Pelvic Floor Physical Therapy
Photo courtesy of PopUplift
Contributions from Annemarie Everett, PT, DPT, WCS, pelvic floor physical therapist, co-founder of PopUplift, @popuplift
Excuse me. What kind of physical therapy (PT)? What is the pelvic floor?
Though the name calls to mind a flat surface, the pelvic ‘floor’ is actually a bowl-like network of musculature and connective tissue between the hip bones, pubic bone and tailbone. It functions as a part of the “core” for postural support and stability, supports the pelvic organs (bladder, uterus, bowels, and cervix), maintains bowel and bladder control, and is the opening through which your baby passes in a vaginal delivery.
A pelvic floor PT is specially trained in addressing the function of your pelvic floor.
If you’re interested in learning more about the anatomy of the pelvic floor, check out Kimberly Johnson’s pelvic floor mapping and ‘walkabout’. Kimberly specializes in birth injuries, birth trauma, and sexual health in the LA- area.
Ok, so how can a pelvic floor PT be helpful during pregnancy?
A pelvic floor PT is an expert at evaluating and treating issues that commonly arise in pregnancy, such as leaking, back/pelvic/pubic bone pain, and pelvic “heaviness.”
Even if you aren’t experiencing specific symptoms, PTs can:
Help you get acquainted with your pelvic floor. Studies show that most people don’t know how to voluntarily control the action of their pelvic floor and there’s no better time to learn than before birth!
Teach you how to properly do ‘kegels’ and feel if you’re doing them correctly. This muscle training has been shown to shorten the first and second stages of labor and prevent/treat urinary incontinence in pregnancy and postpartum.
Discuss appropriate modifications to your exercise routine as your body changes in pregnancy.
Share birth positions to improve comfort if you have been experiencing pelvic or back pain in pregnancy, and minimize your risk of tearing (with the knowledge that many factors contribute to tearing and this is only one of those).
Teach you a technique called perineal preparation. Also called “perineal massage,” this technique can improve your comfort with increasing levels of stretch to the muscles at the vaginal opening. This may reduce your risk of tearing in a first-time vaginal delivery, but most importantly improves your confidence and comfort with the sensations of birth. PTs typically recommend perineal massage from about 34 weeks of pregnancy and on for low-risk pregnancies.
What is an appointment like?
All PT appointments begin with a conversation to help your therapist get to know you, your body’s history, your symptoms, and your goals. Every individual is different, and a PT’s job is to understand how they can address your specific concerns within your specific life context.
During the physical exam, your PT will gather information by watching you move (walking, squatting, etc.) — testing your range of motion and movement patterns that are relevant to your symptoms. If you are seeing a PT to address pelvic floor-specific symptoms, they will likely suggest an internal vaginal exam (or rectal exam if your symptoms are related to bowel function). These exams are never mandatory, but they are the gold standard by which your PT can diagnose and treat the muscles of the pelvic floor. You are always allowed to opt out, or discontinue the exam at any point should you feel uncomfortable!
A vaginal pelvic floor exam usually goes something like this:
In a comfortable reclined position, your PT will assess the vulva and perineum externally by visualizing and then palpating the area with light/medium pressure as appropriate (especially if pain is a symptom).
With your permission, your PT will insert a gloved, lubricated finger into the vaginal opening. If assessing pain concerns, they will palpate both sides of the pelvic floor muscles to determine if they can reproduce your symptoms.
To assess pelvic floor muscle function, you’ll be asked to contract, relax, and “push out” your pelvic floor. Depending on what your body needs, they will instruct and provide verbal and tactile cueing about how to improve power, endurance, range of motion, or control.
Evaluation and treatment most often happen together. Hands-on techniques should always be followed by giving you some take-home tools for managing your symptoms and continuing in the right direction outside of office visits.
Physical therapy is an active partnership — you and your PT need to work together for effective treatment. If you aren’t getting the guidance or support you need, have questions that aren’t being answered, or find an intervention to not be effective, it’s important that you speak up!
You’ll work with your PT to develop a realistic treatment plan for the rest of your pregnancy. Most likely, they will suggest returning to therapy once you are cleared for activity postpartum by your care provider.
When should I make an appointment?
You can of course visit anytime. Some people only visit a PT when they are having symptoms, and others feel strongly about being proactive. If you have been diagnosed with complications or risks in your pregnancy (particularly if there is a risk of preterm labor, you have a cerclage, or if you have been put on some degree of “pelvic rest”), let your PT know. An internal pelvic floor exam is safe in low-risk pregnancies, but it is not appropriate in these higher risk cases. If you’re interested in perineal preparation, you can make an appointment at 34 weeks of pregnancy and on for low-risk pregnancies.
Is PFPT covered by insurance?
Many pelvic physical therapists do not take insurance because of the very real challenges of contracting with insurance companies. You can usually use FSA/HSA funds, or ask for a superbill so you can submit an ‘out of network’ claim on your own. Some large hospital systems do have pelvic PTs on staff who are able to provide care that’s eligible for insurance benefits and will do the billing for you.
Physical therapy services provided for "wellness" or "prevention" but not for the treatment of a diagnosis are generally not covered by insurance. However, if you have symptoms (and therefore a diagnosis) associated with your visit, it should be covered by your insurance plan at the same level as other physical therapy services.
If you are unable to pay for care, try reaching out to ask about reduced rates or other options that may enable access while still allowing your PT to cover their expenses.
Can you talk to me about requirements to become a pelvic PT?
Pelvic PTs are not all created equal — and there aren’t a ton of them, unfortunately. Surprisingly, there’s actually no baseline requirement for education beyond a Doctorate in Physical Therapy to call oneself a “pelvic PT,” so the level of expertise can vary widely between providers.
The highest level of certification available is the Women’s Health Clinical Specialist (WCS) designation, earned after a PT has demonstrated 2000 hours of practice in pelvic PT, passed an extensive written exam, and submitted an evidence-based case report to a panel of experts. You can search for a WCS-certified PT here.
The American Physical Therapy Association (APTA) section on Women’s Health offers a Certificate of Achievement in Pelvic Physical Therapy (CAPP-Pelvic) and in Pregnancy and Postpartum Physical Therapy (CAPP-OB) for PTs who have taken those courses. The APTA maintains a directory of providers who are members and self-identify as pelvic PTs.
If you’re located in California, Annemarie also offers virtual services.