Building Effective Therapeutic Relationships in Pelvic Floor Rehab: A Commentary

Illustration by Michelle Wu for rehabINK

Commentary

By Shirin Modarresi, Sarah Janssen, Hoda Seens & Golale Modarresi


Pelvic floor dysfunction is common and can occur in females, males, and children. The conditions associated with pelvic floor dysfunction can have a significant and debilitating impact on quality of life, resulting in negative psychological consequences such as depression and anxiety (1). These conditions include but are not limited to urinary and fecal incontinence, pelvic pain, prostatitis, endometriosis (i.e., tissue similar to the inside of the uterus grows outside), dysmenorrhea (i.e., severe menstrual pain), dyspareunia (i.e., painful intercourse), vaginismus (i.e., pelvic floor muscle spasm), interstitial cystitis (i.e., bladder pressure and pain), prenatal and postnatal conditions, digestive issues (e.g., constipation), and orthopedic concerns such as low back and sacroiliac pain. Pelvic floor rehabilitation is an essential field of healthcare that encompasses the assessment and treatment of these various conditions through conservative management, the success of which has been highlighted in previous literature (2,3).

Pelvic floor rehabilitation for the aforementioned and other conditions may involve manual therapy, electrical stimulation and biofeedback, patient education, and individualized exercise programs (4). Internal assessment and treatment of the pelvic floor (vaginally or rectally) is beneficial, and often required for clinical diagnosis and guiding treatment. The purpose of an internal exam is to assess the muscles (tone, strength, and endurance), areas of tenderness, and connective tissue integrity. In addition, motor control and the patient’s ability to contract and relax voluntarily are assessed (3).

A thorough subjective and objective assessment guides the clinician in formulating differential diagnoses and an appropriate treatment plan. The patient interview may involve intimate questions regarding the genitalia, sexual function, and bowel and bladder habits. These assessments may induce negative emotions, such as anxiety and embarrassment, which can be barriers to successful pelvic floor rehabilitation (5,6). To achieve optimal results, patients need to feel comfortable, safe, trusting, validated, and become partners in care. This, in turn, requires building rapport between the clinician and the patient (3). Building rapport with patients can be challenging when genitalia or reproductive organs need to be examined/treated. This commentary discusses four key components of building an effective therapeutic relationship in this special patient population.

Karolina Grabowska (Pexels)

Understanding why this patient population may have negative emotions

Having conversations about intimate body parts or having internal organs assessed may be uneasy, particularly if the patient is meeting the clinician for the first time (7). Prior research has shown that embarrassment and feeling anxious about body image are important barriers to internal examinations (8). Patients may be seeking services for pain conditions, including vaginismus or dyspareunia, and may be fearful of evoking additional pain with an internal assessment.

Furthermore, clinicians must be cognizant of the needs of special and vulnerable populations when interviewing and examining patients. Here we will discuss three populations who may experience greater distress during pelvic examinations. First, clinicians must be sensitive to the needs of both transgender men and transgender women (9). For example, transgender women undergoing gender-affirming vaginoplasty may seek pelvic floor physiotherapy pre- and post-operatively to aid in the prevention of pelvic floor dysfunction and dilation of the neovagina. With vaginoplasty, a neovaginal canal is created for penetration during intercourse. Dilation procedures are performed post-operatively to avoid stenosis of the neovaginal canal due to contracture and scar tissue formation (10). Special consideration is warranted to address anxiety with dilation regimens, and pelvic floor physiotherapists are in a unique position to aid with pelvic floor dysfunction and dilation post-vaginoplasty (10). Second, clinicians need to be sensitive to survivors of physical and sexual abuse in order to avoid re-traumatizing them during the interaction (11). For example, survivors of sexual trafficking report hesitancy in interactions with healthcare providers out of fear that providers will not acknowledge or accept their experiences (12). Therefore, it is essential for clinicians, who hope to build trust with survivors, to value and listen to these lived experiences (13). Third, special consideration needs to be given to child and adolescent patients. Clinicians may choose to employ methods to distract young patients during external genital examinations (14).

“Qualities that foster strong therapeutic relationships include being present by providing one-on-one time with patients, as well as being receptive to adapting and changing treatment plans, genuine and honest, and committed to restoring patients’ health and well-being.”

How to build an effective therapeutic relationship

Qualities that foster strong therapeutic relationships include being present by providing one-on-one time with patients, as well as being receptive to adapting and changing treatment plans, genuine and honest, and committed to restoring patients’ health and well-being (15). Strong therapeutic relationships are associated with positive clinical outcomes (16). The following is a step-by-step guide on strategies to improve or build a therapeutic relationship in pelvic floor rehabilitation.

(a) Conduct the patient introduction in an approachable way in a private examination room where the patient is fully clothed for the interview (17). Explain the rationale for an internal assessment/treatment and acknowledge that this can be an uncomfortable situation (17);

(b) Be an active listener and encourage open communication to fully address the patient’s concerns and goals (18). Ask the patient how he/she/they is feeling and if the patient expresses feeling nervous, delve deeper to understand the reasons;

(c) Explain the procedure in lay language, ensuring that the patient understands what to expect. This can be done through the repeat-back strategy. Reassure the patient that he/she/they can ask questions and clarify misunderstandings. This is a vital part of providing patient-centred care (19);

(d) Describe the risks and benefits, offer alternative options, let the patient know that the procedure can be stopped at any point, and obtain informed consent before commencing the procedure. This will ensure that the patient’s approval is a key component of the treatment (20); and

(e) Ensure the privacy of the patient. For example, cover body parts that are not necessary for the procedure (17).

Challenges in developing rapport

Aside from previously discussed points, clinicians may face more challenges that impede developing strong therapeutic relationships in pelvic rehabilitation. For example, patients may have prior negative experiences with physiotherapy, be sexual assault survivors, or have language barriers. In addition, engaging patients who view discussing genitals as taboo for cultural, religious, or personal reasons may be challenging. Lastly, a lack of continuity or adherence to the rehabilitation program can also be a barrier to restoring function and building rapport. A systematic review of studies investigating adherence in physical therapy reported that factors such as low self-efficacy, depression, anxiety, helplessness, and poor social support are among the most important barriers to adherence (21).

Ava Sol (Unsplash)

How to overcome the challenges

The ultimate goal is to overcome all challenges. However, this is a delicate process and will take time, particularly for novice clinicians. In this section, we provide concise solutions on how to overcome the aforementioned challenges.

“Open communication is one of the key components of building an effective therapeutic relationship. When there is a language barrier, it can be helpful to make arrangements to have a translator with whom the patient is comfortable.”

(a) Negative prior experience with another clinician may be one of the most important barriers in building effective therapeutic relationships. It is essential to ask questions about what happened and what went wrong and be an active listener to the patient’s concerns (17). Developing an individualized treatment plan can illustrate that the clinician is an active listener and that the patient’s concerns are considered (22);

(b) If the patient is a survivor of sexual assault or abuse, the patient may be more uncomfortable by a hands-on assessment in a sensitive region of the body (13). In this circumstance, a trauma-informed approach to care can be employed by the clinician. This approach considers the life events of a patient and recognizes how traumatic events can manifest in various behaviours (23). It is vital that the patient’s privacy is respected, and a safe environment is provided. Patients may wish to have a chaperone for added comfort (17). Continually reassure patients that consent is ongoing, and the procedure can stop at any time. Relaxation methods, such as breathing exercises, can also make the patient feel more comfortable (24). It is important to note that certain techniques using a 2-digit insertion may not be performed while performing deep breathing exercises if the patient is experiencing pain or anxiety (25). If the clinician is the first person with whom the patient has discussed past trauma, provide the patient with additional resources or referrals if the patient is interested (17);

(c) There may be some cultural differences between the patient and the clinician. In some cultures, having an open discussion about genitals is not acceptable, and patients may even be discouraged by family members and friends (26). It is important to be sensitive to this and explain that you are committed to supporting them;

(d) There may be language barriers. Open communication is one of the key components of building an effective therapeutic relationship. When there is a language barrier, it can be helpful to make arrangements to have a translator with whom the patient is comfortable (27); and

(e) There can be a lack of continuity of care or barriers to program adherence. Provide patient education about the diagnosis, prognosis, and the benefits of a pelvic rehabilitation program (28). Taking an individualized approach to care and prescribing an appropriate home exercise program can improve adherence (21).

“…building effective therapeutic relationships is crucial in reaching the patient’s goals and attaining patient satisfaction.”

Building rapport with patients is ongoing and strengthens over time (29). Throughout a patient’s treatment, the use of outcome measures can be encouraging by tracking change and improvements (21). Outcome measures intended for assessing pain severity, such as the Numeric Pain Rating Scale (NPRS) or the Visual Analog Scale (VAS), are appropriate options for this purpose.

Mastering clinical knowledge and skills are essential in clinical practice; however, building effective therapeutic relationships is crucial in reaching the patient’s goals and attaining patient satisfaction. Many psychosocial factors can be barriers to building that relationship. Nonetheless, remaining mindful of the challenges and being conscious of the importance of the relationship with the patient can help to improve the clinician-patient relationship, patient satisfaction, and clinical outcomes.

Acknowledgements

Featured illustration by Michelle Wu for rehabINK.

To refer to this article, it can be cited as:

Modarresi S, Janssen S,  Seens H &  Modarresi G . Building effective therapeutic relationships in pelvic floor rehab: a commentary. rehabINK. 2021:11. Available from: https://rehabinkmag.com


References

  1. Laursen BS, Bajaj P, Olesen AS, Delmar C, Arendt-Nielsen L. Health related quality of life and quantitative pain measurement in females with chronic non-malignant pain [Internet]. European Journal of Pain. 2005;9(3):267–75. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=15862476
  2. Schmitt JJ, Singh R, Weaver AL, Mara KC, Harvey-Springer RR, Fick FR, et al. Prospective outcomes of a pelvic floor rehabilitation program Including vaginal electrogalvanic stimulation for urinary, defecatory, and pelvic pain symptoms [Internet]. Female Pelvic Medicine and Reconstructive Surgery. 2017;23(2):108–13. Available from: https://pubmed.ncbi.nlm.nih.gov/28106652
  3. Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. International Urogynecology Journal. 2018 May;29(5):631–8.
  4. FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I: background and patient evaluation. International Urogynecololgy Journal and Pelvic Floor Dysfunction. 2003 Oct;14(4):261–8.
  5. Wieslander CK, Alas A, Dunivan GC, Sevilla C, Cichowski S, Maliski S, et al. Misconceptions and miscommunication among Spanish-speaking and English-speaking women with pelvic organ prolapse. International Urogynecology Journal. 2015 Apr;26(4):597–604.
  6. Larsen M, Oldeide CC, Malterud K. Not so bad after all…, Women’s experiences of pelvic examinations. Family Practice. 1997 Apr;14(2):148–52.
  7. Huber JD, Pukall CF, Boyer SC, Reissing ED, Chamberlain SM. “Just relax”: physicians’ experiences with women who are difficult or impossible to examine gynecologically. The Journal of Sexual Medicine. 2009 Mar;6(3):791–9.
  8. Bennett KF, Waller J, Chorley AJ, Ferrer RA, Haddrell JB, Marlow LA. Barriers to cervical screening and interest in self-sampling among women who actively decline screening [Internet]. Journal of Medical Screening. 2018 Dec;25(4):211–7. Available from: https://pubmed.ncbi.nlm.nih.gov/29649936
  9. van Trotsenburg M. Gynecological aspects of transgender healthcare. Internationa Journal of Transgenderism. 2009 Nov 30;11:238–46.
  10. Jiang DD, Gallagher S, Burchill L, Berli J, Dugi D 3rd. Implementation of a pelvic floor physical therapy program for transgender womenundergoing gender-affirming vaginoplasty. Obstetrics and Gynecology. 2019 May;133(5):1003–11.
  11. Stevens NR, Tirone V, Lillis TA, Holmgreen L, Chen-McCracken A, Hobfoll SE. Posttraumatic stress and depression may undermine abuse survivors’ self-efficacy in the obstetric care setting. Journal of Psychosomatic Obstetrics and Gynaecology. 2017 Jun;38(2):103–10.
  12. Malakouti-Nejad H. Sexual trafficking in the Canadian context: exploring the political landscape, examining discourse, and identifying health issues among women with lived experience [Internet]. Western Libraries. 2012. Available from: https://ir.lib.uwo.ca/etd/960
  13. Farley M, Golding JM, Minkoff JR. Is a history of trauma associated with a reduced likelihood of cervical cancer screening? Journal of Family Practice. 2002 Oct;51(10):827–31.
  14. Berenson AB, Wiemann CM, Rickert VI. Use of video eyeglasses to decrease anxiety among children undergoing genital examinations. American Journal of Obstetrics and Gynecology. 1998 Jun;178(6):1341–5.
  15. Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Archives of Physiotherapy. 2018;8:3.
  16. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical Therapy. 2010 Aug;90(8):1099–110.
  17. Bates CK, Carroll N, Potter J. The challenging pelvic examination [Internet]. Jorunal of General Internal Medicine. 2011 Jun;26(6):651–7. Available from: https://pubmed.ncbi.nlm.nih.gov/21225474
  18. Weger H, Castle Bell G, Minei EM, Robinson MC. The relative effectiveness of active listening in initial interactions [Internet]. International Journal of Listening. 2014 Jan 2;28(1):13–31. Available from: https://doi.org/10.1080/10904018.2013.813234
  19. Williams AA, Williams M. A guide to performing pelvic speculum exams: a patient-centered approach to reducing iatrogenic effects. Teaching and Learning in Med. 2013;25(4):383–91.
  20. Krumholz HM. Informed consent to promote patient-centered care. JAMA. 2010 Mar;303(12):1190–1.
  21. Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual Therapy. 2010 Jun;15(3):220–8.
  22. O’Keeffe M, Cullinane P, Hurley J, Leahy I, Bunzli S, O’Sullivan PB, et al. What influences patient-therapist interactions in musculoskeletal physical therapy?qualitative systematic review and meta-synthesis. Physical Therapy. 2016 May;96(5):609–22.
  23. Chokshi B, Walsh K, Dooley D, Falusi O, Deyton L, Beers L. Teaching trauma-informed care: a symposium for medical students [Internet]. MedEdPORTAL: The Journal ofTeaching and Learning Resources. 2020 Dec 30;16:11061. Available from: https://pubmed.ncbi.nlm.nih.gov/33409358
  24. Hennigen L, Kollar L, Rosenthal S. Methods for managing pelvic examination anxiety: individual differences and relaxation techniques. Journal of Pediatric Health Care : Pfficial Publication of National Association of Pediatric Nurse Associates & Practitioners. 2000 Feb 29;14:9–12.
  25. Reissing ED, Brown C, Lord MJ, Binik YM, Khalifé S. Pelvic floor muscle functioning in women with vulvar vestibulitis syndrome. Journal of Psychosomatic Obstetrics and Gynaecology. 2005 Jun;26(2):107–13.
  26. Ferdous M, Lee S, Goopy S, Yang H, Rumana N, Abedin T, et al. Barriers to cervical cancer screening faced by immigrant women in Canada: a systematic scoping review. BMC Womens Health. 2018 Oct;18(1):165.
  27. Mirza M, Harrison EA, Roman M, Miller KA, Jacobs EA. Walking the talk: understanding how language barriers affect the delivery of rehabilitation services. Disabililty and Rehabilitation. 2020 Jun;1–14.
  28. Broadmore J, Carr-Gregg M, Hutton JD. Vaginal examinations: women’s experiences and preferences. The New Zealand Medical Journal. 1986 Jan;99(794):8–10.
  29. Kornhaber R, Walsh K, Duff J, Walker K. Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review [Internet]. Journal of Multidisciplinary Healthcare. 2016 Oct 14;9:537–46. Available from: https://pubmed.ncbi.nlm.nih.gov/27789958