OT Pioneers: Intro to Pelvic Floor Therapy for Occupational Therapists
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Pelvic OTPs United -- Lindsey's off-line interactive community for $39 a month!
Inside Pelvic OTPs United you'll find:
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OT Pioneers: Intro to Pelvic Floor Therapy for Occupational Therapists
____________________________________________________________________________________________
Pelvic OTPs United -- Lindsey's off-line interactive community for $39 a month!
Inside Pelvic OTPs United you'll find:
...
Today's podcast is deeply personal, <laugh>, and a little bit like my manifesto into becoming a pelvic floor ot. I wanna share with you my six core values or guiding principles that I have stepped into over the last 11 years. And as I think you're gonna see <laugh>, this step did not happen overnight. All right, let's start off with those guiding principles and then I'm gonna talk you through how I got there. So my six guiding principles of a pelvic floor OT are number one being trauma informed. And this goes beyond providing explicit informed consent. Number two, embracing a facilitator versus a fixer mentality. Number three, looking at every aspect of my treatment sessions through an occupationally centered approach. Number four, empowerment through education. Number five, evaluating through the lens of a nervous system based approach. This involves things like interception, polyvagal, and at its simplest form, compassion and curiosity, and last step integration of a psychosocial approach.
(02:25)
All right, Notice <laugh>, notice that orthopedics or biomechanical skills were missing on my list. Now, before you turn this podcast off, this doesn't mean that I don't use them, study them or respect them, but is my firm belief that we need to continually check in with our own core values as OTs when we step into a PT dominated field, Right? And pelvic health is a PT dominated field. The traditional, the common courses that are out there, they have loud voices, <laugh>, but ours can't be quiet. You see my journey, the more I leaned into it, the more I understood what I believed pelvic floor therapy could be through an OT lens, my own voice became so loud that I couldn't ignore it. If I had continued down that path of what was expected of me, what I expected of myself, honestly, I would've experienced burnout. And I think a huge disillusionment. You see, touch is important, but it's only one component of establishing trust with our clients To illuminate their path to change impairment of the pelvic floor requires a whole person, whole body approach.
(04:09)
Everything we do has to be psychologically informed. We are always working with the whole person. So when I first got started in pelvic floor therapy in 2011, I took all the PT based courses. I had to, There was literally only one OT course I knew about. A special shout out to Tiffany Lee, who has profoundly shifted my focus back then and gave me the belief that I could do this. But the other cs, they were PT led, and I really felt like I was a salmon swimming upstream. Okay? I did it. I learned it. I incorporated techniques, but I felt inauthentic. I felt like I was fitting a round peg into a square hole. <laugh>. I asked myself, Is this all pelvic floor therapy? Could be something was missing. I was overwhelmed. I was disillusioned. I felt like the courses were trying to teach us that one magical manual therapy technique that fixes our clients' pelvic floors, and every course had that magical manual therapy technique.
(05:33)
But here's the thing that I found that that really helped me get back on track issues like NIA and cons, constipation, their whole body issues and pain is not one factor. It's not just mechanics. It's not just posture or lifestyle or behavior or socioeconomic factors. It's multifactorial. So each course has its technique, its way to fix our clients. But here's the thing, I never wanted to fix anyone. I wanted to empower them. I wanted to help my clients to see that they could be the detective to their own bodies. And this is what lit me up. This is where I got excited. I leaned into myself as I was a good student, learning these techniques, learning these classes, and I stopped getting excited. So I asked myself, what was I excited about? And it was this. It was helping my clients to be the detectives to their own bodies.
(06:45)
And this is the gateway to self-efficacy. And self-efficacy is a strong OT value. Our physical work has to be psychologically informed. So I started to see that I was leaving OT at the door of each and every one of my sessions. The reason I found it to begin with, the reason I chose OT over PT school was our occupationally centered approach. The focus on the whole person, our desire to facilitate versus to fix. This is naturally how I see the world, right? The OT lens is really deeply natural to me. And when I rediscovered it, I started to incorporate principles of it back into my private practice In New York City, I felt less burnout. I felt more authentic. I felt like the person I imagined I would be in sessions with my clients. Now, <laugh>, the way I talk about this, it seems like I did this overnight.
(07:59)
No, no, no, my friends, this was a long, slow journey. The loud voices of biomechanics were powerful. I thought I had to be a PT in OTs clothing, but every time I read research articles red blogs, listened to podcasts, I found things that told me to look elsewhere. I remember I came across in 2011, a meta-analysis by Adrian Lowe that showed that learning about pain science reduces pain on average by 30% as a standalone treatment. This is powerful. And it reminded me why I needed to bring together mind and body and why I needed to bring together, together education as well as physical based techniques, gut health, pain science, bowel health, movement strategies, sleep hygiene, all can be approached in a psychologically informed way. So I decided to incorporate one thing at a time. So literally one client a day, I tried a new technique.
(09:22)
I tried something that really resonated with me or inspired me. So one day I asked a client, What do you think will help? Now, this was a client who I had probably seen four or five or six times, and we just weren't making the progress that she had hoped we would make. And so I said, What do you think will help? And I just waited. I waited. I held space as this client thought through this question for perhaps the first time, and guess what? She answered her own question, and it was exactly what she needed to get better. It came from her own wisdom. I didn't prescribe something. I didn't guess what she needed. This is the power of self-efficacy and reminding people that the answers are inside of them. I was reminded we don't fix people. We hold space as they do. So the next time I tried leaning more into trauma informed care, all the courses I took told me that a large percentage of our clients will have experienced little tea or big tea trauma, especially in pelvic health, right?
(10:46)
I'm sure you've heard this in your coursework. They tell us, Okay, you're in pelvic health. Your client has had some variation of trauma, but that was it. That was it. They didn't say what I was supposed to do with this. I was left wondering, Okay, what's next? What do we do then? How could I then take the next step? So I researched it. I read everything I could. I listened to every podcast I could, and I started saying more often things to clients, We can stop time. I know you checked yes for an internal exam on your paperwork that you filled out, but you know what? At any time, we can stop. We don't have to do that next step or that thing again. Next time I started sharing things like, Hey, what do you think about? We start to incorporate the things that we're doing together inside our session, outside of our session.
(11:54)
I don't want you to come here two or three times a week while I do to you. We're a team. I started saying things like, Is there anything I've asked you to do that you're hesitant about or that you're concerned about, or that you have questions about? I stopped assuming that their home exercise program was a given, that they knew what to do with a crumpled up piece of paper that was over copied. They knew what to do with that, and they knew where they were gonna do it. So sometimes in pelvic floor therapy, we may give a client and a homework assignment of vibrator work or looking in a mirror and seeing their pelvic floor move very personal, deeply personal work. Do we ever stop to say, When do you think you can find time to do this? Where do you feel most comfortable doing this work?
(12:54)
They're often living with other people. Perhaps. My private practice specialized on pre and postnatal people, and so they often had a toddler at home, and this is work we're asking them to be mindful of, and we're just assuming that they're connecting the dots as to when and where they can do this. But when I stopped giving out an copied piece of paper and as self-conscious and nervous as I was, I started recording audio versions of walking them through their homework or even a video version of the exercise I wanted them to do. I didn't care if the background looked beautiful or if the sound was right. I just knew that they wanted to feel supported by the same person that they shared deeply intimate information with, and maybe used the same words that they heard in their session with me again when they watched the exercise video.
(13:53)
So I got away from this prescribed model. I leaned more into personalization and then taking it a step further by saying, Do you have time for this? Can you imagine yourself doing this? And where and when and how much time do you have to do this? You see, I wanted them to learn to trust their body again, to find joy in movement, to find joy in their occupations. This is the whole spectrum of what it means to be human. None of it is separate. It's all interconnected. And I thought more deeply about what is the impact of what I'm saying? So as rehab professionals, we will often say things in therapy, I don't know. Your back is unstable your pelvis is unstable. How is this heard? Why does anyone say something like this to anyone? How do we actually know their pelvis is unstable? And more importantly, how does this help them?
(15:00)
<laugh>? You see, this is the definition of a nocebo effect. A nocebo effect is when a negative expectation of a client causes a more negative effect than it would've otherwise. So I started thinking deeply about my language and what kind of effect it could happen on another person. I started doing research about additional ways I could start my sessions out with clients. So I came across something called the central sensitization inventory. I'm gonna link more information in in the show notes, but I was like, You know what? I'm gonna add this into my intake paperwork. So in a nutshell, if clients score greater than 40 on their central sensitization score, it indicates they have central sensitization. What is central sensitization? So the formal definition is increased responsiveness of no ceps in the central nervous system to either normal or sub-threshold input resulting in hypersensitivity. So once I came across this, I thought, what a great screening tool, because if they're greater than 40, when they take this inventory, there is no point in doing hands on work.
(16:23)
This is going to be counter in productive. This is going to be counterproductive to them meeting their goals. So we need to know this before we start laying hands on anyone. I think so many times in pelvic floor therapy, we assume the client assumes that there's hands on work, that there is internal work that has to happen, that it's the mechanism for healing, for being fixed, fixed. I can tell you right now that if they have a central sensitization, that is not going to be the approach that is going to be the most beneficial for their client. So if we determine that it is beneficial, we always do it through a sub threat manual therapy approach. This could be through somatic work, visceral work, mfr, dry needling, whatever your approach is. It could be that you have a background in C B T and motivational interviewing.
(17:26)
All of this is fantastic because our work is not operating in a silo. It's part of an integrated system. And so no matter what modality we're using, I ask you to think about how does this inform what we do with our hands? How does this inform what we do in our treatment sessions with our clients? We can tap into light touch listening, touch direct touch, all to with the goal of informing our clients' brain map. So in my own practice, I started leaning into concepts of sensory-based approaches to essentially improve inter reception of the client in front of me. I started asking them things like, Where are you resilient? What is your body doing right now to help you? Awesome. Now let's build on those, right? And listening to what they crave and what their own body is leading them to is how we in the moment decide which of the variety of tools we're gonna tap into.
(18:39)
So let's face it, we are lifelong learners. We're information junkies. I'm sure everyone listening to this podcast has been to at least five courses this year. It might be a minor exaggeration, but we are overeducated. We are always seeking for tools to help. So before you take your next course, let me ask you, are you listening to your client? And are you leaning into their wisdom to help guide which one of those tools you're going to use today? Right? And I based my home exercise protocol on this, not what progression made the most sense. So after leg slides, we go to clam shells. After clam shells, we go to blah, blah, blah, blah. This is so boring. This is so boring. This is not why I got into therapy. How does leg slides inspire a client to be more present in their body? How about asking them to check in with their jaw while they unload the dishwasher?
(19:43)
Or how about we turn the mindfulness of the mundane into a nervous system reset? So when our clients are using ADLs, like lifting their baby from the ground or emptying the bottom rung of the dishwasher, why don't we use these as opportunities to not just get through this activity, but to check in with their pelvis and their neck positioning as they hinge or ask, are they holding their breath to better manage their interabdominal pressure when they're lifting that huge stock pot out from the dishwasher? Right? When we do this, this activity becomes mindful, almost like a sensory anchoring activity of focusing on the here and now. Who needs to squeeze in 10 clam shells at the end of the day, when we can use our life, our environment, our occupations, as a way to reengage and heal, and when these activities become mindful in this really simple way, I have found that that nervous system steps into that parasympathetic flow of really feeling settled, right?
(20:54)
This alone, this ritual of stepping into calmness in small, very frequent moments throughout our day. This dramatically helps the pelvic floor. We know that when we work with the pelvic floor, we are working with the nervous system. So weaving and feelings of safety and belonging are so important in our client's healing journey. And as OTs, we know that sometimes it's about navigating a new role. We know the power of roles, habits, and routines. I'm thinking about a client who was a college student who came to see me for painful intimacy, but she had constipation and SIBO and diarrhea and a host of gut issues. And by understanding her routine as a student, the impact of stress that her graduate program had on her system, how she didn't wanna go to the bathroom on campus and would keep it in all day until she got home, the stress going into meal prep, she was on a strict diet due to her SIBO diagnosis, right?
(22:02)
The loss of enjoyment in meal prep and eating, heightened her nervous system state with school and how it impacted elimination. So she had developed an overactive pelvic floor leading to her reports, which were painful, intimacy and pain with sitting. Again. This shift of role change had a ripple effect on so many areas of her life, and it impacted her pelvic floor. It was so much more complex than a simple diagnosis. It was so much more than just hands on work. We are so much more than just a pelvic floor therapist. As OTs, we literally address the pelvic floor in the context of what matters most to our clients. We facilitate a more meaningful life for our clients by leaning into all of the factors that impact one another. They see it for the interrelated system that it is. They feel empowered, extrinsically, and intrinsically motivated to do something about it.
(23:12)
Manual therapy affects the neuro pathways between our brain and body, right? It's a nervous system modality. It does not put things back in place or lengthen or melt tissue. It literally changes the chemical systems through the nervous system. So we are agents of change of the nervous system, and however you get there, fantastic. I love you for it. Your clients love you for it. You got into pelvic floor therapy to do this, and this is a deeply personal podcast about how I have found it was more powerful to encourage a client to facilitate their own recovery. As Laura Moore, Mosley says, The body has an irresistible urge to heal. We need to stay out of the way or help facilitate it. And so guess what happened? I had all my orthopedic skills in my toolbox that I spent years cultivating, and I personally saw that by leaning into the nervous system and trauma informed care, I needed them less and less.
(24:31)
I started doing pelvic floor internal exams. I don't know, around session three or four, if I saw that the other skills I was using weren't getting my client closer to their own goals, by the way, not the goals I had for them, the goals that they had for themselves. I woven motor planning simple nervous system down, regulating skills, posture work, occupationally centered ADL work. They were getting better faster. Then when I rocked in with an internal exam on session one, telling them that their lava anti was hypertonic, I found myself wondering, is it really the pelvis that was the issue? Or are there other things going on elsewhere? And if we help them find center empowerment, stability in everyday activities, a sense of self-efficacy, could things co-regulate? I would incorporate test and retest strategies and ask them, Well, what does that do when you do this?
(25:41)
When you try that, What was their experience in their body? How did our work change their balance? I don't know. Their efficiency of movement their sensation. And then when I would ask them this, I would use their own language. So let's say we did a nervous system down regulating activity, and afterwards they said I feel my foot now. Well, I would use this term. And then I would follow up with, Well, how is that for you? And I give them a chance to assess it, right? Sometimes the change is so sudden that they're not even sure. And so giving them time to process, knowing that they have time, that you're facilitating time for them to process is so important. And I didn't just assume that the shift we did was better. I remained curious. What was their interpretation of it? After all, I'm there to help them reach their goals, not mine.
(26:44)
So I found our work was, I don't know, quite frankly, more neuro than motor or manual. We simply can't strengthen a muscle that our brain and nervous system isn't using. So we could use verbal cues, we could tape them, we can dry needle it, we can use our hands. We could use motivational interviewing and somatic work and Alexander technique to see if change happens. And for me, ortho based approach, it didn't click with me. I was overwhelmed. I needed a person-centered person first approach, and I didn't find that ortho gave that to me. So my journey was that I started trying and structuring more what I call trauma informed work into my sessions. I found ways to do that because my courses, the courses I were taking weren't incorporating that. So my dear friend Laura DeRosier introduced me to a book called Trauma and Recovery.
(27:55)
And in that book, Judith Herman says that core experiences of psychological trauma are disempowerment and disconnection. So disempowerment is like a decreased sense of personal control over your life or your environment. And disconnection is when you feel separate from others. So Herman says that the guiding principles of all recovery are Reem, empowerment and reestablishment of new and meaningful relationships. And when I read this, and when Laura shared this with me, I thought, This makes me think of choice, right? So simple things. When a client walks into your treatment room, instead of saying, You can sit right there asking them, Where do you wanna sit? Where would you like to be right now? This is so simple, but it's giving them an agency of control, an agency of empowerment, And we all crave empowerment and connection, which brings compassion and curiosity. So my friends, I started leaning into this more and more, and I didn't throw my manual techniques away.
(29:08)
I am so glad I have them <laugh>. I worked my little butt off for them. But I think the purpose of this podcast is to remind you to lean into your truest sense of self as you develop your career as a pelvic floor occupational therapist. Listen to that inner voice. There is no one way to ot. There is not one way to help your clients. There is only the way that calls you, The way that helps you show up authentically. Listen to that voice, find the leaders, the books, and the community that guides you there. Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to ig, Facebook, wherever you post your stuff. And be sure to tag me and let me know why you like this episode. This will help me to create in the future what you wanna hear more of. Thanks again for listening to the OTs and Pelvic Health Podcast.