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Spotlight:Pelvic Health Physical Therapy - Amy Stein, PT, DPT, BCB-PMD

by Meredith Victor Castin


Amy is a pelvic health physical therapist who wrote Heal Pelvic Pain, which was released in 2008, and provides stretching, toning and relaxation exercises to address various forms of pelvic dysfunction. In 2014, she released a DVD, called Healing Pelvic and Abdominal Pain

Can you tell us a little about yourself and how you became a pelvic health physical therapist?

Amy: I graduated in 1999 with my MS and then got my DPT in 2013. It has been a wonderful experience, seeing the whole world of pelvic health physical therapy transform in the last 15-17 years. I had a friend in grad school who was living in the NY area (while I was living in Florida), and she had a hysterectomy. She found herself with pelvic pain and bladder issues, as well as sexual dysfunction, and sometimes she couldn’t even get out of bed. They ruled out her back as a source of pain and I went to my professors and asked what it could be. The professors really didn’t know much. They said to look further down on the chain, and I looked in the sacral area, and I thought maybe it’s the pudendal nerve. It turned out to be that, and the whole experience got me interested in becoming a pelvic health physical therapist.

Once you realized you were interested in pelvic health physical therapy, what was your next step?

Amy: I started taking classes over the years and learned a lot from my patients. It’s been amazing to see where pelvic health has come! There were only 1-2 classes even offered in a period of 5 years when I started. Now, there are whole series offered by Herman and Wallace, and the APTA’s Women’s Health section.

How did you get your first job in pelvic health physical therapy?

Amy: When I graduated, I went right into outpatient orthopedics. I actually wanted to work in a hospital setting, but when I graduated, there was an overabundance of physical therapists, so I had to take what was out there. So I ended up working in an orthopedic clinic, as well as a place that did biofeedback at the time. So I reached out my friend’s physician (a urologist), and started reaching out to other physicians, too. I contacted colorectal doctors, GI doctors, gynecologists, and even some orthopedic surgeons and doctors because of the relation of the sacrum and hip with the pelvic floor). From reaching out to these doctors, I developed great network of resources. Over the years, we’ve learned a lot from each other. It has been a great experience!

How did you learn your biofeedback skills? From physicians, mentorships, or from classes?

Amy: All of the pelvic health classes are post graduate. So I didn’t get much experience with biofeedback during PT school. I think some schools might offer an elective for pelvic health, but biofeedback is just one component of pelvic health. And that, I learned through coursework. Then, I did a biofeedback certification years ago. Now there’s a special pelvic health certification through the APTA, and also through Herman and Wallace. You need to take a certain amount of classes, then an exam, and a practical. It’s very similar to the other certifications you can get through the APTA. Biofeedback is a tool that we use as pelvic health therapists. Other tools are therex and manual therapy. We usually use manual therapy for painful, tight, or overactive pelvic floor muscles. Biofeedback is used more for underactive pelvic floor muscles, meaning the weak muscles. Overactive ones are more like spasms and tightening, versus the weakness, which leads to leaking during coughing or sneezing. In my book, I spell it out very well, separating the two.

Is your book designed more for patients or for clinicians?

Amy: It’s more for patients, but if you’re a clinician interested in pelvic health physical therapy, it’s a good read. It’s an introduction to what pelvic floor dysfunction is, the diagnoses you might see, and a basic treatment home program vs how to treat in the office, because the two are very different. But it’s a good foundation for someone interested in pelvic health.

When did you decide that you felt you had the skills necessary to open your own pelvic health physical therapy clinic, vs working for someone else?

Amy: My first year, I did mostly orthopedics. I saw from 4-6 patients per hour! I only had 1-2 pelvic patients, both with pelvic pain (overactive conditions). Then, the next year, after I reached out to those physicians I mentioned earlier, I had a full caseload of pelvic floor patients. I told my boss that I needed longer sessions to treat these patients because they couldn’t do their exercises on their own. My clinic was accommodating, and allowed me 45 minutes for each patient, but that wasn’t good from their business perspective. So about the third year in, I decided to go out on my own. It was such an underserved population, and most of my patients simply followed me, because there was nobody else in the clinic who did what I did. So I opened my doors in my new office with a full caseload. I felt very fortunate and still do. Now, we have 6 practitioners and me in the office. We see mostly pelvic pain, some incontinence, and some pregnancy and orthopedics.

I know a lot of people hear “pelvic health physical therapy” and immediately think of treating women exclusively. Do you see a lot of male patients?

Amy: We do. Probably 35-40% of our patients are male! When I had my first three patients ever, one was a 25 year old male. He had some testicular pain, as well as urinary frequency and urgency. People even asked me if I felt uncomfortable. I never really did! The only discomfort was that I didn’t really have mentors or experience. Luckily, he was a sweet guy and he was desperate for relief. He was understanding. I’ve learned a ton since then, and there is a much wider body of research and education now than there was 17 years ago.

What if there is a male therapist looking to go into pelvic health physical therapy. Is it considered outside the norm? How would a male proceed with his training?

Amy: There are a couple classes that are taught by males. Peter Philip is one of them. He’s a male pioneer in pelvic health. That’s a great class for a male to take. He goes over how to treat women’s health and women. Some therapists recommend getting a separate consent form for everything you touch or treat. It might seem extreme, but it covers the liability aspect. We just get a general consent form and a verbal consent. One male pelvic health therapist I know treats on his own, and another has a person sit in with him when he treats a female patient. I definitely know some male pelvic health PTs who have had a lot of success.

We understand that you lead educational retreats. Can you tell us about those?

Amy: I have two different venues that I work with. One is the “International Pelvic Pain Society” and that’s geared toward practitioners. The meetings attract gynecologists, urologists, GI doctors and colorectal doctors. Plus, lots of physical therapists. Also, some mental health practitioners attend. There’s a 2 day scientific meeting in October and it’s a great way to learn what’s new in the pelvic health world. As a new practitioner, it’s a great way to get everything in one conference. Bowel, bladder, organic issues (like endometriosis), GI issues. The other retreat is more patient centered. It’s the Alliance for Pelvic Pain. We have had some practitioners come, but it’s mostly geared toward pelvic and abdominal pain patients. It's hosted by 2 gynecologists, 2 mental health practitioners and myself. We educate attendees about how we approach pain from each perspective. We also give them educational tools, like home programs, and ways to find the right practitioner who can really help them. It is helpful because dealing with pelvic pain requires a lot of effort, just to find someone who can treat you effectively. It can be time consuming and some patients start to lose hope.

Speaking of the term “pelvic pain”, do patients know they have it when they come in? Or do they think they have other forms of pain, like back or hip pain?

Amy: It depends. Sometimes, the practitioner has to make the call about what is truly causing the pain. If you are working orthopedically and something doesn’t seem right, don't just ignore your hunch. For example, if a patient is coming in with hip pain, but it’s referring, and/or they’re also having bowel and or bladder issues. Or a great thing to ask is if they’ve had any change in sexual health. Those are all signs that there is something else going on besides a hip tendonitis or a bursitis, or an SIJ problem. So we ask about all of these. If you are in more of the orthopedic world, asking these questions can be a life changer for a patient. If they have urinary frequency or urgency or they feel like they can’t empty their bladder and you send them to a pelvic health practitioner, they will be SO thankful. For some patients, you will make a huge impact on their life.

How soon should an orthopedic physical therapist refer out if the patient is not improving?

Amy: After you have asked about bowel, bladder, sexual health, if you see them for a few visits and they're not getting better, then send them to a pelvic floor therapist for a consult. Another thing I want to add is that there are lots of levels of pelvic floor therapists. This will get more defined. But for now, some claim they treat pelvic pain, but all they do is biofeedback. Others are much more hands on and have done all the training and classes. So some therapists are less educated. So it’s important as a practitioner to find out the education and training of the clinician to whom you refer your patients.

So what would you recommend? Someone with coursework, mentorship, or actual certifications? Or any combo of these?

Amy: If possible, look for a therapist who has completed one of the new certifications (in the last 2 years) or look to make sure that they’ve taken pelvic floor 1, 2, and 3 through Herman and Wallace or the APTA. If it’s a more straightforward patient, I’d be OK if the practitioner only took level 1 and 2, but for more involved patients, I’d at least want them to have taken 3. And then more classes, ideally! There’s one class just on pudendal neuralgia, which is a great class. I learned so much just from that one class. Also, if you have the option, ask the practitioner how many patients they see per month in pelvic health. My office is 90-95% pelvic health, but other offices are more like 1 patient a month. That’s a clue that they might not have as much experience and training with a population.

If you know of a young therapist who didn’t have a chance to do a clinical in pelvic health, but is interested in learning more, what would you recommend? What is the first step to get a foot in the door with the field?

Amy: Personally, I’ve hired practitioners trained in pelvic health, as well as a few new grads. In my office, I’m specific that they need quite a bit of training from us before they even put a hand on a patient. As a new PT or one looking to switch into pelvic health, it’s really just going to Herman and Wallace and APTA and starting with pelvic floor 1. If you’re not sure about committing to the cost, time, and travel required for it, there’s a class called "Orthopedic Causes of Pelvic Pain," where you can dip a toe into the topic, just to see if it’s an interest of yours. There are also practitioners who do training in our office here. I think there is also a fellowship program in the works. Stay tuned in a few years for that! Also, pelvic health physical therapists should be very savvy with orthopedics.

How long are pelvic health physical therapy treatment sessions?

Amy: In my practice, patients are usually seen for an hour. Evals are sometimes a little longer. When it’s a new PT coming to my office, whether they have experience with pelvic health or not, I always give them more time because of the paperwork. It’s not a fun topic, but anyway, I always give them more time in the beginning to get to know the patients and the population. If a patient expresses financial hardship, or are very simple and straightforward case, we might reduce to 45 minutes, but that's not too often.

Typically, for a standard patient, how much of that hour is spent on education, manual therapy, or biofeedback, vs exercise?

Amy: Really, it's similar to ortho. We do spend a lot of time on intake, including asking questions, health history, etc. For overactive patients, there’s lots of manual therapy and functional manual therapy (strain-counterstrain, etc). Not just to the pelvic floor. It’s also the abdominals, thoracolumbarsacral area, hip region, inner and outer thighs, as well as the pelvic region. You need to look head to toe, including a gait assessment. If the gait is off, it can translate to the hip to the knee to the pelvis. You really need to do a hands on manual therapy assessment. ROM, of hips, pelvis, lumbosacral area. Also, you need to do an internal pelvic floor exam, vaginally for women, and rectally for the men. But with some of my female patients, I also need to do a rectal exam and treatment b/c of the relation to the tailbone on the pelvic floor muscles. For the underactive (weak muscles) patients, the ones who leak, those patients generally need a structural and gait assessment, but if you don’t find much and it’s pure pelvic floor, that’s when you just do biofeedback and approach it by increasing muscle strength. Then you add functional activities. If you work with them for a few weeks and they’ve gotten stronger, and biofeedback shows that, you still may need to do functional exercises with them, along with the training they’re getting at the beginning.

What referral pattern might be a hallmark for something that might be pelvic related?

Amy: Travell and Simon have a 2 volume book on myofascial trigger points, so there are trigger points in the abdominal wall, pelvic floor, lumbosacral region, that can all refer into the pelvis. It can cause bowel/bladder issues, sexual pain, but then also muscles of the pelvic floor can refer out. One common thing we see is groin or ovarian pain. If you press on some of the pelvic floor muscles, it reproduces what the patient perceives as “ovarian pain.” It's a sign that the issue is in the pelvic floor, as typically, organs aren’t painful. So we’ll see that, unexplained LBP that is very achy and sometimes close to the tailbone. Also, up the back! Then you press the pelvic floor muscle and it refers. Another thing to consider is that a lot of the nerves from the thoracolumbosacral region refer into the pelvic floor, and not just the pudendal nerve, which is commonly pinched or irritated. But speaking of the pudendal nerve, it’s similar to the sciatic nerve. You can have pudendal nerve irritation, which causes burning with urination and BMs, as well as increased pain and frequency with BMs and urination. But there’s also the posterior femorocutaneous nerve, which refers into the posterior thigh (mimicking sciatica) and into the pelvic regions. There are all these other nerves with branches or portions that refer into the pelvis, abdominal wall, or even the back! It can be confusing for the patient and the practitioner. In my experience, it just comes from years of learning, but when it comes to nerve issues, a lot of the ortho classes that work with the back and thoracolumbar regions can help with those diagnoses. But it’s very challenging because thoracolumbosacral issues and pelvic floor issues can both refer out and have pain referred in!

What are some challenges of being a pelvic health physical therapist?

Amy: Paperwork, because one of the more challenging things about paperwork for this setting is that these patients do come for longer than typical orthopedic patients (I mean orthopedic patients besides ones with chronic LBP and neck pain). Definitely longer than ankle sprains. They do tend to come for longer because of all the organs involved, plus there’s no way to rest the bowel or bladder completely, this creates an extra layer of difficulty with recovery. I start the HEP on day one; we spend at least 15-20 minutes with educating the patients about the muscles, nerves, structure of pelvic region, as well as educating them about what is considered normal and abnormal. Lots of people don’t know they’re should be having a BM every day, but they think 1 every 3 days is normal! Or they don’t realize that getting up more than once per night is not normal. So HEP is huge, and you should be educating patients at every visit. We try to get them as independent as possible, and they must be doing something at home. Another challenge is that sometimes, patients’ anxiety and stress gets in the way of healing. We try to get the patients in touch with the right person who can deal with their pelvic issues and sexual health. They might already work with someone, but we want them to work with the right person for their needs. If they don't address the mental health aspects, it can be challenging.

What are some rewards of practicing pelvic health physical therapy?

Amy: There are so many. The positives definitely outweigh the challenges. Our patients just want help, and a diagnosis. These patients are just so grateful. The reviews of my book are exciting to read those because there are patients in areas where you can’t find a pelvic health therapist, much less one with extensive training and certifications. Lots of these patients still get help from what is in the book, and that part is very rewarding. Giving people hope again is rewarding. Another extremely rewarding feeling is when someone can finally enjoy sex. When you can get someone to the point where they can enjoy sex and start a family, when that initially seems out of the question, it’s just so gratifying.

Would a typical sexual dysfunction be that they cannot tolerate the pain? Or is it something else?

Amy: Some women have pain with penetration because the pelvic floor muscles are too tight. Some have an issue with the tissue - there’s a recent phenomenon we're seeing with women on the birth control pill, where the estrogen in the pill is depleting some of the women of the hormones they need to keep the tissue from getting irritated. This is more common with younger women. Some of our males have pain after sexual activity. The muscles of the pelvic floor are contracting during an orgasm, but if there are trigger points, these trigger points can get worse after they orgasm! So there are lots of different components. Some women, more than men, have pain in different positions. There is really a variety.

What are some of the most typical dysfunctions you see in both men and women? How do these dysfunctions come about, and how are they diagnosed?

Amy: In terms of gastrointestinal issues, IBS (irritable bowel syndrome) is something that we see a lot, often from tightness of the abdominal wall or pelvic floor. There’s often a nutritional and medication component, too. But we often see that and endometriosis. We cannot treat the endometriosis itself, but we can treat pain and scarring related to it the condition.  We'll sometimes see somatoviscero reflexes from irritated viscera sending messages to the muscle in the area.  We'll also see bladder issues, like ICS (interstitial cystitis). Something like 88% of painful bladder dysfunctions have relation to pelvic floor dysfunctions. We treat around the organs to improve blood flow, remove trigger points, etc. We'll see a lot of pain with penetration, as well as post-orgasmic pain in both men and women. Men come in with genital pain (often related to the pudendal or genitofemoral nerve - which runs through the psoas). If it’s pinched from the psoas, it can cause pain. The men can even have a surgery to treat this issue, without even needing it. Think of pelvic floor pain as low back pain. It can come from so many different causes. You have to look at it like you’d look at any orthopedic injury. Consider what the driver is, and address both that and the secondary issues and symptoms.

Speaking of surgeries, some people come in post op or they might need surgery if pelvic health physical therapy doesn’t work. Where does surgery fit in?

Amy: Ideally in the abdominopelvic region, once physicians have ruled out and treated an organic condition (such as infection or cancer) or an orthopedic condition, you want to try conservative treatment first. So definitely a course of pelvic floor PT is appropriate. The patient should notice a difference. They might not be cured, but they should notice a difference within 6-8 visits. Whether the bladder dysfunction is improving, or they’re leaking less, or they’re not as constipated. If they plateau after a few months, it’s time to go back to the physician. Or see another PT in our practice, then go to the physician, or even try another physician. If they have had abdominopelvic surgery, we want to make it where as soon as the surgery is done and they have the physician’s clearance, they go to a pelvic health PT, just to make sure the scar looks ok and go from there. So for a post-prostatectomy or post-hysterectomy, we want to see them both pre-op and post-op, as well as when they have clearance to start the actual sessions of PT.

Given your challenges with defensible documentation, what are some goals you set for pelvic health patients, and what are steps you take to work toward them and ensure they are supported by documentation?

Amy: We are trying to focus more on validated outcome tools. NIH has a male pelvic health outcome measure and a female one. It’s a 10 question scale that a patient fills out every so often. Some questionnaires are more specific to sexual health, bowel and bladder health, and others. Using those helps a lot. Other things you’ll learn in the con-ed classes are big documentation "no no"s. Writing "pain with sexual activity" just won’t get reimbursed, which is so unfortunate. So for females, we have to ask about other related symptoms. For example, these patients might have “pain with tampon use”, "pain with gynecological exams," or anything else, where it's a reimbursable problem they really have. It's just too bad we can't address the other problems. Some insurances will actually deny you outright if you write “pain with sexual activity,” which is so frustrating and implies that we can't procreate. And recently, they’ll even deny you if you write constipation! So staying up to date on these things is definitely crucial. We have to use other descriptors like: “incomplete bowel emptying” or “bowel retention.” It’s very limiting. The VAS scale, an analog pain scale, or using goals of how many/severity of trigger points in the pelvic region, or toileting frequency are all helpful. If something is affecting a patient's ability to work/attend school, like pain with sitting or interrupted work do to severe bladder frequency of 2-3 times/hour, you mention that. Bringing in the functional component is key.

Given the level of intimacy in your line of work, do you ever feel uncomfortable? Or do you deal with situations where you feel threatened?

Amy: Actually, we have weekly meetings in our clinic with case studies, in-services, and physician Q&As. Recently, we met with a mental health practitioner and sex therapist, and we asked her what to do if that came up. Fortunately, it’s rarely come up, if at all. You simply have to be professional. If you feel uncomfortable, your health as a practitioner comes first. You can ask another practitioner or admin staff member to come in during the session. You can also ask the patient to bring a friend or significant other with them. If they’re not options, you can always discharge the patient or refer out. Try to address it upfront if/when it occurs and tell them that you cannot continue their treatment if they continue to make you feel uncomfortable. We rarely have this issue, though, because these patients really just want help and to feel better. And the PT sets the tone. If a therapist is professional from the get go, the patients usually respond with a professional attitude.

Are there pelvic health physical therapy sub-specialties?

Amy: There are definitely some established sub-specialties, as well as some emerging ones. Oncology is a big one. We have one in my office. There is also pediatric sub-specialists. These therapists treat kids with bowel or bladder issues. Prenatal and postpartum care is a big part of pelvic health. I feel strongly that all women should have a few sessions of prenatal physical therapy, no matter what! This is because there is almost always something going on, whether it’s an orthopedic or pelvic floor issue. It's also wise to see a PT postpartum, as soon as the ob-gyn OKs it. Simple episiotomies can turn into debilitating pelvic pain. Sometimes it’s just an issue where they need to mobilize the scar tissue. Men’s health is also emerging as its own sub-speciality.

What is the future of the pelvic health specialty? Is there job security? Will the field grow?

Amy: At this point, it’s really just getting that training in pelvic health. When I started in NYC, there was one pelvic health PT office, and now there are probably 10 in the area. And it’s still an underserved population, but it’s a great up and coming area of practice. I think eventually, having a subspecialty within pelvic health will be the way to go. But for now, it’s all about just training and experience to get started.

Do patients usually need a physician's referral in direct access states? Are there any special requirements to see you?

Amy: I don’t believe there are any barriers beyond a normal set for your state. But you’d be doing a disservice to the patients if you don’t have training in any specialized area before you start training patients. Some people do that, and it’s unfortunate. If they just take one class and feel they’re an expert, it isn’t OK with me. When I was first learning, there weren’t lots of classes, so I traveled to Chicago and San Francisco to train with the experts that were available at the time. Definitely knowing your material and limitations before you start, and taking the right classes before you touch the patient is just the right thing to do. But I don’t think there are actual legal restrictions at this time. I just encourage the PTs in my office to get all patients to have a prescription. Some come from a physician, and some come from my book or from the internet. We screen carefully for organic conditions. We have them check out anything suspicious with a physician before we treat them. In New York State, you can see a physical therapist after 3 years post graduation without a prescription for 10 visits or 30 days, but we try to get all our patients to see a physician first, just for clearance, so you cover yourself.

Is there a central resource to look up clinicians with expertise in pelvic health?

Amy: There are definitely ways...but I don’t know if we have even used them! But the APTA women’s health page has practitioners with specialties and sub-specialties. So does Herman and Wallace. The International Pelvic Pain society has a list of physicians and physical therapists. NVA (the national vulvodynia association) has a list of physicians, mental health practitioners, and physical therapists.

What type of therapist would make a good pelvic health physical therapist?

Amy: Someone who is up for a challenging type of therapy where you have to think. Someone who is flexible and OK with considering the mental health components, and is open to referring out and working with other types of medical professionals. Someone who is open to getting a lot of additional training. This just gives you more knowledge and gives the patient more knowledge. It's a good idea to take some steps if you think you're interested in pelvic health. We do a training program for outside practitioners at my clinic, and I’ve only gotten positive feedback.  We’ve also had practitioners who aren’t sure if it’s something they want to do come in and spend a day or half a day just observing. This can give a better idea of whether it’s something that interests them.



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