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The State of Pelvic Floor Physical Therapy

2023 Women's Health Report

It's an exciting — and challenging — time for women's health

Even as women and all individuals with vaginal anatomy endure dangerous setbacks in terms of bodily autonomy, they are taking ownership of their own pelvic health like never before. From claiming their right to pleasurable sex, to refusing to accept pelvic pain and discomfort as "just the way it is," an unstoppable revolution in body awareness and selfcare is underway — and pelvic floor physical therapists are playing a pivotal role.

Not only are pelvic floor PTs providing evidencebased treatments and education to their own patients, they've become a source of truth and empowerment for a growing contingent of individuals who are seeking solutions instead of suffering in silence. According to Exploding Topics, interest in "pelvic care" has increased by 62% over the past 5 years and searches for "pelvic floor therapy" have increased by 56%. On Instagram and TikTok, pelvic floor PTs are engaging large audiences with accessible and accurate information that's all but impossible to find elsewhere.

Nearly every major news outlet that covers women's health, including Self, Today, Forbes Health, and Vogue — has published one or more articles on the pelvic floor in the past year, drawing on the expertise of pelvic floor PTs. As one Well+Good reporter states, "Public interest in pelvic floor health has boomed."

Of course, curiosity about pelvic floor PT doesn't always translate to getting treatment. Studies show that there are significant barriers to getting this type of care, ranging from overcoming stigma to finding a provider who accepts insurance.

Those who successfully make it through treatment tend to become evangelists for pelvic floor PT

Outspoken fans include Nia Sanchez (aka Miss America), Ashley Green, and Ilana Glazer, who become an Origin Advisor in 2022.

Carine Carmy, Origin Co-Founder and CEO, sees parallels between the current rise of pelvic health and what's happened with mental health over the past five to ten years. "Mental health went from a costly 'nice-to-have' with a history of shame and stigma to an affordable 'must-have,' and many are now sharing their journeys publicly on social media and within their communities," she says. "The same shifts are happening in pelvic and women's health, starting with real talk about pregnancy, fertility, menopause, and pain."

On the clinical side, the pelvic floor PTs we spoke with are encouraged by the surge in demand and excited by a new era in which vagina-owners refuse to ignore symptoms that have been framed as "normal" for far too long. At the same time, the profession has downsides — ranging from the cost of continuing education, to the lack of support for students of color, to a high level of burnout — which are making it hard to meet patient demand.

As a company on a mission to make pelvic floor physical therapy the standard of care for women and individuals with vaginal anatomy, across the U.S., we're eager to reflect on the current state of women's health pelvic floor physical therapy, as well as the opportunities and obstacles we face as PTs and as patients. For our first annual State of Pelvic Floor PT report, we brought together top physical therapists as well as industry experts for candid conversations about what's happening now — and what comes next.

'I look back at my pelvic floor as where I held my anxiety and depression', Glazer says. Her path out of pain would be multi-pronged: an antidepressant, talk therapy, ...and - most impactful - pelvic floor physical therapy. Vogue, July 19, 2022

40M Women need pelvic floor PT, but there aren't enough providers to treat them.

One in three U.S. women suffers from pelvic floor disorders every year

While awareness of pelvic floor dysfunction is growing, there are far too few pelvic floor PTs available. Exactly how many pelvic floor PTs are there? "There is no national registry of all pelvic health physical therapists, but we can use our membership numbers and APTA market share data to form an estimate," says Aika Barzhaxynova, Executive Director of the APTA's Academy of Pelvic Health, one of the two biggest professional associations for pelvic floor PTs. Based on these numbers, it's safe to assume there are fewer than 10k providers to treat 40 million people.

Among PT students, interest in the pelvic floor as a specialty has been increasing at a rate of 3%-5% annually over the last decade, according to Barzhaxynova. The number of non-white members of the Academy of Pelvic Health is also rising (currently 27% of members vs. 22% in 2018). To meet the growing demand for pelvic floor PT, interest must grow exponentially. The problem is that the path to becoming a pelvic floor PT can be so elusive and expensive, only the most committed students are likely to stick with it.

To effectively and safely care for those with pelvic floor dysfunction, PTs need in-depth education on conditions that affect the bowel, bladder, and reproductive systems, additional training on the neuromuscular anatomy and physiology of the associated systems, plus extensive practice of hands-on skills. None of the above is provided as part of the standard physical therapy curricula. As critical as the pelvic floor is to core bodily functions and overall quality of life, there simply isn't room in the PT curricula to cover the complexity of evaluating and treating this area of the body.

The majority of entry level physical therapists lack adequate knowledge of the pelvic floor. "In PT school in 2003, I got one lecture on pelvic floor," remembers Liz Miracle, PT, MSPT, WCS, Head of Clinical Quality and Education at Origin. "I'm grateful for the exposure, but it wasn't enough."

Students or licensed PTs interested in pelvic care have to find the time and money for special courses. "Many people go into debt to take these courses," says Miracle. "And that's on top of the debt they've likely accumulated from PT school. You need the money to fly somewhere, stay in a hotel for a weekend, pay for the course — and, in order to become truly competent, do this multiple times for multiple courses." This can be a major financial investment for a profession that isn't as lucrative as other medical fields.

Since the pandemic, virtual courses are easing some of that burden. "A silver lining to COVID, if I can call it that, is the incredible amount of courses that are now available virtually," says Rebecca Maidansky, PT, DPT, owner of Lady Bird PT in Austin, TX. "Because you don't have to pay for the cost of travel, they help improve access to continuing education around pelvic floor." A downside of virtual courses is that students then have to seek out opportunities for hands-on training.

PTs who participate in a 9-12 month residency — which provides ample opportunity to practice manual techniques — face an intense workload and lower pay (the Mayo clinic, for example, pays PT residents 75% of an entry-level PT salary). And with only 17 accredited women's health PT residencies in the U.S., students are likely to have to relocate.

With so many challenges to navigate, the importance of finding a pelvic floor mentor can't be understated. Every PT we spoke with agreed: If it weren't for passionate clinicians and educators who go out of their way to inspire and encourage students, there would be even fewer pelvic floor PTs in practice.

For Maidansky, a chance meeting with her future mentor became the springboard for her career. "When I graduated from PT school, I wasn't interested in pelvic health at all," she says. "Then, when I moved to Austin, I met Kimberlee Sullivan who founded Sullivan Physical Therapy, which has since joined the Origin family. Kimberlee knew that I had no pelvic floor experience but was open to training and investing in young clinicians. Had I not found somebody like that, I would not have been the person who took those courses and then hit the ground running at my own pelvic floor clinic."

"I also wasn't interested in pelvic health in PT school," says Alicia Jeffrey-Thomas PT, DPT, CLT, PRPC, who practices at MomLife Health and Wellness in Medfield, MA. "I wasn't even supposed to have a pelvic floor clinical rotation and it was only through the kindness of one of the local clinicians that I had one — that was really instrumental in my decision to focus on pelvic floor."

Uchenna Ossai, PT, DPT, LSC, who is a sexuality educator and counselor in addition to being a pelvic PT, stresses that mentors are essential for BIPOC students to succeed in PT school, where DEI initiatives are often lacking (more than half of Program Directors at PT Schools see room for improvement in DEI initiatives). "All those little things that a BIPOC PT student has to deal with that other students don't have to deal with can impact their ability to learn, and retain, and build their confidence," says Ossai. "Having a very good mentor saved me in PT school. I had to switch faculty mentors a year in, and she just happened to have her Ph.D. in public health where she focused on diversity and equity components. If I didn't have that particular mentor, I wouldn't have finished, not because I was dumb or lazy, but because I needed that support."

"I had already completed a pelvic floor course when I started working in my initial job at a high volume, medically complex clinic," says Laura Meihofer, PT, DPT, AT, who maintains a private practice in Rochester, MN, and also offers virtual one-on-one mentoring for PTs. "But so much of my education came from the three senior pelvic floor physical therapists who I worked with there. If you want to go be a pelvic floor physical therapist, I highly recommend going to an existing clinic that has at least one, if not multiple pelvic floor physical therapists. Even if it means you're going to have to do a location change, it's worth it—it'll pay off later."

Thoughtfully facilitating pelvic health mentorships for PT students and newly graduated PTs may be one way to get more people into this specialty. "In the world of mental health therapy, mentorship is not a nicety, it's a requirement of your job, and the folks doing the mentoring get paid for their time," says Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMD, CCI, Head of Education at Herman & Wallace. "I think we need to look more at that kind of model."

While highly experienced pelvic floor PTs like Tanner and Meihofer offer mentoring sessions for an hourly fee, not every PT can afford to hire a mentor. That's where clinics that employ multiple pelvic floor PTs can step in. "At Origin, we've built mentorship into our business," says Miracle. "Not only can our PTs learn practical skills and problem-solving with each other through day-to-day interactions (online and in-person), we offer a mentorship program to current clinicians to support their career development goals and foster their clinical confidence. We also have student programs in all of our clinics."

Last, but not least, is the matter of compensation. "Whereas medical students are eventually compensated for the effort and money that they put into their training, residencies, and fellowships, PTs are not," says Ossai. For that to happen, we'll need systemic change.

"We have our work cut out for us," says Carmy. "We need to ensure that pelvic floor PT is covered by insurance at a reimbursement rate that is sustainable for incredibly talented experts in the field. And we need better, more affordable training, including more affordable continuing education, more clinical rotations, and more incentives for mentorship to support the next generation of PTs."

Committed to compassionate care, pelvic floor PTs face a high risk of burnout

Creating a safe and reassuring space for patients to open up about intimate health issues requires compassion and genuine connection on the part of pelvic floor physical therapists. Over time, this emotional labor can become a lot to bear.

"There is a unique piece of human connection that happens in pelvic floor care," says Miracle. "We're having conversations about things that our patients may not tell anybody else. Though we're not trained as therapists, we are talked to like therapists, and we carry that with us."

Pelvic floor PTs support patients as they describe traumatic events that may have contributed to pelvic floor dysfunction, especially chronic pain. "Folks with pelvic pain have a well-documented increased risk of prior trauma that could involve sexual or physical abuse," says Tanner. "Because pelvic health clinicians are caring folks, who do connect with patients, maintaining boundaries during and after these conversations can be difficult. You have to separate your emotional and mental space from that of the person who is coming in for care. That takes considerable skill."

Even experienced PTs who have been trained in trauma-informed care can struggle

"I can find this work really, really hard on an emotional level and I know I'm not alone in that," says Maidansky. "It's a big load to carry and I don't think that we're given the skills to leave it at the door and to walk away. Without these necessary skills, a lot of people don't last long in pelvic floor PT, despite the fact that it is incredibly impactful and gratifying work."

Studies have found that 58% of PTs and occupational therapists report high levels of burnout — a statistic that's likely to be higher for pelvic floor PTs.

Source: Balogun JA, et al. Prevalence and determinants of burnout among physical and occupational therapists. J Allied Health. 2002;31(3):131-139.

Researchers have also found that the compassion fatigue that develops in response to secondary traumatic stress can compromise a PTs ability to deliver the best possible care. This can be devastating to PTs whose professional quality of life depends on their perceived impact on patients and their ability to apply their skills at a high level.

"Ask any PT why they went into this field and the answer will be 'to help people,'" says Emma Brady, PT, DPT, who is now Assistant Director of Sales at Prompt and a co-founder of The Clinician Transition, an online group of over 2,000 PTs who are looking to move away from patient care. "If a PT gets to the point where they feel like they aren't helping people at their maximum, their job satisfaction plummets."

"I think burnout is a reason why a lot of us have gone to private practices, where we aren't forced to see people for 30 minutes, back-to-back-to-back, which is really difficult when folks have a history of trauma," says Tanner. Research backs up that choice, with PTs in private practice reporting lower rates of burnout compared to those who work in hospitals or larger clinics.

"Being able to spend 45 minutes to an hour of one-on-one time with a patient, to listen to them, answer their questions, address their needs, and provide quality care is obviously going to be better for patients," says Sara Reardon, PT, DPT, who owns a private practice in New Orleans. "And, in terms of job satisfaction and career longevity, it's optimal for the practitioner as well."

"Allowing ourselves the time we need to do a good job is so important," agrees Tanner. "I think there's also more room in our profession for helping PTs decompress and ensuring they have folks to talk to." Which brings us back to the incredibly important role that mentors can play. "Beyond having that clinical mentor who gets you in the gate, it can help to find other mentors who have found a way to make this career sustainable and are willing to give back to other clinicians," says Maidansky.

Kimberlee Sullivan, PT, DPT, WCS, BCB-PMD, Origin's Head of Clinical in Texas, is a big proponent of mentorship at every level of a PTs career, especially during the "burnout bump" that can occur between the 1st and 2nd year after PT school or after starting work in pelvic health. "The first year, it's so new and so exciting and you're finally making a difference — but if you don't set up work-life balance and strategies for leaving work at work, it's going to become overwhelming," she says. "We're taught to give care in PT school but not to take care of ourselves, so you have to develop these strategies."

One strategy that Sullivan recommends to her staff is to visualize the process of leaving thoughts and emotions behind as you end work for the day. To do this, it helps to pick a cue that can act as a physical reminder. "One PT I work with uses the knob on our clinic door; when she reaches for the doorknob to leave work, she visualizes clearing her mind of all work-related thoughts," says Sullivan. "Another PT uses a mailbox on her drive home as a cue. She visualizes leaving all her thoughts about work in the mailbox until she picks them up on the way back to work the next day."

Sullivan also recommends creating a self-care habit. "I walk my dog and listen to music, but it could be anything that helps you to decompress," she says. The important thing is to make it a daily habit, even on good days, when you might not feel like you need to relax. And she stresses how important it is to fuel your passions outside of work. "One question I always ask new hires is 'What are you passionate about besides physical therapy?' You need to keep feeding that passion."

Employers looking to support PTs can focus on fostering competence, autonomy, and self-efficacy, which have all been shown to help protect against burnout. Mindfulness and resilience-building interventions can also help PTs manage the stress of secondary trauma.

"At Origin, we want to make it easier for people to continue in this specialty that they're deeply invested in on so many levels," says Miracle. "One major step we've taken is to allow PTs to devote clinical time to professional development projects that they're personally interested in and that don't involve direct patient care." Origin PTs can also opt into treating patients virtually, which may also help ward off burnout. "Virtual care gives you much more flexibility in your schedule," says Sullivan. "If you have good boundaries, you can use the time you'd otherwise spend commuting to fit in self-care, spend more time with your family, or just toss in a load of laundry."

Reducing time spent on documentation can also help PTs conserve resources. "If you're spending eight to ten hours straight with patients and then doing another five hours of documentation, it's not going to be sustainable," says Brady. "What I've seen is that PTs are often not up to date in terms of what documentation is required or helpful. They think they need to document everything for compliance reasons or to show that they care about their patients, but that's not the case. Overdocumentation only puts you at greater risk of burnout."

Whether a PT is working for themselves or an employer, trying to "push through" feelings of burnout is never a helpful strategy. "It's important that people know that it's okay to step out of this work or reduce the amount of time they spend treating pelvic pain," says Tanner. "It's okay to say 'this isn't right for me until I can gain some tools and do some healing of my own.'"

It takes a village (and virtual visits) to help patients overcome barriers to care

Peeing when you sneeze, pain with vaginal penetration, difficulty achieving orgasm, poop or gas that escapes without warning… the symptoms of pelvic floor dysfunction can be life-disrupting, yet patients are often reluctant to bring them up with a doctor. Fewer than 50% of women with urinary incontinence, for example, and 30% of women with accidental bowel leakage seek care for these issues.

Studies reveal a laundry list of barriers: Many women falsely assume that these problems are a "normal" part of aging, believe that "nothing can be done" to help, or hope their symptoms will "go away," if ignored. Embarrassment or shame can also prevent patients from discussing their symptoms with a health care provider, as well as anxiety around pelvic floor assessment and treatment. Some patients stay quiet because they blame themselves for their symptoms or fear being judged by their healthcare provider. Men and parents may not realize that pelvic floor PT is available for all sexes as well as for children.

With an estimated 80% of pelvic floor physical tehrapists working out-of-network, affordability is another significant barrier. In rural areas (which are home to 14% of Americans) the nearest pelvic floor PT might be hours away. And even if there is one nearby, their first available appointment may not be for months, due to high demand.

10 Reasons Women Don't Seek Care for Pelvic Floor Dysfunction

1. Lack of Knowledge

"How can you talk about something [when] you don't even know what it is?"

"I would have no idea what the treatment even would be if there were one."

2. Normative Thinking

"I'm just accepting that my body's changing and as I age, there will be things that I just have to learn to tolerate."

3. Embarrassment/Shame

"When I was probably 30 my internist said, 'Ah, you have a very weak sphincter muscle,' and I just said, 'Oh.' I was too embarrassed to say, 'Why? What?'"

4. Self-Blame

"'I've read what people say on the internet: You're overweight, so it's your fault and because it's your fault, you don't deserve any help.'"

"This is probably happening because I had anal sex."

5. Stigma/Fear of Judgment

"It's a taboo topic."

"I wonder what [my provider] would think about me when I left that appointment. Did I make them uncomfortable? What is their impression of me?"

6. Provider Barriers

"At the end of my exam, I said, 'I'm having this problem,' and it was like I didn't say anything."

7. Access Limitations

"To see a healthcare provider I have to get off work and take three buses."

"I could not afford to see another health care provider."

8. Fear of Treatment

"They're going to send me to a specialist who's going to be some guy, probing, who I've never met before, and expect me to talk to him."

9. Isolation

"My final conclusion is I was probably one of the only people who had this ongoing problem."

10. Avoidance/Denial

"I don't want this to be part of my story of who I am."

Source: Brown HW, Rogers RG, Wise ME. Barriers to seeking care for accidental bowel leakage: a qualitative study. Int Urogynecol J. 2017;28(4):543-551.doi:10.1007/s00192-016-3195-1.

The problem isn't just that patients aren't seeking care for pelvic floor dysfunction, it's also that providers aren't screening for it

Ideally, questions about bladder or bowel leaks, prolapse, and pain or dissatisfaction with sex would be a routine part of annual check-ups. In reality, there's seldom time for doctors to address these "quality of life" issues. For example, in one survey, only 40% of OBGYNs reported routinely asking patients about sexual problems or dysfunction.

OBGYNs may also lack awareness of pelvic floor dysfunction and pelvic floor PT as a firstline treatment. "In OBGYN residency training programs, other subjects take precedence over urogynecology, so students don't get enough education on caring for the pelvic floor," says Rahel Nardos, MD, MCR, an Associate Professor in Female Pelvic Medicine and Reconstructive Surgery at the University of Minnesota and Director of Global Women's Health at the school's Center for Global Health and Social Responsibility.

On the bright side, there are signs that this is changing for the better, especially in cities where there are more pelvic floor PTs in practice. "I just had coffee with an OB-GYN this morning who is part of a massive, relatively traditional practice in Austin that's been around for a long time," says Maidansky. "When I was working five years ago at a different pelvic health clinic, we were not getting a ton of referrals from that practice, but we're now seeing more and more."

Women's health startups like Gennev, HerMD, Millie, Midi Health, and Oula as well as mental health providers like LunaJoy are also dialed into the benefits of pelvic floor PT and working with companies like Origin to help patients get the care they need. "A multidisciplinary approach is the most pragmatic way to meet patients where they are," says Allison Grant, Head of Marketing and Growth at Origin. "Because pelvic floor dysfunction can impact physical, mental, and emotional health, partnering with other providers such as OBGYNs, psychiatrists and even other MSK professionals is crucial to increasing awareness around pelvic floor PT."

The growth of virtual pelvic care — Origin now offers virtual visits in several states and pelvic floor coaching nationwide — will go a long way toward increasing accessibility, especially for postpartum individuals. "There's a wonderful role for virtual pelvic floor PT to play for anyone who needs the convenience and especially in the immediate postpartum," says Tanner. "A PT can see how someone is moving, see how they're holding their body and their baby, and provide cues to help them optimize their posture and movement."

Virtual PT (or a mix of virtual and in-person visits) can also be game-changing for people with full-time jobs and parents with limited childcare options. "Virtual care may not be right for everyone, but there are a lot of people who don't have flexibility at work or who can't afford a regular babysitter, which makes it nearly impossible to see a PT once a week for four or more weeks," says Maidansky. "Skipping the commute and seeing a PT online in less time can make care possible for them."

For others, a virtual visit can be key to starting pelvic floor PT. "One patient told me that she had wanted to do pelvic floor therapy for a long time but avoided making an appointment because of her history with trauma," says Miracle. "Starting with a virtual visit felt less intimidating and gave us time to develop the trust she needed to come in person."

Social media is making a real, positive difference

Just five years ago, it would be hard to believe that a pelvic floor physical therapist could attract nearly a million followers on social media, but that's exactly what Jeffrey-Thomas (@thepelvicdancefloor) has accomplished on TikTok with her unapologetically direct and often funny posts about pelvic health and pelvic floor dysfunction. As fun as it all seems on the surface, her goal — and her impact — is serious.

"As pelvic floor PTs, we spend a lot of time picking up the pieces of a medical system that has left women and individuals with vaginal anatomy feeling like they don't have control over what happens once they are in an exam room," says Jeffrey-Thomas. "I want patients to feel armed with accurate information, so they can advocate for themselves and get the right care."

Reardon (@the.vagina.whisperer) had no idea that her Instagram account would become a pelvic floor reference for nearly 500k followers. "When started IG it was about sharing my childbirth preparation plan and pregnancy tips with my circle of girlfriends who were all having babies," she says. "The growth of my account is a testament to how much people want and need this information, which they aren't getting from anywhere else."

PTs need look no further than their patients for proof that social media is making a difference. "A young woman came into my office just last week and I asked, 'Was it your doctor who referred you to physical therapy?' And she said, 'Well, actually, I saw it on social media,'" says Tanner.

It doesn't take much scrolling through a pelvic floor PT's feed to realize how little women and individuals with vaginal anatomy are taught about their own bodies. "There is a massive gap in pelvic health and sexual health education," says Maidansky (@ladybirdPT), who provides in-depth information to her followers on Instagram. "For so many people, you have a health class in 11th grade where you learn how not to get pregnant or an STI, and that's it."

Beyond teaching people what their pelvic floor is, how it works, and what can happen when it isn't working properly, a key message these content creators are sending is that pelvic floor PT is different from the care they may be used to. With a pelvic floor PT, there's no such thing as TMI in terms of talking about bladder, bowel, or sexual functioning. There's also no judgment. "Whether I'm in the clinic or recording a reel, I talk to people about penises, vaginas, and butt holes the same way I would noses," says Meihofer (@laurameihofer). Topics like orgasm and anal sex are covered with the same practical, helpful approach as birth preparation or postpartum recovery.

Celebrating the beauty of all bodies and vulvas is another prevailing theme. "Many people struggle with low genital self-esteem," says Ossai (@youseelogic). "On social media and in our clinics, we validate these feelings — by saying 'I get that' — then remind them that their bodies are beautiful exactly the way that they are."

Having so many pelvic health experts with a strong presence on social media is also helping to inspire a new generation of PTs, which, as discussed above, is so desperately needed. "Social media is a huge, huge reason, in my opinion, why we're seeing more PTs going into pelvic health," says Ossai.

Finally, social media gives all pelvic floor PTs a way to check in on their broader clinical community, see what people are talking about, and amplify each other's voices. "Together we can help raise awarenes about pelvic health and dispel misconceptions, like that pelvic floor PT is only for pregnant people or cisgender women," says Ossai. "We can expand our messaging to make it clear that pelvic health is and has always been for all the people."

The State of Pelvic Floor Physical Therapy

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