An Introduction to Non-Internal Pelvic Health Physiotherapy with Pelvic Health Solutions
Why Is There Such a Disconnect with the Pelvic Floor?
Most medical professionals are not learning about the pelvic floor and are rarely learning how to appropriately diagnose and assess pelvic floor dysfunctions. This creates a disconnect between the pelvic floor and the rest of our body - this disconnect needs to be addressed and rectified.
The disconnect continues further between the sexes. We often think that pelvic floor pain is isolated to women, however, this is not solely a female problem and both women and men are not being treated appropriately for pelvic health pain and pelvic health problems.
An internal exam is not always necessary to address pelvic health; there are many exercises that can be performed without going internally. However, as an ethical health care practitioner, you must know when you need to make that referral to someone who will perform an internal pelvic exam.
The Mission of Pelvic Health Solutions
We need to stop working in silos as different health care practitioners and connect the pieces again. One of Pelvic Health Solutions' goals is for the pelvic floor to be incorporated into continuing education for physiotherapists (physical therapists) and allied health care professionals.
Pelvic Health Solutions' mission is to provide evidence-based, biopsychosocial resources to patients and health care practitioners for the assessment and treatment of pelvic health problems in our province (Ontario) and abroad.
Why is Malpractice Permissable in Pelvic Health?
Imagine going to your practice and seeing a patient with an acute MCL sprain, or even a chronic MCL sprain. You greet your patient and then proceed to assess their knee through their jeans - you don’t touch the knee, you just get them to do a few movements and then prescribe a few exercises. We all know that this would quickly escalate to a college complaint – so why is this okay for the pelvic floor? Why are we just guessing at what is happening in the pelvic floor? We have no idea where it is tight, or weak, or how patients are performing their exercises.
Despite the existence of a strong body of level 1 evidence indicating that training the pelvic floor properly and performing internal exams is highly effective for treating incontinence and pelvic pain, the pelvic floor continues to be ignored.
Although we may not go into physiotherapy with the idea that we will be performing internal exams, that is something we too often leave to nurses and medical students, but, is this malpractice? Is this something that we should be doing?
Non-Internal Online Course by Pelvic Health Solutions
Continuing to upgrade our skills is an important part of being a physiotherapist. Sometimes taking an in-person course is not possible due to geographic, budget, and time restrictions.
Pelvic Health Solutions has created a 6+ hour online course that you can take on your time and schedule.
Not all clinicians want to perform this type of exam, or it may not be in your scope of practice. However, if your patients have a pelvis you should understand the implications of pelvic floor dysfunction and the implications when seeing patients with Low Back Pain (LBP), SIJ dysfunction, Pelvic Girdle Pain (PGP), and hip pain.
Learn what the evidence says about linking pelvic floor dysfunction to chronic low back pain, pelvic girdle pain, and hip pain, and learn what you can do about it in your practice.
Help your patients to regain control of these important muscles. Sexual function and bladder/bowel function are arguably some of the most important activities of daily living!
Don’t let your discomfort be the barrier to your patient’s recovery; we will make it fun and non-threatening! We believe this will ultimately make you a better clinician.
In this online course, you will learn:
- The relevance of Pelvic Floor Dysfunction (PFD) when treating orthopedic conditions-specifically LBP, SIJ dysfunction, PGP, and hip pain.
- Pelvic floor conditions as they relate to a weak pelvic floor and an overactive pelvic floor.
- How to tactfully ask patients important questions about sexual function.
- The basic anatomy of the pelvic floor musculature and physiology of the lower urinary tract system (LUTS).
- Simple, non-internal management strategies for pelvic floor retraining that you can use in the clinic right away.
- How to create a prescription and progression of pelvic floor exercises for an overactive and under-active pelvic floor.
- Behavioural techniques to help retrain a variety of dysfunctions of the urinary and bowel system.
- Externally driven techniques for assessing and treating pelvic floor dysfunction.
- When to refer to a specially trained physiotherapist for incontinence, prolapse and pelvic pain.
Watch this Short Introductory Video from this Course by Pelvic Health Solutions:
This course is taught by Carolyn Vandyken, Michelle Fraser, and Nelly Faghani
Importance of Pelvic Floor Function: Maslow’s Hierarchy of Needs
When we talk about pelvic health and pelvic floor function we can talk about physical issues: Incontinence, low back pain and visceral pain syndromes. However, pelvic health is also essential to our psychological well-being.
We all remember Maslow’s hierarchy of needs from Psych 101, the base of the pyramid represents our physiological needs, followed by safety, love/belonging, esteem and lastly, self-actualization at the top of the pyramid. For our higher order psychological needs to be met, our basic physiological needs must first be met: Breathing, food, water, sleep, excretion, and sex. From this, it is clear that pelvic floor health is essential not only physiologically, but psychologically as well.
Basics of Males and Females
What is the pelvic floor? The pelvic floor is a group of muscles, tendons, ligaments, and fascia that close-off the bottom of the torso.
Far too often, we misdiagnose pelvic floor dysfunctions as something else. A few examples of such misdiagnoses include:
- If the pelvic floor muscles are being held in too much tension, it is going to prevent the movement at the SI joint. This increased tension could irritate the pudendal nerve, if this nerve is irritated, you would typically experience pain in the genital area.
- The pelvic floor could also be important in leg dominant pain. A lot of the time when people have leg dominant pain, we might think that it is a disc or L5-S1 nerve root, but it could also be tension in the pelvic floor. Why? Because the piriformis and obturator internus are both pelvic floor as well as hip muscles. If, for example, the piriformis is underworked because of some other muscle imbalance, this might compress the sciatic nerve.
- The obturator internus can also irritate the obturator nerve. If the obturator is tense, it can irritate the obturator nerve which can create medial thigh and knee pain.
Pelvic Floor Muscle Physiology and Importance in Therapy
- Muscle fiber ratio of the pelvic floor: 70% slow-twitch muscle fibers, 30% fast-twitch muscle fibers.
- Slow-twitch fibers are needed for longer, sustained activities such as plank for example.
- Fast-twitch fibers are used for slow, robust activities such as coughing, sneezing, jumping etc.
- When we are retraining the pelvic floor muscles, we must train both fast- and slow-twitch muscle fibers.
- The pelvic floor is innervated by the pudendal nerve and has autonomic nerve fibers, specifically sympathetic nerve fibers. If anything is taking place that would have you sympathetically upregulated, there will be a message coming from the sympathetic nervous system to the pelvic floor muscles to contract.
Five Functions of the Pelvic Floor
What is Pelvic Organ Prolapse
Subjective disorder described as an annoying protrusion at or near the vaginal opening, which may or may not be accompanied by perineal pressure that is aggravated by standing and relieved by lying down.
Types of Pelvic Organ Prolapse:
- Uterine Prolapse
- Vault Prolapse
The Diaphragm and Our Internal Pressure System
The diaphragm is our gateway into our breath system; it is situated above the abdominal muscles, which are in turn located above the pelvic floor. The abdominal muscles, diaphragm, and pelvic floor must work as a coordinated team; overactivity or misuse of any members of this team can result in numerous issues. Below are some examples of misuse and their possible downstream consequences (in women):
- Misuse: Holding the breath as a strategy to keep the core stable.
Response: Responsiveness of the abdominal muscles and pelvic floor is diminished.
- Misuse: Squeezing abdominal muscles throughout the day to help the tummy look flat, or to improve posture.
Response: The diaphragm cannot come down against the pressure created by contracting abdominals and the pelvic floor becomes weakened; aches, pains, and leaks may ensue.
- Misuse: Over-contracting the pelvic floor to compensate for the over-contraction of upper abs. Response: This hypervigilance of the pelvic floor also creates leaks, pelvic pain, constipation, pain inserting a tampon and painful intercourse.
All three of those scenarios represent a static hold of our teammates, but the system does not work that way, it’s the coordinated interaction of all of these muscles that balance the system.
Blog Content Source: Non-Internal Introductory Pelvic Health Course
About the Course Instructors:
Nelly Faghani, B.Sc. P.T., M.C.P.A.
Nelly graduated from the University of Toronto in 1996. Nelly started to treat pelvic health in 1998 and continues to be actively involved in clinical practice, mentoring and teaching. She has helped develop Continence Programs that have been implemented in various long-term care facilities through Ontario. Nelly has been a spokesperson for the Canadian Physiotherapy Association, has co-authored a neuro-urology textbook chapter on incontinence and has hosted a round table at the International Pelvic Pain Society Conference.
Nelly is a member of the ICS Children and Young Adult’s Committee and the ICS Physiotherapy Committee. She regularly attends international conferences and prides herself on staying on top of the current pelvic health literature.
Carolyn Vandyken, BHSc (PT)
Carolyn graduated from McMaster University in 1986 as a physiotherapist and has practiced in a wide variety of clinical settings, focusing primarily on orthopedics. She has been a McKenzie credentialed physiotherapist since 1999 and has been a member of the Canadian College of Medical Acupuncture since 2002.
She received a certificate in Cognitive Behavioral Therapy for Health Care Professionals from Wilfred Laurier University in 2016. Her clinical focus changed to Pelvic Health and Incontinence in 2001. Carolyn was the co-founder of Pelvic Health Solutions, a Canadian-based post-graduate teaching company. Carolyn presents extensively internationally on pelvic health and central sensitization. Carolyn has been using telerehabilitation in her clinical practice for the past 4 years.
She has published several framework articles on integrating central pain mechanisms into clinical practice, a pain education book, and several chapters in textbooks on pelvic pain and central sensitization. She is actively involved in research with Dr. Sinead Dufour at McMaster University and has published multiple studies on the connection between low back pain and pelvic floor dysfunction.
Carolyn won the prestigious Woman of Distinction award from the YWCA in 2003 for her work in pelvic floor rehabilitation. Carolyn won the distinguished Education Award from the Ontario Physiotherapy Association in 2015. She co-owns her practice in Muskoka, Physio Works Muskoka along with her daughter, Brittany Vandyken.
Michelle Fraser, BA, BScPT, FCAMPT, CYT, MEd
Fraser is a pelvic health advocate and educator who works with persons of all genders experiencing pelvic floor dysfunction or interested in understanding the complexities of pelvic health. Michelle’s dedication to making pelvic health internationally accessible is furthered by her commitment to her own continuing education.
Fraser graduated with her physiotherapy degree from the University of Toronto in 1994. In 2004 she obtained her Advanced Diploma of Manipulative Therapy, and she is a Fellow of the Canadian Academy of Manipulative Physiotherapists. Fraser is an associate instructor with Pelvic Health Solutions and the Canadian Physiotherapy Association (CPA).
She will soon be launching online pelvic health physiotherapy consultations for persons in rural and remote areas of Canada and beyond.
Blog Editor: Nataliya Zlotnikov