#PTonICE Daily Show – Monday, January 15th, 2024 – When hands-on is off the table

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to navigate a pelvic PT eval when a “hands-on approach” for assessment & treatment may be off the table due to an individual comfort level with pelvic examinations or when trauma is on board.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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Good morning, everyone. Welcome to the PT on Ice Daily Show. This is Dr. April Dominick here from the Ice Pelvic Faculty Division. And today we’re discussing how to navigate a PT eval when hands-on treatment and assessment isn’t an option. Psychiatrist Jacob Marino once said, the body remembers what the mind forgets. Why should we consider a hands-off approach during an eval for someone with pelvic floor symptoms? Maybe the client has some trauma, maybe they experienced nervousness about what a pelvic floor assessment is, or maybe they’ve had previous discomfort during other pelvic examinations with other medical providers or in a different setting. So for some of these folks, that hands-on assessment and manual treatment just is not going to be the best go-to during the evaluation and maybe even for some subsequent, if not all, follow-up visits. The idea that an internal or external exam is a requirement to make pelvic PT a success is just not true. Is it helpful? 100%. But we are the detectives of the musculoskeletal system. And we take into account the cognitive and emotional state into consideration of the human in front of us. just like all great sleuths like Nancy Drew, she’s not making her next move based off of palpating the person in front of her, but she’s taking cues from the person in front of her. So I’ll give you some tips today for how to go about a hands-off assessment for an eval specifically, from the subjective to the objective, through the treatment, and then post-session. Pre-session, We want to make sure that your intake form has an area for a client to share some trauma or abuse that may have happened to them, whether that’s current or they have a history of it, whether it’s physical, emotional, whatever the case is. Whether they mark something on that intake form or not, as pelvic PTs, we are dealing with an extremely intimate part of the body. And that means that someone may not even realize that they’re holding on to some trauma until maybe in session. They have some sort of trauma response because you palpated their low back, right? Or because you brought up during discussion or during subjective, um, a certain word and that was triggering to them like, um, anus. And knowing that their executive functioning is probably not working optimally in that moment is very helpful for us to make that session for them the best experience possible. If someone has a trauma response, just thinking before we even dive into the subjective, just having that in our head is important. We want to be non-judgmental. We want to be compassionate. in our responses, we should be patient and supportive of a pause that that person may need to take. They may need to take a breath or ground themselves or stretch. I have these little small animals like a llama, this one doesn’t have any legs, just for them to hold on to and little fidgets as well. So know that that may happen in session and later on, You could ask them when they’re not in that traumatic response or in the next session. You could ask them, hey, what would be appropriate for me to do to help you through that? Do you know? They may not have any thoughts on what to do if that does happen again. During the subjective, let’s talk about that. With these clients, I tend to rely heavily on the subjective. We want to be looking at the verbal and nonverbal communication from our clients. These can cue us for the need for a hands-off objective and treatment session, even if the trauma was not shared on the intake. From a nonverbal perspective, when you’re looking at your client, do they have knees to chest? Are they folded in super flexed? Do they have minimal eye contact? Are they wringing their hands and fingers throughout the entire session? From a verbal perspective, type of words for pain. So in the pelvic setting, we hear a lot of really scary sounding words and words that sound harmful. Things like, it feels like there’s a chainsaw in my vagina or every time I sit, it’s like a hot poker is going up my butthole. So listening for those intense words when they’re describing their pain, as well as a tremor in their voice, are they shaking? And then any sort of non-specific description of their pain. Oftentimes I’ll be like, yeah, tell me, can you show me, or can you tell me more about where your pain is? And if they show me, they kind of like, point in this giant circle of like from sternum to mid-thigh is where their pain is, and for some that is where their pain is. But for others, their pain is at the tip of the penis, but they just aren’t comfortable or maybe again, that is triggering to them to say the actual anatomical word. And then verbal communication from you as a provider is important. So we’re thinking active listening, we’re going to ask them about prior health visits, and then you’re going to dial in some of your questioning. So from an active listening standpoint, they’ve probably been dismissed or maybe not heard in previous medical provider settings. So we want to be the ears for them. and asking them specifically about previous physical pelvic assessments, if they’ve had any, how did it go at the gynecologist or the urologist, or even if they worked with a prior pelvic PT, that can give you an idea for what worked and what didn’t or doesn’t work for them. And then get curious about some of their personal life events and their symptoms. So, If they’ve shared any sort of major surgeries or shifts in their personal life, ask with some compassionate curiosity, do you think that your jaw surgery is related to the urinary leakage that you’re now having? And then they think back and they’re like, oh my gosh, the urinary leakage started happening basically when I had my jaw surgery. So they have sometimes like an aha moment or if a family member died or if they shifted jobs or got fired from their job, that’s when they started having intense pelvic pain. So you can, again, be a detective and kind of connect some events together and that can help them feel very heard for sure. And then I went during my actual, if I am going to do a hands-on assessment, before I even palpate someone, I always ask them, hey, is there anywhere that’s off limits or that I cannot touch or assess? And I’m going to do the same thing with the person in front of me. If I feel like this is going to be a hands-off assessment, I’m going to ask them, are there any topics or body regions to avoid during our discussion or assessment? And then finally, for the subjective side of things, preconceived notions about the pelvic PT visit. Do they have any? What have they heard? Be sure that you are explaining the pelvic floor assessment thoroughly and that you ask them for their preferred learning type. So if they are a visual learner, is it okay that I show you this pelvic model? Even that, just the visual look of seeing the perineum could be triggering for someone. I had someone who I was showing them the muscles on the pelvic model and they had a visceral, nauseous, triggering response that we worked through. And they kind of actually had a flashback of when they had some childhood molestation. And then moving towards the objective, we want to reframe this appointment like it’s a virtual visit. which virtual visits are hands-off. Same, same, but different. Lean heavily on your visual range of motion. Again, if that’s okay with them. In terms of asking them to do standing or seated spinal range of motion, hip mobility, we can learn a lot from a seated 90-90 for their hips in general. Abdominal movement with breath. Offer hands-off assessment options that they can select. So is self-palpation of their own pelvic floor okay for them? Or can we do a visual assessment, no hands, but a visual assessment of their pelvic anatomy? And like I said earlier, an external exam, but especially an internal pelvic exam, whether it’s vaginal or rectal, is not required to make a pelvic PT session a success. It can though be something that the client and provider work towards if that’s something that the client is interested in. A previous client once told me, they said, thank you so much for saying that an internal exam was not a requirement because they had apparently gone to two previous PTs who were basically saying like, hey, if we are gonna figure this out, we’re going to have to do an internal exam, which can be very triggering for them. Then in that objective, looking at functional movements like squats, lunges, you get a good idea of range of motion, strength, growth strength, and then the quality. Is it smooth? Is it rigid? Don’t forget to collect some pelvic specific outcome measures or even at the very least, a patient-specific functional scale. And then moving on to the treatment section, tuck your manual skills away and focus on the exercise, the education, the ecosystem. Do they have mental health providers or resources on board? From a exercise standpoint, we wanna be thinking movement snacks for these humans, just to keep it short and simple, or rehab EMOMs that focus on mobility, strength, aerobic activity, maybe some self-mobilization or desensitization on a post-op or a C-section or a perineal area. Any sort of scarring, can they do some work themselves? Are they okay with that? Example of a remom for someone, it’s got four exercise in it and I gave it to a client who had that traumatic response when I was showing the pelvic model. And they weren’t very motivated to exercise. They hadn’t been for six months, but they love to exercise. But because they had some onset of urinary symptoms and a recent jaw surgery, I made sure to ask her, what are your favorite exercises? and they said planks and bridges. So I made a EMOM that consisted of a bird dog with a row. So we’ve got some sneaky strength and motor control of midline, tapping into the pelvic floor based off of the urinary, the, sorry, upper extremity and lower extremity connections. And this is helpful, especially if they are just so disassociated from their pelvic floor. And then I had kettlebell swings. That’s gonna tap into our aerobic piece. A deep supported wall squat with diaphragmatic breathing is going to help us kind of calm the sympathetic nervous system and maybe even help them start to connect with their pelvic floor. And then self-mobilization externally of the jaw. One thing to make sure is that these people are comfortable in the positions, the exercises that you suggest. Some of them may be a little triggering, so just make sure like, hey, is prone okay for you? And then for the objective session or treatment session, education is queen here. Okay, so keep it simple and short. A lot of times these folks don’t have a lot of room for processing lots of detail. Use their learning style to connect with them. If they’re visual learners, send them home with the animated video explaining the anatomy and physiology of the pelvic floor or your whiteboard drawing. And then, definitely tap into their ecosystem, ask them about what’s their sleep like, are they getting adequate fuel and hydration, how do they manage their stress, and do they have any mental health providers on board. And then for the after session of this hands-off eval, make sure you follow up with an email or a phone call, check in with them, make sure that they know that you So appreciate them sharing these things with them.

So when it comes to someone who is apprehensive about a pelvic floor evaluation or who has experienced some trauma, a hands-on assessment may not be in the cards. So be sure that in your pre-session, you’ve got something in your intake forms that they can check off for trauma or any sort of abuse or things like that. From a subjective standpoint, we want to be emphasizing active listening, looking at their nonverbal and verbal communications, and then dialing in our specific line of questioning. From an objective standpoint, remember that you can remind them they are in charge of the session and there are plenty of hands-off objective measurements that can be taken. From a treatment side of things, make sure that you give them movements that align with their preferences and that you’re giving them a ton of education about the pelvic floor and checking in with their ecosystem and mental health providers. And then after the session, give them a roadmap of how the session went. So as a pelvic PT, know that it’s okay. In fact, it may be better not to palpate during the first visit in order to establish trust and rapport. We know a lot of outcomes and symptoms can improve purely based on education alone. In our ice pelvic division, we have two live courses that I’ll chat about in Hendersonville, Tennessee, January 26th and 27th. Alexis and I will be there. Teaching All Things Pelvic Health. And then the following weekend, Christina, Heather, and I will be in Bellingham, Washington, February 3rd and 4th. And there is still time to sign up for those. Thank you all so much for tuning in and until next time.

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