So, now you're going into treatment. Some of my patients come in really, really nervous for their first appointment, but they are the ones that have been referred by their doctor and they have no idea how pelvic floor physical therapy can help them. You probably are not in this boat and you have been counting down the days to get in.
Day one. This is evaluation day. Here are my tips to helping you make your first appointment effective and as stress-free as possible.
1. Plan Ahead Arrive early so if there is any paperwork to fill out, it does not cut into your time with the therapist. Once you’re in the room with the therapist, you’ll hopefully start a little more comfortable as you can now put a name to a face. Your physical therapist will first want to get a thorough history of your pain. This means that they want to know the following information in regards to your pain. Going in prepared to offer the following information about your pain will really smooth out the first appointment.
• When it started • How it started • Did an injury, infection or surgery occur before the pain started • Where is it • When do you feel it • What makes it better • What makes it worse • How bad does it get • How low does your pain get when you're feeling pretty good • What medications are you on • What specialists have you seen • What treatments have you tried • Do you have any allergies • How has this affected your life • What are your goals in coming to therapy 2. Avoid Tangents If your therapist doesn't ask you all of these questions, volunteer the information. But please, be succinct. Avoid going into long tangents. That's the worst thing I think my patients do. They will get off topic and start talking about completely unrelated things during their evaluation. Your time in therapy is precious, so use it wisely.
3. Be Open to Personal, Justifiable Questions Your therapist should also get a very thorough idea of your bladder, bowel and sexual function. This involves asking very invasive questions. If you do not understand why a particular question is being asked, stop your therapist and ask why this is pertinent. They should be able to justify every single question that is being asked.
4. Expect the External Exam The second part of evaluation day consists of an examination. Depending on your symptoms, your therapist will decide to do an external and/or internal examination.
The external exam may consist of examining the following: • screening of the back • screening of the hips • muscle strength testing of the pelvic floor muscles, other core muscles and hips • skin screening for scars • connective tissue screening at the abdomen, bony pelvis (the crotch), inner thighs, outer thighs, gluts, hamstrings, low back • trigger point screening at the abdomen, bony pelvis (the crotch), inner thighs, outer thighs, gluts, hamstrings, low back 5. Expect the Internal Exam The internal exam could be vaginal or rectal. I do not know of any pelvic floor physical therapists that use a speculum to do an exam. And yes, you will kind of be on display. Your lower half will be completely exposed if you are a woman. If you are a man, you may have a towel covering your penis and testicles. But, sometimes even this needs to be moved, depending on your symptoms. Do not worry. (Easy for me to say, right?) But, please, do not worry. If you've researched your therapist well, they have done this before and they will be completely professional. They do this for a living.
An internal exam for the vagina is not gynecological. It is to assess the muscle and myofascial integrity, strength and tone. We can tell if your muscles are overactive, underactive, causing pain or atrophied. Atrophied muscles are really thin, fragile muscle. For women, this can often times mean that they might benefit from a topical estrogen or a selective estrogen receptor modifier to plump up the tissue and improve its health. This can reduce pain and the feeling of dryness.
An internal exam for the anus is assessing for the same things. It usually is not as uncomfortable as people expect it to be. This is because therapists are usually taking their time and use a lot of lubrication for the patient's comfort. We are not being rushed to see another patient every ten minutes, so we are not "in and out". We know that you are there for your pain, so unless we are trying to provoke the pain to determine the source of it, we are trying to make this experience as painless as possible.
Remember, we want to gain your trust and your confidence so that you can relax when you come in for treatments. This is incentive for us to take our time and be very gentle. If you were to be stressed and have anxiety about every appointment for fear of pain, then that would certainly be counter-productive to your goals and our goals.
6. Be Vocal If you have any history of trauma or abuse that makes the idea of an internal examination or even an external examination very unsettling to you, please bring it up! Your therapist may not always know this part of your history. You do not need to go into details. A simple comment like "I am not comfortable with an internal exam today, I need more time to process this and I will let you know when I am ready." That is enough for me. Unless you want to dive into details, I don't have to know any more than that. However, come the meat of the treatment, if and when we get to a point where I really need to look internally, then I will start that conversation. The internal examination gives us a world of information, and there are rare times when it is not necessary to treat internally for pelvic pain.
7. Expect Work Depending on how clear you are with your history and how long your physical therapy evaluation is, there should be a third component to your evaluation day. This is the treatment. This could be a manual technique that the therapist performs on you, it could be instruction in some sort of exercise or stretch that your therapist wants you to perform at home, or it could be sitting down with you and educating you about something that will make a difference in your lifestyle and your symptoms.
8. Don’t Leave Unless You’re Armed with Information It is so important to walk away from your evaluation day knowing the following things: • Your diagnosis - Your therapist should be able to tell you what they think is going on and what they think is causing it. If they have no hypothesis at all, get out of there and find a new therapist. • How long therapy could take - This means that you should be told how long before you should start to see a positive change and how long your therapist thinks it will take for your symptoms to either resolve completely or resolve as much as he or she is going to be able to assist within her specialty alone. For example, sometimes I have patients that come after a mesh placement. I tell them that I can probably help with their pain to an extent, but if the underlying issue is that the mesh was placed too tight, then I can only help so much and it will take X amount of time before we reach a plateau. At that point, if they haven't already spoken to a surgeon and given a revision serious thought, they will need to do so. (Note - this is not the case for all pelvic pain after mesh placement.) • At least one thing you can do at home or at least one lifestyle change to improve the pain - This could be a stretch, a breathing technique, or it could be a diet that you need to begin implementing. (Note - A pelvic floor physical therapist is not going to recommend a weight loss diet for you. They may suggest a low acid, low oxalate, anti-inflammatory or anti-histamine diet to reduce your pelvic pain symptoms.) If you do not leave your evaluation day appointment with confidence in your physical therapist's ability to help you, examine for yourself why that is. Once you've been able to pinpoint your reasons, you may want to call or email your therapist and discuss these things. This is a very intimate type of physical therapy and it can be time consuming for most. You want to make sure your therapist is a good fit for you and, above all, you want to go in for every treatment with the mindset that you are going to get better and that you are in good hands.
Please email Sara@sullivanphysicaltherapy.com with any questions or leave them anonymously in the comment section below.
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