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BackTable / OBGYN / Article
Pelvic Floor Physical Therapy in Practice
Dana Schmitz • Updated Nov 3, 2023 • 127 hits
Pelvic floor physical therapy focuses on rehabilitating the muscles in the pelvic floor after an injury or dysfunction. Ingrid Harm-Ernandes, a pelvic floor physical therapist and the co-director for Duke University's Women's Health Physical Therapy residency program, offers an insightful explanation on the importance of pelvic floor health awareness, and how to put anatomical and physiological information into practice to properly assess function and health of the pelvic floor.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• The American Physical Therapy Association (APTA) initiated board certifications in 2009, with eligibility criteria including completion of several courses and at least 2,000 hours of direct patient care.
• Pelvic floor physical therapy (PT) treats both men and women, addressing issues like urinary and fecal incontinence, constipation, prolapse, and sexual pain. Other conditions, such as back pain, hip pain, vulvodynia, irritable bowel syndrome (IBS), interstitial cystitis, migraines, and asthma, can often be linked to pelvic floor issues and can benefit from pelvic floor PT.
• Education beforehand on what to expect during a pelvic exam and pelvic physical therapy is important to ease patients' fears and increase their understanding and compliance with evaluation and treatment.
• Pelvic floor physical therapy can be an effective alternative to recurrent cycles of antibiotics, particularly in cases where symptoms mimic infections.
• It is crucial to understand the connections within the pelvic floor’s musculoskeletal and nervous systems to achieve effective treatment and to prevent worsening conditions due to misdiagnosis.
Table of Contents
(1) Pelvic Floor Physical Therapy Certifications & Training
(2) Pelvic Floor Physical Therapy: Individualized Care
(3) Understanding the Pelvic Floor: Education and Awareness
(4) The Crucial Role of the Musculoskeletal System in Pelvic Floor Health
Pelvic Floor Physical Therapy Certifications & Training
Ingrid Harm-Ernandes offers an insightful recounting of her journey into pelvic health and the multiple pathway options available towards becoming a specialist in the field. Today, to be eligible to sit for the board exam, candidates must complete several courses, as Dr. Harm-Ernandes did, and accumulate at least 2,000 hours of direct patient care, followed by a successful case reflection submission. Alternatively, the Certification Achievement Program (CAP), which focuses on either pelvic or obstetric care, and certifications such as the Pelvic Rehabilitation Practitioner Certification (PRPC) offered by Herman and Wallace, provide other viable routes to this specialization.
[Ingrid Harm-Ernandes]
Yes. My path probably is a little unusual just because I started so long ago, but I can list out for me, I took numerous courses on women's health, pelvic health, orthopedic, things that all led up to me being able to gain the skills and the knowledge that I needed to get where I wanted to be, and then our national organization, the APTA, started board certification back in 2009. I was that first cohort to sit for the board exam, and that's the WCS that you see after my name.
What they do more these days is you have to go through these numerous courses like I did, and then there are a couple paths you can take. One is the residency program like we do at Duke, and they spend a year with us just being super immersed in everything pelvic and lymphedema. It's pretty extensive. You have to have at least 2,000 hours of clinical direct patient care, and then you are, once you write a case reflection, you're allowed to sit for the board exam.
Our national organization also has what are called a CAP program, which is either pelvic or OB centered. You can go either way, and that's a certification itself. Then there is a company called Herman and Wallace. They teach multiple courses no matter what level you are, and you can take numerous courses and get a certification from them as well, and that's a PRPC. You might see these different alphabet you know behind clinicians, but they all stand for some kind of pelvic floor physical therapy certification that you can get.
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Pelvic Floor Physical Therapy: Individualized Care
Pelvic floor physical therapy consists of a highly individualized approach. It is important to conduct extensive pelvic floor assessments, which may include internal, external, or full orthopedic evaluations to discern a patient's specific needs and formulate a suitable treatment plan. The pelvic floor physical therapy practice is not restricted to women but is increasingly involving male patients, and pelvic floor issues often intertwine with various conditions such as back pain, hip pain, vulvodynia, IBS, and interstitial cystitis. Misconceptions surrounding pelvic floor health include the normalcy of leakage and pain during sex, but these conditions are abnormal and can be effectively treated with pelvic floor PT.
[Dr. Amy Park]
Well, can you explain what is pelvic floor PT? Like what exactly occurs, and how can we best explain it to patients so they actually go to PT?
[Ingrid Harm-Ernandes]
That's a great question because I think sometimes the fear of going to pelvic PT really stops. Even in our urogyne world where that's what we all work with, less than 50% of the patients referred to pelvic PT actually go, right? I think, again, the book has that knowledge in it, so io if someone picks it up, they know what happens in a pelvic floor assessment. They know what happens in a treatment. Basically, what I'll say is every pelvic PT will decide, after doing a long subjective pelvic floor assessment, what does this patient need? What I mean by that is, do they need an internal assessment? Do they need just external assessment?
Do they need a full out orthopedic assessment, which are wonderful skills that all PTs will use for joint motion and mobility and functional level? We will do that depending on the patient's needs and what they desire. Their goals are hugely important for us when we approach how we're going to form a treatment for them or a treatment plan for them. Once we have that assessment, if it's an internal, we look at muscle strength, muscle ability, muscle endurance, muscle quick response, trigger points, fascial restrictions. It's actually extremely extensive what we look for.
I will say that that relaxation component that we look for in the muscle is exceedingly important because we will not prescribe an exercise regimen until we know exactly what they and their pelvic floor can do. I know that sounds funny, but if I have someone with overactive bladder and their pelvic floor is upregulated, is hyperactive, there are many terms that we use for that, and I give them 100 pelvic floor physical therapy exercises to do in a day, I can make their symptoms worse, so we need to prescribe the exercises based on what we find. Then that's kind of the tip of the iceberg, I'll say. From there, we'll do a comprehensive pelvic floor physical therapy exercise program for their core, for their body.
I say knees to toes. I sometimes treat their neck or their feet if I need to in order to resolve the symptoms. Then we do behavioral therapies where it might be, how do we teach them to get their bladder to calm down so that they don't have urgency? How do we teach them to have a bowel movement so they can have a bowel movement without constipation? Because we all know that it's not just our organs, it's not just our colon, but it's our pelvic floor that hugely impacts how we're able to have a bowel movement. Teaching someone how to change their lifestyle, their life, their abilities, their functional level is huge while we're doing all these exercises.
You can see it's like, this is just like I said, the tip of the iceberg. It's extremely comprehensive that once you send someone to pelvic PT, that PT is going to figure out what's going on in their life. I may have two patients with the same diagnosis, but I might not do the same treatment because they're different people. One might be a retired person who has time on their hands. Not all retired people do. Then I might have someone who's pregnant, has three children, and a job. I'm not going to give them the same routine because they can't possibly do the same routine, so it's very, very individual.
[Dr. Amy Park]
There's a couple points that you just brought up that I wanted to just touch on because so many of my patients have underlying conditions like their back pain or hip pain, they're incredibly common. Pelvic pain conditions like endometriosis or interstitial cystitis or vulvodynia, and a lot of people just instead of holding all their tension in their neck and their shoulders, they're holding it in their pelvis. There's so many etiologies.
It's just, I think you nailed it when you talked about how it has to be a comprehensive assessment because if you just address the pelvic floor and you're not addressing some of the underlying issues like the back pain or the hip pain and strengthening their core, then you're just a little bit in a tailspin, I would imagine, so I really appreciate that about your specialty. Would you say that you're all women? Because especially if you're doing the internal work, I think it's very surprising for some patients.
[Ingrid Harm-Ernandes]
Yes. We're majority women, but there are men and it is increasing actually. Over time, we've had more men enter the field. Some of it is because we have, we treat men, so some of the misconception is that, oh, we just treat women and only women have pelvic floor issues. No, everybody's got a pelvis and everybody has a pelvic floor, so we really need to address all the issues across the spectrum. I think men are stepping in because sometimes it is uncomfortable.
I've had many men and they're so hesitant when they first come in and they're like, well, you're a woman's health. I'm like, no, just call me a pelvic health specialist. The poor, you know, post and pre and post-postectomy and prostatitis. Prostatitis kind of fits in this same unfortunate category of recurrent UTIs where everybody's busy blaming it on some infection when it's really not. Quite frequently, it's actually the pelvic floor mimicking the same symptoms. What we do with someone with a recurrent UTI or prostatitis is we actually have to get them off this cycle of antibiotics and antifungals and it just keeps going on and on.
When I started in the field, antibiotics were still given out very regularly and very easy. I had women who said I could just call my doctor, say I've got an infection, and please just give me antibiotics. I'd have to convince them to say, no, please go in for a culture, and if that culture is negative, we know we're looking at something else. They'd come back saying, I can't believe it, Ingrid. You were right. I don't have an infection, it feels like it. We would work on their pelvic floor and the infection-type symptoms would go away, and our men with prostatitis are in the same boat. I feel so bad that we really have to work on getting them away from this cycle of antibiotics, and once we do, they just do so, so much better.
[Dr. Amy Park]
You reminded me that I've heard some stories from pelvic floor PTs, how effective it is. A lot of them tell me it's even more effective for the men. They pick it up easier. It's like a classic story of, for the young men, especially, like soccer players and they have psoas pain or post whatever, you know, vasectomy or whatever pain, they actually respond very well and very quickly, and they're like, it's the most amazing, gratifying treatment. [chuckles]
[Ingrid Harm-Ernandes]
You're 100% right.
[Dr. Amy Park]
Yes, but anyway, I also wanted to just ask about what other indications can you think of to go to a pelvic floor PT.
[Ingrid Harm-Ernandes]
Yes, there are many, many different reasons to go. I would say one of the unfortunate things, once again, is that people, especially women here are taught it's okay to leak. It's normal to leak. It's normal and okay to have pain with sex. Just live with it. Put a pad on, and one of the reasons men get better quickly is pads are for women. They don't want to have pads. They want to get better yesterday, so it has a little to do with that.
It's this issue of, well, yes, you know, we giggle about it. We laugh about it. If I'm with my friends, I laugh and I pee on myself and we just kind of just say, well, no worries, but we have to dispel those myths that it's normal. I want the conversation to be normal about it, but not that the conditions are normal. Some of the most common things are any kind of leakage with coughing, sneezing, laughing, urgency where you can't make it to the bathroom on time, or even if you now make it to the bathroom, in a year or two years or five years, you might not make it to the bathroom. Solve that problem now before it becomes a leakage issue.
Fecal incontinence, my, that is a big one that people don't want to talk about. That is something that is kind of off-limits for people, but I want people to realize out there, if you've got patients coming in and they're hemming and hawing about things, go ahead and ask. Outright ask because these patients actually want you to ask so that they feel comfortable to say, yes, you know, by the way, every time I pull my underwear down, I have a stain on it. What's going on kind of thing?
Or constipation. No, it's not okay to live with constipation. The more you strain, the worse the problem gets, and sometimes it's such an easy fix working on the pelvic floor and proper toileting position can make a night and day difference with them, so constipation is another thing. Don't wait on that. Prolapse for women right after pregnancy and then later in life. It's been shown that operative deliveries are at a high risk for forming prolapse either immediately afterwards or years down the road when menopause shows up and the pelvic floor starts to change because of that. Any kind of bulging, any pressure that you commonly see in your practices can absolutely be treated by pelvic PT.
Pain with sex. That's another big one that people do not want to talk about, but that should be such a big checkoff right there that if they're having pain with sex, whether it's post, and I'll say fourth trimester, not postpartum because we have to stop thinking that the woman is better after six weeks. We may check off that they're okay, their bleeding has reduced or stopped, and now we say they're ready to go. A lot of times they're not. They're not ready to. They have back pain. They have incontinence. They have prolapse. They have fecal incontinence. These are the patients that absolutely need to go to PT. During menopause, pain with sex, again, increases. That's another time.
You mentioned before back pain and hip pain. This is a big one. If they have incontinence and they have back pain as well or hip pain, wow, that's a telltale sign to get them to pelvic PT. I can't tell you how many patients I've treated that come in and they say, well, I have incontinence and this is going on. I go through their history and they say, you know what, I've had a hip bursitis and I've been treated for it. Injections, whatever it may be. It doesn't get better. I treat their pelvic floor and their "hip bursitis" goes away because it was never hip bursitis, it was the obturator internus, a hip rotational muscle, so we need to look at that broad spectrum of multiple symptoms.
You mentioned before vulvodynia, IBS, interstitial cystitis. If they have this suite of problems, they have more than just a simple fix, I'll call it. They have an upregulated system. They have these comorbidities that are very, very typical. I'd say look for these comorbidities, migraines, asthma, all of that fits into this group of upregulated individuals that absolutely can benefit from pelvic PT.
Understanding the Pelvic Floor: Education and Awareness
Because patients often wait years with symptoms before seeking treatment, the underlying pelvic floor condition can ultimately worsen due to the body reacting and trying to compensate. In Ingrid Harm-Ernandes’ book, written to increase awareness surrounding pelvic floor health, mysteries surrounding the pelvic floor are dispelled. The book provides a thorough look at the pelvic floor, how it integrates the musculoskeletal and nervous systems, and the influence of stressors on it. It further connects these insights to various conditions, including incontinence, prolapse, and pelvic pain. A key aspect is the step-by-step guidance through a typical pelvic exam, intended to alleviate patient fears and misconceptions by detailing what to expect during pelvic physical therapy, from biofeedback to manual techniques.
[Dr. Amy Park]
Tell me why you wrote the book, The Musculoskeletal Mystery, How to Solve Your Pelvic Floor Symptoms. I'm assuming you were motivated by all the success you were having, but I also am thinking there's just a general lack of awareness.
[Ingrid Harm-Ernandes]
Absolutely. I would say, patients, especially when I started, sometimes they had symptoms for 5, 10, and 30 years before they stepped through my door. If they didn't have a musculoskeletal condition, to begin with, they certainly have it now because once your body starts to fight these, whether it's pain or fear of loss of urine or fear of losing fecal matter, the body starts to react by tightening and protectively trying to avoid the issue, but the person doesn't know they have it. They can't see their pelvic floor. It's not like having your arm tight or your shoulders up. You can see that. With the pelvic floor, they don't know they're doing it.
Because I saw this delay, I just thought to myself, I've got to get the message out to everybody so everybody speaks the same language. When I wrote the book, what I thought is, how do I do that? My first goal was to dispel a lot of mysteries about the pelvic floor and the musculoskeletal system and how it's hooked neurologically, how our brain impacts, how we respond to things, how we respond to stressors, all impacts the musculoskeletal system. The first part of the book just deals with everything you could think of from the pelvic floor to the pelvis and how it's all integrated so that whether you're a practitioner or you're a patient, you can really see, oh, that makes sense.
Then I link it to the diagnosis, so we talk about how does that then affect incontinence or how does it affect prolapse or pelvic pain, or pain with sex. Then I take it to the next step and I say, well, this is what might happen in a pelvic exam so the patient isn't fearful or if you as a practitioner have this book, you can say, well, when you go to pelvic PT, you might have an internal exam. You might have biofeedback. You might have manual techniques, and then you can explain it to the patient and the patient is so much more likely to go. You've got that literature, that resource right in front of you.
Then I take it the next step to what happens in pelvic PT, some of the things we talked about, so it's like, oh, well, that makes sense. Now I know why they're going to tell me what do I need to do for my bladder or what do I need to do for my bowels. What kind of pelvic floor physical therapy exercises? I spend four pages in the book describing pelvic floor contraction and relaxation, so people understand that a thousand Kegels a day, in fact, I don't even call them Kegels because there's such a misconception as to what they are. I say pelvic floor contraction and relaxation so that they say, oh, okay, I see. This is how we focus on it, this is how we do it, and relaxation is just as important as contraction.
Then there's a whole last section on self-care. I do that because, A, some people, they just like to know what can I do to start my way to get healthy again. For practitioners, it's like, oh, I understand now. This is why they're doing that in pelvic PT. I can now corroborate and I can enforce and I can encourage the right kind of activities in pelvic PT. There's a section on how to put your team together. What does it mean to be a urogynecologist? What does it mean to be an acupuncturist? Why would I involve a sex therapist? That's all in there.
Then I have a section on, I call it how to avoid Dr. Google, right? Because so many of the patients just, they get so worried when they read what's happening on the internet. I wanted to just make sure that people understand what you read on the internet a lot of times is just not true. [chuckles] If we can get people on board there, and my doctors love to use it as a resource to say, hey, I think you should buy this book. I think you should start your journey with all the education here. If you need pelvic PT, you know why it's important, what to do about it. It was my way to give back.
After working clinically for so many years now, I just love doing the educational component and seeing light bulbs go off all over the place from everybody. I feel so fortunate that I've been given this opportunity to help the world find a better way to pelvic health.
[Dr. Amy Park]
Well, that is awesome. I think that there's such a service to the public just so they can have more knowledge and information about the pelvic floor. I always have to explain to patients, well, you have this muscle diaper that keeps everything in, and that can get tense, just like everything else in your body. They're like, you can tell the wheels are turning. Wow, I do have muscles that cover that area. I'd never thought about it. Not like my legs or my arms or my abdomen or what have you. Nobody sees your toned pelvic floor, but also you're right.
I've seen those patients who have two-toned pelvic floors or read about it on the internet, and then they're trying to keep in their prolapse. Then, all of a sudden, their pelvic floor is really tight. [chuckles] It's doing the right technique, like you're saying is crucial.
The Crucial Role of the Musculoskeletal System in Pelvic Floor Health
For healthcare practitioners, educational resources about the rich tapestry of muscles in the pelvis may be lacking; education on the interconnectedness of these groups of muscles and nerves may get sidelined until a more pressing issue arises. Problems within the musculoskeletal system in the pelvic floor can mimic and potentially misdirect the diagnosis of other symptoms. For instance, trigger points in the puborectalis muscle can cause an overactive bladder sensation or constipation, highlighting how a single muscle can generate a range of symptoms. Other instances include the obturator internus muscle's relationship with the hip, and the iliopsoas muscle causing pain mistaken for ovary-related issues. When managing pelvic floor conditions, it is crucial to recognize these connections to appropriately treat and manage conditions that could otherwise worsen over time due to the body's natural pain response.
[Dr. Amy Park]
Why is the musculoskeletal system such a mystery, and then how does it impact patient symptoms?
[Ingrid Harm-Ernandes]
I think there are a couple of reasons why it's a mystery. I think first, if we talk about lay people, there's nothing in any kind of educational resource that says, look, you've got muscles down there [chuckles] and you have a rich resource of muscles all through your pelvis and they work as a unit. Usually, when I educate for lay people, whether I go to a library or a senior center, I do everything under the sun, I start them on what that core means and why it's important. I think the mystery for them is they know somewhere out there that an organ might be affected or their hormones might affect their symptoms. I think they don't make those connections.
I think even for practitioners, I have to say, if you think of how much education you have to cram in your brain to be a practitioner, the musculoskeletal system is taught, but then kind of put over here on the side, and it's not brought to the forefront until something more important happens or there's a link made, which is why when I go to conferences and I talk about it, I talk about those same links to my practitioners and how we can't ignore the fact that the musculoskeletal system, not only does it have symptoms and issues of its own, but it can mimic symptoms.
I'll give you an example. The puborectalis, the muscle that nicely slings around from the front of the pubic bone, around the rectum, and back up again, the front part of that muscle, when it has trigger points, can create an overactive sensation and make someone feel like they have an overactive bladder. The back portion slings around the rectum and can create constipation issues, so one muscle within the pelvic floor muscles can create many symptoms.
Before, I mentioned the hip, so our obturator internus which rotates our hip, is directly connected to our pelvic floor. If we have an issue at the hip and that muscle tightens, for example, it pulls on the pelvic floor and it creates an environment where that pelvic floor no longer can do its job well. We might not notice that immediately. An example might be someone who has hip replacement surgery and a couple of months later, they have incontinence and nobody puts two and two together to say, well, that might be that we disrupted the pelvic floor and that patient needs to go to pelvic floor PT.
The iliopsoas, I've had patients come in and say, I have ovary pain, I've been tested, I have ultrasounds, I've had this, I've had that. I test their iliopsoas and it mimics the pain. What we have to look at is that the mystery, I think, for practitioners is that these muscles, the knowledge is there that they are there, but the knowledge isn't there that they can create symptoms that we blame on other body parts, right?
It's very important to make those connections that these multiple different muscles create symptoms that seem like they're something else that can actually be fixed quite easily. If we ignore them or treat them in another capacity, we won't be able to resolve it and it will just keep cycling and in fact, over time get worse because of that upregulation that I was talking about, which is a natural occurrence for anybody that if you have pain and you have problems and they're not resolved, your body really starts to fight that.
[Dr. Amy Park]
Absolutely, and I think you raised such great points about how this one particular muscle can manifest in different ways and can be attributed to other organs, et cetera.
Podcast Contributors
Ingrid Harm-Ernandes, PT
Ingrid Harm-Ernandes was a physical therapist specializing in women's health with Duke University Medical Center for nearly two decades.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2023, July 20). Ep. 28 – Pelvic Floor Physical Therapy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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