Category Archives: Evidence-Based Medicine

Treatment Highlight: Internal Pelvic Floor Manual Therapy

Over the past week, and really the past year, the cases of sexual abuse and assault perpetrated by Larry Nassar, a medical doctor with MSU and USA gymnastics, have rocked the nation. The horrific abuse he inflicted on well over 150 young women, under the guise of “appropriate medical intervention” is deplorable, and I know many of us were glad to see him held accountable for his actions with both the verdict and sentencing last week.

In the pelvic PT world, this hit very close to home, and made all of us completely infuriated. For this person to take a completely valid, evidence-based and extremely beneficial treatment technique, and contort it into being an avenue for abuse was unfathomable to those of us who have dedicated our careers to helping men and women with pelvic floor problems. Several colleagues have spoken out about this. Particularly, Lori Mize, the incoming Vice President of the Section on Women’s Health, wrote an excellent post for the Huffington Post, that I would strongly encourage you to read.

Over the next year, I want to highlight a variety of treatment techniques used in pelvic floor physical therapy to help you better understand treatment options, and hopefully alleviate some fear that some of you may have about “the unknown.” In light of these current events, I thought it would be meaningful to start by discussing internal manual therapy techniques for the pelvic floor muscles.

What is it?

Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Before we get started, if you want to better understand the anatomy of the pelvic floor, check out this post by my friend and colleague Tracy Sher. Tender or overactive pelvic floor muscles can occur when someone is experiencing problems like pelvic pain, painful sexual intercourse, tailbone pain, as well as urinary or bowel dysfunction.

These techniques are performed either vaginally or rectally by a skilled medical practitioner who has undergone advanced training to learn to evaluate and treat the pelvic floor muscles. They are only performed once the patient has been thoroughly educated about the treatment techniques and consents to participating in the treatment.

What does treatment involve?

The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles. Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), sidelying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the vaginal or rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening. These techniques can include:

  • Holding gentle pressure while the patient focused on relaxing and breathing
  • Holding gentle pressure while the patient performs a contact/relax of the muscles or a pelvic floor bulge.
  • Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
  • Sweeping stretches over the muscle belly

Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment. Personally, I tend to prefer more gentle approaches while also focusing globally on improving awareness and calming the nervous system. This is not a “no pain no gain” situation– in fact, most often we see the best results when we are able to keep pain at a very minimal level.

What type of training should the therapist have?

It is very important that the person performing this treatment has had specialized training in this technique. At minimum, they should have attended an initial continuing education course that teaches a beginner level evaluation and treatment of the pelvic floor, generally weekend course including at least 24 hrs of instruction. Many training programs now include a 3 or 4 course series, and I strongly encourage clinicians to complete the coursework to learn how to comprehensively care for their patients. At Herman and Wallace Pelvic Rehabilitation Institute, the organization I am a faculty member of, we have a 4-course series which includes a level 1, 2A, 2B and Capstone. The Section on Women’s Health has a 3- course series and there are now several other companies offering varying training programs. Of course, I’m biased as a faculty member of H&W and if you’re reading this and work in healthcare in pelvic rehab, you should definitely come to one of my courses!

Who does this treatment help?

As I mentioned above, manual therapy to the pelvic floor is helpful when a person has overactive, tender and/or shortened pelvic floor muscles that are contributing to the problem they are experiencing. This can occur when a person has pain in and around the pelvis or if the person is experiencing urinary, bowel or sexual dysfunction.

We are producing more and more research about these techniques every day, but here are a few snippets:

  • In this study, 50% of the men treated to address chronic scrotal pain saw a significant reduction in their pain.
  • In this study, 93 people were treated with pelvic floor techniques to address coccyx pain (as well as pain after coccyx removal). Overall, they saw an average of 71% improvement.
  • This study compared comprehensive pelvic PT to cognitive behavioral therapy for women with provoked Vestibulodynia. They found that 80% of the women in the PT group had significant improvements compared to 70% in the CBT group.
  • This study evaluated the effects of pelvic floor physical therapy techniques on pain reduction in men who had chronic pelvic pain. Treatment included internal and external techniques and over 70% experienced moderate or robust improvements.
  • This study found that 62% of women experiencing urinary frequency, urgency and/or bladder pain who were treated with physical therapy interventions, including internal manual therapy techniques, reported feeling “much better” or “very much better” following the interventions.

I hope this was helpful and removed some of the fear from this technique! If you think this treatment may be a helpful one for you, talk with your health care provider! As always, I love to answer any questions you may have!

~Jessica

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Urinary Urgency, Frequency, and Incontinence– What’s New in Research?

I’m sort of nerdy (you already knew that though, didn’t you!)… so periodically, I like to go to my favorite medical search engines to find what is new in the literature regarding all things pelvic health. This helps me to keep aware of new treatments that are available, and helps me to constantly re-evaluate the treatments I provide for patients to make sure I am providing the best treatment I can!

Urinary urgency/frequency, urge incontinence, and overactive bladder problems are often not as frequently discussed in physical therapy circles as stress incontinence. Surprisingly, pelvic PTs actually treat these problems equally as often, if not more! A comprehensive PT program can be extremely effective for these types of problems! (So, if you are having urinary urgency, frequency or overactive bladder problems, and you live near Atlanta, give me a call! :))

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So, what’s new in the research to help with overactive bladder problems and urge-related incontinence?  

  1. Myofascial release techniques can be very helpful for patients with urinary urgency and frequency. I was pretty excited to see this study come out in the Journal of Female Pelvic Medicine and Reconstructive Surgery. Pelvic PTs have noticed for quite a while that many men and women with urinary urgency  and frequency actually tend to have hypervigilant overactive pelvic floor muscles rather than the traditional weak and stretched out muscles people like to think they have. Manual therapy, included within a comprehensive rehabilitation approach, can be very effective for helping this population, and I’m excited to see a recent study supporting the same thing!
  2. Mindfulness-based stress reduction (MBSR) seems promising in helping to reduce symptoms of overactive bladder and urge incontinence.    I didn’t find this surprising at all, but was again, excited to see this coming out in the literature. If you see in my first note above, many people with urinary urgency and frequency actually have a “hypervigilant” or “overactive” pelvic floor muscles. Stress reduction and mindfulness techniques help to calm the whole body–pelvic floor included! Along with this, we often find that people with urgency/frequency problems tend to live in a more sympathetic nervous system dominated state (basically, the “fight or flight” response is in overdrive!). Calming this system can be very helpful in calming the bladder.
  3. Pelvic floor muscle training continues to be recommended as a first line treatment for stress, urge or mixed incontinence.  It’s true, the most updated Cochrane Review published in 2014 continued to recommend pelvic floor muscle training to assist in improving all bladder symptoms. Their review showed close to a 55% cure rate–which is pretty good, considering this was just retraining the muscles in isolation. Imagine what could happen when the right retraining of the pelvic floor muscle is combined with behavioral retraining, dietary training and retraining the pelvic floor within the body as a whole? I bet the results would be much much better.
  4. Percutaneous tibial nerve stimulation may help to reduce urinary frequency and urge-related incontinence. This started becoming popular a few years ago, and honestly, there needs to be more higher quality studies in order for us to really see how effective this treatment is or isn’t. But, that being said, some of the initial results seem promising. If you are not familiar with this technique, it utilizes a very thin needle which is placed near the ankle to stimulate the posterior tibial nerve with a low electrical current. The thought is that this nerve comes from the same level in the spinal cord that the nerves to the bladder originate, so stimulation could possibly help modulate an overactive bladder. (Similar concept to the Interstim treatment which stimulates at the sacral nerves, but less invasive) Looking forward to what the research shows on this treatment in the future!
  5. Losing weight can help improve bladder symptoms.  This is true for both urge related incontinence and stress incontinence (although, seems to help stress incontinence a bit more). In this particular study, 46% of the participants in the weight loss program achieved more than a 70% reduction in their incontinence symptoms. So, if you are overweight or obese, beginning a weight loss program may be a great first step toward improving your bladder function.

The great news is that we continue to learn more and advance in our understanding of helping men and women with these problems every day! What new research have you seen that is promising? As always, I’d love to hear from you!

**Note: I didn’t include medication in this list… not because I don’t think it’s effective or that the research is exciting, it really is! Mostly, because this is where my search took me this time around. The right medication can be a significant helper to many people having these problems– perhaps a future blog can talk about that! 🙂