The Top Down Approach To Pelvic Health: Why Occupational Routines Matter

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References from Hannah:

• Occupational Therapy Practice Framework: Domain and Process-Fourth Edition. (2020). The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 74(Supplement_2), 7412410010p1–7412410010p87. https://doi.org/10.5014/ajot.2020.74S2001

• Fisher, A. G., & Marterella, A. (2019). Powerful practice: A model for authentic occupational therapy. Center for Innovative OT Solutions, Inc.

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Transcript

Lindsey Vestal Have you ever wondered what what special sauce is in Pelvic health? Do you want to know more about its unique role in supporting clients in occupational routines? We go there today. It is one of my very favorite topics. It is so uniquely O.T.. 

Intro New and seasoned OTs are finding their calling in Pelvic health. After all, what's more ADL than sex, peeing and poop? But here's the question. What does it take to become a successful, fulfilled and thriving OT in Pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions and this podcast will give you the answers. We are inspired, OTs. We are out of the box, OTs. We are Pelvic health OTs. I'm your host, Lindsey Vestal, and welcome to the OTs and Pelvic health Podcast. 

Lindsey Vestal I want to share a little bit about Hannah Schoener. She's the otter who I talk with today in our episode, all about occupational routines. Now, Hannah graduated from Colorado State University in 2021, and she's officially been an O.T. for a year. She's a contributing author of a case series that identifies women's experiences receiving O.T. for pelvic floor dysfunction. Hannah has a deeply rooted passion for women's health on her journey to discovering her home in pelvic floor O.T.. She completed training as a Dula assisted in midwife led trauma informed yoga classes, and taught ESL women's health classes in her community. She currently works in pediatrics, where she supports kids in all of their daily occupations, including those related to toileting and pelvic health. Hannah's meaningful occupations include cross-country skiing, throwing pottery, going on road trips, and spending quality time with friends and family. Hannah, my dear. Today we're going to be discussing the unique role OTS play in supporting clients in their occupational routines. And I have to admit, this is probably one of my very favorite conversations because it gets back to the very essence of what O-t is. And you and I are going to specifically focus on Pelvic health, which I think I cannot talk about enough. The relationship between both routines and the OTs approach as it relates to Pelvic health. So thank you so much for being here. 

Hannah Schoener Thank you so much for having me. Lindsey I am just so excited to talk about this too. And since we did our chat on The OTs for Pelvic health Facebook group, I have just been thinking about this nonstop and so excited to continue our conversation. 

Lindsey Vestal Yeah, and we had so many comments come in after our Empower hour and so many DMS that I know this is a riveting conversation for us all, So thanks for jumping over to the podcast with me and continuing this conversation. And I have to say, I want to get right into it. Will you please, Hannah, describe for us what it means to be a top down practitioner. 

Hannah Schoener So when I think of being a top down OTC practitioner, I kind of revisit my memories from old school. And when we see a client for the first time as a top down practitioner, the first things that we're thinking about are. What does this client value? And are they able to do the things that they value? And our biggest concern as a top down practitioner is helping them do the important things in their day. That they're interested in doing. And so as a top down practitioner, we are not immediately looking at the body. We are not immediately looking at the mechanics of movement. We're looking at what does this client's schedule look like? Does this client have the ability to do all the hobbies that they want to do? Are they able to socialize in the ways that they want to socialize? And if you're having trouble remembering that key term top down practitioner, I invite you to look back at a textbook that you likely read in what school called powerful practice. And Lindsay, will you put that in the show notes for for our listeners to kind of check out if they're wanting to revisit that term? Absolutely. So when we think about that for pelvic floor health, it means that when we are a generalist O.T., we have the skills already in our pocket to look at a client's occupational profile and say, Hey, is this client leaking? Because they are in a routine that doesn't give them bathroom breaks. Rather than saying immediately, do they have musculature concerns? So as a top down practitioner, we're really thinking about the person and what they're doing every day rather than their deficits in their body first. 

Lindsey Vestal Why is this important? Why is this O.T.? 

Hannah Schoener I think the most important thing to think about here is that when we are pelvic floor clinicians, there are so many pelvic floor connection clinicians that work as a team. We have OB-GYNs, we have midwives, and we have parties. There are so many great individuals here working together to solve a client's issues, and we don't have to be experts on everything. We have the ability to refer to other disciplines when we're not experts so that the client gets the best plan of care. And rather than feeling like we need to be experts in the body, we need to be dietitians, experts on the client's diet, experts on the client's organs. We are experts in routines and roles and a client's ability to do the occupations that they love. And so that is our unique our unique superpower. And so when we are thinking of how to help our client, we have to remember that, they may never have had someone say, how does your routine affect your ability to affect the issues you're coming to me with? How does your routine affect your leaking? How does your routine affect sex? How does your routine affect pooping? And that is our unique role. No other practitioner is an expert in that. We are experts in that. And it's not only that we bring this special expertise to the table, it's also that no one else is in. So if we are not addressing that client's mental health and how that affects their continence, they may have no one that is that is doing that work. 

Lindsey Vestal And so you can't see me, but I basically just gave myself whiplash with the enthusiastic head nodding, my gosh, I'm so glad. And what what when you say this, Hannah, what it really makes me think about is we could have all of the best physical modalities we could have, all of the best hands on skills cultivated, which so many of us do. And if we're not stopping to look at that routine roles and habits piece, my question is, do is is the client going to get better? Right. Even if we address the lack of coordination, address the trigger points, address the the physical strength and tone, If if the other piece isn't looked at, are they going to get completely better? But what you also just said made me think a lot about the fact that we can be trained in the most sophisticated physical hands on techniques which many of the OTS in our community are. But if we're only using that as our treatment protocol, we're missing a big picture because even if our coordination is intact, our tone is restored. All of that, the trigger points are gone, you name it. If someone isn't stopping to ask how their routine is affecting what they're experiencing, I think they're missing a huge piece of the puzzle. So I think that it would be an incredible combination to have both at our disposal. And that's that is a superpower as well, because. We can if you feel inclined, if your intuition takes you there, take all of the physical, physical aspects, the movement courses, anything you want to do to add into your toolbox. But always coming back to that top down view of asking in that non hands on way how performance and participants and and routines are actually affecting the client's ability to participate. That's the whole package. And we can do that as occupational therapists. 

Hannah Schoener Right. I agree with you so much there, Lindsay, because I think we need to remember there's a reason why a client's musculature. Is out of whack. There's a reason. And so when we're talking about occupational roles and routines, we're using our our lens to kind of see what's going on in your routine that's affecting your pelvic floor health and how can we make sure that we adjust the routines so that after we kind of help you with with those physical modalities, you're not just going to return to having those problems because you have a routine that makes you susceptible to running into these issues again and again. 

Lindsey Vestal I love that. I love that. That that was spot on. Well, let's get this is great. Let's get a little bit into the practical now. So how Hannah would this look in practice? How are we using this knowledge of routines as this first solution? 

Hannah Schoener So to answer your question, I'm going to give you a couple of case studies. So the first case study I want to give you. Think of an older woman. She has constipation. And she's wheelchair bound. And maybe, as a lot of us do as we age, she has a little bit of arthritis. So immediately, if you were addressing the musculature, you might say, hey, is she able to push enough to go to the bathroom? Is she does she have the right, the right motor plan for for defecating? But as a top down practitioner, you might say, hey, who is this woman? What does she value? What does she do every day? What is her routine look like? And in practice, that might look like having her write down her routine. And I remember in one of your recent podcast episodes, Lindsay, you talked about bowel and bladder diaries and how we can use these diaries to begin a conversation about talking about a client's daily routine. And this is the perfect time to do that. How come right out the routine, what they do every day, what a typical day looks like for them. And then we can kind of dive into things a little deeper. So from a body mechanics point of view, you might be asking about the way that she's sitting on the toilet or her motor plan. But from a routine focused lens, you might say, Hey, after looking at your bowel and bladder diary, I'm noticing that when you go to therapy every week, when you go to your your party every week to work on your ability to stand or your ability to move your lower extremities a little bit better, I'm noticing that you don't go to the bathroom for about four hours on your way to and back from therapy. Is there a reason for that? And you might learn something there. Like when you see the routine, you might learn, hey, they're a little bit scared to drink a lot of water because there's not a wheelchair accessible toilet. Or you might learn, hey, they're a little bit embarrassed because they're not able to do to do proper, proper hygiene at their therapy office because they don't have access to their bidet or their wipes that they like to use when they're going to the bathroom. And then you're able to see their routine and make some adjustments. Another example is if they if you have their whole routine down and you notice, hey, you're in your wheelchair a lot of the day, could your constipation be possibly due to your lack of kind of getting up and moving throughout the day? Are there easy times that you can stand up out of your wheelchair to kind of get everything moving? And when we're looking at routines, we're not saying, hey, you need to change your whole day because that's not realistic. We're talking to our client and finding ways to eat slowly, incrementally and easily change their routine so they can just make slight adjustments to their day to reduce their constipation. And then we're not just focusing on like changing their musculature or having them do key goals or having them drink more water, although there's definitely a time for that. And it is important. We're focusing first on their routine and then moving to that stuff. And that's what it means to be a top down practitioner, starting with a client's routines. And then after we address those, eventually evaluating their environment or evaluating their body function or evaluating the context of their every day. And those things are important as opposed to they're just not the first thing we look at. 

Lindsey Vestal So, Hannah, you. You were an oat pioneer alumni. And in the course, we talk often about the importance of not over preparing for our sessions with clients. And I think this can be really hard as a new practitioner because we naturally crave the recipe, right? We crave the step by step because we want to do best by our clients. However, I'm thinking back to something you shared with me on our recent OTs Power Hour on the OTs for Pelvic health Facebook page. And that was you said something like Planning sessions often creates an environment that doesn't solve our client's unique concerns. And instead, when we come with an open mind, our sessions can be more client centered. Can you talk a little bit about this? 

Hannah Schoener Absolutely. Lindsey And when we talked last time, I kind of joked with you we had a conversation about how OTs are kind of like plumbers. And the silly answer to like how our OTs like plumbers is we both fix leaks. But the more in-depth answer to that question is if you've ever had a plumber come to your house and you say, Hey, something's going on with my pipes, my toilet isn't flushing, right? If the plumber came in and he had all the tools that he thought he needed in his toolbox, and he came in and he just went about fixing your toilet immediately, you might be like. Does he actually know what the problem is? He hasn't seen my house. He doesn't know what the plumbing looks like. He doesn't know. He doesn't know what's causing this problem. He's just kind of coming in. And it may or may not fix your plumbing issue. And I kind of think about being a occupational therapist and specifically a pelvic floor occupational therapist in the same way as new practitioners. We come to the table and we think, okay, this is such a specialized field. I'm intimidated. Look at all these amazing pelvic floor practitioners out there and this incredible continuing education they have. I need to know how to do. I need to know how to do skin rolling. I need to know how to use dilator. I need to know how to teach a client how to do the perfect legal exercises to be a pelvic floor therapist. And I'm going to bring that to every single one of my clients, and it will solve their problems. I think that's the lie that we tell ourselves or the misconception that we tell ourselves. And in truth, all of these amazing tools and techniques are so important, but they're not important for every single population or every single client. And so I kind of think of all those tools and all the use you could possibly take as tools that you have in your to keep the plumber analogy in your van that you bring around to different clients homes. You have all those tools or maybe you eventually will have all those tools. But right now, when you're first meeting that client, the best thing to come in with is an open mind. The best thing to come in with is good questions, and the best thing to come in with is a listening ear. And we take the time to really hear our client and figure out what is bothering them and to be a good investigator in and figure out what is wrong, what is going wrong that's affecting their quality of life or their performance with their daily occupations or their ability to go to the bathroom, have sex and feel comfortable in their body. We come in with that listening ear so then we can choose tools from our van of all these techniques and see, use or gain the tools by taking the seat use. Once we figure out, Hey, I'm kind of missing, I have a hole in my knowledge that actually help our clients rather than coming in with techniques that really don't apply to our clients and won't fix their problems. And so related to that, I think it's important to think as a as a newer attorney in this field, I don't need all the tools right now because I don't know what my clients are going to need. I have the baseline knowledge to be a pelvic floor practitioner, or I can take 1 or 2 courses to begin to be a pelvic floor practitioner. And as I learn what my clients need, I can learn more techniques and take more continuing education units to fill the holes in my knowledge to be the best practitioner I can be. 

Lindsey Vestal I am so inspired by you saying that because, you know, after I've been supporting O.T. since 2018 and I think that this desire to be the best practitioner we can be, which is so authentic and I admire it so much, sometimes it can lead us down a path where we're pursuing course after course after course, or we're trying to achieve a certification when actually our clients need us now and our clients teach us so much. It's this opportunity to synthesize all of the theory and all of the stuff that you learn in your courses and bring it to everyday life and to allow the client to teach us that it's not always this A-b-c equals D approach. And I think the sooner that OTs can get out there and start incorporating this work, the better. Whether they've taken O.T. pioneers or another another pelvic health course, or they're just taking their fundamental ability to look at task analysis, to use a task analysis as it relates to roles, habits and routines with toileting and hygiene. Sometimes it's just that simple. And so if you're on the fence and you're listening to this and you're thinking, I think I'm really interested in this, I invite you to bring some aspect of what your client may need to the clinic tomorrow and just try it on, Right? And if you get the bug and you want to pursue more study, fantastic. But what I really hearing you say, Hannah, is that we don't need to have a job in Pelvic health to incorporate this information. And we. Certainly don't necessarily have to take courses right away to start weaving this information in because at its very fundamental core, Pelvic health is ADL. It is an ADL. And so getting out there, if your client has a pelvis, they have a pelvic floor. If they have a pelvic floor. Odds are there's some habit in there that can be optimized. 

Hannah Schoener I 100% agree, Lindsay. And I think I've seen I've been on both sides of this. I think when I first got interested in pelvic floor health and first became an note practitioner just over a year ago now, I was really intimidated to bring these things into practice. I was feeling like, you know what? I just I don't have the skills that I wanted to begin bringing this into practice, but I'm also scared to specialize. And then I thought, you know what? I'm going to have a little bit of confidence. I'm going to take one course on on pelvic floor health. And I and I took your Oti Pioneers course, and I learned so much, but I also learned how much I already knew. I think taking your course reminded me, like, yeah, a lot of these, these, these things that I'm learning in this course are very related to my, my education. And I know more than I think I know. And I can begin to do this work now after taking one course. I don't have to wait till I have five courses. And I think part of that is due to the fact that O.T. Pioneers is very comprehensive and teaches so much, but it's also super empowering to chat with other Pelvic Floor or OTS who are interested in pelvic floor health and to hear everyone kind of like chatting about how nervous they are to begin this work and then to hear 1 or 2 people say, Hey, I actually did, and it went great. And then when you start to practice it, when I started to practice it, I was like, my goodness. So many of my clients that I began to do this work with had great improvements and it made me realize I know more than I think I know. And it also made me realize it's really hard for clients to get pelvic floor therapy. There's not that many pelvic floor therapists out there. And so by feeling like we can't practice until we are the most accomplished pelvic floor therapist not only takes away time from us, but it takes away time from our clients because they can grow from the knowledge that you have right now. 

Lindsey Vestal And then the O.T. can grow from being in front of the client and going through that experience. So it's a win win for everybody.

Hannah Schoener It really  is a win win for everybody. 

Lindsey Vestal So, Hannah, I want to talk a little bit about something that you a project that you've been on that is so important not only for our field and our future, but also just really amazingly exciting to talk about. And that is this this paper that's going to be published soon in the British Journal of Occupational Therapy. And I know you worked with a few very talented OTS on this, including our dear Kelsey Mathias, who I work with on the Pelvic health Summit. I would love to hear about this research because there's not enough research going on out there about OTs specifically about really everything we've talked about today, which is making our work personal and specific to the client, helping the client to really feel empowered. You give us a little bit of a snapshot into this. Absolutely. 

Hannah Schoener So in OTs School, one of my dear friends, Joanna Schmitz, did her thesis on pelvic floor health. And I helped a lot with the coding of interviews and kind of analyzing some of the data of that research. And an article is now coming out. It's going to be published in the British Journal of Occupational Therapy soon, and it's called Women's Experience Receiving Occupational Therapy for Pelvic Floor Dysfunction. And it's a case series. And we did some qualitative and some quantitative research here. And a really big theme that we found in this work is how much clients valued occupational therapists coming to the field after a journey of seeing many different clinicians. And that's not to say all of these clinicians didn't bring really, really useful feedback to these clients, but. All the clients that we interviewed highlighted that their journey and pelvic floor therapy wasn't complete until they saw an occupational therapist because the occupational therapist addressed how their symptoms were affecting their life. Yeah. So they were just seeing their symptoms in a silo and saying, hey, we're going to address your symptoms. On their own, they were saying, how? How do your symptoms affect affect your daily life and your ability to go jogging with friends or your ability to be intimate with your partner? And these are the the things that, like, really causes. Stress and upset when we're experiencing symptoms. It's it's our ability to participate the way that we want to in our life. And and all of the people who we interviewed in the study also expressed how OTs empowered them not only to or how OTs empowered them to learn about their own bodies so that they could help themselves. That OTs gave them the knowledge to continue to heal themselves and get better rather than relying on someone else to to heal their body. 

Lindsey Vestal And that is the perfect synthesis of everything we've been talking about. So I am so excited to read this research paper. I know that it's also going to be represented as a poster at the National Conference at the Aot A this April 2023 in Kansas City at Inspire. So make sure to stop by in and check out the poster. And I am definitely going to keep an eye on when this research is published because we need to be shouting from the rooftops about how incredibly supportive this is about our own profession and about our natural our natural outlook on what serves the client the best. 

Hannah Schoener Absolutely. Well, I'm so excited for this research to be shared with the world and so thankful for all the amazing OTs that I got to work with in this research. 

Lindsey Vestal Well, I will definitely when it becomes published, I will add it to the show notes so that people can very easily be excited. 

Hannah Schoener Thank you, Linsey. I think I just want to kind of conclude this episode by reminding where by synthesizing this conversation with saying that if you are interested in pelvic floor Oti, the time to start is right now. So bring the knowledge that you have into your practice. Start with asking clients those questions about how their bowel habits, about their bladder habits and about their sex. Right now in your in your sessions and in your evals and begin this practice now feel empowered in the knowledge that you have from all the education that you participated in in your own career. And then add add to your toolbox as you go. 

Lindsey Vestal I love that. Hannah. I am so grateful for your time today and your wisdom. And I also just want to kind of call out that you've been a practitioner for a year and the confidence that you radiate, I'm sure was a journey, but I want to just tell you how much I admire it and how much I cannot wait to see how you as a practitioner grow into the future and your future self, because already you have hit the ground running and. 

Hannah Schoener Well, see, that means so much. Thank you. 

Outro Thanks for listening to another episode of OTs and Pelvic health. If you haven't already, hop on to 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 posted 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 want to hear more of. Thanks again for listening to the OTs and Pelvic health podcast.