YOUR FIRST APPOINTMENT: PELVIC FLOOR PHYSICAL THERAPY

YOUR FIRST APPOINTMENT: PELVIC FLOOR PHYSICAL THERAPY


– So in one of my other videos I talk about the pelvic floor
structure and function. So go ahead and take a look at that video for more information on this area, and specifically what it does. Right now what I’m going to focus on is what to expect in a
physical therapy evaluation. So this is a wonderful
video for both providers and patients, because
you should really know when you’re coming in to see someone for pelvic floor dysfunction what can you expect in that first visit. So after I take a very detailed history we move onto the physical exam. So this video will focus
specifically on your physical exam. So the pelvic floor, like I talked about in earlier videos, has
to deal with our back. So one of the things
that we want to look at is the bony alignment and
movement of the pelvis, of our sacroilliac joint, or commonly referred to as SI joints. It’s important for a physical therapist to also assess what’s
happening at your lumbar spine, as many of the nerves
that exit the lumbar spine feed into the pelvic floor. I personally like to look all the way up into our second, or
middle part of our spine called the thoracic spine. Oftentimes people can have dysfunction at what’s called the TL junction,
or thoracolumbar junction. So after a thorough assessment occurs in your thoracic, lumbar,
sacroiliac joints, and pelvis, the next thing that’s important
to look at is our hips. So our hip socket is right here. And some of our pelvic floor
muscles are also hip muscles. So seeing what’s occurring at our hip is very, very important. Because the pelvic floor must coordinate with our abdominal muscles. And oftentimes many people who struggle with pelvic floor dysfunction
have abdominal pain, or maybe they’ve had abdominal surgeries. I like to take a thorough
look at all four quadrants that make up our abdomen. It’s good to look for scars,
how those scars might move, if there’s any tenderness,
or I call it stickiness because the scar just doesn’t really want to move equally in all planes. It’s very nice to see if a patient can engage their abdominal core, but also can they relax and
push out with their tummy. So kind of seeing what
is your understanding of this area of your body. Now the thing that I think
patients and providers sometimes get very concerned about is assessing those muscles, specifically the pelvic floor muscles. So first and foremost I
always, always, always get explicit consent from the patient before proceeding with any
part of the examination. I think it’s really important to explain exactly what I will be doing
and where I’ll be touching before and during the exam. If at any point you feel uncomfortable, you’re the captain of the ship and you can tell me to stop. That is completely okay. And we can gather a lot of information of how to treat you with
so much of our exam. But you don’t have to do something that you’re not comfortable with. So for today, I am
going to be using models that are typically assigned to females. I think I’ll have to do a video later on how I would do an
assessment for someone who would have, again,
typically a male pelvic floor. I think it’s important to note that I treat a lot of transgender patients and I’m very confident in
switching the language. However, with the models I have today, they are female oriented. But look forward to more videos that are transgender friendly
and really gender inclusive. So I’m going to go ahead and
switch from my pelvic model to some laminated copies of pelvic floors. So the first thing we want to do is we want to look at what
is the range of motion. So this sheet that we’re
looking at right now is showing our layer one
muscles and layer two muscles. So again, even though I
am showing this right now with a typical female pelvic floor, this is something that we would also do in the male examination as well. So first I want to see, when I ask someone to contract their pelvic floor muscles, if we’re observing this
perineal space right here, does that move up and into their body? Or does it not move at all? Or even worse, does it maybe bear down instead of going up and in? So when I’m documenting
that, I will often say voluntary contraction, and I
might say present or absent. And I might explain how far it goes up into their body, like minimal ascent. This is going to play into what
my palpation reveals for me. The next thing that I’ll go ahead and do is ask them to bear down. So again, we’re looking
at that perineal space and we’re seeing, does
it come out towards me? I should also mention the patient is usually lying on their
back with their legs bent. However, based on what they can tolerate with their spine and comfort level, we can do this in a side lying position, which is also really, really nice. The next thing I look at, is
there involuntary contractions? So when they cough, do I
see these muscles contract right before that cough? Lastly, I ask them to take
a nice diaphragmatic breath to see, does that pelvic
floor move down and descend. So that’s looking at our range of motion. Next I like to look at
sensation and sensory awareness. So here we have the dermatomes that make up the pelvic floor. So one of the things
that’s important to note is the nerves that come
out of our lumbar spine, and even down lower in our sacral spine, feed into this area of our body. So I want to test, does someone have equal sensation from side to side? Maybe the reason why they’re dealing with some pelvic floor issues isn’t necessarily because
the muscles are affected. Maybe it’s something in the back. So I will go through and do light touch through these different areas. And then I also like to
do the anal wink reflex. So you might find as a patient that your provider takes
the end of a cotton swab and just runs it right next to the rectum to see that contraction. So after we have done the
sensation and range of motion, now I like to move onto the
palpation portion of things. So I’m going to move back to this model. When we’re doing the
palpation we want to make sure that we’re checking
those inner thigh muscles as they attach right here. I like to follow that all the way up and into our common hip flexor tendon. We can come down to our sitz bone and assess and palpate
through our hamstrings and gluteus maximus muscles. So again, from a patient perspective you really want to make sure
that your physical therapist isn’t just going straight
to your pelvic floor because there are so many other areas that can feed into what
you’re experiencing here, whether that’s pain,
whether that’s leakage, whether you’re having
abdominal discomfort. All of these things need to be looked at from a global perspective. So after we assess through the legs, then I go ahead and
start to actually palpate those pelvic floor muscles. So I was taught in a clock pattern. So I usually always start
on the patient’s left if I’m standing on their right side. And I will push through
these different muscles gently as if I’m trying to
appreciate around my eyeball. So it’s just enough to kind of change the color of your fingernail. What we’re trying to see when
we’re pushing on these muscles is what is the tone of that muscle? Is it super tight? Does it really not have
a lot of muscle bulk? Is it equal from right to left? So we push on these different areas, also communicating with
our patient to see, does this illicit their pain? That’s the important thing. Can I reproduce their pain? After I go ahead and do this externally, then again, if the
patient gives me consent I can move to my internal palpation. So these 26 muscles are kind
of like in a level form. So the most superficial or closest to the surface is layer one. Layer two is about at my second knuckle. And layer three is about
at my third knuckle. So I go ahead and I will separate labia. This is a great opportunity for me to check the skin of this area. And I might even take
a Q-tip before I enter and place to see if that
causes any discomfort. Then I go ahead and I reassess
those layer one muscles, again checking each single one to see, does it reproduce their pain, do I feel any increased resting tone, or is there a lack of muscle bulk? After checking layer one, I go ahead and move on to layer two. So I’m going to show you
a different picture here to kind of give you a
different perspective. So here, this picture, which is lovely, shows on this side layer one. You can see the muscles
here as well as this fascia, or covering that goes around the muscles but also can go in between the muscles. So we see this here. And then on this side we’re
seeing layer two muscles as well as the clitoris. So many people think that the clitoris is just that one part that we can see. Actually, the legs of the clitoris go down our bone right here. And we have some muscle
that lays over them. So it’s good to know, are
these muscles tight and tender, because that might be one of the reasons why you’re having pain with intercourse of maybe difficult with arousal or orgasm. So layer two, which
you can see right here, again is about at the second knuckle. Whereas layer one is about
at this first knuckle. So after assessing layer two then I go ahead and move onto layer three. So I’m going to move to
a different picture here, which is really, really nice because it switches to an inside view. So now it’s as if I’ve
removed all of our organs and we’re looking at this pelvic floor straight into the bowl. So you can see here we have
our layer three muscles, again about at my third knuckle. I like to describe it from
a provider perspective as layers one and two as like I’m moving up the stem of a wine glass. And layer three I’ve
fallen into the wine glass. So this layer three is a nice bowl where a lot of our organs sit on top of. So it’s a great support
structure for our spine but also to support those organs. So here I’m pushing at
all of these muscles, which are commonly referred to as the levator ani muscle group. And also through here,
our obturator internus. I think it’s really
important as a provider and also as a patient, when
they’re pushing on these muscles to follow them all the way up and around to where they attach onto
the front of our pubic bone, to really get a sense of that
entire muscle body and bulk. Oftentimes, depending on the length of your examination finger and
the patient’s body habitus, you can sometimes assess the tailbone, or as those muscles
come into the tailbone. If there’s no pain or tenderness,
I will do a strength test. But it’s very important
to note that in order to strength test these muscles we need to have full range of motion. If someone has muscle spasm through here we need to first work on
relaxing, not on strengthening. So if this person has full pelvic floor range of motion and no tenderness, I will go ahead and do
a muscle assessment. With this I’m seeing, can
they squeeze around my finger? And oftentimes, and what
you should feel, is a lift. So I ask someone to
squeeze around my finger. I might use cueing like,
stop the flow of urine, don’t pass gas, close the
vagina, whatever works for them. And then when they do that I’ll see, how long can you hold that contraction? So I am usually looking at a clock to see, can they hold it for 10 seconds? Can they hold that same grade and level? And their breathing, what
is their effort level look like on their face? Then I ask them to relax. I’m assessing their ability to relax, how quickly they can do that. And then next I’ll ask them
to do quick contractions, which I really find is less about strength and is more about coordination. So again, I’m watching a clock
to see how many contractions can you do in 10 seconds. From there we really can
gather a clear picture of what is going on with
someone’s pelvic floor. So after taking my
comprehensive verbal history, then really looking at them globally from this entire canister, hips, pelvis, and then lastly taking into consideration what’s occurring at that pelvic floor, we can then paint a
picture for the patient of what do expect for their
plan of care moving forward. So thank you for listening to this video. Please refer to my other videos of what the functions
are of the pelvic floor. I know this was a lot of information, but I hope it’s helpful.

One Reply to “YOUR FIRST APPOINTMENT: PELVIC FLOOR PHYSICAL THERAPY”

Leave a Reply

Your email address will not be published. Required fields are marked *