Not Just a Kegel: The Growing Specialty of Women’s Health Physical Therapy
Women’s health physical therapy is a growing field that aims to treat pelvic floor muscle conditions in women
By Christine L. King, PT, DPT
The term “Women’s Health” is commonly used in physical therapy jargon these days. I find many patients asking, “What is Women’s Health?” For most people, the term conjures up images of a group of women exercising in an aerobics class-type of atmosphere with the common goal of preventing injuries and musculoskeletal conditions affecting women, specifically osteoporosis and sarcopenia. Women’s Health physical therapy actually refers to a specialized training and skill set obtained by a physical therapist to evaluate and treat diagnoses involving the infamous pelvic floor muscles.1
Pelvic Floor Muscles
The next question I am usually asked is, “What exactly are the pelvic floor muscles, and what do they do?” The pelvic floor muscles (PFM) are a group of muscles arranged like a sling at the base of the pelvis. Their purpose is to maintain sphincteric control of bowel and bladder continence, support the pelvic organs by keeping them within the pelvic cavity, maintain sexual function including arousal and climax, and assist with providing lumbar and hip stability. The PFMs are comprised of the superficial urogenital diaphragm (bulbocavernosus, ischicavernosus, and superficial transverse perineal), the deep urogenital diaphragm (sphincter urethrae, compressore urethrae, and deep transverse perineal, the levator ani (pubococcygeus and iliococcygeus), coccygeus, obturator internus, and piriformis muscles. Another popular misconception with this muscle group is that the answer to any dysfunction occurring here is to simply “do your Kegels!” A Kegel, or a global PFM contraction, only addresses the strength of this muscle group. It doesn’t address any issues with hypertonicity or poor motor recruitment,
and roughly half of women are still unaware of how to properly isolate the levator ani without getting overflow from the gluteals or hip adductors even after brief verbal instruction.1
Function of Pelvic Floor Muscles
What exactly can go wrong with this muscle group? You name it. The pelvic floor actually has one of the hardest jobs of any muscle group in the body. Unless an individual spends the majority of the day lying down, the pelvic floor is working against gravity all day. The pelvic floor also has the added weight of a woman’s internal reproductive organs, challenging its integrity all day. On top of all of this, the PFMs also co-contract with the transverse abdominis,2 one of the biggest lumbar stabilizers. Just as any other muscle group, the pelvic floor can become restricted and hypertonic or overstretched and hypotonic. In either of these cases, the PFM loses strength, endurance, and coordination. These dysfunctions can be caused by childbirth, sacroiliac joint dysfunction, lumbar dysfunction, falling on the coccyx, repetitive clenching or contracting, trauma, lack of awareness, or general weakness.
Pelvic floor dysfunction can manifest itself with a variety of symptoms. These symptoms include, but are not limited to: stress or urge incontinence, urinary urgency/frequency, difficulty voiding urine, frequent constipation, painful intercourse, internal or external burning, and coccyx pain. The specific diagnoses treated by Women’s Health physical therapists can be found in the table at right.
Origins of Women’s Health Physical Therapy
Women’s Health physical therapy was originally fostered by physical therapists to help women before, during, and after pregnancy with any musculoskeletal issues they may encounter. The Section on Women’s Health of the American Physical Therapy Association (formerly the Section on Obstetrics and Gynecology) was originally founded in 1977 to help clinicians share resources regarding pre- and postpartum patients.1 In the years since then, the scope of practice for Women’s Health physical therapy has grown exponentially. A comprehensive Women’s Health physical therapy program will cover the aforementioned diagnoses, as well as osteoporosis, rehabilitation following breast surgery, lymphedema, and conditions specific to the female athlete.
Growth in the Field
The majority of growth in the field of Women’s Health physical therapy is happening in the private practice setting. Given the sensitive nature of some of the diagnoses within the scope of the practice, many women feel more at ease going to a specialty clinic where clinicians deal primarily with the pelvic floor and related issues. When a standard orthopedic private practice chooses to establish a Women’s Health program, it is essential to have private treatment rooms away from the main gym area so patients feel they are in a safe, clinical environment.
There are multiple reasons the field of Women’s Health physical therapy has had considerable growth in recent years. As the Baby Boomer generation reaches its fifth and sixth generations of life, there is an increased report of stress and urge incontinence from these patients. Literature has been emerging that a 3-month trial of supervised PFM exercises should be the first line of defense for stress or mixed incontinence, rather than opting for surgery right away.3
Each subsequent generation is more open to discussing these seemingly “taboo” issues, with more and more women being open to discussing urinary incontinence, sexual dysfunction, and issues with frequency/urgency. As the field continues to grow and more research supports these interventions, practitioners are more aware of the scope of a Women’s Health physical therapist and which patients would be appropriate to refer. Therapists who do not specialize in Women’s Health, but are familiar with the field, are becoming cognizant about how to identify patients whose low back, hip, or coccyx pain is likely secondary to pelvic floor dysfunction, and can refer the patient to a Women’s Health physical therapy specialist. Many women also make referrals to their friends once they have had relief from their symptoms through physical therapy.
Products and Exercises for Women’s Physical Therapy
Aside from employing a knowledgeable physical therapist trained in pelvic floor evaluation and treatment, there are some products that may help a practice establish a foundation for a Women’s Health physical therapy program. Some clinics may choose to use a biofeedback machine, either internally with a probe or externally with surface electrodes, for neuromuscular re-education to pelvic floor musculature. This can provide patients with visual and tactile cues for the pelvic floor and may be beneficial when patients have difficulty isolating the muscles, or lack the awareness of whether or not these muscles are firing. These machines can also help when patients tend to chronically “over-contact” these muscles by letting the patient know when they have “turned off” the muscles.
Once patients can isolate their pelvic floor muscles without verbal or tactile cueing from the therapist, it is appropriate to progress them to a traditional therapeutic exercise program focusing on the pelvic floor. A good starting point is having the patient in hook-lying because it puts the PFM in a gravity-assisted position. The therapist can then begin to incorporate lower-extremity movements, such as a bridge or hip external rotation, while maintaining a pelvic floor contraction. The next progression is for the patient to be seated on firm surface, such as a therapy mat. A patient can also sit on a therapeutic exercise ball, which would be more of a challenge and can incorporate lower-extremity marches or even
upper-extremity movements using a Thera-band (Hygienic Corporation, Akron, Ohio) or sport cord such as Stretchcordz (NZ Manufacturing, Tallmadge Ohio) for resistance while maintaining a pelvic floor contraction.
A Pilates Reformer is a piece of resistive exercise equipment invented by Joseph Pilates.4 It consists of a platform that moves back and forth along a carriage. Resistance is provided by the exerciser’s body weight and springs attached to the carriage and platform. It can be used to have patients practice functional lower-extremity and upper-extremity movements while maintaining a pelvic floor contraction and a neutral spine for strengthening purposes. Pilates technique and theory emphasizes transverse abdominis recruitment via a neutral spine. Because the transverse abdominis co-contracts with the levator ani, Pilates exercises complements a pelvic floor-centered exercise program. Pilates products are offered by several manufacturers, including Balanced Body, Sacramento, Calif; Merrithew Health & Fitness, Toronto, Ontario, Canada; and PHI Pilates, Pittsburgh.
It is important that the therapist overseeing pelvic floor-specific exercise programs is trained specifically for evaluation and treatment of Women’s Health-specific diagnoses. For physical therapists interested in Women’s Health, the best place to start would be locating a Women’s Health specialist in your area who would be willing to act as a mentor. The Section on Women’s Health1 has a physical therapist locator on its page to assist with this. A specialist in your area will be able to give you a comprehensive overview of their practice. The American Physical Therapy Association5 also has several continuing education courses that can help get you started in the field as well.
Women’s Health is a fast-growing specialty, and there is an impressive market for it within the private practice setting. As the field grows, importance must be placed on patient education regarding specific diagnoses. A comprehensive pelvic floor evaluation will assess for scar tissue, nerve entrapments, muscle tone, strength, coordination, and endurance. A Women’s Health physical therapist will then put together an individualized treatment plan—not just instruct a Kegel. PTP
Christine L. King, PT, DPT, is the women’s health program director at Mariners Physical Therapy, a private practice in Santa Ana, Calif. Ms King graduated with her DPT from Chapman University, Orange, Calif. She practices a hybrid of orthopedic manual therapy and Women’s Health physical therapy. For more information, contact PTPEditor@nullallied360.com
1. Section on Women’s Health website. Available at: http://www.womenshealthapta.org. Accessed February 14, 2013.
2. Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markswell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn. 2001;20(1):31-42.
3. Price N, Dawood R, Jackson SR. Pelvic floor exercise for urinary incontinence: A systematic literature review. Maturitas. 2010;67(4):309-315.
4. Pilates Reformer website. Available at: http://pilatesreformer.com. Accessed February 14, 2013.
5. American Physical Therapy Association website. Available at: http://www.apta.org. Accessed February 14, 2013.