What is a “Good” Pelvic Pain PT Session Like?

Share the KnowledgeShare on Facebook0Share on Google+0Pin on Pinterest0Tweet about this on Twitter0Share on Reddit0Share on LinkedIn0Print this page

QA-612x3722

Recently we received a question from a reader asking us to describe what a “typical good pelvic floor physical therapy session” is like.

It’s a question I’m sure every pelvic pain patient prescribed PT has thought about. Currently, there is no standard of care for pelvic pain PT. So unfortunately, patients get PT ranging from good to mediocre to inadequate to a complete waste of time. The hope is that when patients begin to push for the best standard of care, change will occur. The problem is that the majority of patients have no idea where the bar should be set when it comes to pelvic pain PT. Going into it they get very little, if any, information from their prescribing physicians, who themselves often have little knowledge of the treatment.

This brings us back to the original question: What is a “typical good pelvic floor PT session like?” With this post, we plan to answer that question by giving a play-by-play description of both an evaluation appointment at our clinic and a typical follow-up appointment.

Before we go any further, however, you’re likely wondering who the heck we are to presume to set the standard for pelvic pain PT? Well, for one thing, over the past decade we’ve focused solely on the treatment of patients with pelvic pain, both women and men. Plus, during that time, we’ve worked extremely hard to educate the PT community and the general medical community about pelvic pain PT (click here to get to know us better). But the most important claim we have is that we know what we do works because our patients get better!

Now, back to the question at hand. Below is the reader question that sparked this post.

Question:

I’m curious as to what a typical good pelvic floor PT session is like. I went to PT for a while to treat my pelvic pain, but I’m not sure it made a difference. The PT didn’t really explain anything—the only thing I heard was that I have some tight muscles, but that seems pretty vague to me. My PT sessions consisted of about 20 minutes of conversation, then I got up on the table, was guided through a leg stretching exercise, then my belly was massaged for a bit. From there I got undressed and had about 15 minutes of vaginal massaging. This never varied.

Answer:

Evaluation Appointment

At the evaluation appointment, the first thing we do is interview the patient. What we’re after is the patient’s full pelvic pain history. Among the questions we ask are:

When did your pain start? What does it feel like? Where is it located? What exacerbates your pain? What alleviates your pain? How does it affect these three functions: Urination? Bowel movements? Sex? What activities does your pain limit? What kind of work do you do? What doctors/other PTs have you seen? Have you had any diagnostic procedures done? What past treatments have you had? What medications are you taking?

It’s important that the interview not go over 15 minutes! That’s because we want to make sure we have enough time to get our hands on the patient. That’s how our time and their time is best spent. So after 15 minutes, whether we’ve gathered all of the info we need or not, we ask the patient to undress and hop up on the table. We leave the room to give the patient privacy and time to get situated and comfortable. If there is still info we need from the patient—and there always is—we will simply continue the conversation as we begin evaluation and treatment.

The evaluation  is the actual hands-on work that we do on the patient. The goal is to begin to uncover the contributing factors of each impaired area.

We choose where to begin based on what we’ve already learned from the patient. Because we’re limited by time—the evaluation appointment is a one-hour appointment—we must prioritize. So, we’ll pick selective things to work on during that first appointment. We want to tackle the areas causing the patient the most pain first.

While every patient’s pain is its own unique puzzle, there are two areas we will always check out on evaluation day. These are a patient’s connective tissue mobility and their internal pelvic floor muscles. We’ll access the latter either vaginally with our female patients or rectally with our male patients.

During the internal exam we are on the lookout for hypertonic (tight) muscles, trigger points, and a gauge of the patient’s pelvic floor motor control and function. Plus, we will palpate the peripheral nerves to identify irritability. As for the connective tissue, it’s a rare day that connective tissue is not involved in a patient’s pelvic pain. In fact, we go through the connective explanation every single time we have a new patient.

In case you’ve never gotten an explanation for how connective tissue contributes to pelvic pain or you need a refresher, this is our schpeal: “Connective tissue becomes tight as a result of underlying dysfunction in muscles, nerves, organs, or joints. As a result, there is reduced blood flow and the tissue becomes hyper-sensitive. Therefore, it becomes difficult and painful to manipulate. If we don’t fix it, it’s going to continue to contribute to the underlying impairments in corresponding muscles, nerves, organs, or joints, and the pain cycle will continue.”

So, in the evaluation appointment, we definitely examined the patient’s connective tissue mobility and their pelvic floor, plus other areas we were able to get to that we believed were contributing factors to their pain. Ultimately, between this first appointment and the next appointment or two, all areas on the patient will be evaluated from the ribs to the knees, back and front.

An Explanation

One of the things that bothered us in the reader’s question was this line, “They didn’t really explain anything—the only thing I have heard is that I have some tight muscles, but that seems pretty vague to me.”

We don’t ever want our patients not knowing why we’re doing what we’re doing! Throughout the treatment session, we explain to them what we’re doing and why.

If your PT is not giving you these kinds of explanations, it’s important that you ask for them. Asking her will not only bring you up to speed, it’ll force her to develop a plan, and not just treat you in a scattered, directionless way. And do not accept a half-hearted explanation that what she’s doing “decreases muscle tightness.” Your PT needs to be able to tell you why she thinks the tightness is there, what she thinks is causing it, and what she’s doing about it.

On top of explanations throughout, at the end of every appointment we give our patients a briefing on what we did, what we found, and what our expectations are. For instance, we’ll say something like, “So I worked on such and such trigger points today, they’re still there, so basically I don’t expect your pain to change until these start to change more. For the next four weeks, I’m only going to focus on this area and if I can’t get things under control I’m sending you for trigger point injections.”

A Typical Pelvic Pain PT Session

At the beginning of a typical PT session, we walk into the room with the patient dressed. We question the patient for two minutes at the most. Just as on evaluation day, time is precious. We only have one hour, so we want to begin manual therapy on the patient as soon as possible. If we don’t get all of the info we need  in two minutes, then we’ll just continue the conversation once we begin treatment.

One bit of info we want to get from the patient is a description of their symptoms after their last treatment. We especially want to know how those first two or three days were after treatment.

This is important for a few reasons. For one thing, oftentimes we will focus our treatment for the day based on what their response is and what is bothering them the most. For another thing, it allows us to educate our patients about reasonable expectations. For instance, based on their response to the question, we’ll explain why they were sore (if they were). Or why their pain was better or worse.

Also, from looking at the chart before the patient comes in, we’ll have a few very specific questions to ask. For instance, if it’s a patient who is having pain with sex, we’ll ask whether sex was possible since their last appointment.. If it was, we’ll want to know if anything was different about the experience. We’ll want to know whether the pain was less in intensity, less in duration, or in a different area.

After our two minute chat, we’ll leave the room so that the patient can change and get situated on the table. When we come back into the room, we’ll tell her or him what we’ll be doing during the appointment and why.

The first thing we’ll do during treatment is to treat the patient’s connective tissue. The reason we do the connective tissue manipulation first is that it makes it easier to treat underlying trigger points, it calms the nervous system down some; it increases blood flow to the area; and it relaxes the pelvic floor a bit.

For the most part, there are four rungs to the ladder of pelvic pain treatment. They are: working out external trigger points, working out internal trigger points and lengthening tight  muscles, connective tissue manipulation, and treating at structural abnormalities. However, the last, treating structural abnormalities, is only incorporated when it applies. So during a typical appointment, we are focused on these strategies.

Typically we spend about half the appointment on connective tissue manipulation and external trigger point release (external work), and half the appointment on internal trigger point release and muscle lengthening (internal work). An appointment lasts for one hour. And patients either see us twice a week or once a week.

So that’s what we do during a typical PT appointment. What we don’t do during an appointment is: We don’t ever leave our patients alone in the room hooked up to a tens unit or to a biofeedback machine or performing exercises with an aide. When it comes to the successful treatment of pelvic pain, what works is manual, hands-on treatment, so that’s what we do.

Also, we don’t use a cookie cutter, one-size-fits-all approach to pelvic pain PT. Not only will every patient’s treatment be different, but a specific patient’s treatment will change and evolve from appointment to appointment!

And, we don’t spend precious time cheer leading our patients through stretches and strengthening exercises. While we do arm patients with therapeutic home exercises from day one, like pelvic floor drops, we don’t spend more than a few minutes teaching patients how to do them. As for stretching and strengthening exercises, they do have their place; when pain is either completely gone or way down and when trigger points are gone, and the muscles are either tight or weak. That’s the time, and the place for them is when the patient is at home.

So, now that we’ve given you a rundown of what we believe is a good pelvic pain PT session, we’d love if you’d share your experiences with us and our readers! Do your PT sessions differ from what we’ve described? If so, in what way/ways?

Please either leave any questions or comments you might have in the comment box or email us at: blog@pelvicpainrehab.com.

If you’d like to leave an anonymous comment, just don’t fill in your name or email address and it will be posted as “anonymous”.

Be well,
Steph and Liz


34 thoughts on “What is a “Good” Pelvic Pain PT Session Like?

    • Hi Guy,

      Stress can often be a contributor that negatively affects pelvic pain, but it cannot be labeled as “the primary cause” for any pelvic dysfunction. There is no ONE cause for pelvic pain. Every patient is unique in their presentation of sypmtoms and medical history. Yes, a big part of what we do at PHRC involves patient education, and stress is a topic that is discussed with them.

      Best,

      Malinda

  1. Thank you very much for this article. I actually used part of a paragraph to email my PT and send it to her. I’m driving long distance through a level 8 pain and don’t feel like I’m getting anywhere with my PT. Four session later I’ve only been givin breathing exercise for home. Her specialty is internal and I’ve she is very good with the internal . Now I have a host of pain and problems that know on can figur out. I ripped lower rectus ab which effected my psoas muscle where eight befor I has a inscional hernia repaired. I need someone to hep with this most painful injury and my left ileoinguinal region. My surgery nov 2012 has left me in horrible chronic pain, so I think PF PT,should be able to help. She can’t, internal is her specialty and this article helped me to realize I. Must not continue to try to get this person to help with my other problem . Dont waste precious time get in give my pain scale how long since last bm ang get my treatment. I’m don’t have a lot off session for I’m to leave some for another PT to help with my pubalgia. I am hopeless and feel there is no hope. Until someone figures out what going on in abdomen PT is a waste. I haven’t had sex in a year and pelvic floor continues to decline. So I’ll shut up and let her do my internal ang get the most out of the next 4 weeks gofer I’m suppose to move on. Thank you for making me realize how,precious the PTs, time is. What specifically is connective tissue work? Previous I had about 100 hours of John f Barnes trained myofascial work done. Is that the type of connective tissue work u mention? I get none at current Pt. I went from flexible active person to lay in bed and sleep most day so I don’t have to dear with pain.

    • Hello Lydia,

      I am sorry that your experience with your therapist has failed to resolve your issues. It sounds like your current therapist does treat your pelvic muscles internally, which from your description of symptoms, may be what you need. I would recommend that you communicate with your therapist, and commit to pelvic floor therapy with her, or another provider.

      All my best,

      Stacey

  2. I saw a PT twice for my severe IC. One session was just talking, during which I felt that I was educating her. The other session was me on the table while she tried to teach me how to breath and relax my pelvic floor, although she said my muscle movements were what I should be doing for a bowel movement. Then she hooked me up to a TENS unit, which felt nice, but ultimately did nothing for me. For this I owed $550 (my insurance company did not cover pt), and got no benefit. IC is a very expensive disease to have, and I surely would have rather spent the $ elsewhere.

    • Hello Linda,

      Usually IC requires that your physical therapist treat your muscles internally, particularly if your pelvic muscles are tight, and spasming. I would suggest that you continue therapy with another physical therapist in your area.

      Best,

      Rachel

  3. My PT does not do connective tissue manipulation or spend much time on external trigger points. I have asked her about connective tissue manipulation at one of my appointments and she said she was doing it by walking her fingers down my right inner thigh muscle. I’ve read your blog post on connective tissue manipulation and the skin rolling technique and what she was doing was nothing like that. Unfortunately after 10 PT sessions I’ve only seen minimal improvement and have resorted to taking amitriptyline. I wish you had offices closer! I’ve given up hope of ever getting better.

  4. My sessions are very similar to what you’ve described above. We do typically talk for more than 2 minutes, however my symptoms are all over the place so it does seem necessary. I sense my therapist is very good and well educated in PF therapy, and I’m critical in nature. Each time I leave a PT session I do feel better. Sometimes amazingly better, even completely well by the time I leave, and other times I feel about 80% “well.” But soon symptoms creep in again, either later that day or the next day. Some days are better or worse than others – my symptoms seem to have a mind of their own. So it seems that if I lived in PT I would be pain free! Is this a sign that PT is curing me and I am headed for full recovery? Is it a sign of anything to you? I am interested to know your thoughts? I’ve been going twice a week for about 5 weeks.

  5. Hello. My sessions are very similar to what you’ve described above. We do typically talk for more than 2 minutes, however my symptoms are all over the place so it does seem necessary. I sense my therapist is very good and well educated in PF therapy, and I’m critical in nature. Each time I leave a PT session I do feel better. Sometimes amazingly better, even completely well by the time I leave, and other times I feel about 80% “well.” But soon symptoms creep in again, either later that day or the next day. Some days are better or worse than others – my symptoms seem to have a mind of their own. So it seems that if I lived in PT I would be pain free! Is this a sign that PT is curing me and I am headed for full recovery? Is it a sign of anything to you? I am interested to know your thoughts? I’ve been going twice a week for about 5 weeks.

    • Hello Anonymous,

      It seems that although you experience brief moments of relief, pelvic PT is helping. Usually, phyiscal therapy requires more than 5 weeks of treatment, but over time, you should begin to notice that your moments of relief last longer, and severity is minimized. However, I should also mention that a multidisciplinary approach is necessary. Remember to be aware of your stress levels and how stress affects your pelvic floor. Does your stress create systematic tension throughout your body, including your pelvic floor? Are you mindful of your daily body mechanics and movement? Are you consistent with any home program you are given by your therapist? All of these factors will determine your overall improvement. It sounds like you are on the right track, so I would suggest that you give PT a bit more time.

      All my best,

      Rachel

  6. I have doing PT for abut 2 months and stopped about 2 weeks ago because I felt it was a waste of time. I wasn’t getting the one on one attention and my questions weren’t being answered. Can you recommend a Physical Therapist or Facility on Long Island NY that shares your vision, practice etc… regarding Physical Therapy?

    • Dear Tara,

      I’m sorry, but we are not familiar with a PT in Long Island that shares of practice philosophy; however, the following PT who is located in New York City does. All my best, Liz

      Futterman Stacey PT New York NY 212 226-2066 Five Points Physical Therapy

  7. I live in NZ. I had a sacrosinous fixation plus anterior and posterior repairs plus pelvic floor repais on December 11 2013 and I have now found that I have an anterior prolapse. I have not been able to walk far since the operation – because walking and standing give me very uncomfortable pelvic floor pain. I presumed the pain was part of the healing process but at 4 months I feel fine when lying down and most times sitting down (provided I’m not sore from walking/standing). What should I expect at a physio session for this problem? I have been given lots of info about the usual things and have been taught how to do Kegels properly and given a plan for what to do for the next couple of weeks re these Kegels. I am not able to keep in a cube pesssary. Do physios help with advice about pessaries?

  8. I’m not sure what connective tissue manipulation is, so I don’t know if that is being done or not.

    I have now completed 6 sessions and she does the same routine of procedures which seem to be somewhat working with reducing my pain.

    The routines that she is doing now is a few minutes of lower perineum pressure point release with me lying on my side, then she does interior trigger points on the aelevator amie (I know this is miss-spelled) muscle all around the rectum then up on the prostate, first with one hand and then the other hand to get a different angle.

    I then lay on my back and she puts a pillow on the sides under each knee while I’m in what she calls a butterfly position. She then does a upper perineum trigger point from base of my testicles to about half way to my rectum. There is some sort of ridge area that I have in the middle of my perineum that she pushes on rather hard, in fact it is very painful. She says it is because the muscles are so tight there, its like a continuous trigger point she keeps her finger jabbed in till it releases.

    It hurts like hell, but afterwards the overall pain level does seem to drop at bit. Does these procedures sound correct?

    • Hello Ray,

      What your therapist is doing does sound like trigger point release. Connective tissue manipulation is a bit different, and involves the therapist pinch-rolling the affected tissue below the skin and above the muscle between his/her thumb and four other fingers, with both hands.

      Best,

      Allison

      • As you describe connective tissue manipulation in not being done in my case. Would not doing connective tissue manipulation make the trigger point release procedure less effective? Thanks for your answers.

    • Hello Ray,

      Yes, I can recommend a few pelvic floor therapists that have taken our course. Their information is below.

      Shannon Forrestall, PT
      PT Northwest
      Salem, OR
      (503)551-1099

      Nora Collins, PT
      Ability Physical Therapy
      McMinnville, OR
      (503)434-9495

      Regards,

      Stacey

  9. My husband has had severe pelvic pain since March. After we finally figured out what we we dealing with he started a PT program. Our PT is certified in postural restoration and is utilizing that philosophy in his program. He has made improvement but it seems he has recently hit a plateau and we are not seeing recent improvement. Do you think postural restoration is appropriate or should he be doing more hands on and trigger points?

    Thank you.

    • Hi Anonymous,

      It’s difficult to advise additional treatment your husband may need since we have not evaluated him. However I can tell you that most, if not all of our pelvic pain patients do receive some degree of myofascial trigger point release therapy. I suggest your husband receives an evaulation and second opinion from a pelvic floor physical therapist.

      All my best,

      Stephanie

  10. Could you recommend a pelvic floor therapist in the Charlotte, North Carolina area who will do a thorough evaluation and treatment plan as outlined in this blog? Thank you!

  11. Hello,
    I recently moved to Phoenix and have tried 3 different so called Pelvic PT’s. I have CPPS, IC, and prostate issues.
    All they do is soft shin and muscle massage on my abdomin and thighs.
    Prior to moving to Phoenix I was lucky to have had a P.T. who was more aggressive. She did lots of internal releases bladder work and as well as prostate. Pleanty of discomfort during most of her work but good results. I was much better and could go longer between treatments prior to my move but now things are as bad as they were before any treatment.
    I have tremendous perineal, testicular, penis pain bladder pain and frequency and Inguinal pain. Needless to say, sex is out of the question.
    I have had better treatment from a massage therapist who is massage therapist and a registered nurse. She says that we just have to do theses areas and calm down the tight muscles., However she doesent do internal work.
    I am so frustrated and have quit their treatment and try to do things my self which is difficult.
    I am thinking of moving back just to get the relief I received from my first P.T.
    Thank you and I enjoy reading your posts.

Leave a Reply

Your email address will not be published. Required fields are marked *