Comprehensive Approach to Pelvic Floor Assessment and Intervention

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses what a pelvic floor exam looks like in light of updated practice patterns & research,.

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EPISODE TRANSCRIPTION

ALEXIS MORGAN Good morning. Welcome to the PT on Ice daily show. My name is Dr. Alexis Morgan. I am one of the faculty with the pelvic division and happy Monday. I'm excited to be here this morning to talk to you all about the 2024 version of the pelvic floor assessment. We've been through so many iterations as a profession of the pelvic floor assessment. And I want to just take a few minutes today to talk with you all about the 2024 version, the updated version, the modern way to assess the pelvic floor. Thanks for joining me. Let's jump right in.

HISTORY OF THE PELVIC FLOOR EXAM So when we think about the history of the pelvic floor exam, this goes way back, all the way to Dr. Kegel. I've actually done some podcast episodes on the history, and if history's not your jam, don't worry, I won't bore you with the history details today. But our pelvic floor exam does go way back decades, closing in on 100 years now. And over the last several decades, of course, we've had a lot more research come out and a lot more evidence, a lot more understanding of these muscles that are at the base of the pelvic floor. And so with, of course, new updates, new pieces of understanding, we're still gathering information, but of course, as we change in the way that we understand a group of muscles, of course we're gonna change in the way that we assess them clinically, right? We see this so frequently when we look at the evidence on strength. So strength is not necessarily indicative of problems or lack thereof problems. Yet we are so often talking about assessing strength and obsessing about what manual muscle test grade is there. And yes, if you're not familiar, we do have a manual muscle testing score for the pelvic floor. but realize that that is such a small piece of the entire picture. And we're starting to see this in the evidence as just described, and there's several studies that are making us go, hmm, maybe it's not all about strength. But how do we then take that into our clinical practice?

FOCUS ON RANGE OF MOTION & MUSCLE COORDINATION First and foremost, we ourselves need to back off of obsessing about strength, right? We need to really get a full understanding of the person in front of us and really gather that information and not just talk about strength, but talk about the entire picture. So, here's the updated version of the way that we do our assessments. First, we're going to test their range of motion. I'll dive into each of these details, but I want to give you all the overall picture first. So first, we do a range of motion assessment. Then we go into coordination. And after coordination, then we might go into a strength assessment. We might go into a palpation assessment. or we might go into a prolapse assessment, depending on how that person shows up in front of us. We may take it a few different directions, our assessment, but we're going to start with the range of motion and coordination assessment. Range of motion and coordination are important for all people. No matter what we are assessing, no matter what problem, no matter what genitalia we are looking at, all of the people that we are assessing with the pelvic floor, we need to start with range of motion and coordination. So what is the range of motion of the pelvic floor? What do you mean by coordination? Well, range of motion of the pelvic floor, you've heard us talk about this a lot here at ICE, is squeezing up, we call it squeezing into the attic, going up towards the head, going to baseline, and then going into the basement. So in our A-frame analogy, we've got the attic, the first floor, and the basement. So we need to assess all of these areas. That is the range of motion. There are going to be problems if somebody can't raise it up. There's also gonna be problems if they can't push their pelvic floor down. There's problems when the full range of motion does not exist. So we need to A, assess it, and then B, help them find their full range of motion. That's beyond the scope of this podcast. Come to our live course where we talk more about this. But that is range of motion assessment. Very important as it is first. Then we go into coordination. So coordination is me assessing your pelvic floor with certain coordinated movements or certain movements that you do in the day. And I'm assessing to see what does your pelvic floor do and is it coordinated with the core muscles? How does that function? So we might would look at a cough We would definitely look at a brace, especially if the individual is having issues with some type of bracing mechanic. And you may do it in a lot of other different positions. I have clinically assessed pelvic floor coordination for a yogi who is having difficulty with downward facing dog. Yes, we got into that position to assess the coordination of her pelvic floor. That was where her primary complaints were. That's where we need to do that assessment. It's not a strength assessment at that point. It's a coordination. What is she doing with her core and pelvic floor in the problematic position? That is coordination. With these two important pieces of the assessment, There's a lot of different ways in which you might assess. Range of motion, coordination. That could be assessed just visually. Just externally, I am looking at maybe the rectum, maybe the vagina, male or female. Whatever it is, I might be just looking externally. Or I might do an internal assessment. vaginal or rectal. I might would do it in standing, a standing assessment. There's a lot of ways in which we're going to match the assessment with the problems that the person presents to us with. We're going to match them, but realize that they're going to start with a range of motion assessment and coordination. Then of course we can dive into our other three options, that strength assessment, that palpation assessment, and the pelvic organ prolapse assessment. So it's important for you to know that All of these options that exist, you may not use all of them in a client. You may not use them all in one day. It may take you several months or weeks, depending on the person in front of you, to go through all of these assessment tools. That doesn't matter as much as what matters is that you're testing the problems that they're presenting with, and of course, that you're making progress along the way. So that strength assessment is important. It is a piece of the puzzle. Someone needs to be able to generate enough force in their pelvic floor to squeeze off their holes. That way they do not have problems of a lack of force. That is important. But only when we know that they're coordinated enough to squeeze their pelvic floor. Right? Because if they can squeeze it on their own, but whenever they're bracing, they're not squeezing it, it doesn't really matter to work on strength. It matters to work on coordination. You see where I'm getting at? So once they get that, those first pieces, the range of motion and coordination, then we move on to strength.

WHAT NEXT AFTER RANGE OF MOTION & COORDINATION? So with that strength assessment, we might do that in supine, we might do that in standing, testing their strength, their ability to squeeze the pelvic floor. With the palpation assessment, and again, we go into all the details. I'm skimming the surface here. We go into all the details in our live course. When we are doing a palpation assessment, that is purely to reproduce their pain. You hear us at ICE all the time talking about, and no matter which course you're taking, when we are doing a palpation exam, we are trying to reproduce their main complaint that they're coming in to see us for. So, same is true in the pelvic floor muscles, each of the layers, left side and right side. Does this reproduce their problem? Their problem might be urgency. When I gotta go pee or poop, I've got to go. Let's see if pressing on some of these muscles causes that urgency. or round ligament pain or adductor pain or might even look or sound like what the patient may come in with is sciatica, right? Or radicular pain. All of those could be caused by the pelvic floor muscles in which you would find in that palpatory exam. So that palpation exam is important to rule out the pelvic floor as a potential root cause of some of their symptoms that they are experiencing. And then lastly is pelvic organ prolapse. So we may not do this pelvic organ prolapse assessment. There's a lot of podcasts where we're talking about our thoughts on POP or prolapse, and I will have to guide you to those. I'm not gonna take all of your time talking about that this morning either, but it is a piece of the exam that you might would add in. We might would add in the prolapse exam if the person is coming in with their main complaint saying the word prolapse. Saying that I've been diagnosed with prolapse. Discussing some concerns about prolapse. Similar to the obsession about the strength scores, we can also see an obsession about a prolapse grade. Something about these numbers gives us this black and white, this very clear picture in our heads, but it's not exactly the full clinical picture. So really, do the pelvic floor assessment. If you need to do the prolapse assessment, absolutely do that. And again, you can do that in supine. You can also do it in standing and apply that to that individual. But just remember that 50% of individuals assessed objectively are going to have some sign of dissent, aka some sign of prolapse, so we don't need to be freaked out about it. Rather, what we need to do is focus on their range of motion, focus on their coordination. Those two pieces are so incredibly fundamental and important for everyone to be able to utilize their pelvic floor effectively. Whether that is in preparation for birth, whether that is performance under the barbell, or trying to reduce pain with sex, Whatever the topic is that the individual is coming to us for, we're going to start with that range of motion assessment. We're going to go into that coordination and we might hang out there for a while and work on the goals of pulling pelvic floor up, pushing down, feeling all of those differences of the pelvic floor, and then coordinating it. Coordinating it with diaphragmatic breathing, with bracing, with whatever problem they have, matching it to that. That right there added with it the three options of the strength, the palpation, and the prolapse assessment, that is the updated version of the pelvic floor assessment. That is what aligns with how we understand, as of today, the pelvic floor function. It matches what we see in the newest literature all the time, which is maybe it's not all about strength. Maybe there's some other aspect. And when you look at these studies, we recognize that individuals are assessing this, but it's not really been discussed about in this way. This is what we're doing. This is how you create change. This is how you have some organization in your assessment. This is how you get the patient on board. You tell them we're gonna do range of motion. We're gonna do coordination. We're gonna see how you do with each of these. This is gonna look a lot like this problem that you're experiencing. We're gonna match that up and we're gonna talk about what optimal is. Really focusing in on what matters to them helps them stay focused.

SUMMARY So use this, let me know what you think, and if you are so excited to see us maybe in Greenville, South Carolina this coming weekend at the live course, we're excited too. Or we've got several courses coming up in Colorado, in Missouri, in Alaska, In New York, we're all over the place this year. So look for a course that's near you or near somewhere that you would like to travel to. We would love to have you at our course. We also are discussing these topics in a little bit different ways in our Online Level 1 and our Online Level 2. Our first cohort of the Level 2 is actually sold out. Our second cohort of the season of the year is in August. It will sell out. If you are interested in joining us, you should go ahead and purchase that ticket. We'll be talking about all of these aspects of what we just discussed today in both of those courses. head on over to PTOnIce.com, check us out, we would love to have you join us in the courses. Have a wonderful day, a wonderful week, and let me know what you think about the new way of doing the pelvic floor assessment.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.