top of page

BackTable / OBGYN / Article

Improving Access to Pelvic Floor PT

Author Dana Schmitz covers Improving Access to Pelvic Floor PT on BackTable OBGYN

Dana Schmitz • Aug 16, 2023 • 36 hits

Pelvic floor physical therapy (PT) is more than just targeted exercises; it's a multifaceted and interdisciplinary practice that can significantly impact patient recovery. The lack of immediate access to pelvic floor PT, resulting in long wait times, reveals an essential area of need in patient care. A collaborative approach, coupled with patient empowerment and resources to locate trained pelvic floor PTs, builds a comprehensive framework that goes beyond mere symptom treatment.

Pelvic floor physical therapist Ingrid Harm-Ernandes shares her experiences with improving access to pelvic floor PT and working with a multidisciplinary team to manage pelvic health issues. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable OBGYN Brief

• Long wait times highlight access challenges and the immediate need for more pelvic floor PT availability.

• Effective treatment of pelvic floor conditions often requires interdisciplinary coordination throughout several fields, including gynecology, urogynecology, orthopedics, and sex therapy.

• Pelvic floor PT is more than Kegels and incontinence treatment; it's a comprehensive program that can address a wide range of ages and issues.

• Treatment options are diverse and individualized, and may include work on musculature, fascia, guidance through painful experiences, and psychological barriers like fear.

Improving Access to Pelvic Floor PT

Table of Contents

(1) Access to Pelvic Floor PT: Multidisciplinary Collaboration

(2) Managing Pelvic Health: From Self-Care Techniques to Specialist Referrals

(3) Redefining Perceptions of Pelvic Floor PT

(4) Improving Access to Pelvic Floor PT: Global Comparisons & Advocating For More Frequent Referrals

Access to Pelvic Floor PT: Multidisciplinary Collaboration

A multidisciplinary approach in the management of pelvic health issues is important. A patient may present with diverse symptoms, highlighting the essential role of team-based care in addressing the symptoms comprehensively. Multiple dimensions of a patient’s health must be considered, from physical to emotional, and from musculoskeletal issues to sexual health concerns. The patient is an integral part of this team, and should share responsibility for their care. This team-based approach can dramatically improve patient outcomes by addressing the multifaceted nature of pelvic health issues.

[Dr. Amy Park]
I just am thinking of all the times that I've sent patients to pelvic floor PT. There's really an access issue, to be honest, because once you identify it, then I know now I'm referring patients since May and there's a three-month wait. They can't get in until August, so they have to put themselves on a waitlist, so it's actually very frustrating for the patients as well. Can you also just, you alluded to this earlier, but just tell me why is teamwork so invaluable in pelvic care?

[Ingrid Harm-Ernandes]
I think that particularly for pelvic care, because there are so many subsets of things that can go on, so before we talked about, I've had a patient come in and a pelvic floor, I've incontinence and I find there's a hip issue. For some of my folks, they're okay with talking about the fact that they have incontinence, but when I go through their subjective history, I find out that they have pain with sex because I ask all my patients about abuse history. I ask them about pain with sex. I ask them what causes the pain. I get real specific and nitty gritty and they realize it's okay for this person to be asking me about this. To her, it's perfectly normal. It's part of what she does.

If I can get all of that information, then I realize, well, we may be able to work on the musculature. I may be able to stretch things. I may be able to get the fascia to work. I may be able to guide them through getting, through trying intercourse again, when they're so fearful, they want nothing to do with having any kind of intercourse because of the pain, right? That cycles with low libido because your brain is saying I'm never doing that again, it was painful. What we then sometimes have to say is, well, we might have to pull a sex therapist in. We might have to pull an orthopedist in. I might have to get them to go to gynecology or urogynecology because they've never been.

They've found me through someone else and I have to say, you know, I think we need to look at this a little more deeply. You might need imaging. You might need things that just give us a much clearer picture of what's going on. I've had folks with endometriosis that come to me and I'm like, I think it's time to go back. I think, you know, whether an endocrinologist or it's a gynecologist, I think you need that extra piece of the puzzle so we treat you as a whole. I think for all of us, everybody in, especially for pelvic pain, we can't possibly feel like we can address this as an individual.

I have a lot of people, a lot of practitioners come up to me and say, oh, I don't know if I can do pelvic pain. It's so exhausting. I say, well, are you trying to do it yourself? You shouldn't be. Call on other practitioners to form the team. Empower your patient to ask for care, acupuncture, massage therapy, chiropractic. I have had so many practitioners at my fingertips that I feel very comfortable reaching out and saying, you know, this is what's going on with my patient. I really think I can't go alone with this. What do you think? Once you form that team, you don't have to be an Allwood Center.

Although I was at Duke, I had practitioners all through our triangle area, and I felt like my knowledge base was so enriched that if I did courses, I asked and reached out to these people to do the courses with me so that the PT sitting in the audience, the MD sitting in the audience, the nurses had this really comprehensive panel of people in front of them, and you could see them say, wow, why was I trying to do this on my own? A team is what we need, and the patient is part of that team. I make the patient understand they're just as responsible for their care and doing the things that they should do as every other practitioner on their team. Once we talk about that team, the situation usually changes dramatically and the care and the rate at which the patient gets better improves dramatically.

[Dr. Amy Park]
That's awesome. Well, how can people find these trained pelvic floor PTs?

[Ingrid Harm-Ernandes]
There is a, our national organization, the APTA is one way, and you can go on and there's the Academy of Pelvic Health. There's a little tab on the top that says PT Locator or PT Finder. If they click on that, if you're a practitioner, you can do the same thing. Usually what it says, put your zip code in and then put a radius of where you're willing to travel or look for a PT, 25, 50, 100 miles, whatever it happens to be. What will come up is an entire group of pelvic PTs who might have the whole alphabet after their name, or they might not.

A lot of private practitioners, it's very expensive to do this coursework and to do the certification, so they may have the coursework but they don't have all the certification. I tell my practitioners, pick up the phone, call them, ask them some of the questions about doing internal work, biofeedback, manual work. If they're all excited and they can explain it all to you and they're really into it, you've got someone who really specializes in it, and a patient can do the same thing.

I've had patients call me and just say, what do you do? I'm really not sure. Before I come in, I would feel better if you could just explain some things, so I will do that. I've done that over the years and I find that it just breaks that wall down and then the patient feels a lot more comfortable seeing the pelvic PT. The more you have some pelvic PTs at your disposal, the more we get the message out, the more pelvic PTs there will be. We're really working on getting more pelvic PTs out there. It's just, you know, now that people know about it, the growth of the pelvic PTs is lagging a little bit, but it's getting there and it will get better and I think we'll finally hit this nice even point where patients will have access much quicker than they do now, but it's all in the works and it's all getting better.

Listen to the Full Podcast

Pelvic Floor Physical Therapy with Ingrid Harm-Ernandes, PT on the BackTable OBGYN Podcast)
Ep 28 Pelvic Floor Physical Therapy with Ingrid Harm-Ernandes, PT
00:00 / 01:04

Earn CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.

BackTable CMEfy button

Stay Up To Date

Follow:

Subscribe:

Sign Up:

Managing Pelvic Health: From Self-Care Techniques to Specialist Referrals

Self-care techniques and professional support for managing pelvic health provide a balance for improving patient symptoms. Abundant resources are available to individuals seeking to understand and manage their pelvic health, including books, online platforms, and social media accounts. While attempting self-care techniques for pain or difficult pelvic floor symptoms, it is important for patients to seek professional assistance. Pelvic floor physical therapy is a highly specialized field, with practitioners undergoing rigorous training.

[Dr. Amy Park]
What are some techniques that people can access on their own versus with the guidance of a pelvic floor physical therapist? I mean, I know my bias is referral to pelvic floor PT, but a lot of people for their incontinence have already figured out the NAC and some other techniques on their own. Are there, I mean, it looks like you have a YouTube channel. I've seen people on social media. I think one is called the Vagina Whisperer. [chuckles] I'm just curious what your thoughts are.

[Ingrid Harm-Ernandes]
Yes. There are some good resources out there for sure. I'll say my book is the first thing because that is that comprehensive, you know, covers everything and it has that self-care at the end. You would understand how to do a pelvic floor contraction, a relaxation, if it's okay for you to do it, if it's not okay. One thing I'll say for everybody, if you try this stuff on the internet and you're having, as a patient, you're having pain or you're having difficulty, that is the sign you need to go to pelvic PT. I just, as a warning, I say to everybody, you can try the wonderful things, but if you're struggling and you're having pain, go to pelvic PT, because it really means that what you're trying could make the symptoms worse and we definitely don't want that, so that's super important.

On my YouTube channel, it's called The Pelvic Detective, and I have a few out there right now that go through some of the things we just talked about that kind of guide and is a good resource for patients as well. There are some nice resources I'll say through AUGS. The American Urogynecological Society has the pelvic floor, the PFD for Voices, and there are some great resources out there that are patient-centered, so a patient can go on the website and get it. I find that's a nice starting point for a lot of people.

There is, so there's the Pelvic Guru. She does a lot, a lot of stuff for both practitioners and for patients. She's on Instagram and Facebook and LinkedIn, all sorts of things. On LinkedIn, I post about once a month, so I don't do a lot, but I post things that have to do with that month so that it gives research-based information to people, so it's good for practitioners and patients as well. Those are some starter things. Then Herman and Wallace has some patient-centered information, and our APTA, the Academy of Pelvic Health, also has some reputable resources there. I would start with those reputable resources because I know for sure they've got research-backed, evidence-based information, and you're not saying, well, I'm not so sure about this.

[Dr. Amy Park]
Awesome. Well, that's, I think, really helpful, and I think just getting the awareness out, but also just increasing the supply, it is hard to get all that extra training. I know the PT training baseline is so rigorous, and then having to get another level of it really means that the pelvic floor PTs in the field are passionate about pelvic health and helping the patients in that realm. Because it is still considered somewhat niche, I would just say, even though that's my niche and I know about it, but like you're saying, a lot of people don't.

Redefining Perceptions of Pelvic Floor PT

Pelvic floor PT caters to a diverse age group, each with a unique set of needs. Treatment plans are tailored to the individual and can involve a mix of relaxation, strength training, core work, biofeedback, and manual techniques. Some patients require hip mobilization to manage challenges during pregnancy and childbirth. Increased awareness about the broad scope of pelvic floor PT to help alleviate symptoms that many assume they have to live with is needed. Early intervention is crucial; educating young adults about pelvic health could help prevent issues later in life.

[Dr. Amy Park]
What are some conceptions that people have about pelvic floor PT, and what is the reality?

[Ingrid Harm-Ernandes]
People tend to think that we just give out a bunch of Kegels, so we really have to work hard at dispelling the myth that all we do is treat incontinence, we treat old people. People don't even look at pregnancy in the fourth trimester, yet the fourth trimester has so many similarities with menopause. There are things that we need to do a good job getting out there and saying, look, we can treat an 18-year-old, we can treat a 90-year-old. I've had 95-year-olds who do so well at PT, they're so dedicated to it, and so we can change it at any age, is kind of what I'm saying with that, so it's another myth to dispel.

We do so much more of a comprehensive program that may or may not include pelvic floor. For me, most everybody had some kind of pelvic floor program, but it might have been very relaxation and down training centered rather than up training and strength training until they could tolerate it. Core work was always part of it, biofeedback was often part of it, manual techniques where I would get in there and I'd do what's called hip mobilization where they had such restriction at their hips. I had patients who were afraid to give birth because they couldn't open their legs up, and I had to do mobilization and work on their adductors, their inner thigh, in order to get them to open their legs to give birth.

It's that extensive and that varied that we treat, so I think we have to get the message out that it is extensive, it's wide-ranging, it's all genders. We do so many different things that if we can get that message out that if you've got a pelvic floor and a pelvis, and even some of these symptoms that people think are okay to live with, that pelvic PT often is the answer.

I feel like if we had every 18-year-old through the door to set them up with some basic knowledge, to begin with, we probably would have less problems later in life, but that does not happen, and I don't know if it ever will.

Improving Access to Pelvic Floor PT: Global Comparisons & Advocating For More Frequent Referrals

Pelvic floor physical therapy accessibility and recognition differs in the United States versus other countries. In places like Europe, pelvic floor PT is a standard part of maternity care, and if requested, patients are promptly referred. However, access and session limitations can still be a challenge in these regions. By comparison, the US is still struggling to achieve this level of integration in maternity care. Interdisciplinary collaboration is vital in this endeavor, with referrals coming from urogynecologists, OBGYNs, physiatrists, family medicine practitioners, dermatologists, and gastroenterologists. While there is importance in patient self-advocacy to access care, better education needs to be provided to healthcare providers about the scope of pelvic floor PT.

[Ingrid Harm-Ernandes]
I'm certainly hoping that pregnancy and fourth trimester get an immediate attention and care like it does in Europe and it does around the world. We're a little lagging in that, and I really wish that would change. We're working on legislation that will change that presently that will improve that.

[Dr. Amy Park]
Well, you brought up a really good point. Can you compare the US systems and access to other countries where pelvic floor PT is more accessible? Like I've heard some places it's just part of maternity care.

[Ingrid Harm-Ernandes]
Yes, so it is part of maternity care. If you have symptoms and you ask for pelvic PT, you're immediately referred. There is no ifs, ands, or buts about it. I recently talked to someone in Sweden, and there is sometimes some limitation in that they may be referred, but then they don't necessarily have access or they have very limited visits. There's, I think, around the world, everybody's got their issues associated with it, but I do think that here in the United States, it's not recognized as something automatic.

At Duke, what we did, and that's really, I have to say thanks to our urogyne fellows who worked so hard to get every person who has a third or fourth-degree laceration has an immediate referral to pelvic PT so we can really catch things before oasis injuries really become a huge issue. It's such a refreshing thing to see someone where we can immediately get in there, do a few treatments, and really help them so it doesn't become a long, extensive process. We catch things early and hopefully prevent things later in their life as well. Those are things that are changing. There are some of our larger organizations through the United States are starting to recognize that and doing that, so I think we're getting better at it, but we really, really, really need to work on getting that information out there and changing that.

[Dr. Amy Park]
Oasis, meaning the obstetric anal sphincter injury, correct?

[Ingrid Harm-Ernandes]
Yes.

[Dr. Amy Park]
It sounds like you've been collaborating with your gynecologists. How about the urologists? Do they also refer or primary care? Where are you getting most of your referrals from?

[Ingrid Harm-Ernandes]
Yes, that's great. Urogynecologists and OBGYNs are our biggest. I have physiatrists, Family med, dermatology, GI. It's a pretty broad spectrum who will refer, with that biggest group, like I said, being urogyne and OBGYN. It's funny you say that. In two weeks, I'm actually going to do a presentation for our Family med group because they know about it, but they feel like they don't know enough. I'm going to go through the process of what we do and what we treat so that they feel more comfortable referring.

I've talked to urgent care groups because although they won't necessarily, while that person is in that urgent need, they recognize it and they can at least say, you know, I think when you're over this urgent need of whatever the problem is, I think pelvic PT might be an answer for you. They're actually introducing, I know that sounds wild. That's very recent, but because I've gone out and talked to people, I've changed people's entire thought process.

I work with our pain group. That's been a big one. I've done some presentations for pain societies because they, although they know there are all these different wonderful things they can do, the pelvic floor somehow seems to be left out of that. Just getting them to open their eyes to pelvic floor and the link to backs and hips and knees and everything else we talked about. I'd say eventually, we'll have a much broader spectrum of physicians that are referring to us, but it will take that teamwork and really talking to everybody before that happens.

[Dr. Amy Park]
Wow. I just, I think that the Duke team is so lucky to have you, but also just getting the word out there for the patients to self-refer as well so they can be empowered to go to their NP or MD or DO or whoever they're seeing in the office to say, you know, I heard about this pelvic floor PT, I'd like to go. I think pretty much everyone would be like, oh yes, PT, no problem, but like you said, not a lot of people know about it. I think urologists, I thought, I thought that they would refer too because there's a lot of people with the perineal pain, right?

[Ingrid Harm-Ernandes]
They do. They do refer. I think it depends on the group sometimes and their whole thought process. I have some urologists that are, you know, jumping up and down and excited about pelvic PT and other are a little resistant. I think over time that will change. I think once they understand how much we can help patients, that will change, but that's kind of been for me, you know, my history because I started so long ago, I have to say that my first couple of physicians that I reached out to explain what I do, looked at me like I had lobsters crawling out of my ears and like you what? What do you do? Once they refer the patients, they could see the change.

I feel like when I approach new groups or groups that aren't used to it, it's that same kind of lobsters crawling out of my ears, but because they may have heard a little bit, the thought process changes a little quicker and we get people on board a little quicker. That's been an awesome change that I just have been so honored to see, a change in my career of total, what are you talking about, to, yes, that makes sense.

Podcast Contributors

Ingrid Harm-Ernandes, PT discusses Pelvic Floor Physical Therapy on the BackTable 28 Podcast

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 discusses Pelvic Floor Physical Therapy on the BackTable 28 Podcast

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.

backtable-earn-free-cme.jpg
backtable-plus-vi-cta.jpg

Podcasts

Pelvic Floor Physical Therapy with Ingrid Harm-Ernandes, PT on the BackTable OBGYN Podcast)

Articles

vNOTES Surgery: Understanding & Applying the vNOTES Technique

vNOTES Surgery: Understanding & Applying the vNOTES Technique

Pelvic Floor Physical Therapy in Practice: Awareness, Assessment & Anatomy

Pelvic Floor Physical Therapy in Practice

Topics

Get in touch!

We want to hear from you. Let us know if you’re interested in partnering with BackTable as a Podcast guest, a sponsor, or as a member of the BackTable Team.

Select which show(s) you would like to subscribe to:

Thanks! Message sent.

bottom of page