Disparities in Pelvic Rehab Education
Written By: Swathi Mettela, Joanna Bhasker
TLDR: Pelvic floor dysfunction encompasses much more beyond bowel and bladder incontinence, but there is no standardized education for PM&R residents on this topic despite significant interest from trainees and a large patient need. Physiatrists are uniquely positioned to manage pelvic floor dysfunction due to their training in MSK topics and experience caring for patient populations that routinely have concerns about pelvic floor dysfunction. The physiatry community should prioritize multidisciplinary care teams, asking patients about the various presentations of pelvic floor dysfunction, and creating more formal and informal opportunities for mentorship and education on pelvic rehab topics.
Pelvic floor dysfunction refers to musculoskeletal (MSK) or neuromuscular problems that cause pelvic floor muscles to become uncoordinated. We tend to see urinary and fecal incontinence being more routinely managed in physiatry, but these symptoms are only the tip of the iceberg when it comes to pelvic floor dysfunction.
These conditions can impact a variety of activities of daily living (ADLs) and health maintenance including but not limited to:
Urination
Defecation
Sexual function & Fertility
Using menstrual products
Cervical cancer screenings
STI testing
Sitting, Dressing, & Gait
The loss of these functions often goes unmanaged, especially in cultural communities where sexual and reproductive health is associated with significant stigma and shame. If we don’t ask, patients are unlikely to bring up their concerns on their own (Mettela et al., 2024).
Physiatrists are uniquely positioned to care for people with pelvic floor dysfunction due to their comprehensive understanding of muscles, nerves, and joints and nonoperative management of MSK conditions. Moreover, they must learn to manage these conditions because their population includes people affected by stroke, spinal cord injury, brain injury, sports injuries, chronic pain, spasticity, cancer, and more– ALL of which can result in pelvic floor dysfunction.
However, despite having training emphasis in MSK systems, physiatrists rarely apply this knowledge to muscles, joints, nerves, and connective tissues of the pelvis. A 2019 survey study revealed that only 6 of the 55 ACGME-accredited PM&R residency programs included women’s health MSK education, including pelvic floor dysfunction. Of these programs, only one incorporated hands-on education on how to conduct a pelvic floor exam on patient models (Bennis and Rho, 2019). These topics are not represented in the PM&R ACGME core curriculum nor the American Board of PM&R certification examination topics outline.
As it stands, training in pelvic rehab is largely acquired through mentorship opportunities with physiatrists working in the field rather than in formal educational settings. The deficit in formal education in these topics is not due to lack of interest or necessity. In a 2023 survey study, only 19% of sampled PM&R residents felt comfortable caring for patients with women’s health MSK concerns, but 94% viewed women's health MSK as important, 89% requested additional exposure to the field, and 88% requested consideration of formal addition to their curriculum (Ye et al., 2023).
What is part of the solution?
Refer rehab patients to pelvic floor physical therapist and urogynecologist friends whenever appropriate and broaden our multidisciplinary care teams
Consistently ask rehab patients about pelvic floor dysfunction and all the ways it may present outside of bowel and bladder incontinence
Encourage or give resident-led lectures on pelvic rehab topics
Use elective time and conference networking opportunities to meet potential mentors and colleagues in pelvic rehab
Advocate for inclusion of pelvic topics to be included in your residency program’s didactics
Create a virtual resource meant for educating trainees on pelvic rehab topics accessible to PM&R residents at any program
Use your network to connect trainees interested in pelvic rehab to mentors in this field
Organize and advocate for ACGME to include pelvic floor dysfunction and other womens health MSK topics to the PM&R ACGME core curriculum and American Board of PM&R certification examination
Helpful Links:
Interview with a Women’s Health Physiatrist
Women's Health Physical Medicine and Rehabilitation Fellowship
References:
ACGME Program Requirements for Graduate Medical Education in Physical Medicine and Rehabilitation. Accessed March 31, 2024. https://www.acgme.org/globalassets/pfassets/programrequirements/340_physicalmedicinerehabilitation_2023.pdf
Bennis S, Rho M. Musculoskeletal Women's Health Education in Physiatry: A Mismatch in Residency Education and Clinical Practice. PM R. 2019;11(11):1151-1158. doi:10.1002/pmrj.12140
Cohen S. An important web of muscles that often goes overlooked. www.uclahealth.org. Published July 19, 2023. Accessed March 31, 2024. https://www.uclahealth.org/news/important-web-muscles-often-goes-overlooked
Foreman H, Weber L, Thacker HL. Update: A Review of Women's Health Fellowships, Their Role in Interdisciplinary Health Care, and the Need for Accreditation. J Womens Health (Larchmt). 2015;24(5):336-340. doi:10.1089/jwh.2014.5187
Mettela S, Chima M, Costigan H, Stuckey-Peyrot H, Baweja R, Riley K. “Pap smear horror stories, self loathing, feeling like I was less of a woman”: A qualitative content analysis of an online vaginismus forum. Journal of Endometriosis and Pelvic Pain Disorders. 2024;0(0).
Physical Medicine and Rehabilitation Milestones the Accreditation Council for Graduate Medical Education. Accessed March 31, 2024. https://www.acgme.org/globalassets/pdfs/milestones/physicalmedicineandrehabilitationmilestones.pdf
Scott KM. Pelvic Pain. Phys Med Rehabil Clin N Am. 2017;28(3):xv-xvi. doi:10.1016/j.pmr.2017.03.013
Ye A, Gray E, Bennis S, Rho M, Hwang S. Physical medicine & rehabilitation residents' perspectives on women's musculoskeletal health. PM R. 2023;15(11):1436-1444. doi:10.1002/pmrj.12969
