How Pelvic Floor Physical Therapy Can Help MS Patients

Dr. Caudle:
What do you think of when you hear the term “physical therapy”? Do you think of a condition like carpal tunnel? Or maybe even a common sports-related injury like a sprained ankle comes to mind? But despite the common misconception that it’s simply meant for temporary injuries, physical therapy is an effective and oftentimes essential component of treatment regimens for a variety of chronic diseases, including multiple sclerosis.

Welcome to Everyday Family Medicine on ReachMD. I am your host, Dr. Jennifer Caudle, and joining me to discuss the benefits of physical therapy for multiple sclerosis is patient Crystal Gouldey and her physical therapist, Catherine Apicella.

Crystal and Catherine, thank you so much for being here. It’s wonderful to have you.

Crystal:
Thank you.

Catherine:
Thank you for having me.

Dr. Caudle:
Absolutely, absolutely. So this is a really important topic, and I want to start with you, Crystal. Let’s really start by learning more about your journey. Can you tell us about your journey and what led you to begin physical therapy, and how did you end up being paired with Catherine?

Crystal:
Sure. So I actually started with Catherine before I was even diagnosed with MS. I was having a lot of problems. A little over a year ago I was noticing that I was having to go to the bathroom more frequently, trouble with intercourse and even using tampons, and it was getting to be really annoying, so I went to the doctor a few times. I was convinced I had UTIs, but they all came back negative. And I also started noticing problems with my balance and intermittent vision issues. So last year I wanted to have a baby, and I was like, “I need to get this all figured out,” and I went to my primary care doctor and I told him everything that was going on, and that was the first time that a doctor said, “I’m a little concerned about MS.” But they had to do a bunch of blood tests and said that, “If they come back clean, you need to do a full workup with a neuro and also go talk to your OB/GYN,” so that’s what I did. And it wasn’t until I went to the OB/GYN and talked to them about all the issues I was having that they said that pelvic floor physical therapy was something that could help while we’re figuring out what’s going on.

Dr. Caudle:
Right, right.

Crystal:
And I was really, really nervous and skeptical at first. All they did was give me a brochure and say it could help, and I did not have an open mind going into it at all. I was not...

Dr. Caudle:
That’s helpful to know. That’s really insightful.

Crystal:
Yeah, I was not looking forward to it.

I feel very fortunate that I was paired with Catherine because she was incredibly good at making me feel comfortable and safe. And then when I was ultimately diagnosed with MS, she helped me feel reassured and empowered that I could control my symptoms through physical therapy.

Dr. Caudle:
Wow. I mean, that’s such a powerful story, and there’s so much that sounds like you were going through during that time and a lot of emotion there, and I really appreciate you sharing that—and also, your immediate, sort of initial skepticism, your first sort of response, which I don’t think is necessarily uncommon with people, so it’s helpful to understand how you were feeling.

Catherine, I wanted to kind of get your perspective as well. Let’s talk a little bit about specific types of physical therapy. So, are there specific types of physical therapy that would be more beneficial for one patient over another, or does it really depend on the disease? What do you say about that?

Catherine:
I believe it really depends more on the presentation than the disease itself.

Dr. Caudle:
Ah, okay.

Catherine:
So, for example, in Crystal’s case initially, and a lot of times with MS, some of the primary symptoms that present are bowel, bladder, sexual function, so sometimes people come into pelvic floor PT and without a diagnosis yet of MS but they present with symptoms that can be helped with pelvic floor physical therapy.

So how people present is really more important. It’s what their functional limitations are, what their disabilities are, meaning their difficulties with functioning in their daily lives and what they need help with or whether it’s pain or balance issues or strength issues or endurance, sensory changes, bowel/bladder issues, so it really depends on how they present as far as what kind of physical therapy could be beneficial for them.

Dr. Caudle:
Right. I think that’s a really good point that you’re very clear about. It’s not necessarily the condition or the disease. It’s more about what a patient actually needs help with and what symptoms they’re having that they need assistance with.

Catherine:
Yes. I think a lot of times... You know, I work in a primarily orthopedic physical therapy clinic. We treat musculoskeletal conditions primarily, but people come in and say, “Oh, but I have diabetes,” or, “Oh, but this,” and we say, “Okay,” but that’s good for us to know so that we can modify things and be aware, but it doesn’t mean you can’t do things, you can’t get stronger, decrease your pain, improve your sensation and balance and functioning in your daily life.

Dr. Caudle:
No, I think that’s really helpful, and I think... You know, I’m a family physician. As I’m listening to your story and also your story and perspective, I think it’s very helpful for us, I think, as physicians and clinicians to be reminded of kind of opening our minds to how we can help patients. Let’s talk a little bit about... Let’s go sort of into the weeds. We had the background. Can you explain to our audience really what pelvic floor physical therapy entails? And either Catherine or Crystal, both of you, any thoughts about that?

Catherine:
Well, yeah, I can kind of go into—

Dr. Caudle:
Sure, please.

Catherine:
—kind of what pelvic floor PT is, and then you might want to kind of describe your experience with it particularly. So pelvic floor physical therapy, we primarily kind of focus on conditions affecting bowel, bladder, sexual function, whether it’s just urinary incontinence or constipation or painful intercourse, interstitial cystitis or bladder pain syndrome, a variety of types of pelvic pain, and even musculoskeletal conditions that affect the pelvic girdle. The pelvic floor is a sling of muscles that has a lot of different functions, and they really affect stability of this whole area, and they are part of your inner core, so anything that kind of involves that functioning can be treated and assessed with pelvic floor physical therapy. As kind of musculoskeletal experts, we kind of hone in on the pelvic floor muscles. We assess them internally or externally and treat them based on what we find. We check for tone, tension, spasm, strength, coordination, just like any other muscle.

And we basically base our treatment plan on what we find, just like any other assessment.

But what’s important to know is that we are also... Education is a huge part as well. There’s a lot of just education and training. We spend a lot of time talking to patients about what they can do to help themselves. And it’s also important to know that we also tailor treatment. We only go where a patient is comfortable going.

Dr. Caudle:
Right, right.

Catherine:
And so we’re very...

Dr. Caudle:
It’s very individualized, it sounds.

Catherine:
Very. It is. It is. And sometimes people are very comfortable. They are like, “Do you know what? I’ve come this far. Just do what you need to do.”

Dr. Caudle:
Right, “Do what you need to do.”

Catherine:
Some people are like, “I’m not comfortable yet,” and we just—we go with what patients are comfortable with.

Dr. Caudle:
Right, right. And that’s so helpful to hear. So I’m wondering… I think one of my questions really is: Was it what you expected, or were you surprised? I mean, that’s sort of what I was wondering. What was your response and how did you feel? Were you like, “Oh,” or “Oh!”

(Laughter)

Crystal:
Right. Yeah, I was definitely—I was definitely surprised because I... So going into it, I couldn’t—I couldn’t even do a Kegel.

Especially feeling the release, I could not do that at all, but they have the biofeedback equipment that let me kind of see what was happening and kind of become more in tune with my body. And also just doing like the relaxation and stretches and things like that, like I had no idea how many of my muscles were involved in the pelvic floor.

Dr. Caudle:
You didn’t know how many muscles you had, did you?

(Laughter)

Crystal:
Right, exactly, yeah, so for me it was just like—it was an incredible learning experience about my body and how it works, and now it’s obviously helped me with the pelvic floor issues but also just in general knowing what’s going on.

Dr. Caudle:
Absolutely, and that’s so... I think that’s really encouraging. It sounds like there was a lot of insight that you gained through this process about your own body as you’re talking about... I kind of jumped the gun, and our next question really is about some of the benefits, but any more—anything else you want to add about that? Any other benefits that you’ve experienced since beginning the exercises and maybe how it plays a role in your life since starting therapy and maybe what role that plays now?

Crystal:
Yeah, I mean, these symptoms are pretty embarrassing and not something that you really want people to know about or talk about, and it was really mentally draining for me to have to deal with that day-to-day; and now that I have more control, it’s just been 100% better for my quality of life but also for my relationship. And I also went into this not wanting to take a lot of medications. I know eventually—like it’s a progressive disease—that I might have to introduce medications to control the bladder symptoms or spasms eventually, but I wanted to control it as conservative as possible, and physical therapy has allowed me to do that.

Dr. Caudle:
That’s excellent. That’s excellent. This has been so helpful and so insightful, and I think that both of you are really giving us a lot of information I think people really need to understand how pelvic floor physical therapy can help different symptoms, etc., how it’s changed your life and affected your life.

Before we close, I just want to know: Are there any other thoughts or takeaways that both of you have? Maybe, Catherine, we’ll start with you. Any other takeaways or whether it’s recommendations for healthcare providers or for potential patients, any thoughts?

Catherine:
Yeah, I think that... I mean, especially for healthcare providers, familiar practice physicians especially who I think get to see their patients maybe at least a little more regularly—that, you know, to ask the tough questions, to ask the questions about the bowel, the bladder, sexual function.

I have so many people who come in and say, “I had no idea this existed.” “Nobody ever told me about this.” “I had no idea that I could affect anything.” And we have... You know, there’s kind of a saying in our field: “Leakage is common but not normal.”

Dr. Caudle:
Sure.

Catherine:
And so, because it’s become “everybody has it,” it doesn’t mean that you can’t change it, you can’t make it better, you can’t improve it—you can’t improve your life, and I just think that by kind of opening the conversation… Because once people kind of find that safe space to be able to open the conversation, then they just say, “Oh my gosh, I want everybody to know about this,” so making it more comfortable, making it more normal to express and express your concerns. And it’s your body. You want to be able to… You know, don’t just accept things that might be happening.

Dr. Caudle:
Right.

Catherine:
Investigate and kind of do a little bit of your own research and check it out.

Dr. Caudle:
It’s very empowering. I like that because it empowers, I think, us as clinicians and healthcare providers to be proactive and to ask about symptoms that we may not always ask about and letting patients know it’s okay, but also empowering patients to… As you said, I think normal but doesn’t mean that—common but doesn’t mean it’s normal. Did I get that right?

Catherine:
Yes.

Dr. Caudle:
Okay. So just because it’s happening, doesn’t mean you have to live with it, as you said, so I really appreciate that.

Catherine:
Yeah.

Dr. Caudle:
Thank you for that.

Catherine:
Oh, sure.

Dr. Caudle:
And, Crystal, what about you? Any final thoughts that you have for anyone out there who might be listening?

Crystal:
Yeah, so sort of echoing what she said, I think it’s really important for healthcare providers to find places like CORE 3 Physical Therapy with therapists like Catherine because... So, I ride horses, and I’ve had to do a lot of physical therapy over the years, but I’ve never been anywhere that’s provided such individualized treatment, and that has made just such a huge difference in my life. So I think that it’s important that they find these places and have these referrals ready, because something like MS is really scary, and luckily for me it’s not as scary anymore and I’m able to be more positive because I have that as a resource.

Dr. Caudle:
Absolutely. I appreciate that, too. I think that’s really important for our listeners, the importance of a good sort of provider/patient relationship, which it seems like you both definitely do have, so I appreciate that as well. This has been really great. I’m so glad that you both joined us to talk about this topic and shedding light on it for patients and for clinicians, so thank you very much for being here.

Crystal:
Thanks.

Catherine:
Thank you so much for having us.

Dr. Caudle:
I’m Dr. Jennifer Caudle, and to access this episode and others in the series, please visit ReachMD.com where you can Be Part of the Knowledge.