On my recent trip to O’ahu to visit my sister I had the pleasure of meeting and talking with Sierra, a physical therapist and her husband! Sierra and her little family live in the heart of O’ahu and when she isn’t caring for her two littles (one of which is diagnosed with spina bifida), she is developing her skillset in pelvic floor rehab and building her small business to serve women on the island of Hawai’i.
While Sierra isn’t an occupational therapist, OTs and PTs alike can work in this specialty field. So I thought, why not have Sierra share about her passion with us! Pelvic floor therapy is an up and coming area of area within OTs and PTs scope of practice, something that I’ve even taken a few CEUs on because of my interest in women’s health, and also for some of my cancer patients experiencing pelvic dysfunction due to prostate cancer.
Thank you so much, Sierra, for taking time out of your rich schedule to share about your area of practice!
I hope you enjoy this interview and that it helps answer some questions you may have about pelvic floor therapy!
So my first question would have to be, why did you choose to become a physical therapist?
I had a hard time choosing what I “wanted to do with my life” when I was in my early college years. I knew I wanted to do something meaningful and ideally that would involve helping people. My dad had broken his back when I was 2 from a fall at work. The treatment back then was to be in a pretty constricting brace for the healing time. When the brace was removed, my dad was in severe pain and unable to stand up straight. After doctors were at a loss on how to help him further, he found a physical therapist who knew just how to treat him. I was really moved by this story I had heard from him several times, because my life would have been so different if my dad had never recovered. Instead, my dad was able to be active with us and coach our teams, swim in the pool, teach us how to water ski, ride horses together, and all sorts of other activities.
I am very grateful for my childhood with a dad who could play with us as we grew up! With that, I was really interested in being able to help people in this way. I decided to shadow a physical therapist for one day, and upon entering the therapy gym, I knew that Is what I wanted to do with my life! It was a really cool and exciting feeling.
Why and when did you choose to become a pelvic floor specialist?
I graduated in 2013 and I met my husband, Chris, at a coffee shop in California as he was studying to become a physician assistant. We became great friends and eventually married 2 years later! He decided to go back to school after filming a documentary at a hospital in India, and realizing he had a deep desire to provide medical care to the underserved populations of the world. After reading a book called, “The Hospital By the River,” by Dr. Catherine Hamlin, he really had a passion for delivering babies and helping women and babies who often die from very treatable conditions. This inspired me to acquire more medical knowledge and skill sets to improve my ability to help women around the world who were suffering from common and treatable postpartum conditions. I wanted to be useful as a medical provider in lower income countries. This is what inspired my journey to becoming a pelvic and abdominal specialist in 2018.
What settings have you worked in? Do you have a favorite, and why?
I have worked in several settings including, outpatient orthopedics, geriatrics, outpatient and inpatient neuro, a bit of pediatrics, and now pelvic health. I have loved all settings for different reasons, but I have particularly loved women’s health the most. I love it because I see almost immediate results, and I have the privilege of providing a safe space for my patients to talk about and get treatment for common conditions that are not so “common” to talk about. And quite often, their medical provider doesn’t have a solution outside of medicine or surgery, whereas physical therapy is a great option for a more conservative, holistic treatment approach. It is a combination of an orthopedic and whole-body treatment strategy. And there is so much to learn about pelvic and abdominal health! I absolutely love it.
In general, what is pelvic floor therapy? What is the pelvic floor and how does dysfunction in this system impact the individual?
The pelvic floor muscles are a group of muscles in both males and females the lie at the bottom of the bony pelvic ring. They are in the shape of a bowel and create a sling type support for the pelvic and abdominal organs above. Pelvic floor dysfunction is often a big contributing factor in bowel/bladder complications, as well as pelvic pain, all of which can be very life-altering for the individual.
The job of the pelvic floor is to:
- Support the pelvic and abdominal viscera (organs: uterus, bladder, rectum, prostate).
- Support the urethral and rectal sphincters to keep them closed and therefore prevent passage of urine or fecal matter.
- Help to maintain continence with increased intra-abdominal pressure, such as during a cough, sneeze, exercise, or lifting.
So as you activate these muscles (as in a kegal exercise) you are helping to close the urinary and anal sphincter, hence, preventing any unwanted urinary incontinence, fecal incontinence, or flatulence. In the photos below you will see an inferior view (the first photo), and superior view (the second photo), and how the internal organs sit above the pelvic floor muscles (the third photo).
In a recent course I attended, the instructor encouraged us to change our description of “pelvic floor specialist” to “pelvic and abdominal health specialist.” I think as this field of practice grows and we continue to learn more and more, we have understood that pelvic physical therapy is about so much more than just the pelvic floor muscles. It truly encompasses the pelvic and abdominal cavity and the elements of the pelvic girdle, as one will affect the other. So as a therapist, we are treating this entire system.
What is physical therapy’s unique role in the treatment of pelvic floor dysfunction?
Oh man, we are so valuable in the treatment of pelvic floor dysfunction! I am truly amazed at this profession and grateful to be a part of it. I will list 3 ways we are unique to other medical providers:
1. Time: I think one of the biggest benefits we can offer is simply our time. Compared with other medical providers, such as OBGYNs and urogynecologists, we have ample time to take a thorough history and really get the full picture of what is bringing the patient in for treatment. Pelvic and abdominal symptoms and conditions are, very often, a result of lifelong contributions, or from changes occurring from pregnancy and postpartum, which for some patients took place many years prior. We also have the time to explain and educate our patients on the causes of their symptoms and how to devise a treatment plan.
2. Knowledge of the body’s musculoskeletal system as well as acquired knowledge of the abdominal and pelvic viscera, digestive system, and urinary system: As physical therapists, we tend to be focused on gross motor movements. We try to think outside of the box in where a patient’s symptoms are coming from and how the body’s musculoskeletal system is contributing. We understand that the body is connected by different fascial layers, which encompass the body’s muscles, ligaments, and internal organs. We have a deep understanding of the muscles of the pelvic floor, the joints of the pelvis, and the internal organs in the pelvic and abdominal cavity and how they are affected by limitations in movement or muscle dysfunction. We also have an understanding of how the pelvic floor muscles and the urinary and digestive system are connected and affect one another.
3. Resources: In our world, there are tools that can help different conditions, including urinary incontinence, prolapse, fecal incontinence, digestive problems, and various causes of pelvic pain.
What are some common diagnoses seen in pelvic therapy
Common diagnoses that we see are:
- Urinary incontinence
- Urinary urgency/frequency
- Overactive Bladder
- Interstitial Cystitis/painful bladder syndrome
- Pelvic organ prolapse
- Postpartum conditions
- Low back pain/SI joint pain
- Pregnancy related Low back pain
- Diastasis Recti
- Lichens Sclerosis
- Fecal Incontinence
- Irritable Bowel Syndrome
What would a typical treatment day look like?
Treatment protocol varies between all patients and is dependent on the patient’s symptoms and details obtained at the initial evaluation. An initial evaluation often includes a thorough medical history intake followed by an internal manual assessment of the pelvic floor muscles, as well as assessment of the surrounding tissues. The internal assessment allows a therapist to feel the resting tone of the pelvic floor muscles, assess for pain, and assess both the strength of the muscles as well as their ability to relax. This is not like a typical gynecological exam. It entails the use of 1 finger and guided with participation from the patient to ensure patient comfort.
Follow up treatment sessions are determined by findings at the initial evaluation. For instance, if someone is coming in for symptoms of incontinence and they have weakness of the pelvic floor muscles determined during the internal assessment, treatment would likely be focused on strengthening of the pelvic floor muscles and the core, using tools such as biofeedback and/or estim and instruction on proper strengthening exercises.
If the main complaint is frequent bathroom trips and/or leaking with strong urge, we will spend time assessing a bladder diary, discussing the anatomy of the bladder and how to control strong urges, and also ensure that the pelvic floor muscles are able to contract and relax appropriately.
If pain with intercourse or use of tampons is the main symptom, the majority of treatment may involve manual therapy to work on relaxing the muscles of the pelvic floor and the myofascial components surrounding the pelvis.
These are just 3 examples of different treatment protocols, but there are also different treatment strategies for the different causes of pelvic pain, constipation, pelvic organ prolapse, diastasis recti, endometriosis, and other conditions. The variety of treatment options makes it a really exciting and interesting practice!
What settings can a pelvic specialist practice in?
I know the outpatient orthopedic setting is the most common setting, as we are a specialty of general outpatient orthopedic physical therapy. We can treat men, women, and children with pelvic floor dysfunction and pelvic/abdominal conditions in the outpatient setting. More recently, I have been seeing courses for pelvic floor rehab in the home health setting, which would be working mostly with the geriatric population, which makes so much sense!
Do you have to be credentialed in pelvic floor therapy in order to practice in this area?
A physical therapy license to practice is the only requirement as far as credentials. You do not need a specialty certification, however, it is required to take at least the level 1 course through Herman and Wallace or APTA in order to begin seeing patients.
*Additional courses I’ve found include:
And do you know the process of becoming credentialed?
There are two types of specialty certifications for pelvic health PT:
1. One is through the APTA (American Physical Therapy Association) and it is called the Women’s Certified Specialist (WCS) certification.
2. Another is through Herman and Wallace, called the Pelvic Rehabilitation Practitioner Certifications (PRPC).
You do not have to choose one or the other. The major difference is that the PRPC focuses on treatment of pelvic floor dysfunction, and the WCS also includes treatment for breast cancer and lymphedema to encompass all aspects of women’s health physical therapy. The APTA certification is only for physical therapists, but the Herman and Wallace certification is open to other types of providers who have taken their courses.
There is a full comparison chart available here: https://hermanwallace.com/pelvic-rehabilitation-practitioner-certification/comparison-chart
Do you have any other interests in physical therapy that you would like to pursue?
After having my son in 2020, who was born with spina bifida, I am very interested in learning more about pediatric conditions and how to help, specifically for spina bifida. I am actually signed up for a course this May to learn more about treatment for pediatric pelvic conditions, which I am excited about!
Do you have any words of advice for someone wanting to pursue this area of practice?
It’s an amazing field of practice. You really get to come alongside your patients and help them in a way they have never found help before. It can be truly life changing. Those are just words of encouragement :). Words of advice would be that I have taken both the APTA and the Herman and Wallace courses and I tend to like the Herman and Wallace courses better.
You can follow along with Sierra’s business over on her socials: