Caring for the Complex Pelvic Patient Part II: Treatment techniques

In the second installment of this three part series: Caring for the complex patient, we will review the patient’s presentation and discuss the treatment techniques employed and how documentation using bestPT supported the treatment.

The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse (POP). The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.

The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lived at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds. She is an avid runner and aerobics instructor. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.

Physical therapy examination revealed abdominal strength to be 3+/5 on the Kendall scale. The Pelvic Floor Impact Questionaire (PFIQ-7) was utilized as standardized outcome tool. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale. Internal examination and musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.

The first priority of intervention was patient education to avoid bearing down and valsalva maneuvers. Discussion on the day of evaluation included contracting the pelvic floor prior to lifting her toddler or infant, safe lifting spinal mechanics, and breathing technique to avoid abdominal bulging or bearing down. Avoidance of constipation was discussed, though this was not an issue for this patient, nor was weight management. The patient was issued a copy of the American Physical Therapy Association’s postpartum health awareness information brochure to provide further education regarding postpartum back and pelvic pain, pelvic floor muscle care, post partum fatigue, posture, and cesarean scar management.

Following the internal pelvic exam, the patient was given a pelvic floor strengthening program. Given that the role of connective tissue in providing support to the pelvic floor has gained significant emphasis in the literature, it is understood that if the patient does not benefit from a pelvic floor strengthening program than other means of intervention may be warranted. The rationale for intensive strengthening of the pelvic floor muscle to treat POP is that strength training will build up the structural support of the pelvis by elevating the levator plate to a higher resting point, and maintain this position through hypertrophy and improved stiffness of the pelvic floor muscles.

As no single or absolute protocol has been reported to be the absolute gold standard in the literature, pelvic floor muscle (PFM) training was dosed based upon compilation of evidence in the literature, and patient response. Initially the patient was given a program of 80-100 kegels per day, with 4 sets of 10 being 5 second hold, and 4 sets of 10 being 15 second hold to address speed and endurance of the muscles. These numbers were calculated based upon her muscle test scoring durng initial evaluation. Due to her busy schedule and PFM strength of 4/5, she was advised that these could be performed in various positions, including supine hooklying, sitting, and standing. She was educated to gently draw in the abdominals during PFM contraction as transverse abdominis co-contraction has been demonstrated to enhance activation of the pelvic floor.

Progression of PFM exercise and lumbo-pelvic stability exercises were increased each visit as the patient became stronger. Progressions included diaphragmic breathing pattern with pelvic floor muscle contractions, sidelying clams while performing a PFM and transverse abdominis contraction, and quadruped PFM with transverse abdominis contraction. This exercise was progressed by adding an opposite upper and lower extremity lift (commonly referred to by physical therapists as a bird dog). Pelvic brace with cough was added to address co-ordination and timing of PFM contraction prior to increased intra-abdominal force.

Planks in the forward and side position were introduced at the fourth visit with instructions to contract the pelvic floor muscles and transverse abdominis. At this point, the patient was able to sustain this contraction and sense lift of the pelvic floor for approximately 20 seconds. Sit to stand with kegel and small range squats were added as well. At this point in treatment the patient reported that she was already feeling much better, noting a 50% improvement in overall symptoms during activities of daily living.

Manual therapy consisted of myofascial release (MFR) and scar mobilization, and was performed on the first several appointments to address restriction and adhesion from her cesarean scar. The scar was mobilized in all planes by applying gentle pressure to the scar itself and moving it in the caudal-cephalad, medial-lateral, and rotational planes. Myofascial release of the surrounding tissue was performed similarly. Tissue restriction was assessed to be restricted in all planes both above and below the scar.

Treatment consisted of applying gentle pressure downward with the patient positioned comfortably in supine-hooklying with a bolster under the knees. The theory behind MFR is that the pressure will stimulate increased blood flow and subsequent heat production, enhance lymphatic draining, and provide proprioceptive input into the tissue addressed. Treatment technique of this nature can be direct, wherein the tissue is mobilized in the direction of restriction, or indirect wherein the tissue is mobilized away from the direction of restriction, similar to sliding a stuck dresser drawer backwards in attempts to gain a smooth slide outwards.

Both direct and indirect techniques were utilized on this patient due to the fact that she tolerated both quite well. Once pressure was established and direction of restriction determined, which was both superior and inferior to the Pfannenstiel’s incision, and on the left of the incision, gentle pressure was held until a giving way sensation was felt. The patient was educated in self scar massage technique and advised to perform daily. Additionally, strain-counter-strain (SCS) technique was utilized to release tight and shortened iliopsoas muscles bilaterally.

Muscle energy technique (MET) was utilized in order to re-establish symmetry to the sacroiliac joints of the pelvis. The pubic shotgun technique was utilized prior to torsion MET to draw the left anterior innominate posteriorly and thus level with the right. The patient responded extremely well to treatment. The final installation of this three part series will discuss her outcomes and provide insight to other possible treatment techniques for this patient population.

-Amanda Olson, DPT

Outcome Measurement Tools As Evidence

Outcome Measurement Tools as Evidence

In a day of medicine in which physical therapists feel stressed by increasing demands for specified insurance guidelines, codes, and outcome measures, it serves a therapist well to have a great understanding of various outcome measurement tools.  Standardized outcome measurement tools are vital to a therapist’s ability to establish baseline performance and track change over time.  In addition, good outcome measurement tools have high inter-tester reliability, making them easily replicated by another therapist.  This means that if I do an evaluation and my colleague were to perform the reassessment, my scoring methods will remain in line with each other.

The beauty of outcome measurement tools is that they provide evidence as to what improvements my patient makes as a result of therapy.  If any of my claims go to review or I need to submit an appeal for denied coverage, using proper outcome measurement tools gives I justification for services.  Nowadays it seems like insurance representatives scour medical documents, looking for any reason they can to deny payment.  As a therapist, my job is to fill my documentation with reasons that they must pay.  They key to this evidence lies in choosing an appropriate outcome measurement tool for my patient.

Physical Therapy Outcome Measurement Tools

Click to enlarge this image.


Figure 1. Data “persists” from document-to-document and within one document. This means you can view Prior or Current Levels or Goals from any of the relevant sections

First, I determine what my primary patient population will be.  There are functional outcome measurements that are specific to predicting fall risk or rating extent of disabilities.  These types of outcome measurements are ideal for the therapist working with the geriatric population in various settings.  There are many outcome measurements tools that test specific body parts, such as functional use of an arm or a leg.  In addition, there are many pediatric specific outcome measurement tools.  Because of high interest in research, more and more outcome measurement tools are being created each year, by highly motivated and dedicated clinicians.  I find the type of outcome measurement tool I are seeking and then I become well acquainted with it.

Outcome measurement tools should not take long to administer and should be easily recreated and repeated.  If I am learning how to administer a new tool, I try practicing with an experienced clinician.  I have the clinician present as a patient might and administer the testing items.  After I perform a test a few times, I will likely master it.

Outlined are several common and highly reliable outcome measurement tools based on topic:

Geriatrics: Tinetti Outcome Measurement Tool, BERG Balance Scale, BESTest, Functional Independence Measure (FIM)

Pediatrics: Alberta Infant Motor Scale, Batelle Developmental Inventory, Peabody Developmental Motor Scale, Pediatric Evaluation of Disability Inventory

Upper Extremity: Disability of Arm and Shoulder and Hand (DASH), Penn Shoulder Score, Shoulder Pain and Disability Index (SPADI)

Lower Extremity: Lower Extremity Functional Scale (LEFS), Get Up and Go, Six Minute Walk Test, Lysholm Score

Functional Mobility: Timed Up and Go (TUG), Six Minute Walk Test, Get Up and Go

Physical Therapy Outcome Measurement Tools

Click to enlarge this image.


Figure 2. Only relevant fields appear for selected functions. No unnecessary fields get in the way.

The beauty of outcome measurement tools is that they are standardized and tested in the literature.  Once I become familiar with some of the most common outcome measurement tools used in therapy, I can more readily understand current evidence and quickly understand the functional status of my patients.  When documenting within the bestPT software, I can easily utilize outcome measurement tools.  I simply select the outcome measurement tool I would like to input in my evaluation or reassessment note.  You can easily compare my patient’s evaluation score with their (hopefully improved) score at discharge.  This evidence of improvement serves to satisfy me as a therapist, the patient, and the insurance payers.

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.


3 Must-Haves for Credit Card Processing | Q & A from the Webinar

Q&AIf your practice currently accepts credit cards, or if you are considering incorporating them into your payment options, you likely have questions regarding the policies surrounding their use. To help you get the answers you need, we have compiled all the questions that were asked during our recent webinar, 3 Must-Haves for Client Credit Card Processing, along with the presenter’s responses. Feel free to add any new questions in the comment section below.


Q: What is PCI?

A: PCI compliance stands for Payment Card Industry compliance. This is the regulation that the federal government puts on the credit card industry as well as merchants who accept credit cards. Similar to HIPAA in terms of documentation and patient record-keeping, PCI is the regulatory board that oversees all aspects of credit card payments.

Q: What sort of fines do practices face for non-compliance?

A: Most people don’t realize that they can be fined up to $2,500 per card that they’re not handling properly. So if you see 400 patients over the life of your practice, and you handle those cards improperly, you would face $1 million in fines. A big company like Target can handle that, but for most medical practices, that would put them out of business.

Q: What percentage of medical offices are PCI compliant?

A: An estimated 95 percent of practices are not PCI compliant, in one way or another.

Q: How do I know if my office is PCI compliant?

A: The first year you set up with a merchant services company, you have to take a PCI compliance survey. Then there’s a yearly survey after that. If you haven’t taken some sort of survey, or don’t remember taking one, chances are, you’re not compliant and there’s a 100 percent chance that you’re being charged a monthly fee. That fee can range from $20 to $100 a month.

ICD-10 | 100x More Complicated | Q&A

ICD-10 Q&AAs your practice is preparing for the impending ICD-10 changes, you might have many questions concerning physical therapy billing procedures and software requirements. To help you get the answers you need, we have compiled all questions that were asked during our recent webinar ‘ICD-10 | 100 Times More Complicated,’ along with the presenter’s responses. Feel free to add any new questions in the comment section below.

watch the workflow webinar recodring now

Q: I have a question about the top 50 ICD-9 codes we use, and doing the crosswalk to ICD-10. Where is the best resource for being able to do that?

A: CMS GEMS would be one website that you can use; that’s CMS’s GEMS System, which is the General Equivalent System that they use — the General Equivalent Mapping System that they use to translate ICD-9 to ICD-10.

Another good site for you is Click on their ICD-10 link and they have a feature where you type in our ICD-9 and it returns the equivalent ICD-10 code.

GEMS prompts you to choose the lateralities and origins, whereas AAPC is more one-to-one, but GEMS is really what most systems are basing their crosswalk from, and GEMS is built and maintained by CMS, the CDC, and AMA.

watch the workflow webinar recodring now

Q: I’ve done all my conversions from ICD-9 to ICD-10 and I’ve done the left and right conversions. We’ve changed some of our documentation so it’s more specific about mechanism of injury — the when, where, the why and the how. What else is there really to do?

A: You really want to make sure that how the practice is supposed to document the guidelines for PT documentation are clearly outlined in your policies and procedures manual. And that means adding in specificity and laterality. The manual should also have references as to where you seek the information; your reference point would be to CMS.

Q: If I want to take a coding course to get certified, do I need to be certified on ICD-9 and ICD-10?

A: Right now, you have to certify for both, but after October 1, you only have to certify for ICD-10.

Q:  Are you able to come out and help us train our staff?

A: We can give you the tools that you need in order to train your practice. For PT documentation, have them listen to our webinar in March, but they can also take external classes — specifically from the AAPC, because their classes on physician documentation are extraordinary. In terms of crosswalking, we will work with you.

Click here to download an additional ICD-10 resource!

watch the workflow webinar recodring now

Physical Therapy EHR | Win $500 for Telling Your Best Patient Story

physical Therapy EHR software_ bestPT Contest

Tips for Your Story

  • What made this patient story so special?
  • How has this experience affected you as a PT and/or your practice?
  • How does this story inspire you, your practice, and other PTs?

Entry Qualifications

  • Must be a bestPT user
  • Like us on our Facebook page and simply post your patient success story as comment on our wall
    • Feel free to add video and pictures (no more than 5 min. video)
    • 300 – 400 words
  • If you are not active on Facebook, you can e-mail us at
  • Deadline: March 31, 2014

Physical Therapy Software | New Network Members in August 2013

physcial therapy software_ new network membersThirteen new members joined bestPT in August. Each member benefits from the size of  bestPT’s network as we use the shared knowledge in the battle against the payers. This proverbial strength in numbers helps you build your dream practice with our physical therapy documentation software and coaching services.

Let’s welcome bestPT’s newest members:

  1. Abigail Licona of Active Performance Physical Therapy, West Carroll, Iowa:
  2. Lauren Reineke and Lauren Lax of Big Sky Pediatric Therapy, Austin, Texas:
  3. Melissa Schmidt, Megan Danley, and Heather Milligan of Elite Orthosport Physical Therapy, Los Angeles, California:
  4. Tina Simpson and Anna of Melwood Rehabilitation Center, Upper Marlboro, Maryland:
  5. Jennifer Berg of Midlothian Village Physical Therapy, Midlothian, Virginia:
  6. Leslee Carroll of Mike Walsh Physical Therapy, Dover, Delaware:
  7. Fran Hill of Pearson Physiotherapy Specialists, Craig, Colorado:
  8. Stephen Edwards of Physical Therapy & Sports Rehabilitation Clinic, Terre Haute, Indiana:
  9. Erica Newman of Summit Physical Therapy, Hixson, Tennessee:


physcial therapy software_ new network membersIn July ten new members joined bestPT. Each member strengthens bestPT’s network in the battle against the payers, so the more we grow the more we know and succeed in helping you build your dream practice with our physical therapy software and coaching services.

Let’s welcome bestPT’s newest members:



Physical Therapy Software | New Network Members in June 2013

physcial therapy software_ new network membersIn June 23 new members joined bestPT. Each member strengthens bestPT’s network in the battle against the payers, so the more we grow the more we know and succeed in helping you build your dream practice with our physical therapy software and coaching services. Read more

Physical Therapy | Patient education improves compliance

Physical Therapy Billing | patient educationIn a recent survey on the benefits of patient education used by physical therapists the general consensus was that educated patients are more compliant with their care plans.

“It would add immensely to the comfort a patient has with his/her diagnosis and make them both more compliant in taking their medications as well as feeling more empowered about their own health care,” says Erin Stevenson, an independent Hospital & Health Care Professional. “Also, patients could ask more pointed, better defined questions regarding their present and future health around their current situation and finally, it could compress the patient-provider time required to get to the underlying cause of their illness and expedite not only the exam time, but deepen the provider’s knowledge about the patient’s past history and hopefully allow providers the opportunity to see more patients.”

Sixty percent of the survey respondents believe the greatest benefit of using a patient education system integrated into your physical therapy software is the improved compliance of patients to the treatment plan.

“The patient, seeing the added benefit would certainly let friends and family know and extol the virtues of their new found knowledge.” agrees Michael Hughes with Creative at Forte Holdings. “Patient Education system would act as a ‘wow’ factor to justify perhaps the cost of care to patients based off seeing what all goes into the care and what kind of conditions/solutions they can tangibly see.”

One-hundred percent of the survey respondents are certain that a patient education system is helping the PT do a better job and even expediting the patient’s rehabilitation.

Physical Therapy Billing | patient education SURVEY RESULTS


“When a patient actually understands the root cause of their symptoms and how the plan his physical therapist is recommending will help them regain the functionality in their lives, they will tell their friends and loved ones about it!” adds Jason Barnes, COO of Vericle, “This lays a foundation for healthy patients and a healthy practice.”

Physical Therapy Billing | Simplify patient data collection with EHR Kiosk


Physical Therapy Billing | xDocsXDocs are now integrated with your bestPT physical therapy software as Kiosk login so that your patients can fill out their patient intake forms right at the time of check-in.  The xDoc will be saved in the patient’s account, eliminating the need for your Front Desk to compile the paperwork.

Interested in adding this feature? Open a ticket to your SPOC with the name of the template you want to add to your Kiosk login.

You can only add one XDoc template at a time. If you would like to merge your XDoc templates so that the patient can fill out all your necessary forms, please open a ticket to your SPOC.