What the Health: Pelvic health PT
One thing I love about the field of physical therapy is that there are so many areas one can focus on and specialize in. I chose travel therapy because I wasn’t sure what setting I wanted to be in, but I didn’t even think of all the areas I could potentially specialize in as well! I have heard about pelvic health PT since PT school, but I never really knew the specifics. Since I have been out of school, I have found myself advocating for pelvic health frequently, and I don’t even know all the ins and outs of it! Dr. Farren Balzer PT, DPT is a pelvic health PT in central Connecticut and was kind enough to take time to tell me more about the fabulous field of pelvic health including who it can benefit, diagnoses she addresses, how she addresses them, and more. You can find her on instagram @pelvichealthct Dr. Balzer earned her DPT at Uconn, home of the huskies. She did not do a residency for her pelvic health specialty as it is not required. One of my first questions when speaking with a pelvic PT was “WHAT made you want to go into this specific area?!”
Dr. Balzer shared her unique experience: “When I was in school I did a project where I taught an exercise class to prenatal patients. During the research phase of that project I was introduced to the world of pelvic health physical therapy and fell in love with it. It is such an underserved population and pregnancy is just the tip of the iceberg. It takes a certain personality to be able to do this kind of work, and it was an immediate fit for me. I bring a lot of positivity into everything I do, and I have a way of making people feel comfortable in situations that would otherwise be uncomfortable. Both those traits are critical in this area of PT.”
Throughout this interview, readers will see a common theme of pelvic health being an underserved community. That could be why I randomly became so passionate about it. Now what does a pelvic health clinic look like? It can’t be your basic outpatient clinic with a large open space and hardly any privacy can it? Dr. Farren Balzer describes her space in more detail. “My space is in a healing arts center that does all different types of healing. My room is set up to feel like a comfortable spa-like environment. I don’t need a large gym for the exercises I teach. The vast majority of my sessions are hands-on work on a treatment table with the expectation that my patients are doing their exercises at home.”
Dr. Balzer sees patients with a number of complaints including Pain with bowel movements, incontinence, urgency, painful intercourse, bladder pain, pelvic pain/pressure, genital itching, hip pain, low back pain, prenatal preventative care etc. Common diagnoses she sees includes interstitial Cystitis, pelvic floor dysfunction, pudendal neuralgia, constipation, diastasis rectus abdominis (DRA), incontinence, overactive bladder, organ prolapse, vulvodynia, vaginismus etc. So who commonly has issues like this? Pregnant/ Postpartum? Middle aged women? According to Farren, all of the above, she generally treats ages 18-65.
Now this seems like an exclusively female area to address, and in fact some pelvic therapists ONLY treat females. That is not the case for Farren. Her response on if she treats male patients and her experience with it: “YES! It makes me very sad to hear of pelvic floor therapists that won’t treat men, and there are a lot! It doesn’t phase me at all, anatomy is anatomy. I feel like most men I see are several years into intractable genital pain that has been misdiagnosed. They have had everything thrown at them and nothing has worked. They typically find me on their own through web searches and others recommending finding a pelvic floor specialist.” Along with these populations, she also has experience with trauma patients and I was so intrigued to hear how she approaches that as I’m sure that is a population she sees more frequently than others. According to Farren, it is all about building trust. “ This subject has to be approached very delicately after a rapport has been established and the patient feels safe. Some people open with this, others don’t mention it until several visits in. With this population I talk through everything I’m doing throughout the entire session and ensure thorough patient understanding and rationale for why I’m doing whatever I’m doing to a far more verbose level than with other patients. I’ve been told how much this is appreciated and continues to build trust.”
Now that we have a better understanding of her patient population, I HAD to know more about her examination. I like to think I am very professional and somewhat mature for my age, but all I can think about is “what all do you poke around down there?” Obviously I did not ask it in that fashion… But I was thinking about it. First she explains the basic foundations she check with almost every evaluation. “Regardless of what the diagnosis is, I always ask about bowel and bladder function as well as pelvic pain. More often than not there is something going on in one of those areas that they haven’t talked about with their medical provider. I always assess hip and lumbar range of motion as well as checking for the presence of a DRA if the woman has ever had a baby or if the man has a larger abdomen. Checking standing and sitting posture as well as gait gives me a lot of information as well.” I think Oh okay, sounds simple enough, I can do that. I then had her further elaborate on the specifics of examining the pelvic area. “I always end my verbal explanations of the patient’s condition with “this is the point where I would do an internal exam to check all these muscles if you feel comfortable with that. If not, we can save it for another day.” Most patients are happy to do this the first day since that’s what they came for. Others are much more hesitant if they weren’t expecting it (e.g. overactive bladder or incontinence Dx). I never push it, but I certainly prefer to do an internal exam the first session because that’s how I get the most important information that other PTs or practitioners missed. If they consent to an internal exam, I generally progress as follows: 1) check for sensitivity in the vaginal fourchette (skin at the entrance), 2) Check baseline muscle tone/tenderness in the bulbocavernosus and transverse perineal muscles, 3) check for baseline muscle tone/tenderness in the levator ani, 4) check for baseline tone/tenderness in the obturator internus (usually a hotbed of trigger points), and 5) check for baseline tone/tenderness in the coccygeus. Sometimes I can get through all these muscles, sometimes there is so much tenderness at one point that I stop there and treat. I never push past resistance or through discomfort of more than 5/10 or patient’s tolerance. I’m constantly verbally checking in with patients on how they are tolerating it and if it is getting to be too much. Typically, a patient with incontinence has no pain and I can begin to assess strength. When I stop pushing into the muscle and am just resting (about one knuckle deep) I ask them to squeeze my finger. That gives me a ton of information to go from and continue to coach the pelvic floor contraction, if needed. I assess their ability to do quick flicks (squeeze-relax, squeeze-relax) and endurance holds (hold max contraction as long as you can). Their performance on these two measures is the foundation of my exercise prescription. If a patient has pain, I may or may not assess strength depending on how deep I was able to get. Again, I don’t ever force anything and I’m fine if we don’t get to the point of “squeeze my finger” until several visits in.” Never mind, not that simple. So after the evaluation, what type of exercises do you give pelvic patients? All of them are prescribed kegels right? Fun fact, pelvic therapists do not LOVE that therapists in other fields are always prescribing kegels. Awkward. However, Dr. Balzer explains to us why that is and is very respectful about it. “I think the best comparison would be to ask how an orthopedic PT would feel about everyone being prescribed McKenzie exercises for low back pain. Those are great exercises for some people, but would make the condition significantly worse for others. You have to examine and evaluate the patient before you go prescribing something that could potentially cause harm. Unless you have evaluated a patient’s pelvic floor, you should not be telling them to do pelvic floor contractions. Period.” Okay okay, I’ll leave the kegels to the specialists. I asked Farren some of her favorite exercises to prescribe to her patients. “For the incontinence diagnosis, I always start with just the isolated pelvic floor contraction the first visit and don’t add to it until the next visit. I want them to perfect the contraction in the pelvic floor without using accessory muscles. From there I like to add exercises involving the hips and core. For pelvic pain my go-to is diaphragmatic breathing with pelvic floor elongation. Teaching people how to relax their pelvic floor through breath is the most effective tool I can give them early on.” Now as therapists, we all know it is hard enough having other medical professionals advocate for our abilities, and pelvic PT is no exception to the ostracism. “Most of my patient’s find me through web searches because they have read blogs of other people with their same symptoms saying the pelvic floor PT is the only thing that helped. I find that OBs hardly ever refer. I frequently have patients tell me that when they told their OBs they were seeing a pelvic floor therapist that the doctor’s reaction was “Oh, you don’t need that.” OBs tend to either not understand or not appreciate what we are able to do for their patients. The referrals I do get primarily come midwives, doulas, or other PTs. I am trying very hard to get in front of urologists, gastroenterologists, and OBs to let them know how I can help their patients. It’s a struggle to get an audience with any of these docs because the reality is that they don’t have time to learn about what I do. My most effective way to reach them is to treat their patients and have the patients go back and tell them it worked. The docs that do refer to me refer because of this.” What can the healthcare community do to shed more light on this specialty? “Allow conservative care to be the first line of defense. Incontinence and OAB are perfect examples. Most docs go straight to meds or surgery without even offering the option of pelvic floor PT. I can fix both of those things very quickly by educating the patient and teaching them basic exercises. I think docs assume people just want a pill for everything. I’d like to think that people are becoming more health conscious and would like non-pharmacologic and non-surgical options first. We need to get the word out that this exists, and it’s called pelvic floor physical therapy.”
I hope you have learned something new today with this insightful interview with Dr. Farren Balzer (@pelvichealthct on instagram). Interested in learning more about pelvic health PT? Farren has a few books she recommends. “Headache in the Pelvis” By David Wise is a must-read for anyone with chronic pelvic pain, and “The Vagina Bible” By Dr. Jen Gunter is a great get-to-know-yourself book.
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