1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
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2. Faculty Disclosure of Financial Relationships:
Leah Tobey, PT, DPT, cert D.N. has no financial relationships to discuss.

3. How to join our poll questions:
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4. Objectives
Identify common conditions treated by physical therapist, certified in pelvic floor rehabilitation
Understand the patient’s perspective of pelvic floor physical therapy
Understand the two types of kegel exercises for up-training & the importance of down-training for pelvic pain

6. Pelvic floor physical therapy (PFPT) Dispelling rumors & creating understanding
What is it?
Why should I know?
Effective & beneficial treatment
Considered conservative management
Patient empowerment
Crucial for patient quality of life & confidence beyond our office doors
Similar to controlling HTN with medication, pelvic floor therapy can better manage a person’s myofascial pain or weakness/UI.
Creating understanding:
Many patients are initially hesitant when this type of therapy is brought up as part of the treatment plan.

7. Misperceptions Incontinence is a natural part of aging
Incontinence after childbirth is normal
Nothing can be done to change incontinence
Walking up to urinate every night is normal
It is normal for intercourse to be painful
2014 Cochrane Review found high quality evidence to support pelvic floor muscle training as the 1st line treatment for stress & mixed UI in women.
Credit to Island Optimal Health & Performance PT group

8. PFPT
Pelvic floor PTs provide evidence-based physical therapy interventions while promoting lifelong musculoskeletal health.
Treatment emphasis is placed on patient education, therapeutic exercise, home exercise and symptom management. Our goal is to restore function and return our patients back to social, home and leisure activities.

9. Pelvic Floor Functions
Pelvic Floor Dysfunction RFs:
Support of organs
Sphincteric
*Maintain continence
Sexual
Sump-pump
*Helps move
Lymphatic & venous
fluid

10. Pelvic Rehab PT Services (PFPT) Common Conditions
Pelvic floor muscle weakness
UI, FI, POP
PPUI: Post-prostatectomy urinary incontinence
Pelvic pain
CPPS: Chronic pelvic pain syndrome
“chronic prostatitis”
IC: Interstitial cystitis/Painful Bladder Syndrome (PBS)
PN: Pudendal Neuralgia
Coccydynia
Dyssynergia
Constipation/IBS-C

11. Pelvic Floor Muscle Weakness
UI or FI:
Stress
Urge
Mixed
Pelvic organ Prolapse:
Cystocele
Rectocele

12. PFM Weakness: Subjective reports
“I’ve tried those ‘Kegels’ and they don’t work for me!”
44 y/o WF s/p bladder sling/ TVT
“My surgeon gave me a handout on these exercises but I don’t know if I’m doing them right.”
68 y/o AAM s/p prostatectomy

13. To Kegel or not to Kegel? Type of Kegel Purpose Quick flicks (Type 2)
For urgency delay, nocturia, bladder retraining
Endurance holds (Type 1)
Main-bulk of pelvic floor
Most important for long-term training strengthening
4-6 sets of 10 second holds per day (initial)
*Not appropriate for Down-Training
*Must first relax PFM (pelvic floor muscles)

14. Technique is KEY Top 8 exercise mistakes Using the wrong muscles
Incorrect form
*breath holding
No variety
Following the wrong routine
Not measuring progress
Forgetting to relax
Not being consistency
Giving up before seeing results

15. Pelvic Floor Rehab …what to expect
Services for men and women
Evaluation and internal/external Examination
Orthopedic evaluation
Bowel and bladder evaluation & retraining
Dietary & food considerations (related to constipation, IE)

17. The Journal of Sexual Medicine
Table 2.  Manual muscle testing grading scale
No response 1
Flicker 2
Weak contraction 3
Moderate contraction, some degree of lift 4
Good contraction, against some resistance 5
Normal muscle contraction, strong squeeze, and lift
*Currently there is no standardized method of grading PFM tone but this guide is the most commonly used. There is however, reported high reliability and diagnostic agreement among PTs in diagnosing pelvic floor pathology.
Reissing ED, et al. Vaginal spasm, pain, and behavior: An empirical investigation of the diagnosis of vaginismus.

18. PFPT for pain Pelvic Pain
Sometimes this pain is mistaken for other conditions or missed entirely.
Important to diagnose the initial cause of the pain
Secondary problems as well, to get the best results.
“Myofascial pelvic pain in women may be the underlying cause of chronic pelvic pain in 14% to 23% of cases and up to 78% of cases of interstitial cystitis, which is a type of otherwise unexplained bladder pain.”
2012 article in the Journal of Obstetric, Gynecologic & Neonatal Nursing
June 2019 Vanderbilt University, Women’s Health Department: My Southern Health.

19. Commonly treated pain diagnoses
IC/PBS: Interstitial cystitis/Painful bladder syndrome
CPP: Chronic pelvic pain
Constipation
PN: Pudendal neuralgia
EDS: Ehler’s Danlos Syndrome
Important for pelvic floor therapist to teach patient how to relax his/her pelvic floor.
Down-training
Imagery
Reduce stress
Diaphragmatic breathing

21. Pelvic floor anatomy review
Urogenital triangle: Layer 1 & 2
Colorectal triangle: Layer 3

23. The pelvis is a complicated place

24. Neuromodulation for Pelvic Pain

25. Neuromodulation for Pelvic Pain
Recent advancements in neuromodulation have lead to the use of spinal cord stimulation for the treatment of severe pelvic pain.
Multiple Case Reports/Case Series have demonstrated benefit with the use of Dorsal Root Ganglion Stimulation for Pelvic Pain
Two randomized, multicenter studies are currently on-going to examine efficacy of this treatment

26. Dorsal Root Ganglion Stimulation for Pelvic Pain Treatment.
Current Described Technique: Placement on Bilateral L1 and S2 nerve roots.
Treats neuropathic or post surgical pain from Ilioinguinal, Iliohypogastric, Genitofemoral, and Pudendal Nerve distributions.

27. Barriers? Compliancy PFPT Provider availability
Study about compliancy of pts in treatment for CPP
Frustrating
Similar to OUD, SUD/Addiction
PFPT Provider availability
List of statewide providers can be available to you on our website.
Most all patients need 2-3 PT sessions
8-12 sessions are suggested for optimal outcomes

28. PFPT What does all this mean?
PTs routinely use education, manual therapy, and exercise to manage pelvic pain conditions
(Alappattu, M. Journal of Women’s Health PT: April/June 2019-Volune 43-Issue 2 p 82-88).
Physio/PT, similar to CBT therapist can be a helpful team-member to include in complicated patient cases.

29. PFPT Study 17 countries with just <1K PT responses.
>80% PTs used Education, Exercise, Manual therapy for patient with PP
Differences/Challenges/Future research:
Geographical differences in patterns of use-specific manual therapy and exercise interventions.
Differences were also noted on the basis of the levels of advanced post professional training
Most common interventions considered effective *but not used frequently were:
CBT
Dry needling
Acupuncture
Topical medications
Internal pelvic manual therapy techniques

30. Special thanks to:
Dr. Lori Mize, board-certified WH specialist & instructor at UCA.
Dr. Goree

31. Discussion Continuing Education Credit: TEXT: 501-406-0076
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32. Questions about the Topic
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