Pelvic floor therapy can remedy a variety of problems

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Muscles in our pelvis may need rehabilitation because of injury or dysfunction. Did you know there's physical therapy designed for the pelvic floor? I'll talk about this with two doctors of physical therapy from Upstate who specialize in pelvic floor disorders. With me are Tania Gardner and Jillian Cardinali. Welcome to The Informed Patient.

Tania Gardner, DPT: Thank you.

Jillian Cardinali, DPT: Thanks. Glad to be here.

Host Amber Smith: Let me start by asking you to define the pelvic floor.

Tania Gardner, DPT: Well, the pelvic floor is a group of muscles in our body that sit in the base of our pelvis. They are unique in the sense that you are familiar with what your biceps are, your quadriceps, are muscles around your body that move your joints and help you move, but they're unique because of their location. They have some specific functions in that they close around our openings. So they help us deal with continence of the bowel and bladder. They are responsible for sexual function, and they also provide support. So they support our pelvic organs -- your bladder, your uterus, your rectum. And also, they work together with the muscles of our abdomen and our spine, and even our diaphragm to give us support and work as part of our core muscles. People talk about core strengthening. So, they make up that inner unit that really is the base of our stability in our body.

Host Amber Smith: And, Dr. Gardner, as you're explaining that, I'm thinking about muscles and how throughout our lives we do exercise to keep our muscles strong. But I don't know that I've ever done pelvic floor exercises. Is that what pelvic floor PT is all about?

Tania Gardner, DPT: It certainly is a large component. And you probably have done pelvic floor exercises without even knowing it. Your pelvic floor muscles are working when you're walking, when you're running, when you're doing strength training. And then there are some specific exercises that we work on, making sure that those muscles can contract and relax and lengthen. People are familiar with the term kegal muscles, or kegal exercises, and that often as what you think of, when you think of pelvic floor exercise.

Host Amber Smith: Well, Dr. Cardinali, let me ask you about the training for physical therapists who want to specialize in pelvic floor disorders. Is this something above and beyond becoming a physical therapist? Is this in addition to?

Jillian Cardinali, DPT: Yes, so, Dr. Gardner and myself actually teach an elective at the PT school. Some physical therapy schools will have somewhat of an introductory of what is pelvic floor physical therapy, but really to be a practicing pelvic floor therapist, these therapists are doing training outside of their doctoral PT degree. This is postdoctoral training. All of the therapists here Upstate have taken our training through Herman and Wallace Pelvic Rehabilitation Institute, which is an Institute that focuses primarily on training therapists and other individuals, including nurse midwives and occupational therapists to treat the pelvic floor. There are multiple institutions, though, that also do this training.

Host Amber Smith: So how would a person know that they need to see a pelvic floor physical therapist? What are some of the common diagnoses that you see?

Jillian Cardinali, DPT: Some of the common diagnoses we see include incontinence. That can be a loss of urinary, bowel, even gas outside of your awareness. It can be difficulty emptying, so it could be difficulty emptying the bowel or bladder, difficulty voiding. We do see patients for any form of pelvic pain. And then we see some more specific patient populations such as, patients who are pregnant or postpartum, and some postoperative patients, so possibly after a prostatectomy or after a prolapse surgery. So those are some of the most common diagnoses we will see.

Tania Gardner, DPT: And also I'd like to add, we do see children or pediatric patients, and those include kids who are sometimes having bed wetting or daytime incontinence, or constipation - those are common diagnoses that we see. Kids sometimes can experience difficulty emptying their bladder. They can, have urinary incontinence or leakage during the day, they can have constipation, they can have fecal incontinence too. Sometimes those issues can arise from pelvic floor dysfunction. So just like with the other providers, usually the pediatrician or pediatric urologist or pediatric gastroenterologist will treat what they can treat and rule out things that are involved. And sometimes they are able to see that, this is a result of pelvic floor dysfunction. So, sometimes they have difficulty relaxing their muscles when they use the bathroom. And so then they aren't able to empty as well. And then they ended up having leakage later in the day. Or, a lot of times, kids are busy and kids are distracted, and they don't want to take the time to go to the bathroom. And because that occurs, their muscles actually will be in a shortened state and less efficient. So, we work on all those things to help them have better control and be more in charge of their bowel and bladder.

Host Amber Smith: It sounds like there's some psychology to this too, kind of mixed in?

Tania Gardner, DPT: Definitely. With, I would say with every population, I mean, because of the location of these muscles and some of their functions, they're not as easily discussed or understood. So there's some barriers sometimes with people seeking treatment because of that. But also, as Dr. Cardinali mentioned, when talking about bowel and bladder habits, a large part of what we do is education and understanding our patients, and making some behavioral changes sometimes can really help to go a long way for them.

Host Amber Smith: Well, Dr. Cardinali, you mentioned pregnancy, postpartum types of things. Do you also see male patients, or is this mostly for females?

Jillian Cardinali, DPT: We absolutely do see male patients. Males can also experience pelvic pain for a variety of reasons. And then, a large patient population that we see for males is males experiencing prostate cancer. So, the research has found that pelvic floor physical therapy is very helpful for those patients, especially if they're going to undergo a prostatectomy, which is the removal of the prostate. So we will see those patients before their surgery, as well as after their surgery to help with some of the symptoms that they might be experiencing due to this diagnosis.

Host Amber Smith: Let's talk a little bit more about which issues might arise in women, during prenatal, when they're pregnant, or after they've delivered. What types of issues are you able to help with physical therapy? Dr. Gardner?

Tania Gardner, DPT: Pregnancy is a really big event in your life. Your body goes through a lot of changes over the course of nine months. Regardless of how the baby comes out in the end, whether it's a vaginal delivery or a cesarean delivery, just the changes in your posture and the way that you move, the way that your muscles are lengthened. Many people go through it without any complication or trouble, but there are patients, too, that experience pain, whether it's pelvic pain, low back pain. In order to accommodate the growing baby, your abdominal muscles have to lengthen and separate. Everybody who has a baby experiences this. And then sometimes after delivery, it can require some specific retraining to help get that stability back, bring things back together. You may have heard of a term called diastasis rectus abdominis. That's a common thing. Sometimes, depending on the way the delivery goes, there can be injury during delivery, vaginal tearing. There can be soft tissue injuries. And a cesarean section is a pretty significant abdominal surgery. So a lot of those patients do well, even just a couple of visits to help them kind of regaining their strength, regain their stability and have the energy and mobility they need to take care of their new little baby at home, too.

Host Amber Smith: This is Upstate The Informed Patient podcast. I'm your host, Amber Smith talking with Tania Gardner and Jillian Cardinali. They're both doctors of physical therapy, and we're talking about PT for the pelvic floor.

Dr. Gardner, is it common for you to see patients who complain of pelvic pain?

Tania Gardner, DPT: Especially in our current situation with a lot more people working from home, there is a lot more time spent on Zoom meetings or phone calls and things, and they're not moving around as much. And sitting can put a lot of pressure on your pelvic floor. In addition to that, I think we're all living in a very high stress environment right now. And when you mentioned that there's some psychology to this, a lot of people, you can see if they're stressed and their shoulders or in their ears, or you might recognize that you clench your jaw when you're really stressed. But so many people are holding their stress in their pelvic floor muscles. So they're having them in a shortened state. They're not really moving. And that can become really uncomfortable. I think we've even seen an increase in some of the referrals that we're getting of patients with pelvic pain, and that is across the board -- male patients with pelvic pain, female patients with pelvic pain, even kids are under a lot of stress. And I think that that plays a big part. So our job is to teach them where these muscles are in their body, teach them what they feel like when they are tightened and clenched, and what they feel like when they move and what they feel like when they relax, so that then they can better recognize when they are in those holding patterns, and kind of move past that pain and introduce some more movement into their day when able.

Host Amber Smith: How long does it take pelvic floor therapy to start making a difference for a patient, Dr. Cardinali?

Jillian Cardinali, DPT: During our initial evaluation, we always try to give our patients something that they can immediately begin to work on. So before they're leaving that first session, it might be something small, like trying to make a different bladder habit a part of their daily lives, or it might be an exercise, or even a stretch that they begin. It's very variable, I suppose I would say as far as the overall duration of therapy. It's quite dependent on how long their symptoms have been going on or if this is something new to them or if it's been going on for quite a while. But I would say we try to make some changes pretty immediately, even if that's small habit changes that can really make a big impact in someone's life.

Host Amber Smith: Are the exercises that a patient learns from therapy, are they going to be things that they can continue to do on their own, even after therapy's done?

Jillian Cardinali, DPT: Absolutely. So I always tell my patients that I try to build them a toolbox. So I want them to have, whether it might be exercises or good habits or something that they can always have to take with them and build on that. So of course, during the course of our treatment, I'm expecting them to make progress with their symptoms, but then they'll also have this toolbox, so that if something else comes up later in their life, they're going to be like, "oh yeah, I remember when I saw that physical therapist, she told me to do this," and they can bring that tool back into their life and begin to do that again. So for some individuals, that might be an exercise such as kegels. For others, it might be more of a stretch or a relaxation technique, maybe some yoga poses, or something that will help them with lengthening their pelvic floor muscles. And then, generally speaking, we do try to teach good bowel and bladder habits, so that I would say as a part of their lives. And hopefully they even share it with their family members and their friends, so we can continue to learn about good pelvic health.

Host Amber Smith: What are good bowel and bladder habits? Are you talking about regularity?

Jillian Cardinali, DPT: Oh, there are so many. So I guess my biggest tip, I would say, for our female population, is that when you're trying to empty your bowel or your bladder to please sit on the toilet. Have your feet firmly planted on the ground. So my tip would be, no hovering. If you're hovering, because you don't want to sit on the toilet, you're going to actually activate, you're going to engage your pelvic floor muscles. And when we empty our bladder or our bowels, we need our pelvic floor muscles to completely relax to allow those processes to happen.

Host Amber Smith: Interesting. That's a helpful tip. Well, Dr. Gardner, let me ask you, is a physician referral needed? Like, how would someone get physical therapy?

Tania Gardner, DPT: So in New York state, physical therapists do have direct access, which means that a patient can be seen by a physical therapist who has at least three years of experience for 30 days or 10 visits without a physician referral. Dr. Cardinali and I both work at Upstate, so we are under that Upstate umbrella, which is regulated by the DNV accrediting body. So, because of our institution, one of the requirements is that we do have a physician referral. And oftentimes these patients, because of the proximity of the pelvic floor muscles to the pelvic organs and some of the sensations that they're feeling, it is a good idea to see your physician first to rule out anything more sinister, to make sure that that pelvic pain really is coming from the pelvic floor muscles rather than something else.

Host Amber Smith: So it might be helpful to bring these issues up with a primary care provider first, and get their assessment of whether they should come for pelvic floor PT?

Tania Gardner, DPT: Absolutely. And oftentimes we find that patients will request pelvic floor physical therapy because they heard about it, that their girlfriend went through it, or their dad went through it after he had a prostatectomy, or they read a blog post on the internet and they heard about it. And most often, the physicians are very supportive and will honor that request, and they're able to just make sure that there's not something else going on. And when patients have their follow-up after having a baby and they follow up with their obstetrician or care provider, they're often able to get that referral then.

Host Amber Smith: Is there a phone number or a website that people can go to to learn more information about pelvic floor PT?

Tania Gardner, DPT: We have our upstate.edu website, and if you search for "pelvic floor physical therapy" on there, you'll be directed to our page. And our main phone number for scheduling appointments is 315-464-6543.

Host Amber Smith: Well, I want to thank both of you for making time for this interview. My guests have been physical therapists, Tania Gardner and Jillian Cardinali. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/Informed. I'm your host, Amber Smith, thanking you for listening.