Assessment is patient specific – we don’t do ALL the tests with ALL the patients. We are trying to confirm a hypothesis, or check and ‘clear’ an area/system. If there are no problems, the assessment itself is not at all painful or even unduly uncomfortable. If there is pain or discomfort, it indicates any number of dysfunctions depending upon its nature and area, and what is needed to provoke said pain.
You know you story best. No matter how good the additional information you bring, and please do, you will be asked certain questions to establish:
i. characteristics of your (multiple) symptom(s)
ii. pattern of your experience
iii. signature of your pelvic response
Or put more simply you have SYMPTOMS. These indicate in which SYSTEMS things are out of balance. We identify your symptoms, assess your systems, create change in the pelvis, and assess the outcome on your symptoms. This helps to confirm or negate a hypothesis about what could be causing your problems/experience in the first place. Be prepared to talk about bladders, bowels, sexual activity (if appropriate), pain and other weird things going on.
The majority of assessment is manual or hands-on, augmented by technology such as electromyography and ultrasound.
Mindful awareness starts with breathing, and the change or transfer in pressures through the body are important. Most breathing is diaphragmatic, but we do make mention of hypopressive technique and its role in producing a negative pressure in the female pelvis.
In certain patients with musculo-skeletal pain and no pelvic muscle or organ dysfunction, we may choose to do an external only assessment of the various forces on the pelvis and surrounds. Different sporting populations have varied pelvic needs; stand-out population include soccer players, ballet dancers, gymnasts, cyclists, runner and rowers, although that doesn’t disqualify other sporting pursuits. Pain that shifts around the pelvis is of interest – what was a hamstring strain, turned into buttock pain and is now groin pain.
In pregnant patients with pelvic girdle pain, we assess internally, then do the inside thigh and front of hip. Then we get you up, and do your buttocks in standing – which is the position in which the pelvis has to bear weight. Other muscular imbalance is also addressed.
Muscles and Dense Connective Tissue (Fascia)
Often, an internal examination is indicated be it vaginal (females) or rectal (males and females). This includes assessment of normal anatomical markers and pelvic floor muscle function – at its simplest: can you squeeze and can you let go, and can you do it voluntarily and does it work involuntarily? Tension and muscle length are assessed through palpation. Assessments are gentle, and always done within pain limits, however in pelvic pain patients the internal examination may reproduce their symptoms.
A standard postnatal check should include both an internal vaginal examination and an abdominal assessment for diastasis (separated tummy muscles).
Electromyography and ultrasound are additional assessment tools of muscle activity and function – see below.
Nerves and Loose Connective Tissue (Areolar)
Disclaimer: This is a super simplistic explanation! Do not take out of context.
Loose connective tissue lies under skin and around the innards (viscera) and nerves and blood vessels (neurovascular bundle). When restricted, it appears it can impact negatively on function. Nerves, both motor and sensory, can be ‘under-active’ and not send enough signals, but they can also over-send messages creating muscular over-activity, dysfunction and pain. We can have peripheral sensitivity in an area e.g. thrush or bladder infection causing irritation and we can have central sensitization where we are constantly ‘listening’ for the pain. By moving the skin, and hence loose connective tissue, we influence other parts of the system. This appears to have the effect of releasing tension throughout the body, often with autonomic nervous system responses – sympathetic (fright or flight) versus parasympathetic (pee poo pleasure). Would be assessed in patients presenting with pudendal neuralgia, persistent pain that is aggravated by surgical interventions, pain with excessive anxiety as a feature, peritonitis survivors, persistent pain post neurological trauma, other clinical flags.
Visceral manipulations is a very gentle ‘tummy massage’ focused on holding the viscera/guts and allowing them to move appropriately – can be done for anything from infertility (endometriosis or tubal scarring), pain, overactive bladder, constipation, gastro-oesophageal reflux disorder (GORD) etc.
We can use EMG to see how the muscles are working. This is usually an up-training modality or treatment, because tight patients who can’t get the electrode in have learnt the necessary skills by the time we can insert one. Very useful postnatally and during the menopause, if trying to get a connection with your core! There are a variety of different probes, depending upon what we are wanting to retrain. A work : rest test is performed and compared at the beginning and end of each session. Although it lacks validity as to actual numbers, sessions are compared to identify patterns over time. We are less interested in the value you achieve (strength), and more interested in your neatness and precision (ease of activation and control).
We can use real time ultrasound rehabilitation is a wider range of patients, as we don’t have to insert anything.
There are 2 main approaches:
Trans-abdominal where we can assess:
- all four of the abdominal muscles including separation (diastasis)
- the bladder including volume
- the anterior pelvic floor muscles post vaginal delivery
Trans-perineal (running in the mid-line from front to back) to visualize:
- the pelvic floor muscles as a whole
This allows us to understand their co-ordinated movement patterns of contraction and relaxation, assisting rehabiliation (see below).
Advice and education
First line management is explaining your current state of pelvic function, as established on assessment.
A cornerstone of management is an awareness of our own behaviour, its response to environmental changes and the role of stress. If deemed appropriate, referral to a mindfulness based stress release program is made.
Pain neuroscience education (PNE)
Chronic pelvic pain needs to be managed within the greater context of pain neuroscience. Simplistic explanation: peripheral sensitisation (more pain fibers ‘feeling more’ at the site of pain) and central sensitization (more ‘listening’ for pain from the affected site) need to be addressed, as do perpetuating beliefs and misconceptions (thought viruses). The role of stress and its impact upon the function of the autonomic nervous system (sympathetic and parasympathetic) is central in many pelvic pain presentations.
Question: In what position does a human being evacuate the bowel?
Hint: Its not sitting….
Basic bodily functions can be disturbed by social and cultural influences. Obvious examples are women with frequency:urgency and possible incontinence whose behaviour drives their toilet dependence, positioning on the toilet, and hyper-diligence when it comes to cleaning down below. Sometimes your behaviours are the cause or driver of your pelvic problems. In these cases, simple advice can make all the difference e.g. a young woman overly diligent in washing, gets thrush, then urinary tract infection, takes antibiotic, gets constipated, pelvic floor muscles get tighter, pain with sex etc. Advice to stop using soap, and relax in a good position (squat) can break the cycle and prevent recurrence.
What can you do about your problem? We have life hacks for:
- diet / food (fiber)
- fluid intake
- breathing techniques for everything from calming, to sucking your insides in, to mobilising the colon, to mobilising secretions in the chest to clear a chest infection
- movement to normalize load through the pelvis
- positions for bodily functions
- positions for sex
- manual techniques for sex (when you want to encourage things along….)
- squeezing and/or letting go your pelvic floor muscles at specific times (core activation and release)
What can the physio do?
Up train e.g. pelvic floor muscle contractions, abdomino-pelvic synergy, core activation, awareness and exercise, posture correction, bio-mechanical tips and cheats, electromyography, ultrasound, neuromuscular stimulation….
Down regulate e.g. pelvic floor muscle relaxes, breathing, mindfulness, letting go of Stuff, release work including hands-on manual therapies for muscle, nerve, connective tissue and visceral release…..
Myofascial Release and Trigger Point Therapy
Myofascial release techniques including trigger point release, muscle stretching, and muscle energy techniques. Done for a range of pelvic floor muscle dysfunctions and symptoms. Often when co-morbidity exists – lots of things going wrong at the same time.
Connective Tissue Mobilisation (Skin Rolling)
Beneath our skin is loose connective tissue. It is the same tissue that lies around our nerves and blood vessels (neuro-vascular bundles) and our innards (viscera). If there is scarring due to surgery or chronic inflammatory conditions e.g. fibromyalgia or endometriosis, or if the nervous system is ‘tightly wound’, we can roll the skin to mobilise the structure through which the nerves run. Done for pudendal neuralgia, pain that is aggravated by surgical and other procedures, survivors of peritonitis etc.
This gentle ‘tummy massage’ requires complete relaxation and trust. The patient allows the therapist to sink gently into the abdomen and assess movement of the viscera with subtle ‘holding’ techniques. Done for anything from infertility (endometriosis or tubal scarring), pain, overactive bladder, constipation, reflux etc.
Technology exists allowing us to view the body’s electrical activity:
- the heart is monitored via ECG
- the brain is monitored via EEG
- the muscular system is monitored via EMG
Using an internal probe (electrode) the amount of electrical activity of pelvic floor muscle contractions can be measured. This is viewed on a screen, providing an invaluable feedback tool. It allows for increased client understanding and control when learning how to use the muscles correctly. Aspects such as strength, endurance, stability, fatigue and control can all be assessed and addressed.
An excellent teaching tool and motivator – treatments are easier!! If you have just flown an aeroplane with your vagina (squeeze to go up and miss the mountains, let go to come down and miss the clouds) you know exactly where your muscles are when you walk out the door….
Electromyography is not painful. After insertion of the electrode most patients equate it to the sensation of wearing shoes – once there, you forget about it, unless you actually focus on it… Of course, this is more less true for women who haven’t been pregnant or are tight for other reasons.
In clients who are presenting with pelvic pain (especially if due to tension in the vaginal muscles) the electrode may cause significant discomfort, or be difficult to insert. In such cases, alternatives options may be more appropriate.
Realtime rehabilitative ultrasound has revolutionized our understanding of appropriate pelvic floor muscle function. When comparing clinical patients to asymptomatic controls we see differences in their movement, both of the abdominal muscles and the pelvic floor muscles. Using trans-abdominal approaches, we can assess for diastasis abdominis rectalis; view appropriate abdominal activation of ‘the core’; and the anterior pelvic floor muscles and base of the bladder (to assess to levator avulsions post vaginal delivery). Using a trans-perineal approach, we can assess and retrain pelvic floor muscle activation and release. This is highly beneficial in patients who are unable or unwilling to have an internal examination e.g. children, men, and non-sexually active post-menopausal women.
Neuromuscular stimulation (NMS)
NMS is a type of electrical stimulation that activates nerves and their associated muscles. Different types of nerves (sensory or motor fibres) can be activated by selecting different settings, depending on the desired goal of treatment. Transcutaneous nerve stimulation (TeNS) is used for a wide range of conditions and ailments. We have obstetric TeNS available, for those preferring a natural delivery and seeking additional pain management strategies.
NMS is not painful. On different settings, the sensory component is felt either as pins-and-needles or a gentle vibration; the motor component is reported to be a contraction or a creepy crawly cramp. Most people describe it as feeling ‘peculiar’, or ‘odd’. Some find it ‘comfortable’, and ‘not unpleasant’. Very few are ever ‘alarmed’. And the odd soul ‘quite likes it’!
Using an internal probe (electrode) light electrical currents can be applied to the pelvic floor stimulating the nerves and causing muscle contractions. This teaches the correct action and use of the pelvic floor muscles.
Inappropriate nerve responses can be ‘calmed’ e.g. the overactive bladder that wants to go to the toilet all the time can be calmed so that the urge itself is not as intense; this in turn makes it easier for the pelvic floor to be the boss. We can use external sticky electrode (over the sacral nerve roots) in those individuals in whom internal treatment is not deemed appropriate.
With the correct management, you should be able to manage your own pelvic experience, without needing to return to pelvic physio for the same condition over time. You should learn, own, and move on…. The aim is to integrate you back into your own life and community. If you have an identified imbalance around the pelvis, modalities such as swimming, walking, gyrotonic / gyrokinesis, yoga, Pilates, callanetics, and Tai Chi are encouraged.
Of note: it is better to attend a class just-around-the-corner twice a week, than it is not to attend a class all-the-way-across-town!