In this podcast episode, Melanie Hamilton-Basich of Rehab Management and Physical Therapy Products is joined by Ingrid Harm-Ernandes, PT, WCS, BCB-PMD, one of the first certified pelvic health physical therapists in the United States, to discuss the different ways physical therapists can provide solutions for people with pelvic floor dysfunction, including useful tools and techniques, and why more people don’t seek help from PTs for these issues.

Ingrid Harm-Ernandes, PT, WCS, BCB-PMD, has been a physical therapist for 38 years and began specializing in Women’s Health 26 years ago. She recently retired clinically from Duke University Health System where she treated a wide variety of pelvic patients in the Urogynecology and Physical Therapy clinics. She was a co-director and mentor for the Women’s Health Physical Therapy Residency Program, responsible for Women’s Health team program development and participates in PFDN research projects. She is board certified in Women’s Health (WCS) and Pelvic Floor Biofeedback. She has served on various committees for the American Urogynecologic Society (AUGS) including serving as the chair and vice chair for the APPTAH SIG for AUGS. She enjoys presenting on the importance of recognizing and assessing the pelvic musculoskeletal system. She has presented on pelvic physical therapy related topics including sexual dysfunction, prolapse, pelvic pain, vulvar pain, urinary and fecal incontinence, and the mysteries of the musculoskeletal system for various organizations and societies nationally and internationally. You can purchase her book The Musculoskeletal Mystery: How To Solve Your Pelvic Floor Symptoms via Desert Harvest.

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Podcast Transcript

Melanie Hamilton-Basich:
Welcome. This is Melanie Hamilton-Basich, the Chief Editor of Physical Therapy Products and Rehab Management. For this podcast episode, I’m happy to be joined by Ingrid Harm-Ernandes, who spent 38 years as a physical therapist and became one of the first certified pelvic health physical therapists in the United States. She retired clinically as a senior physical therapist at Duke University Medical Center in Durham, North Carolina recently, and treated a wide variety of pelvic patients in the urogynecology and physical therapy clinics there. She now spends her time speaking and writing about the benefits of pelvic physical therapy and has recently written a book on the topic called, “The Musculoskeletal Mystery: How to Solve Your Pelvic Floor Symptoms.”

Melanie Hamilton-Basich:
Today, we’ll be talking about the different ways physical therapists can help people with pelvic floor dysfunction and why more people don’t seek help for these issues. Welcome Ingrid.

Ingrid Harm-Ernandes:
Thank you. I’m so happy to be here and excited to talk about this topic.

Melanie Hamilton-Basich:
First, can you share a bit about how you got started in pelvic physical therapy and why it’s a passion for you?

Ingrid Harm-Ernandes:
Yeah. I would say that my path is a little bit more circuitous than most, because when I started, there really wasn’t a well formed women’s health as it was called then path that physical therapist [inaudible 00:01:40]. When I graduated there wasn’t really that sub-specialty. But shortly after I started treating, some of my pregnant patients would quietly say, “I’m having problems with leakage.” And so I wanted to know what that was all about and I looked it up and I’m dating myself, because I went to the library and it really took me a while to figure out what this was. And then when I started to learn as much as I could, I realized that it could make some big changes in people’s lives with just some simple techniques.

Ingrid Harm-Ernandes:
And from there I just kept taking more courses. In the United States, it was building a little bit of momentum there. And it was really awesome to see how you could change people’s lives in so, so many different ways, not just physically, but all their relationship and just their overall ability to do things in their lives. So it became such a strong passion for me, because I could see these amazing changes.

Ingrid Harm-Ernandes:
But then I have to say, as I started to treat men, I also saw the same problems start to come up, that there was often five, 10, and even 30 years of a delay for people to actually get referred to me for treatment. And that was just so frustrating is why was this? And I really did think it through. And then I started to see a common link and that was a gap in knowledge. And that’s for patients, that’s for practitioners, it’s really across the board that this gap existed.

Ingrid Harm-Ernandes:
And I realized that if I could help people understand what that knowledge gap is, then maybe people could get care earlier. And the knowledge gap really started with the muscular skeletal system, hence calling “The muscular skeletal mystery, how to solve your pelvic four symptoms” because it truly is a mystery to people. And so my hope is that with that book that I can open up a whole new world for patients and other practitioners inside of therapy and outside of therapy and that we can all get to treat patients so, so much earlier than, than we are presently.

Melanie Hamilton-Basich:
And what are some of the types of pelvic floor disfunction that can be treated by physical therapy for women and for men?

Ingrid Harm-Ernandes:
Well, a very, very large group of conditions. So I think it might be best to separate that into some categories. And one of the big categories is pelvic pain. And that could be pain with sex. It could be vaginitis. What you now might see, is genito-pelvic pain or penetration disorder, chronic pelvic pain, vulvadynia, pelvic congestion syndrome, interstitial studies. You can see in itself, that’s a very large group of conditions that have to do with pain, but you can kind of say between rib cage and knees. I actually would say between nose and toes, because it really does encompass the larger area.

Ingrid Harm-Ernandes:
Then another group would be urinary incontinence and fecal incontinence and constipation. A lot of people realize that they can get treatment for constipation and the pelvic floor has a huge impact. That’s not just bowels, but our pelvic floor that can create constipation. Prolapse, where is the basic description of that is an organ such as your uterus or your bladder or your bowel starts to fall into the vaginal canal and actually bulge out the vaginal opening and can be quite, quite scary for someone who wakes one day taking a shower and thinking I have cancer because I feel a bulge, right?

Ingrid Harm-Ernandes:
So we try to educate more on that. So it’s not so scary. Fourth trimester care. So here’s something that I think is growing beautifully in the last just couple years. It’s really to consider that after birth time period as a time period where a woman really, really, really needs a lot of care and physical therapy. Pelvic PT is perfectly suited for it and can get that person back to their life much quicker.

Ingrid Harm-Ernandes:
So one thing to think about with all of these is there is a commonality of the musculoskeletal system here as well. So when we treat as pelvic PTs, we often treat backs and knees and hips and everything that is involved in the pelvic region and beyond just so that our patients can really return to their full life, right? Not just we’re worried about the pelvic floor alone, but really it’s a whole body.

Melanie Hamilton-Basich:
What are some of the ways physical therapists can treat pelvic floor dysfunction that you were talking about? Are there any that you wish more physical therapists were aware of or that others were aware of?

Ingrid Harm-Ernandes:
Yeah, yeah, absolutely. So that is also very complex in that there are snippets of things people hear and it’s really important to realize what we do. So we may do what’s called internal work. So that’s actual internal vaginal or anal work where we can target most and fascia and organs and get them to function better. That’s our goal with the internal work. But I do want everybody to realize that that intern work is only performed after a very careful assessment and with consent of the patient. So informed consent here is huge. We really want the patient to be ready for that kind of work and willing to work with that.

Ingrid Harm-Ernandes:
So sometimes I would do internal work from the first treatment on and sometimes it might not be until a few treatments later and then it could also be not at all. It’s really dependent on the patient. We’ll also do external work. So just like many physical therapists do mobilizations and soft tissue work and grass skills and other things that we do that help with external work, a pelvic PT will do the same thing, but usually more targeted to the pelvic area if needed.

Ingrid Harm-Ernandes:
Then another big categories that are called behavioral techniques. And those are really self skill techniques where we teach the patient how to take care of themselves. And it could be as simple as how do we get them to stop urgency from happening? How do we get them to get to the bathroom successfully without leakage? How do we inform them on things in their diet that might help with having a better bowel movement while we’re working on the musculature of the pelvic floor?

Ingrid Harm-Ernandes:
So you can see that’s a huge category in itself. And it’s very enjoyable because we get the patient to go home and work on those skills and help themselves. We empower them to help themselves basically is what means. Then biofeedback is methodology where the patient can actually on a screen see the contraction and relaxation of the pelvic floor so they can better learn how to use their pelvic floor. And then exercises are huge. So all PTs know, we love this to exercises, but one important myth is kegels. So kegels, everybody thinks, “Okay, well that’s just contracting my pelvic floor as strong and as many times as I can.” Well, we actually need to assess exactly what the patient can do because sometimes a pelvic floor contraction is not appropriate or it’s not appropriate on the first visit, but it might be appropriate on the fourth or fifth visit.

Ingrid Harm-Ernandes:
So what a PT does is looks at what a patient can do and then teaches them the correct methodology for doing it and teaching them how often they should do it and whether it’s okay or not to do. So basically the entire pelvic floor exercise instead of kegel is based on the specific need of the patient.

Ingrid Harm-Ernandes:
And then of course home programs are so important with this patient population because at home when they repeat what we teach them, that’s when they gain that strength and that empowerment that I mentioned before that really sets them on their path to improvement. And the main thing I think for other therapists, like you were saying before, what are other therapists, what do we wish they knew? Well, all those different things that are listed out are things indeed that I wish they did know because if they can say, “Since you’re having a problem with incontinence,” let’s say they have a back problem and they also have incontinence, they can then broach the subject more comfortably and they can explain what we do in PT and that what we assess in PT and that that will be helpful.

Ingrid Harm-Ernandes:
And then the patient’s more likely to actually go to pelvic PT and we can partner with that other therapist or any other practitioner. So really family medicine, GI, all the different subspecialties, your gynecology. If we can have that better communication, then we can show everybody that these conditions are common, but they’re not normal. We really spell and myth that these are normal conditions that we just live with. No, we don’t need to live with them. Pelvic PT really can be the answer. And I think the other PT and the other practitioners can be that first step into getting the patient the right kind of care.

Melanie Hamilton-Basich:
Did you want to talk about the use of pelvic wands and dilators to treat pelvic floor issues and how those can be used?

Ingrid Harm-Ernandes:
Yes, absolutely. So in some of that self care mentioned, pelvic wands and dilators are an important part of that self care. So there’s a slight difference between a wand and a dilator. Dilators generally come from a very, very small size. So imagine maybe the width or diameter of your pinky, and then they go all the way up to what you might normally see as a dilator or a sex toy or anything like that would be the largest size. And the goal there is to slowly and comfortably stretch the pelvic floor musculature to the point where that patient can return to using a tampon, to getting a pelvic floor exam, and then eventually to have intercourse comfortably and enjoyably. So those dilators are important to be used properly. And that’s where pelvic PT comes in and explain exactly how to do that.

Ingrid Harm-Ernandes:
Now a wand, on the other hand is usually S-shaped. And the reason why that can be so great for the patient to use is they literally can move around to musculature, let’s say, on the side of the pelvic floor and be able to treat a trigger point very specific to that location rather than stretching the hole. Right? So these dilators and wands are a great, like I said, self-help tool that with a pelvic floor PT’s guidance can be an awesome way for a patient really, really to make gains and all these different things that I just talked about.

Melanie Hamilton-Basich:
Do you have any tips for how physical therapists can help their clients find the best pelvic wands and dilators for their clients?

Ingrid Harm-Ernandes:
Yeah. Yeah. So like I mentioned, the needs of the patient are like the most important before even trying to make a decision.

Ingrid Harm-Ernandes:
So it’s the patient’s toleration of pain and stretch, what their goals are, where they want to go, the use of the dilators. That would be the first thing. So it’s really talking to the patient and finding out what their needs are. After that, once that’s determined, and let’s say you want to go with, I’ll start with the wands first. So there are many different kinds of wands out there. There are plastic, silicon, there are glass ones. And I know that sounds kind of odd, but there’s a particular kind of glass wand that you can find at Desert Harvest. It’s a medical grade glass that actually doesn’t break. You can drop it on the floor and it doesn’t break. And the beauty of this device is it can be heated and it can be cooled for more comfortable usage when they’re doing this trigger point release work.

Ingrid Harm-Ernandes:
And I will add an extra little thing that’s really important. So not only the wand itself, but the lubrication that is used while using the wand is vital. So trying to use any one of these dilators or wands without lubrication can be quite painful. And the patient will not want to use it at all. Again, for my patients recommend Glide or aloe vera Gele, because there as natural to the body’s makeup as possible. So both on pH level and what’s called osmolality, the natural lubricant, the natural moisture level is most closely reflected in these aloe vera Geles and Glides. So that’s just as important as the device itself in being able to do a comfortable stretch or trigger point work.

Melanie Hamilton-Basich:
Thank you. You talked about how physical therapists don’t always have the ability to let their clients know what is needed, or people are seeking relief that they might not know where.

Melanie Hamilton-Basich:
Do you have any tips for how physical therapists and doctors can work together to help clients find relief for their pelvic floor symptom?

Ingrid Harm-Ernandes:
That’s a great question. So I have to say that’s one thing that I think we should all work on better. And my tips for that from my experiences are that every one of us should reach out and shadow or spend time with someone we’re going to team with. So my examples, I used to be able to go into the clinical room, which [inaudible 00:15:09] the GI doctor, spend time with them and their patients. And we used to have the most awesome discussions on how we can help our patients the best as a team. And the patients loved it because they got two heads thinking together on an issue. And they could see how this teamwork really helped them tremendously.

Ingrid Harm-Ernandes:
And I have to say as I went initially to shadow and learn myself, the person that I was shadowing almost would ask more questions of me than I would of them because they suddenly learned that, “Wow, wait a minute. This is what pelvic PT is all about. I’m amazed. I had no idea that you did all this. I had no idea it was so comprehensive.” So I think sharing information is key, is absolutely key. Share information about patient specific needs. So once you get to meet your fellow practitioner, you team up with them, keep the combination going. I can’t imagine having treated so many of my patients without having them being open minded about why does someone approach it this way? How do they do it surgically? How do they do it with medication? How does that impact patients? So although I never perform surgery or I never prescribe medication, I still understand why it impacts my patient and can advise them if they need to go back to another practitioner.

Ingrid Harm-Ernandes:
So I think that opens us up to a whole new world of really being able to understand how better to treat our patients. And I also, I think, again, the book, “The Musculoskeletal Mystery,” talks so much about the teamwork what is each and everyone, whether it’s mental health, sex ed, or all these components of care are so still very important to really treating the patients better. So my advice would be reach out to the other practitioners and have a great conversation with them so you can help your patients better, and we can make these conditions that everybody thinks are so normal to say, Nope, they’re not normal. We can help you with it. And this is how we can do it.

Melanie Hamilton-Basich:
Well, thank you. That’s all the time we have for today. Thank you Ingrid for sharing your expertise and insights with us.

Ingrid Harm-Ernandes:
Thank you so much for having me. I really appreciate this opportunity.

Melanie Hamilton-Basich:
Thank you for your sharing your expertise and insights with us. And thank you to our listeners for more great content from physical therapy products and rehab management, visit us online at ptproductsonline.com and rehabpub.com. And while you’re there, subscribe to the publications and our newsletters.