The What and Why of a Women’s Health Physical Therapy Evaluation

by guest blogger, Michelle Herbst, MPT, DPT

Physical Therapists are skilled allied health care providers who evaluate and treat illnesses and injuries specific to the musculoskeletal system.  A Women’s Health physical therapist has received additional specialized training to evaluate and treat the musculoskeletal components of uro-gynecological diagnoses such as incontinence, pelvic organ prolapse, and pelvic pain.  When evaluating musculoskeletal disorders, the physical therapist gathers information about the patient’s past and current medical history, onset of her symptoms and activities that affect her condition.  The physical therapist also collects objective information by observing the patient move, administers outcome tools, and palpates the surrounding and affected tissues.  The information collected assists in the formation of a physical therapy prognosis and plan of care.

The process of a women’s health physical therapy evaluation is similar to a physical therapy evaluation of a shoulder, knee, or spinal disorder except that there are additional and specific questions asked of the patient’s obstetrical and uro-gynecological history.  Yes, the women’s health physical therapist will ask personal questions.  Yes, with your permission, the PT may ask to observe the pelvic basket and floor.  Please keep in mind it is normal to feel some apprehension and nervousness.  And, the quality and quantity of information provided to the women’s health PT will affect the quality and accuracy of the physical therapy prognosis and plan of care.  Lastly, the evaluation completed by a women’s health physical therapist is similar yet very different from that of a medical evaluation for uro-gynecological diagnoses.  The main difference is that the focus of a women’s health PT evaluation is muscular-based whereas the physician is looking primarily at placement and overall condition of the pelvic organs.

So, what is a women’s health physical therapy evaluation?  It involves collecting information about the patient’s health history including their obstetrical and gynecological history while further defining her current complaints in relation to musculoskeletal presentation.  In simple terms, the women’s health PT, in a comfortable and professional manner, will gather information and examine how your body in functioning.  However, prior to meeting the PT you will complete forms or outcome tools describing your condition.  These forms are meant to identify your condition on a particular date and are designed to be re-administered periodically to monitor your progress after PT has been initiated.  Examples of outcome tools specific to pelvic floor dysfunctions are the Pelvic Floor Distress Inventory and Incontinence QOL Survey.  If you have incontinence symptoms you may be asked to complete a Bladder Diary prior to your first appointment.  The information gathered will greatly assist the women’s health PT in developing the most effective and efficient plan to evaluate and treat your condition.

Upon meeting your women’s health physical therapist you will likely be shown to a comfortable, private exam room.  The PT will begin with the subjective portion or open-ended question segment of the evaluation.  You will be expected to describe your problem and why you are seeking the help of a physical therapist.  Here is a list of possible questions the PT may ask, but please keep in mind the questions will be tailored to your specific problem.:   When did your problem first start?  Has your problem been getting worse, better or staying the same?  What makes your condition better or worse?  How does your problem bother you and affect your daily activities?   How do your symptoms vary with position changes, prolonged standing and walking or sudden motions and involuntary processes such as sneezing?   Have you had treatment before?  If so, did your previous treatment(s) help?

Once sufficient information has been gathered in the question and answer portion of the evaluation, the physical therapist will transition to making detailed observations of motion. The PT will observe your normal posture and may ask you to perform basic tasks such as moving from sitting to standing, bending and lifting objects and walking.  If your women’s health PT suspects that current or past spinal, pelvis or hip conditions may be aggravating your pelvic floor condition she may ask to evaluate those areas as well.  The anatomy of the pelvic basket and floor can be greatly affected by spinal, pelvis and hip pathologies due to their common and complex anatomical arrangements.  In considering the common anatomical attachments of the pelvic basket to the spine, hip and pelvis the women’s health PT is providing a comprehensive evaluation.

Only with your permission may the physical therapist begin observation of the pelvic basket and floor musculature.   The pelvic basket incorporates muscles in the abdomen as well as the musculature sling between the pubic bone and tail bone.  Examination of the abdomen typically occurs with the patient lying on her back.  Pillows or a foam roll may be placed underneath her knees to assist in relaxation.  Examination of the perineum involves the patient removing their clothing from their waist to just upon their knees.  The physical therapist ensures safety, comfort and privacy of the patient by wearing examination gloves, providing extra pillows for comfort and draping the patient with a sheet.  At all times, the PT maintains patient privacy and completes palpation wearing examination gloves and palpates lightly using 1 or 2 fingers.  The patient may lie on her side or back with her knees supported during examination of the perineum and pelvic floor musculature.  The PT will observe skin integrity and the patient’s ability to contract and relax the pelvic floor.  If the patient consents to palpation of the perineum, the PT tests sensation and presence of pain, tissue tightness and will likely test muscle strength of the specific pelvic basket muscles and the overall strength and function of the pelvic basket muscles.   The examination may be ceased at any time.

Why all the effort and what is the PT looking for?  The physical therapist observes motion and the quality and nature of the affected tissues to determine a physical therapy prognosis and plan of care.  A lot of information can be obtained by completing an external pelvic floor evaluation but a more complete clinical picture is obtained with the completion of an internal pelvic floor muscle exam.   During the process the PT is observing and is making many key judgments based on the following:  Can the patient complete a Kegel?  Is the patient holding their breath while Kegeling?  How long can the patient hold the Kegel?  Can the patient fully contract and relax the pelvic floor muscles?

In conclusion, a women’s health physical therapy evaluation is complex process but a worthwhile and necessary one to optimally rehabilitate pelvic floor dysfunctions.  The evaluation process does not need to be completed in one visit but may be completed over several visits based on the patient’s comfort level.  As a women’s health PT, I hope that by presenting the What and Whys of the evaluation process, you will be able to participate with a steady and calm focus.  Remember – knowledge is power.