At the First World Congress on Abdominal and Pelvic Pain in Amsterdam last month (WCAPP), I had the opportunity to gain a more vivid understanding of how pelvic pain PT is administered outside of the U.S. And what I realized is: Good pelvic pain PT is hard to find…no matter where in the world you live.
In this blog post, I’m going to discuss some of the obstacles pelvic pain patients and PTs face in countries outside of the U.S., like Great Britain and France. But this is not just a post about PT outside of the U.S. As it turns out, shining a light on pelvic pain PT across the globe actually provided me with some valuable insights into the current and future status of pelvic pain PT right here in the U.S.
First a quick word about why this post is important to me: The major reason I wanted to write this post is that my role in the planning of WCAPP as IPPS president reminded me that the more the medical community works together across borders to solve the problems related to treating pelvic pain, the better hope we have of raising the standard of care and improving outcomes for all patients—the very reason WCAPP was conceived to begin with.
Now, let’s hop across the ocean to take a look at some of the challenges patients and PTs are facing outside of the U.S. when it comes to getting and administering “good pelvic pain PT”.
We’ve already talked quite a bit about the challenges involved in finding appropriate pelvic pain PT, but in case you need a refresher on what I mean when I refer to “good pelvic pain PT,” what I’m talking about is hands-on, manual PT within a multidisciplinary framework that is tailored to each individual patient. (Click here if you’d like a more indepth refresher.)
In learning about the different approaches to pelvic pain PT internationally at WCAPP both from the presentations and in chatting with my international colleagues, the first conclusion I came to was that patients and PTs outside of the U.S. have every bit as difficult a time finding good pelvic pain PT as those in the U.S.
Take England for instance. England has a publicly funded universal healthcare system under the National Health Service (NHS). (Disclaimer! Before I go any further, I feel I need to stress that this blog is by no means meant to be a treatise on the superiority of privatized healthcare over public healthcare. In fact, as I make clear further down in the post, in the U.S., under a private healthcare system, we have our own set of issues surrounding pelvic pain PT. Nor is it my intention to bash the healthcare system in any other country. I am far from an expert on any one country’s healthcare system! My intention here is to simply offer up a discussion of the different challenges faced in the pelvic pain PT arena.)
Now, getting back to pelvic pain PT in England. If a pelvic pain patient is being treated within the NHS, it can take anywhere from 18 to 24 months of waiting before the patient gets in to see a pain specialist who will then provide him or her with a referral for PT.
What I learned from two British PTs who delivered a lecture at WCAPP on the topic is that pelvic pain PT under the NHS umbrella is a very different animal from the standard of care that we offer at PHRC.
Within the NHS model, patients are treated in a group setting (about eight patients per group), and the focus is on delivering treatment in a “cognitive behavioral therapy framework.” Basically, this means that treatment is aimed at improving the quality of life and functionality of patients through strategies that do not involve the musculoskeletal system. The nuts and bolts of treatment are: “goal setting, pacing activity, thought challenging, stretch, communication, exercise/activity, medication management, and sleep.”
The aim of treatment includes:
· “supporting patients in constructively acknowledging the impact of chronic pain within the context of their own life”;
· figuring out how to help patients meet their personal goals “alongside pain”;
· and supporting patients in developing self-management strategies to enable them to continue managing their pain and working towards goals after completion of treatment.
So treatment is not one-one-one, is not hands-on, is not truly multidisciplinary (technically there is a “team,” but they do not work together to adapt treatment plans in the way that we do at PHRC), and does not involve evaluating or treating the pelvic floor musculature or the surrounding areas.
My initial thoughts upon learning of this approach were: What about conducting a pelvic floor evaluation? What about treating trigger points and tight pelvic floor muscles? Connective tissue manipulation, assessment of the pudendal nerve, internal work…where do these important components of pelvic pain PT factor in?
Indeed, all of the things that I most associate with pelvic pain PT were nowhere to be found in this model. As you can imagine, the explanation of this treatment model didn’t sit very well with me. For one thing, the underlying causes of the patient’s pain are not addressed at all. Not to mention that it’s a cookie-cutter approach, and I think most of you already know how I feel about those.
Don’t get me wrong, the model, which is at its heart a cognitive-focused approach to pelvic pain PT, does have its merits and its place, but for the vast majority of patients, that place is as an adjunct to one-on-one, hands-on, manual treatment.
For instance, I recently saw a 27-year-old female patient who is a triathlete. Her pelvic pain symptoms, pain with intercourse and pain with sitting, started about six months ago after a round of UTIs and a few yeast infections. As her PT, if I were to follow the approach laid out by the PTs from Great Britain, I wouldn’t be helping this patient, I’d be setting her up to become a lifelong pelvic pain sufferer. To be sure, this patient has musculoskeletal impairments, hypertonic muscles, trigger points and some connective tissue restriction; all of which I can manually work on and she can work on at home with specific exercises. And more than likely, the end result will be the resolution of her symptoms.
However, as I said before, many of the techniques of the NHS model can be beneficial as an adjunct to manual PT, because at the end of the day, they do have the potential to quiet down the nervous system, which is always a major ringleader in any kind of chronic pain. On top of that, there are certain patients, who have been dealing with pain for so long that, even if they do have musculoskeletal impairments, their central nervous system is so amped up that before their impairments can even be addressed, their nervous system needs to be quieted down.
For example, I have a patient who, after 11 abdominal surgeries and years of constant, daily pain is having a difficult time tolerating manual therapy. She presents with several trigger points, but her tissue is so hypersensitive that before I can apply manual therapy techniques, I first need to work with her to desensitize the tissue. (More on this topic next week!) Plus, this patient is basically bedridden, so again, she would benefit from many of the behavioral techniques within the NHS model that are aimed at improving functionality.
During their presentation, my British colleagues provided ample research to show that a patient’s quality of life improves thanks to their approach. But the fact of the matter is that anyone’s quality of life is going to improve somewhat after this therapy because it teaches positive thinking and coping skills. As a pelvic pain PT, I’m absolutely committed to helping to improve a patient’s quality of life. But my role is to do whatever it takes to diagnose and treat their musculoskeletal impairments in order to lower their pain levels. This is what’s going to have the most impact on their quality of life!
Now, I should point out here that throughout England, there are pelvic floor PTs who work outside of the public health system who do their own thing. Furthermore, the NHS does allow a private health insurance market to operate. But at the end of the day, going outside of the NHS is going to be a much more expensive alternative for patients. Not to mention that the number of private practitioners is few and far between.
Another international example of pelvic pain PT within a public health model that did not sit well with me exists in France. Surprising, right? Considering how advanced France is when it comes to postpartum pelvic floor rehab. A colleague I met described how she treats 35 patients a day by setting up three rooms of patients at a time. These patients are either hooked up to biofeedback or e-stim. The patients are then sent home with various home exercises. For her part, the PT is reimbursed only 8 euros per patient, which explains why she’s under such pressure to see so many patients simultaneously.
One question these two examples brought up for me was whether or not a public healthcare framework makes it all that much more difficult for patients to find good pelvic pain PT—or for PTs to administer it for that matter. At first blush, it does seem that cookie-cutter approaches to pelvic pain PT could become much more firmly entrenched in a public healthcare system versus a private healthcare system; however, I simply do not know the answer to this question. Plus, it must not be overlooked that under a mostly privatized healthcare system, like the one we have here in the U.S., obstacles to good pelvic pain PT also exist.
For instance, the amount of time it takes to treat a pelvic floor patient, the one-on-one component of treatment, and the resources needed to work with health insurance companies can make it financially prohibitive to operate a pelvic floor-focused PT practice. The reality is that orthopedic PTs can see more than one patient at a time and do not have the same struggles with insurers that pelvic pain PTs do.
For that reason, it’s fairly common for pelvic floor PT practices to operate as cash-only practices. And while the majority of insurance companies do reimburse patients for treatment, typically from 50% to 75% of the amount, there are those that will not reimburse any amount if a patient goes outside of network. Plus, when it comes to Medicare, it’s illegal for a pelvic pain PT outside of the Medicare system to treat a patient even if that patient is willing to pay cash.
Now considering the obstacles that exist within a private healthcare system, the question remains: does “good pelvic pain PT” stand a better chance of becoming the standard of care in a private healthcare system versus a public one?
Those that would argue “yes” will say that within a private healthcare framework, because of the more competitive nature of the landscape, there is simply going to be more of a financial incentive for PTs to offer good pelvic pain PT. On the flip side, those who disagree will say that if good PT is ultimately embraced within the umbrella of a public healthcare system then it will become the law of the land and will be accessible to all, similar to how postpartum pelvic floor rehab has flourished in France.
After the Fifth World Congress, I’ll consider the question again, and by then I’m betting that I’ll be able to answer it because I do believe we’ve reached an important tipping point whereby good pelvic pain PT is going to start becoming more readily available across the globe. That’s because two market forces—greater patient awareness (thanks in part to the Internet!) and demand and better access to education for PTs—will result in a higher across-the-board standard of care for pelvic pain PT. And that’s the good news.
International readers, we want to hear from you. If you are a PT or a patient outside of the U.S., please share your experiences with pelvic pain PT with us!
All my best,