An Occupational Therapist’s Journey Into Pelvic Health

bladder hysterectomy mfr occupational therapy pelvic health postpartum pregnancy prolapse women's health Sep 30, 2019

The Story

It was a snowy, winter evening in Minnesota, the nights when we’d hunker down with friends for games and fellowship. With snow-laden boots, I ventured to the basement on the wooden staircase, when my feet swiftly slid out from under me descending step by step on my tailbone. I had never experienced anything so excruciating. Many health care providers checked me out with no relief. I could not sit normally for years, always slightly cock-eyed to one side. The thought of having to poop nearly brought me to tears. Time passed, the future of kids was nearing, but the thought of delivering a human was even more daunting.

I had been a JFB Myofascial Release Practitioner for a few years and had knowledge of the women’s health treatment within this approach. I knew I had to do something, so decided to trek to Sedona, Arizona for a week of treatment at Therapy on the Rocks with John and his talented staff. This is where my journey into holistic women’s health began. I came home from Sedona pain-free. It was not easy, but a journey within, literally!

It wasn’t a passion of mine to work in women’s health until I experienced life-changing treatment after an unfortunate event. I knew there were many women who needed the same relief I had been so desperately seeking. I took my first women’s health seminar when I was 16 weeks pregnant with my third child. And I’m so glad I did! The need for personal intervention continued after 3 pregnancies, 2 cesarean sections, bladder prolapse, and a partial hysterectomy.

I have been an Occupational Therapist in various settings and management for 19 years. The field of Occupational Therapy was chosen due to my fascination with the mind-body connection. I am a graduate of the School of Medicine and Health Sciences at the University of North Dakota. I discovered my calling in 2004 when I began my holistic therapy journey with John F. Barnes and his Myofascial Release approach. My empathy for women suffering from pelvic health disorders led me to expand my holistic practice into women’s health in 2010. This included board certification in Pelvic Muscle Dysfunction from the Biofeedback Certification International Alliance (BCIA). In the spring of 2018, I opened a private practice in Detroit Lakes, Minnesota. My practice dedicated to empowering women to overcome pain, movement limitations, and women’s health concerns. All of this done holistically, bringing joy and confidence back to their life.

The Dysfunction

Pelvic floor dysfunction is an all-encompassing term for disorders and dysfunctions relating to the lumbopelvic region. The term describes a group of clinical conditions including sexual dysfunction, elimination problems, incontinence, pelvic pain, and pelvic organ prolapse.

Urinary issues may include leaking, urgency, frequency, hesitancy and retention. Bowel issues include constipation, incontinence, and rectal pain. Sexual dysfunction may include dyspareunia, vestibular pain, and vaginismus in women, and erectile dysfunction or perineal pain in men. Even persistent hip and low back pain can trace back to pelvic floor dysfunction. Pelvic organ prolapse (POP) is another common condition that can be challenging for women. This occurs when the pelvic organs, descend from their normal position and bulge into the vaginal wall. POP is not only common among postpartum women, but also nulliparous athletes. Pelvic floor dysfunctions do not discriminate by age, gender, or health status.

Symptoms of pelvic floor dysfunction may occur due to postural and pressure imbalances, decreased strength or elevated tension of the pelvic floor muscles, muscle incoordination, decreased muscle endurance, fascial restrictions, muscle spasms, and joint impairments of the spine, pelvis, or hips.

The impact

Individuals with pelvic floor dysfunction within the United States is on the rise. This not only creates billions of dollars in direct medical costs annually, but profoundly impacts the daily activities that give life meaning. This can’t be measured in terms of dollars. Due to the personal nature of these problems, many people are too embarrassed by their symptoms and fail to seek help. Impairments in bowel, bladder, and urogenital function can result in depression, loss of self-esteem, and create difficulty maintaining a healthy lifestyle and fulfilling relationships. Activities outside of the home, social interaction, and sexual activity may be avoided entirely.

Treatment for incontinence and pelvic floor disorders includes surgery, pharmacology, and behavioral interventions. Surgical and pharmacological treatment are most familiar to providers and clients. According to Neumann, Tries, and Plummer, published medical guidelines have advised using conservative treatment before surgery. These behavioral techniques include but are not limited to: scheduled toileting, habit training, bowel and bladder retraining, dietary and fluid modification, and pelvic floor muscle training. The use of behavioral techniques has given rise to rehabilitation services aimed to improve pelvic floor disorders. Individuals need to be educated that there are options other than pads, medications, and surgery.

The OT Role

Occupational Therapists are currently underrepresented in the field of pelvic floor rehabilitation, yet are the most uniquely suited due to their comprehensive approach. The holistic approach looks beyond the neuromusculoskeletal concerns and recognizes performance patterns such as environmental and habitual barriers. In addition, OTs have the background to address and support the psychosocial distress related to the disorders, such as depression, social anxiety, and fear.

Occupational Therapy (OT) is a holistic profession that focuses on human occupation, helping clients improve their ability to engage, initiate and execute meaningful tasks. This intimate approach is especially helpful in treating pelvic floor dysfunction, which affects the urinary, bowel, sexual and physiological structures. Pelvic floor dysfunction impacts client occupations including toileting, sleep, sexual relationships, social engagement, and psychological and physical well being.

According to the Occupational Therapy Practice Framework (OTPF): Domain and Process, 3rd ed., (Framework-III], AOTA, 2014) “Occupational Therapists (OTs) can be involved in numerous aspects of pelvic floor rehabilitation that impact our activities of daily living such as toileting, rest, sleep, and sexual activity.

The Conservative Intervention

All occupational therapy practitioners have the education and clinical skills to provide basic intervention for incontinence. Traditional pelvic floor rehabilitation and incontinence intervention may include pelvic floor muscle exercises, self-regulation techniques, progressive muscle relaxation, behavioral modifications (scheduled toileting, habit training, bowel and bladder retraining, dietary and fluid modification), mindfulness education, environmental modifications and adaptive equipment/techniques and education/caregiver training.

The evaluation process consists of generating the occupational profile of the client. This will review the client's occupational history and experiences, prior level of function and patterns of daily living, interests, values, and needs, creating an understanding of their lifestyle and occupations that are most affected by their current condition. Basic intervention assesses and trains deficits in functional self-care skills. This may include clothing management or the skill component of grip-and-pinch strength.

Next, a functional assessment of bowel, bladder and sexual function is completed. It’s important to provide ample time and an environment that promotes privacy and trust as clients disclose very personal information during the assessment. This information is obtained through client voiding diaries, analysis of habits, routines, behaviors, and activities associated with the problem. Treatment plans are client-centered and the recommendations and interventions are transferred functionally into the client's everyday occupations. Treatment planning takes into account what the client wants the most improving their functional well-being and occupation.

The Specialized Intervention

Therapists may deliver advanced intervention for incontinence and pelvic floor disorders by pursuing further education and competence in the urinary, digestive, and reproductive systems and administration of specific assessments (including internal and external pelvic floor exams, pelvic floor manual muscle testing), and treatment to the pelvic floor muscle dysfunction. Competency can be obtained through continuing education, comprehensive clinical training with qualified mentors, or certification through an accredited training program.

In addition to the above assessments and interventions, occupational therapists with advanced training may provide a comprehensive pelvic floor muscle assessment. The neuromusculoskeletal assessment may include pelvic floor muscle tone, isolation, and coordination. This may be completed via a standardized digital exam of vagina or anus and/or pelvic floor muscle electromyography (biofeedback) using vaginal or anal sensors. Palpation of the pelvic floor to assess soft tissue mobility and pain may also be performed. Advanced interventions may include pelvic floor muscle re-education involving biofeedback and pelvic floor muscle stimulation to improve strength, endurance, train functional relaxation and coordination, and teach inhibition of maladaptive motor responses. Advanced interventions may also include manual therapy techniques, visceral manipulation, and desensitization techniques when pain or soft tissue restriction impairs bowel, bladder, or sexual function.

The Opportunity

Incontinence and pelvic floor disorders are common problems that significantly affect an individual's ability to function in daily life. Occupational therapy practitioners are educated to address intimate self-care skills. Further education is recommended to be a competent pelvic floor therapist, even though a certification is not required at this time. Currently, there are three recognized certifications available to support competency in treating pelvic floor dysfunction for Occupational Therapists.

Herman and Wallace: The Pelvic Rehabilitation Practitioner Certification (PRPC)
- http://hermanwallace.com
Biofeedback Certification International Alliance (BCIA): Pelvic Muscle Dysfunction Certification (BCB-PMDB)
- www.bcia.org
Evidence in Motion
- www.evidenceinmotion.com

There are other certifications related to the pelvic floor as well as additional education options available that do not have a certification yet offer valuable knowledge in this field. Occupational therapy practitioners are required to abide by state laws/practice acts and other regulatory requirements to determine the scope of practice.

The treatment of incontinence and pelvic floor disorders is an effective area of rehabilitation that is underdeveloped in the area of occupational therapy. This area of practice holds great potential and rewards for professional growth, but more importantly, the potential to affect many individuals who are suffering.

I hope you feel more informed about the relationship between OT and pelvic floor rehabilitation and the options for further exploration in this field. If you have questions please contact me at [email protected].

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-----THIS INFORMATION IS NOT A SUBSTITUTE FOR, NOR DOES IT REPLACE, PERSONALIZED MEDICAL ADVICE, DIAGNOSIS, OR TREATMENT. IF YOU HAVE ANY CONCERNS OR QUESTIONS ABOUT YOUR HEALTH, YOU SHOULD ALWAYS CONSULT WITH A HEALTH-CARE PROFESSIONAL. THE USE OF ANY INFORMATION PROVIDED IS SOLELY AT YOUR OWN RISK. -----