Pelvic Pain Unplugged: Expert Insights with Dr Sandy Hilton

In this episode Dr Sandy Hilton shares with us how we can approach pelvic pain in a more healthy manner as young clinicians. Including how we can help people without internal assessments and even without internal treatments. She describes it as a spectrum of information gathering.

👉🏻 See Sandy’s full Research Review here - https://physio.network/reviews-hilton

Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with a neurologic and orthopedic emphasis including a focus in pelvic rehabilitation for pain and dysfunction.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is Michael Rizk (@ThatPhysioGuy)

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

UNKNOWN 0:00

Thank you.

SPEAKER_02 0:05

We've got level one evidence for the treatment of incontinence, urinary incontinence specifically. And it's something like 86% of people who are retrained in pelvic muscle function and bladder habits and good breath control will completely resolve their symptoms in up to 12 weeks. And that's fabulous because we don't have that for very much in physical therapy.

UNKNOWN 0:30

Music

SPEAKER_01 0:30

Pelvic pain can be quite a complex and daunting area for young clinicians, so today we had Dr. Sandy Hilton on the podcast. Sandy teaches and speaks internationally, and she also covers a lot on how we can apply pain science to this area. I particularly found interesting the part on do we need to do internal assessments to be able to help people with pelvic pain. Sandy's done a research review on this, and if you're interested in our research reviews and applying the research to practice, please check out the show notes. Enjoy this episode. Welcome, Sandy. Thank you for joining us.

SPEAKER_02 1:11

I'm so glad to be here. Thanks for having me.

SPEAKER_01 1:13

We had a really awesome off-air conversation about all things pelvic pain, but this first question, how does the current understanding of pain apply to pelvic pain? What are your thoughts around that?

SPEAKER_02 1:23

I think that all of the structures through the pelvis and the viscera are part of the human just like everything else. So everything that we've studied with hypertonicity, with what to do with muscle spasm, they're still muscles even if they're on the inside of the pelvis. Much of what we do has to do with the spinal roots. So things that are on back pain pertain. All the pain research on what to do, how to explain pain, kind of unscare it, same because we're dealing with a human. And even more, the parts that are involved with peeing and pooping and sex and sitting are so important to everyday life and all of it's supposed to feel good. So when in pelvic conditions, you get something that should be good and rewarding that now is painful and aversive, it matters huge. So we pull all of that research and use it.

SPEAKER_01 2:15

Is this question framed because I've certainly found this in my experience. I wonder what yours is like. Do young clinicians or clinicians in general view pelvic pain is different? Is that something you've experienced?

SPEAKER_02 2:27

Oh, I'm rather old in the field of physical therapy. My students have been like, sometimes felt really intimidated by it. I think it's sold like, okay, you're a PT, but you've got to go take all these super secret classes and get the decoder ring to be able to do pelvic health. But they still are parts of a human. And the fabulous people that started classes in pelvic health still had to teach themselves based on what they knew as physical therapists. and put the courses together so people coming along later didn't have to reinvent that structure. But I think a lot of it has been the shame of humans. The original Oswestry has a sex question on it, and then they... redid it in 2001, I think. It's a huge problem for me because I was in the States using the original Oswestry, moved to Germany for three years, came back and went to pull one at the clinic I was working on and literally standing in the lobby going, who took the sex question? Because they had revised it to remove that question so they didn't have to ask it We have all of this training in biopsychosocial and treating the whole person. But if you think sex is icky and you don't want it on your form, are you really treating the whole person, dealing with things that matter to them? Does revising a form to take the icky sex stuff off

SPEAKER_01 3:49

helpful? There's a fear of a difficult conversation.

SPEAKER_02 3:52

Right. And there's people who don't want to talk about it at all. And sometimes it's their own experiences. So I don't think working in pelvic health is for everyone. People understand if you're afraid to do the thing you're asking them to do. Like me trying to get someone to do those really high box jumps. You can tell that I can't do it and jumping on that box would be a little terrifying.

SPEAKER_01 4:14

There's obviously a pre-framing if you're going to a pelvic clinic, which so many of them are named. Would you have any tips for those practitioners in a normal clinic? I put in quotations. to approach those questions where they could do it in a more sensitive way where that pre-framing is not there if they need to ask those questions?

SPEAKER_02 4:35

I think the onus is on us as clinicians to not make something awkward. And it's only awkward if we make it awkward, but you might want to have some practice in how to ask about Do you have pain when you have bowel movements without blushing or getting that awkward hesitation? So you might need to practice it a little bit with friends and family. It should make for really fun conversations. But the data on both men and women that have pelvic pain or constipation issues, which can lead to pelvic pain or continence issues is massive. It's more likely someone has had something happen to them than not.

SPEAKER_00 5:15

Would you touch on those numbers that you mentioned off there that

SPEAKER_01 5:37

it's level one evidence and that I think it was in the 80s percentile that people get better?

SPEAKER_02 5:47

For incontinence?

SPEAKER_01 5:48

Yes.

SPEAKER_02 5:49

I wish that was true with pain. But for incontinence, yes, CARIBO's research has shown we've got level one evidence for the treatment of incontinence, urinary incontinence specifically. And it's something like 86% of people who are retrained in pelvic muscle function and bladder habits and good breath control will completely resolve their symptoms in up to 12 weeks. And that's fabulous because we don't have that for very much in physical therapy. So incontinence for sure is under-referred and under-utilized. Even though pelvic health therapists are really busy all around the planet, there's people that aren't getting to the care for far too long. We've barely started reaching out to young women that are starting to have periods and having pain to get them to come in so that they don't have to suffer every month to learn how to Relax the muscles if everything clamps up and how to self-treat their discomfort so they don't have to suffer. And there's just too many people that need help.

SPEAKER_01 6:49

That's a really good point you come to, but self-treatment. We wanted to touch on that. And there's self-treatment, then there's do you need to be able to do internal exams to help patients? Mm-hmm. So could you speak to self-treatment for pelvic pain? What does that look like? And do you find that effective? And I know you do online consults as well. So you could even speak to that.

SPEAKER_02 7:11

Highly biased about my idea that, yes, there's self-treatment for pelvic pain. We teach that for everything. I don't think the pelvis should be any different. The problem is the logistics can be tricky because if my hand hurts and I want to desensitize it, I could rub it while I wait for my turn in the grocery store. That's not happening for pelvic parts, hopefully. Yeah. the grocery store while you wait. So there's a logistic thing and you can't hang out in your living room with your family around doing work with dilators or rectal relaxation techniques. So you need some privacy. You need a safe place for it because the pelvic muscles tighten if you feel threatened. So the therapist that's working with you needs to not be a threat. The Techniques you're doing for yourself need to not feel threatening, or your pelvic muscles will stiffen and tighten, and then you're not going to make progress. So it's a matter of aiming what you can do as self-treatment for what logistically works in your life, what materials you have available, and things that you don't find noxious or challenging. overly confronting. Just like in sports training, you need enough to make a difference, but not so much it's torture. Very much important in the pelvic health with the reflexive nature of the structures. Do you need to do an internal? The answer to that has to be no, because there are plenty of people for many reasons who refuse to have internal assessments. They can still get better. It has to be the patient's choice whether or not we do it. We can certainly find out the most with a well-done vaginal or rectal exam. And we can still find a lot with just a visual exam. And we can still help people that are like, you know what, I'm not comfortable getting undressed at all. Talk me through what you want me to do. The answer to that has to be yes. It's just levels of information that we're able to get, which is why you can do telehealth for pelvic health too. Because while I'm missing information, I can walk a person through what to try and feed back that information to me. And just like with treating pain in general, it's a matter of trusting the person. A lot of times with telehealth, it's like, okay, I've taken you as far as I can without more info. Let me find you some local people that you can go do an internal exam with if you're willing to do that. But yeah, we can do a lot. Even in those clinics where there's just no private space, you can still do a lot.

SPEAKER_01 9:38

Yeah. What does that look like as much as you're comfortable to share? I had an experience with a men's health physio. I was having pelvic pain for 12 to 18 months. And a lot of it was breathing, relaxation, doing some work on my adductors, which were fired up. And a lot of that didn't require internal or anything internal for me to do as well. What does some of the stock standard treatments look like with or without the internal exam?

SPEAKER_02 10:06

Well, one thing we should have are stock standard treatments, but we don't because there's a lot of research that's underway just to establish norms. Then we could have good reliability studies, et cetera, et cetera. But field testing, what a lot of things look like is if the tissues are overly painful and don't allow normal touch and pressure, then the first step would be calming that down. So desensitization techniques, which like you would do anywhere, would be either temperature or... progressive from light touch to firmer pressure to movement, whether that's on the perineum or vaginally or rectally, based on the symptoms and what's helping them the most. Fingers work great. Partners can help. For places where it's available or legal, you can have dildos or dilators. It's important if you're doing, for anyone listening to this, if you're doing any rectal work, which is important because it can be life-changing. If someone's using something rectally, it has to be something made specific to be safe in the rectum because rectal tissue pulls things up and in. And any ER physician can tell you about the things they've had to retrieve. I think it's important to not create an ER visit. So it has to have a flare on the end so that it's not going to get sucked up inside the body. Working vaginally, it's a matter of preference. Things that are made to be inside the body, that aren't porous, that aren't going to be transmitting any bacteria to the internal cavity. It's a little more complicated than working on hands, but a lot of similarity into ways you could restore normal sensitivity and decrease a muscle spasm. A lot of times with pelvic pain, we want to check to make sure the muscles aren't just in a wad and haven't forgotten how to relax.

SPEAKER_01 11:54

I'm thinking of a lot of patients that never got The internal work from a therapist or did internal work themselves that got better, is that a large percentage of what you see? And I'm thinking for younger therapists as well, can they get to a place where they can help without doing internal or advising internal work? And does that come to breathing, releasing, strengthening, everything around? Or is that not common?

SPEAKER_02 12:21

Yes, what you said, breathing, relaxing. Not so much strengthening usually as getting that selective relaxation and coordination so that you're using the muscles appropriate to the task and not overly like you would with any sport or dance or gracefulness. Restoring gracefulness to your pelvic floor. That you can get your own biofeedback externally like sitting on a large therapy ball. because of the convex nature of the ball. When you put yourself on it, it molds to the surface. So you have all of that sensory input. You can use that surface to lift away from it and relax down onto it and practice doing that with different kinds of breathing, with different arm and leg movements. It's a biofeedback body awareness way. You have feedback with your ability to pee and poop and your tolerance for intercourse. So yeah, There's some creative helps to have privacy when discussing the programs kind of way.

SPEAKER_01 13:20

Yeah. I had one more question that was coming to mind for me was where would you recommend people learn about this, young clinicians learn about this at a base level where they feel like they can help or at least start the journey of health for most of their patients? And I'm thinking of the private practices where maybe pelvic health isn't to the forefront. Mm-hmm. Would you have a great resource or a few resources where you would start?

SPEAKER_02 13:48

Yes, there are some fabulous ones. It still tends to be very like there's girl information, there's boy information. And I really would like it to just be pelvic information. But Julie Weeb works all external. She's a physio here in the US. She has a lot of really good information online. Sarah Haig, my business partner with Entropy, teaches a course of pelvic health for the non-pelvic therapists. I have a couple books out that would be helpful. There's Laurie Forner down in Australia has a fabulous podcast with all sorts of information. It goes back years now, and it's just a wealth of great ideas and clinicians that have good ideas. Jilly Bond is up in England. She has fabulous information out there. For the gents, Carl Monaghan.com. has a really good podcast. Tom Astle, I don't know if he's active much. He was a researcher out of South Australia doing really good stuff in men's health, but I don't know where he is now.

SPEAKER_01 14:45

The very first course I did in this was Julie Wiebe's online course. And I think I did that seven or eight years ago, my third year as a physio. I still remember it. And it really empowered me to help a lot more people, even though I was predominantly treating shoulders and backs and knees. It was amazing how many people... could benefit from that kind of help, even when it was just a knee or just a back. It often wasn't. So I'm glad you mentioned all of those. Thank you.

SPEAKER_02 15:09

Yeah, it's a wealth of information and it's really a moving target because there is really good knowledge coming out all the time.

SPEAKER_01 15:16

Sandy, thank you so much for your time. And I'm going to mention this, but it's 1am where you are, so it deserves a special mention. So this was a really thorough and informative podcast for young and experienced clinicians alike. So thank you so much.

SPEAKER_02 15:29

Oh, you're so welcome. It's fun and we need more people.

SPEAKER_01 15:33

Absolutely.

UNKNOWN 15:34

Thank you.