The Intersection of Orthopedics and Pelvic Health: How My Experience in Both Fields Helps Me Treat Patients Better

Sonali-Patel
Dr. Danielle Santora, PT, DPT, OCS
Intersection of Orthopedics
As a child and an adolescent, if you were to ask me what I wanted to be when I grew up, I would have most definitely
replied by saying a professional student. Seriously. I loved taking notes and studying for exams, and most of all, I
loved learning new information.

Knowing this, it is probably not surprising that I decided to pursue physical therapy after undergrad. Physical therapy
school is usually an additional three years after undergrad, and I was excited to further my education. Once in physical
therapy school, I was most drawn to orthopedics. I liked that it felt like a puzzle. A specific diagnosis could be
driven by various different factors based on the individual, and it was up to the collaborative efforts of the PT and
patient to determine those factors, and come up with a solution. I was certain that this was the field I wanted to
pursue.

I was introduced to the pelvic floor towards the end of physical therapy school, much the same as most physical therapy
students are, which was for a few hours in my “Special Topics” class. It was presented to us as a specialty within
orthopedics. We were taught the most basic concepts, and then told the rest was “to be continued…”. If we wanted to
learn any further, we’d have to take additional courses. My interest was instantly piqued. How could I effectively treat
patients when it appeared that there was vital information regarding the pelvis that might not be readily available to
the average physical therapist?

A good student through-and-through, I decided to begin my professional career in orthopedics, gain more knowledge and
experience, and then take the appropriate courses and find the best mentorship before transitioning to pelvic health. I
will admit, I spent more time in ortho than I had originally intended. There was a lot more to learn than what had been
presented in school and more than that, I was genuinely enjoying myself.

My interest in the pelvic floor was renewed a few years into my practice, following a personal experience with pelvic
floor physical therapy (more on that later). Not only did I want to learn more, but I finally felt ready to apply my
orthopedic knowledge and experience to this new field. I eventually made the transition, and I have not looked back
since. I have learned, and continue to learn, so many new things from my studies, my colleagues, and especially my
patients. I am so grateful that I have found my niche that allows me to fulfill my goal of being a lifelong student.

Now let’s discuss the ways in which my beginnings in orthopedics have shaped the way I practice as a pelvic floor
physical therapist, and how my transition into the world of pelvic health has changed the way I treat currently. I hope
it helps answer questions for practitioners who are thinking of transitioning to pelvic health, as well as for patients
who are curious about what pelvic floor physical therapy entails, and what it can offer them.

Quick disclaimer:The below is my personal experience as both an orthopedic and a pelvic floor physical therapist. Each physical therapist practices differently, and the interventions they employ will vary greatly based on the practitioner, setting, and patient. There is not a correct or incorrect way to practice PT.

What I’ve taken from my orthopedic experience to my pelvic floor practice:

  1. I am still looking at the body in its entirety.
  2. In orthopedics, it is common for PTs to take a “full-body” approach when treating patients, as it is
    well-accepted that dysfunction in one area of the body, may contribute to pain or dysfunction in another area of
    the body. We call this “regional interdependence”. For example, a patient who complains of knee pain when weight
    training may benefit from hip strengthening to improve the dynamic alignment of their lower extremity when
    performing a squat.

    Despite the fact that pelvic floor physical therapists are specialists, the pelvic floor does not function in
    isolation, and we also treat based on the concept of regional interdependence. For example, stiffness in the
    foot can impact a person’s ability to absorb force and subsequently contribute to urinary incontinence. In this
    case, if you were to solely strengthen the pelvic floor, it is likely that the patient would improve, but
    perhaps not enough to return to running.

    Regional interdependence as it relates to the pelvic floor was the final push for me to transition to pelvic
    health. When I sought out pelvic floor PT for complaints of pelvic pain, I was shocked that the therapists I
    worked with suggested I work on upper back mobility and my squat form. As a physical therapist, these were
    deficits I had already identified in myself but had put on the back -burner (PTs admittedly do not always take
    their own advice). This experience helped me to begin to bridge the gap that exists between pelvic floor
    physical therapy and orthopedics. It simultaneously gave me confidence in my already existing knowledge and
    practice, while pushing me to want to learn more.

  3. I am still prescribing both traditional PT exercises and functional exercises when appropriate.
  4. While the pelvic floor has a reputation for being mysterious, it really is just a group of muscles, and the
    normal rules of rehab still apply. Strengthen what is weak, lengthen what is overactive, and train what is
    uncoordinated. Over time, I have found ways to incorporate a lot of the exercises from my previous practice into
    my current treatment plans, although often with a different focus or intention.

    For example, I still use weighted squats and deadlifts to teach lifting mechanics and pressure management to
    people that are postpartum and individuals with pelvic organ prolapse. I frequently incorporate standing rows
    and other exercises traditionally used for posture training into my sessions, as changes in the natural
    curvature of the spine and/or the tilt of the pelvis can contribute to changes in the length and tension of the
    pelvic floor muscles. Additionally, research has shown that improving hip strength can also increase pelvic
    floor muscle strength – so yes, I will still occasionally prescribe clamshells. And these are just a few ways in
    which I have been able to carry over some of my favorite exercises into pelvic health.

  5. I still place great importance on the PT-patient relationship.
  6. Just as important as the education and interventions we provide, is our relationship with the patient. In fact,
    research has shown that a strong physical therapist-patient relationship wherein the patient is an active
    participant in their plan of care, may improve pain levels in those with chronic pain. In both settings I have
    worked in, I have tried to facilitate trusting relationships with my patients by actively listening to their
    stories, providing reassurance and encouragement, collaborating with them to determine which interventions are
    best suited for them, and determining goals that are important to them.

    While this therapeutic alliance is of the utmost importance no matter the physical therapy setting, it is
    especially important in pelvic health, as those who seek out pelvic floor physical therapy often have seen many
    providers in the medical system, and may have long and complicated histories. My time spent in orthopedics
    helped me to build my listening skills and refine the way in which I communicate with patients, giving me the
    confidence to approach more sensitive topics, such as bowel, bladder, and sexual function.

     

    beyondbasics physical therapy

How my practice has changed and evolved since becoming a pelvic floor PT:

  1. I’ve had to look beyond the musculoskeletal system.
  2. In orthopedics, we primarily deal with the musculoskeletal system, which provides our bodies with form,
    stability, and movement. As the name suggests, it is comprised of muscles and the skeleton (including cartilage,
    tendon, ligament, and connective tissue). As I mentioned above, pelvic floor physical therapy is technically an
    extension of orthopedics. As such, pelvic floor physical therapists are proficient at treating all of the
    above-mentioned structures throughout the body, especially at the level of the pelvis. However, based on the
    diagnoses we encounter, we need a working knowledge of additional systems of the body. When I first started to
    treat the pelvic floor, I had to crack open my dusty anatomy books, and re-familiarize myself with different
    organs, functions, and concepts, the most prevalent of which were:

    • The urinary system, as coordination of the pelvic floor muscles is necessary for both urination and urinary
      continence.
    • The gastrointestinal system, and its role in defecation, fecal continence, abdominal pain/bloating, and
      constipation.
    • The reproductive system, as it relates to menstruation, menopause, pregnancy/postpartum states, and sexual
      function.

    Working with multiple systems has allowed me to broaden my approach to care, and to treat in a way that is more
    holistic. Not only am I educating my patients regarding exercise, posture, and body mechanics, but also about
    sleep, diet, nutrition, and stress management. I have a greater working knowledge of medications and their
    effects/side effects, surgeries, and different testing procedures.

  3. I am treating areas I had previously not been qualified (or comfortable enough) to treat
  4. When I decided to transition to pelvic floor physical therapy, I knew that I would quite literally be taking on
    new territory. One of the most obvious ways in which pelvic floor physical therapy differs from traditional
    orthopedic physical therapy is that we have the ability to assess and treat the pelvic floor muscles both
    externally and internally. For those of you who are not familiar with pelvic floor physical therapy, a therapist
    with advanced training can use one gloved finger to assess and [if necessary] treat the pelvic floor. This is
    done only with the patient’s consent. This aspect of care was totally new to me, and I am grateful to the PTs
    who mentored me, to help me develop a gentle touch and a greater sense of confidence when treating such a
    sensitive area.

    To my surprise, another area I found myself regularly treating was the abdomen. Previously, I had thought of the
    abdomen only as it relates to core stability. While I spent a lot of time strengthening my patients’ core, I was
    totally overlooking the mobility of the abdomen. The abdomen is made up of the abdominal wall, and within the
    abdomen are the viscera, or organs. The abdominal wall is composed of skin, muscle, and fascia (connective
    tissue), and the viscera are connected to the abdominal wall and one another via fascial connections.
    Restrictions in the abdomen due to surgery and/or chronic inflammation can affect the organs’ function, the
    muscles’ ability to contract or relax, and even the mechanics of the entire trunk. For example, as the bladder
    fills, it expands into the abdominal cavity, displacing the small intestine. If the small intestine has
    restrictions and is unable to move freely, this may limit the bladder’s ability to fill. In theory, this may be
    a contributing factor to urinary frequency. Additionally, restriction in the small intestine can limit the range
    of motion of our trunk, as the small intestine moves over the top of the bladder during forward bending. While
    the small intestine may not be the first thing I assess when someone complains of difficulty bending over to tie
    their shoes, it is something I definitely keep in mind! And while I do still help patients strengthen their
    abdominals when necessary, I only do so when the abdominal wall is free of restriction.

  5. I have added surprising tools to my PT toolbox.
  6. As mentioned above, I came into pelvic floor physical therapy with a knowledge of muscles and a plethora of
    exercises/stretches to treat those muscles. While I had anticipated adding a few more pelvic-floor-specific
    techniques to my repertoire, I was surprised to find that some of the most useful techniques I learned were
    those geared toward treating the nervous system. In short, if we are in a state of chronic stress due to work,
    finances, or interpersonal relationships, we are frequently activating our sympathetic nervous system (i.e. your
    “flight fight” response). Over time, this frequent activation of our sympathetic nervous system may affect our
    health and our bodies, contributing to pain, and tight and tender muscles. If a person is experiencing pain in a
    particular part of their body, and their nervous system is “up-regulated”, treating the muscles is often not
    enough. This patient’s plan of care must include interventions aimed at “down-regulating” their nervous system.
    Examples of down-regulation techniques include breathing, vagus nerve stimulation, humming, and mindfulness.
    Diaphragmatic breathing is a technique I employ with almost every patient I encounter, and it is an intervention
    I wish I utilized more frequently with patients when I was ortho-based.

    In summary, while there is no “correct” journey to becoming a pelvic floor physical therapist, I am grateful for
    the experiences and knowledge I gained from working in ortho first. It has no doubt shaped who I am as a
    clinician today. That being said, I am equally as grateful to have made the transition to pelvic health. Since
    doing so, I’ve improved my hands-on skills, discovered new interventions, and learned to treat in a more
    holistic way. Every patient teaches me something new, and each day is a learning experience. I look forward to
    continuing my journey as a life-long student, as I continue to add new tools to my PT toolbox.

    REFERNCES:

    Ferreira, P. H., et al. “The Therapeutic Alliance between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain.” Physical Therapy, vol. 93, no. 4, 8 Nov. 2012, pp. 470–478, academic.oup.com/ptj/article/93/4/470/2735348, https://doi.org/10.2522/ptj.20120137.

    Horton, R. “The Anatomy, Biological Plausibility and Efficacy of Visceral Mobilization in the Treatment of Pelvic Floor Dysfunction.” Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, vol. 117, 2015, pp. 5–18, www.hermanwallace.com/images/course_images/vtus/Visceral-Mob_R-C-Horton-2.pdf . Accessed 14 Nov. 2023.

    “Musculoskeletal (Muscles and Skeleton) | Health Effects of Exposure to Substances and Carcinogens | Toxic Substance Portal | ATSDR.”Wwwn.cdc.gov , wwwn.cdc.gov/TSP/substances/ToxOrganListing.aspx?toxid=17.

    Nygaard, I, et al. “Relationship between Foot Flexibility and Urinary Incontinence in Nulliparous Varsity Athletes.” Obstetrics & Gynecology, vol. 87, no. 6, June 1996, pp. 1049–1051, https://doi.org/10.1016/0029-7844(96)00079-8. Accessed
    10 Jan. 2020.

    Raman Uberoi, et al. “Visceral Slide for Intraperitoneal Adhesions? A Prospective Study in 48 Patients with Surgical Correlation.” Journal of Clinical Ultrasound, vol. 23, no. 6, 1 July 1995, pp. 363–366, https://doi.org/10.1002/jcu.1870230606. Accessed 14 Nov. 2023.

    Umesh, Mahantshetty, et al. “Transabdominal Ultrasonography-Defined Optimal and Definitive Bladder-Filling Protocol with Time Trends during Pelvic Radiation for Cervical Cancer.” Technology in Cancer Research & Treatment, vol. 16, no. 6, 22 May 2017, pp. 917–922, https://doi.org/10.1177/1533034617709596.

    Wainner, Robert S., et al. “Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come.” Journal of Orthopaedic & Sports Physical Therapy, vol. 37, no. 11, Nov. 2007, pp. 658–660, https://doi.org/10.2519/jospt.2007.0110. Accessed 28 Apr. 2020.

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