Pelvic PT Rising
Pelvic PT Rising
When to Prioritize Rectal
In this 'sode, we flip how you're prioritizing rectal evaluation and treatment on it's head!
We'll give some specific case studies, but this is the framework from the Rectal Course on how to prioritize rectal with your patients. It divides your cases into:
- Crucial
- Important
- Helpful
- Unnecessary
Critically, we generally put far too few of our patients into the 'crucial' or 'important' categories - at least 75% of patients belong in these categories!
It's rare for rectal treatment to be only 'helpful' and extremely rare for it to be truly 'unnecessary' in someone's plan of care.
We hope this is helpful, and something you can use this week with your patients!
If you're enjoying the podcast, please consider leaving a review - we love to hear from you!
Rectal Cohort #2
The second cohort of the Rectal: Evaluation & Treatment course is starting in October! Wait list is open, and doors open next week on Oct 23rd. You'll get $50 off the course and a LIVE Q&A. You can find the details at www.pelvicptrising.com/rectal
About Us
Nicole and Jesse Cozean founded Pelvic PT Rising to provide clinical and business resources to physical therapists to change the way we treat pelvic health. PelvicSanity Physical Therapy together in 2016. It grew quickly into one of the largest cash-based physical therapy practices in the country.
Through Pelvic PT Rising, Nicole has created clinical courses (www.pelvicptrising.com/clinical) to help pelvic health providers gain confidence in their skills and provide frameworks to get better patient outcomes. Together, Jesse and Nicole have helped 400+ pelvic practices start and grow through the Pelvic PT Rising Business Programs (www.pelvicptrising.com/business) to build a practice that works for them!
Get in Touch!
Learn more at www.pelvicptrising.com, follow Nicole @nicolecozeandpt (www.instagram.com/nicolecozeandpt) or reach out via email (nicole@pelvicsanity.com).
Check out our Clinical Courses, Business Resources and learn more about us at Pelvic PT Rising...Let's Continue to Rise!
In the last 10 years, our field has gone from an unknown specialty to a household name. This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve. In order to help others get better, we need to be better. This podcast will help you to become more confident with your patients, more successful in your practice or business and a leader in pelvic health, and we're going to have some fun along the way. Join us as we rise together. We're Jesse and Nicole Cozine, founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle, and this is Pelvic PT Rising.
Speaker 2:Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine. Hey, nicole, hello, all right, talking today in our little bit of a rectal series here in honor of Nicole, the cohort number two of your rectal course is going to be launching one week from today.
Speaker 1:Yes, and I am really excited about that. Rectal treatment and the option to do that in most folks is really something that I just love doing. I think it can yield such amazing good results and it gives us a more thorough assessment of what is actually going on at the pelvic floor. So I am pretty passionate about this and I'm excited to launch this course again.
Speaker 2:So we're going to be talking about when to prioritize rectal. If you guys do have an interest in learning more about this, make sure to head to publicptrisingcom. Slash rectal, get on the wait list For first priority. You'll get $50 off. You'll get a live Q&A with Nicole, all of the good things. So head over there and check it out. But, nicole, one of the things we wanted to talk about is when to prioritize rectal, and I think this is one of the areas and we touched on this briefly last week, but this is going to be a bit of a deep dive into that. It's one of those things that we don't think it's important unless it's an obvious rectal issue.
Speaker 1:Yes. So I think that one of the biggest things that I've observed and we just spoke a little bit about this on last podcast was, if it's not glaring at us in the face where somebody has a primary GI complaint or they don't have a transvaginal option, then it's like, oh, we need to do rectal. But this whole course is meant to challenge that assumption, or challenge that clinical rut you've gotten yourself into where that's just what we do. We visit the option of doing a transrectal assessment if we need to, and we're basically pushing that towards the end of their plan of care. And if we don't get to it and we get good results, then great, we didn't need to do that and we're almost celebrating that in a way Like, oh, few didn't have to do that.
Speaker 2:Or relieved. Find yourself relieved. Oh good, I don't have to do rectal.
Speaker 1:Yeah, oh gosh, I'm getting a little bit anxious about bringing that up to my patient. I don't know. I think one of the amazing things about my career is that I had a really great, awesome mentor from the very beginning of my pelvic PT journey and she did rectal treatment on almost everybody, and so I come at this treatment philosophy from that lens Like that's how I was taught. There was no other way. It was just so obvious that that was such an important tool in our toolbox to have and we needed to do that, to do a thorough assessment, and so very grateful to that person for being that guide for me in that way, and I'm hopefully going to challenge you all that take this course to think that way also. And so I got to learn by observing somebody do that day in and day out, and so this rectal course is essentially me breaking that down and being like why is it important? What have I learned along the way in my 15, 17 year career, whatever it is now?
Speaker 1:And the biggest thing I think we teach in that course is this framework of how to make that clinical decision.
Speaker 1:And we talk about this as being so important because I think that if you make the decision on how important it is to this person's case before you have to talk to the patient about it.
Speaker 1:It makes the clinical conversation with the patient 10 million times easier, and it's almost like you know how.
Speaker 1:It's a little bit similar to we've had a boundary podcast about how to create boundaries, and we've talked about boundaries as being essentially decisions that you just make in advance, and in this way it's sort of like that we decide for ourselves clinically how important we think it is to either figure something out or implement this in their plan of care for symptom relief or to really dive into the why of what's going on.
Speaker 1:And if we make that decision before we actually presented to the patient, the conversation goes so much easier because we have a grasp on it for ourselves first, and so that's really one of the major pieces of this course that we go over, and we're going to go through some of that on the podcast today because I truly believe in getting this out to as many people as I can. But so we're going to go through that framework and in the course we go through it in greater detail and give a ton of examples and case studies and weave that through the entire course, but I am going to tell you what the framework is right now.
Speaker 2:Yeah, and Anonico, you are always so huge on clinical honesty and if you genuinely believe that this is important for somebody that you have an obligation as a medical provider to tell them to be able to perform it, to feel comfortable doing that and not let yourself get in the way of it. So let's go ahead and dive into that framework. Basically, you have to make a decision when you have a patient coming into your office. Is rectal evaluation and treatment? Is that something that is crucial, important, helpful or unnecessary? Crucial, important, helpful or unnecessary? And this is how you break that down. So let's walk through each of those, nicole. So what do we need to know about this framework?
Speaker 1:So one of the things I want you to keep in mind as we're going through this framework is that this is the first step in your clinical process is deciding for yourself, with your expert knowledge, how important, crucial, helpful or unnecessary the rectal assessment and treatment is for that patient. There are other steps that you need to go through that are obvious, that you need to make sure you have that conversation with the patient, that we talk about ongoing consent and all of the things which we go over also in the rectal course. I just wanted to make sure that we know that this framework is for you to decide as the clinician. How important do we think adding this treatment into their plan of care is?
Speaker 2:Okay, so hit me with crucial. When is this just absolutely crucial?
Speaker 1:In my opinion, the rectal treatment and assessment is absolutely crucial. When somebody has a primary bowel complaint and that's a lot of it right Is that they have a primary bowel complaint. There's a very strong clinical indication why this should be a part of the assessment.
Speaker 2:And now what about somebody who doesn't have a primary bowel complaint? So we just had an out of town patient who came in with IC symptoms. The constipation was a major contributing factor to those symptoms. Is that crucial, then, or does that fall into a different category?
Speaker 1:I would say that that falls into a crucial category, because if their symptoms are exacerbated by a bowel situation or they notice a difference between oh, when I have my symptoms, then I tend to be more constipated, or if I have an IBS flare, then my urgency is increased. That, in my opinion, goes from important to crucial.
Speaker 2:Got it. So if it's a bowel thing, is either the primary thing or it's a major contributing factor that the patient has already noticed is contributing to their symptoms, and then for male patients or people with only one access point. Basically, if they're having public floor issues, then that also probably yeah, it's in that crucial category because it's like we can't.
Speaker 1:And this is where we can have a whole other conversation about internal versus external therapy. But my feeling is that we are pelvic floor specialists. Our distinguishing factor is that we are trained to do internal palpation and assessment and treatment of the pelvic floor muscles. So just because we can access them externally doesn't mean that that's the best way to treat them. Now, that's a whole different story for a different day. But in my opinion, if the person has an access point to treat the area of their primary concern complaint and or symptom reproduction then it becomes crucial that we then assess that area.
Speaker 2:And then you would convey in your conversation with a patient then and I know this is stuff you go into the course but you'll be conveying to the patient that you actually think that a rectal evaluation and treatment is relatively crucial to their positive outcomes.
Speaker 1:Yeah, because it's like, how else do you think we're going to? Otherwise, you're guessing, I mean at that point. So I feel like that is we go over all of that stuff in the course too, about, like, how to actually have that conversation. What happens if somebody is apprehensive, all the things, and there are steps to be able to do that. But the whole point of having this framework is to lead with clinical honesty, and in order to be clinically honest, you have to understand what you believe clinically, and this is the framework to help you to decide. Is this essentially more than important? Is this crucial to my understanding of this patient's symptom, symptom presentation, anatomy, all the things? Is it crucial for me to really do to assess the pelvic floor in this way? And if it is, then we talk about how to talk about that with the patient in a way that is going to be a lead for two-way conversations and making sure that everyone understands why we're doing it and all of that stuff.
Speaker 2:So drop it down then. So that's crucial Is that either it's a primary bowel thing, it's a major contributing factor to their symptom that they're in for, they only have that access point and you need to do a pelvic floor evaluation. All that lands in the crucial category. What drops it down to important? How do you differentiate between crucial and important?
Speaker 1:So this category of important, I think, is one of the ones that gets missed the most Because really it's in the very important category.
Speaker 1:If somebody has things like comorbid with their primary complaint, like tailbone pain or perineal pain, and then you might be like, well, why perineal pain? And that is because there are anatomical considerations here in this category that make it extremely important to do a rectal assessment and treatment. So in the course we go over the fact that the perineal body has attachment points to the external anal sphincter and the external anal sphincter has attachment points to the tailbone, all of which are very easily palpated, and, I would argue, more easily palpated from a trans rectal approach than trans vaginal. And so when you have a combination of anatomical indications plus somebody's history of something that has to do with the posterior part of the pelvic floor, then it becomes really important, regardless of the person's primary reason why they're seeing you, and that's the key here it becomes extremely important regardless of the reason why they're coming in. So they can be coming in with vaginismus and all these things, and it's still extremely important to that person's assessment to do a rectal assessment as part of a thorough plan of care.
Speaker 2:So let me ask a question there. So you know, we had published that study from Public Sanity at IPPS that showed that 73% of our people coming in with other diagnoses vaginismus and continence prolapse, whatever it was everybody coming in had a 73% chance of having some sort of bowel complaint. So one of the things that I'm hearing you say and correct me if I'm wrong here is that really all of those 73% should be in either the crucial or the important category. First of all, is that true?
Speaker 1:Yeah, I think for sure important. And then it's whether or not you decide that it's like, oh, crucial for this to happen in order for me to understand something.
Speaker 2:And the differentiating factor there is that it's actually truly and the patient can even feel that it's contributing to what's going on, as opposed to it being kind of this like silent contributing factor. That might be more important, right? So that would be like the person is like oh man, every time I'm constipated, my symptoms get worse would be crucial. But oh, I've also just had this totally unrelated history of 20 years of constipation and it has anything to do with my incontinence.
Speaker 1:That, basically, is what that IPPS thing showed was that 73% of people who came in for other things, when they filled out their form and our form had bladder, bowel, sexual health and orthopedic sections to it had something checked in that bowel section. It's not like that's part of the problem. They're not connecting the dots on. Oh, this thing is a problem. However, when asked, do you have constipation? Do you have feelings of incomplete emptying of the spells? Do sometimes you have about urgency, those kinds of questions they say yes to.
Speaker 1:But that's very far from why they're coming in. They usually have another reason why. An excuse essentially is to why that happens. Oh, it happens when I get nervous. Oh, it's because I've always been that way. I've never not had that. I've had that problem since college and it's like right, but that's still extremely. We know and this is where it comes in where we know that that is a significant potential contributing factor to what their primary complaint is and that's what why we're the experts like that. We know that they don't know that and that's what we have to convey to them with our clinical honesty, with being like hey, you mentioned this on your intake form. I'm telling you that it's very potentially related to your symptoms, of whatever you came in here for because of XYZ. Most of the time that's an anatomy decision and an anatomy connection, and so once you can explain that to them, it's like, oh yeah, cool, and let's do it like oh my gosh, why wouldn't we want to?
Speaker 2:I love when our numbers tied together, because last week I asked you what percentage of people you felt that you probably did rectal evaluation treatment with, you said 75 to 80%, regardless of diagnosis, like saying everybody, that's what you felt. That really puts at least 73%, which is almost 75% of people, in that crucial or important category, just by definition, just with like what we've seen in research. Can I also ask one of the things we did for the Cousine screening protocol was asked about a history of falls on the tailbone and 49% of people I'd have to double check that it's something like that, though I think it's 49% said that they did have a history of falling the tailbone. Does that start to push them into that important or crucial category as well, or could they have that history I know you mentioned, you know you take that history there. Does that push them into the important category or could you have that and it not really be relevant and it kind of downgrades them to the next category to talk about?
Speaker 1:I mean it absolutely keeps them in that important category. I have yet to see someone with a history of falling their tailbone that they can remember, and that's usually how I pose it to patients If you can remember it, it was important in your history. So someone's like, oh, I mean, I probably fell, I don't know that important. But someone's like, oh, my gosh, I totally remember this kid pulled out a chair when I was in third grade and I fell smack dab on my tailbone and it hurt for days and my mom didn't know what to do and like that's the kind of fall If you can remember it, it's important. I don't care how old you were. If you can remember it, it was important and that so in that category, then, yeah, they would go automatically into the important category, if not the crucial category.
Speaker 2:So most people then and I guess I mean I feel like I'm late to the party here because you've been saying this for years now but most people then fall into the category where rectal evaluation is crucial or important.
Speaker 1:Yes.
Speaker 2:Okay. So then I guess this is going to be almost more interesting then is talking about the last two categories, because these are going to be the exceptions to the rule. But basically, if you have no prior knowledge, if you're brand new, you should almost be assuming that rectal evaluation is important or crucial for folks. But talks to me about this helpful category that kind of falls below that important, so nothing really rises to the level where you truly feel like it's important for the person.
Speaker 1:Yeah, so that would be somebody that has intermittent symptoms, just in general, that the contributing factors are just kind of they're just sometimes there, sometimes not. They are improving with what you're doing, but they're also plateauing a little bit. So they're in this like well, I'm pretty sure I've gotten most of it all figured out and what else am I missing? Kind of a thing.
Speaker 1:You know I give an example to here where it's like somebody that comes in with incontinence or prolapse symptoms and they are also saying something about sometimes have constipation, or I did when I was in college, but man, that's been really great ever since I started really eating well and training for this triathlon, and so you really start to believe that like, oh yeah, like maybe they did at one point, but it really hasn't been a problem now for a long time. That's not a primary bowel complaint that they're coming in for. They're having intermittent symptoms that are bladder related or you know something like that, and so it's like you're just kind of in that like well, it wouldn't hurt to do a rectal exam, but are you really going to get like that really crucial and important information from it? That's going to be like that aha moment. Probably not.
Speaker 2:And these are the folks that you feel and maybe you don't treat like this. But it's just viable then for these folks to maybe defer rectal until there is a plateau or until there's something that's really not making sense, because you might be able to get them all the way to where they want to be and where you want them to be Without rectal treatment.
Speaker 1:Yes, totally, and yeah, and that's the. I guess the differentiating factor too is that, like I feel like in this case, if I were to cease, this person whose symptoms were 70% better and they really wanted it to be the rest of the way and they came to see me for a remote consultation and I'm going through all my things and there's nothing really they don't have a history fall in their tailbone. They had a transient case of constipation a while back. Like there's nothing. That's really being like oh aha, we've got to explore that kind of a thing.
Speaker 1:Then, yeah, it could be helpful to do, it's not going to be bad to do. That would be the thing where it would be like well, you know what, let's just double check and make sure we don't have something missing. That's really lurking that under the radar here. But my hypothesis then would be that if I do a rectal exam, I'm actually not going to find something, versus the other way around. And so then if you do find something, that it's like huh, what now? I'm like now I'm not really interested because I'm like, whoa, that I didn't expect that, because nothing pointed towards that direction and anatomically, nothing is really making a huge connection to that stuff. So that's kind of that helpful category.
Speaker 2:Got it, and so the final category you put into the course was unnecessary. Knowing you and how passionate you are and how important you think that this is, that you're literally missing like half the public floor. If you're not doing this, I'm guessing this is a pretty small category of people where you're just like you know what. I would actually be surprised if you did do rectal on these people.
Speaker 1:Yeah right, I mean, this category is very small in my opinion, but it's the kind of category where someone's already kind of an anomaly in your office. So for instance, at pelvic sanity it would be somebody that has a primary sciatica kind of presentation, with really no pelvic floor stuff. They're healthy, they're young, maybe they haven't had kids, they are an athlete, they're. Everything else about their presentation is really like oh gosh, why do you have sciatica? I'm not sure, and they've failed treatment from three other orthopedic therapists Like that person.
Speaker 1:I'm curious. But if they don't have any of those secondary bowel complaints, if they don't have anything in their history, if they have never fallen on their tailbone, if they, it's kind of like there just really wouldn't be a reason to do it. And so you're kind of like, yeah, I think you're super ortho, maybe you'd get away with doing a transvaginal assessment on that person just to check their pelvic floor, to see if there's a pelvic floor component going on, and then. But to go to the rectal category, it would be like, oh yeah, like that, pretty unnecessary, pretty like there's a lot of steps before that that we would want to go to.
Speaker 2:Would somebody who's coming in for, like, a check in pregnancy be in that category too of like that you know? Hey, I'm in the second trimester. I heard this is really important. Everything's feeling great. Actually Just wanted to make sure everything was going good and have a great delivery. Is that person in that?
Speaker 1:Yeah, that person is someone that you know maybe do a transvaginal pelvic floor assessment on, and then you're not like, oh it's really important for me to double check your pelvic floor rectally, Unless you know they either wanted that or there's some other reason in their history that that would bump up the importance level. So that's a good example too of, like you know, we're not rushing to do a rectal assessment. Now, if we start to do, you know if they all of a sudden start, if we do a transvaginal assessment and they have an elevated perineal body and they have really problematic area at their 5 to 7 o'clock, we are having a trouble doing perineal massage because of that. Now, all of a sudden that goes into that important category, because now they have perineal dysfunction and there's an anatomical reason why we would want to do the rectal assessment.
Speaker 2:Okay, interesting. So I think and I know you go through this in so much more detail but to me, one of the big takeaways just from this conversation being completely ignorant myself is that three quarters of people belong in either the crucial or important category, almost by definition, and it might be higher than that.
Speaker 1:Yeah, for sure, and then we do go over that. I mean, that's like the biggest takeaway of the whole thing is that more people. This needs to be explored in more people than we're probably doing. It as a whole.
Speaker 2:We're very much, as a profession, then, airing on the side of doing it far too few. That's not the right way to say that. Yeah, not enough, or not we're airing on the side of doing it not enough. You've never met somebody who you felt was airing on doing rectal too much.
Speaker 1:Right. Or, and the other issue that we see right is that they're doing it not early enough in the plan of care, so we're deferring it because we're basically essentially placing it in the unnecessary category until we're using it as a last resort. And what we're trying to do in this framework is flip that and give you real reasons why it's basically crucial or important for most folks. That you see and you guys know how much of an anatomy nerd I am but, like anatomy, here is the key and that's one of the biggest reasons why most people fall at least in the important category, because the anatomical indications are there and that might be some of the reason why, the underlying why behind, why someone's not getting better, why someone has presenting in the way that they are, even though they don't have a primary bowel complaint, and that's huge.
Speaker 2:You know this reminds me of. There's a phrase that comes out of medicine, and I don't know if this is like ubiquitous in physical therapy side, but you know, when you're diagnosing things, think. You know you hear hoof beats, think horses, not zebras. And I feel like that's such a misunderstood phrase because the problem is is, nobody knows what the fuck a horse is versus a zebra is.
Speaker 2:And but what you're saying with this is basically, like your assumption, the horse, the thing that's more common is that rectal evaluation treatment is crucial or important. That should be where the assumption is, until proven otherwise, instead of it being the opposite, which is the way that's probably being done and taught now. It's like, oh, rectal is unnecessary, unless it's super obvious that it is, and you're saying, hey, we need to flip that on its head. We need to basically be making the assumption that, like, it's probably going to be at least important, if not crucial, until something proves otherwise. And you're almost. I love how, when you describe these, you almost sound incredulous, Like if somebody's in the unnecessary category, like wait what you have no history of constipation, no bowel issues at all, no history of a fallen tailbone like huh and you're in here, right, okay, that's the other thing.
Speaker 1:And please do not forget, folks, that the patients that are coming into your office have a problem. We're not doing this to people that are just randomly off the street, that are have no issue at all. And I think that sometimes where, like well, you're just doing rectal willy-nilly on everybody and it's like no, I mean the person sitting in our office, they have a pelvic floor issue, they have symptoms that are related to their pelvic floor. The pelvic floor literally slings across these access points and why are we only choosing one of them? That's what's so nuts. It's not like we're just putting fingers up buttholes all over the place and like it's like no, that's not it. They're sitting in front of your office, they're saying I have a problem, and so that's where, in that unnecessary category, those are the people that are. They're sitting in your office.
Speaker 1:They maybe got to you in sort of a roundabout way a friend of a friend of a friend who actually has a pelvic floor dysfunction problems. So this physical therapist is so amazing. And they were like this has happened to us at Pelvic Sanity. I know you have this place called Pelvic Sanity. I actually did not even want to fill out your form because it's so like has all these symptoms that I've never had. I never have had like I don't have these things right now, but my back hurts. Can you help me? My friend of a friend said that you're amazing. That's the kind of person where I'm like you know what. Let's just not go there right now, where I might not even do a transvaginal assessment on those folks unless and until I really take a deep dive into their history and figure out is there any reason why I would believe that there's a pelvic floor problem to this person?
Speaker 1:And now, you can now start talking about. Well, if they have a history of lumbar spine pain and SI joint pain, now all of a sudden their history comes in and they can go into that important category. But all that is to say is that the unnecessary category is really, really small, and it's usually because it's like some sort of tangential reason why that person is even in your office in the first place, because most people that are coming into our pelvic floor specific clinics have a pelvic floor specific problem and we need to assess the pelvic floor then in the most thorough way possible, which can and should and usually does At least have rectal treatment as an important or crucial part of that assessment.
Speaker 2:Got it. So, for those of you guys who are just listening in, I hope this framework has been really helpful. Again, that's analyzing whether you feel like and this is going back to clinical honesty whether you feel like rectal evaluation and treatment is crucial, important, helpful or unnecessary. If you guys do want to take a deeper dive into this, with case studies and understanding all of the caveats and all the different things that go into each one of these things, that is what the course is for. That is going to open up If you're listening to this on the day it drops.
Speaker 2:It opens up on the 23rd of October, so that's a week away. Make sure you are on the waitlist. You can get on that at pelvicptrisingcom slash rectal but you'll get $50 off the course. We'll do the live Q&A, all of the things. That's going to be really transformative. It's. I know something, nicole, you think it's just so important and so overlooked in the field. You guys are on the fence. I hope you guys are looking at that and seeing if it's right for you and your practice at this point. So, as always, if you have questions, please reach out. Please let us know. We hope this has been helpful for you guys. We want to keep this conversation going and let's continue to rise.