Improving Access to Pelvic Floor PT

[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.

[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.