see PT and OT services as less central – more discretionary, further compromising future payment schedules for therapy, just as we see rising barriers for care access in underserved populations including rural communities, Medicaid beneficiaries, and disabled Medicare recipients.

Already, non-physician graduate providers such as nursing and rehab professions have voiced national opposition, warning that the policy threatens clinician access, patient care access, and educational affordability.

 

Provider frustration and burnout: a documented crisis

Working in health care is a constant battle. Rehab providers face:

• High student-loan burden
• Salaries that often fail to keep pace with inflation
• Declining reimbursement rates
• High documentation burden for insurance compliance
• Specialty training costs largely out-of-pocket
• Longer patient waitlists with fewer clinicians
• Rising provider burnout across allied health

Meanwhile, private insurance stakeholders continue posting record profits. For example:

• UnitedHealth Group
• Humana Inc.

Insurance profits have rarely correlated with rehab care sustainability – and the result is visible: burned-out clinicians and suffering patients with less access to skilled providers.

National journalism has already warned of clinician outrage and pipeline risk, particularly for professions excluded under the new borrowing rules like nursing and rehabilitation.

 

When patients pay the price for policy abstraction

If nothing changes, federal policy could fuel cascading harm:

• Fewer students able to afford PT/OT doctorate programs
• Fewer clinicians able to afford pelvic-health specialization
• Longer wait times
• Clinic closures or capacity reductions
• Fewer interdisciplinary partners for pelvic pain care
• Lower reimbursement justification due to workforce scarcity
• Patients left untreated – or under-treated

This means that patients suffering pelvic pain or dysfunction might wait months to be evaluated, lose access to conservative care options entirely, or be returned to a solely medical path that is statistically less sufficient for functional restoration.

 

The call to action

This is a moment for advocacy – not passive acceptance.

Professional associations including the American allied-health coalition have already mobilized opposition, warning that programs like DPT and OTD are essential, intensive, and must be recognized as professional-level training tracks to preserve our workforce pipeline and patient access to care.

If the rulemaking definition can be updated to reflect modern educational rigor and clinical necessity, the damage could still be mitigated. But if nothing changes, we risk losing the next generation of pelvic-health therapists – and our patients will suffer most.

______________________________________________________________________________________________________________________________________

Check out our recently published e-book titled “Vulvodynia, Vestibulodynia, and Vaginismus,” designed to empower and inform individuals on their journey towards healing and understanding.

Are you unable to come see us in person in the Bay Area, Southern California or New England?  We offer virtual physical therapy appointments too!

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.

Do you enjoy or blog and want more content from PHRC? Please head over to social media!

Facebook, YouTube Channel, Twitter, Instagram, Tik Tok

By Stephanie Prendergast, MPT, PHRC Pasadena 

Many people think of Restless Leg Syndrome (RLS) as a sleep-related leg problem ; the irresistible need to move, the creeping sensations, the nights spent pacing instead of resting. But growing research and clinical observation suggest something much broader: RLS may be part of a whole-body sensory and motor dysregulation, with ties to bladder symptoms and pelvic floor dysfunction, including a number of pelvic pain syndromes. 

At the Pelvic Health and Rehabilitation Center (PHRC), we’ve seen this overlap firsthand. Patients with persistent pelvic tension or ‘tightness’, urinary urgency and/or frequency, irritative bladder symptoms, or genital discomfort sometimes describe “restless” sensations not just in their legs, but deep in their pelvic structures. Understanding these links helps us design more comprehensive treatment plans that address both the pelvic floor and the nervous system that governs it.

 

Understanding Restless Leg Syndrome in Context

As outlined in our previous post, RLS is a neurological condition characterized by an urge to move the legs, especially at night or during rest. It’s thought to arise from dopaminergic dysregulation and iron deficiency in the brain, both of which disrupt smooth motor control and sensory processing.

Beyond the legs, the condition reflects a sensory hypersensitivity ; the nervous system becomes overly reactive to otherwise normal sensations. This helps explain why some individuals also experience “restless” or uncomfortable sensations in other regions, including the pelvic and genital area.

 

Restless Genital Syndrome: A Clue from the Pelvis

A condition called Restless Genital Syndrome (RGS), first described in the early 2000s, presents with sensations of tingling, pressure, or internal agitation in the genital or pelvic region. Importantly, these sensations are not linked to sexual arousal and often worsen at rest, just like RLS.

Neurophysiological studies have shown that some people with RGS also meet criteria for RLS, and both conditions often respond to dopaminergic medications (like pramipexole). This overlap suggests they share a common mechanism ; likely involving the lumbosacral nerves that control both the legs and the pelvic floor.

At PHRC, we think of RGS as part of a continuum of sensory-motor dysregulation. The same central nervous system patterns that drive restless legs ; dopamine imbalance, sensory hyperexcitability, and altered movement feedback ; can easily extend into the pelvic region.

 

Shared Pathways: The Neurology of RLS and the Pelvic Floor

The pelvic floor is more than a group of muscles; it’s a hub of sensory and motor information, richly connected through the sacral spinal cord and the pudendal nerve. These nerves share close connections with the pathways implicated in RLS.

Here’s how the two systems intersect:

• Shared nerve roots: The lower spinal cord (L2–S3) sends fibers to both the legs and pelvic organs. When these circuits become dysregulated, sensory symptoms may appear in either or both regions.
• Autonomic involvement: RLS is linked to changes in autonomic nervous system activity (fight-or-flight vs. rest-and-digest). Pelvic floor tone is also heavily influenced by autonomic balance ; many people with chronic stress or poor sleep develop hypertonic pelvic floor muscles.
• Neuroinflammation and iron metabolism: Iron deficiency, microglial activation, and dopamine dysregulation seen in RLS may also affect pelvic nerves, influencing pain perception and muscle tone.
• Movement and muscle co-contraction: Just as RLS causes involuntary leg movements, some people experience unconscious pelvic floor tightening during episodes of restlessness or nocturnal movement.

In other words, the restlessness of RLS may extend into the pelvis, resulting in pelvic floor overactivity, urinary urgency, or genital discomfort.

 

Bladder and Bowel Clues

Several studies have explored the connection between RLS and overactive bladder (OAB). Patients with RLS often report more urinary urgency, frequency, and nocturia (waking to urinate at night). One hypothesis is that both RLS and OAB stem from hyper-responsive sensory circuits in the spinal cord and brainstem.

Similarly, chronic constipation ; common in both pelvic floor dysfunction and RLS ; can worsen sensory feedback loops, leading to further pelvic tension. At PHRC, we see how unaddressed bowel dysfunction perpetuates pelvic and lower limb discomfort.

These observations reinforce the need to look beyond single symptoms. A patient’s nighttime restlessness, urinary urgency, or pelvic pain may all share a nervous-system origin.

 

The Female Connection

RLS is twice as common in those assigned female at birth, particularly during pregnancy and menopause ; life stages characterized by hormonal shifts that influence both the nervous system and pelvic tissues. Estrogen and progesterone fluctuations can alter dopamine sensitivity, while pregnancy increases venous congestion and iron demands. These same changes can trigger or worsen pelvic floor dysfunction, pelvic pain, or bladder symptoms.

Recognizing these overlapping hormonal and neurovascular influences is critical for accurate diagnosis and individualized care.

 

How Pelvic Floor Physical and Occupational Therapy Can Help

Even though RLS is a neurological condition, pelvic floor physical and occupational therapy can play a valuable role, especially when pelvic symptoms coexist. Here’s how:

1. Muscle down-training and relaxation: Manual therapy, biofeedback, and breathing techniques help calm hypertonic muscles that may tighten reflexively during RLS episodes.
2. Nerve mobilization: Gentle neural gliding and positional release techniques support the pudendal and sciatic nerves, improving blood flow and decreasing neural tension.
3. Circulatory enhancement: Movement, stretching, and soft tissue work improve lower-body and pelvic circulation, which may reduce discomfort from venous congestion.
4. Autonomic regulation: Incorporating mindfulness, diaphragmatic breathing, and body-scan exercises helps reduce sympathetic overactivity ; the same system that amplifies both pelvic tension and RLS restlessness.
5. Interdisciplinary care: Collaboration with physicians is essential to address systemic contributors such as iron deficiency, sleep deprivation, or dopaminergic imbalance.

When treatment combines neurologic management and pelvic rehabilitation, patients often notice better sleep, less pelvic tension, and improved quality of life.

 

Practical Tips for Those With Restless Leg Syndrome and Pelvic Floor Dysfunction

 

Screen for overlap: If you have pelvic pain or urinary urgency plus nighttime leg restlessness, tell your provider. Both may stem from one nervous-system imbalance.

 

Check your iron: Ferritin levels below 75 µg/L are linked with RLS; optimizing iron can help both leg and pelvic symptoms.

 

Move regularly: Gentle evening stretches, walking, or yoga reduce both leg and pelvic tightness.

 

Support sleep: Consistent bedtime routines, magnesium intake (if appropriate), and stress reduction lower symptom intensity.

 

Work with a multidisciplinary team: A pelvic health physical therapist, primary care physician, and possibly a neurologist can coordinate a plan that addresses all levels ; muscular, vascular, and neural.

 

 

The Takeaway

Restless Leg Syndrome is more than a “leg problem.” It’s a systemic sensory-motor dysregulation that can influence the pelvic floor, bladder, and even sexual function. For some, the pelvis becomes part of the “restlessness loop” ; muscles tighten, nerves fire excessively, and the nervous system can’t find calm.

The good news: once recognized, these connections can be treated. Through integrated care ; neurologic, musculoskeletal, and behavioral ; patients can regain rest, comfort, and control over both their legs and their pelvic health.

At PHRC, we treat the body as an interconnected system. Whether your symptoms start in the legs, pelvis, or both, our goal is to restore balance, reduce tension, and help you feel at home in your body again.

 

 

References

Malykhina, A. P. (2007). Neural mechanisms of pelvic organ cross‑sensitization. Neuroscience, 149(3), 660–672. https://pubmed.ncbi.nlm.nih.gov/17920206/

Malykhina, A. P., Sengupta, J. N., et al. (2005). Mechanisms of pelvic organ cross-talk: Impact of colorectal distention on bladder afferent nerve activity. American Journal of Physiology – Regulatory, Integrative and Comparative Physiology, 288(3), R555–R564. https://pubmed.ncbi.nlm.nih.gov/23542407/

Panicker, J. N., Marcelissen, T., von Gontard, A., Vrijens, D., Abrams, P., & Wyndaele, M. (2018). Bladder-bowel interactions: Do we understand pelvic organ cross‑sensitization? International Consultation on Incontinence Research Society. https://pubmed.ncbi.nlm.nih.gov/31821639/

Quaghebeur, J., et al. (2024). Integral theory and pathogenesis of LUTS and chronic pelvic pain. Pelviperineology, 43(1), 30‑39. https://pelviperineology.org/pdf/07d42497-fb2b-47e0-be2f-8805fa940376/articles/PPj.2024.43.01.2023-11-3/Pelviperineology-43-30-En.pdf

Ustinova, E. E., Fraser, M. O., & Pezzone, M. A. (2010). Cross-talk and sensitization of bladder afferent nerves. Neurourology and Urodynamics, 29(1), 77–81. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805190/

Vlasie, A., Trifu, S. C., Lupuleac, C., & Cristea, M. B. (2021). Restless legs syndrome: An overview of pathophysiology, comorbidities and therapeutic approaches. Experimental and Therapeutic Medicine, 22(6), 1355. https://www.spandidos-publications.com/10.3892/etm.2021.11108

Moral, C., Aydın, M., Yılmaz, A., İrkılata, L., Bitkin, A., & Kırdağ, M. K. (2025). The relationship between restless legs syndrome and overactive bladder: A cross‑sectional, controlled study. International Journal of Urology. https://pubmed.ncbi.nlm.nih.gov/40045817/

American Academy of Sleep Medicine. (2024). Treatment of restless legs syndrome and periodic limb movement disorder: Clinical practice guideline. https://aasm.org/wp-content/uploads/2024/03/Treatment-of-RLS-and-PLMD-CPG.pdf

______________________________________________________________________________________________________________________________________

Check out our recently published e-book titled “Vulvodynia, Vestibulodynia, and Vaginismus,” designed to empower and inform individuals on their journey towards healing and understanding.

Are you unable to come see us in person in the Bay Area, Southern California or New England?  We offer virtual physical therapy appointments too!

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.

Do you enjoy or blog and want more content from PHRC? Please head over to social media!

Facebook, YouTube Channel, Twitter, Instagram, Tik Tok