Amy Robinson of Clear Passage Physical Therapy recently phoned in from her clinic in Indiana to talk about pelvic floor physical therapy and how it benefits women suffering from health problems because of transvaginal mesh. Amy has two decades of experience in physical therapy, and for many of those years she specialized in pelvic floor health.
She treats many women who come to her suffering from pain, sexual dysfunction and even bowel issues after mesh implantation and removal. As a result, she is very familiar with the life-altering problems faced by women who have had mesh.
She uses the Wurn Technique, which is the proprietary technique developed by Clear Passage founders Belinda and Larry Wurn. It has proven to be a powerful healing tool for many women.
This special technique involves approximately 200 physical therapy techniques designed to promote intensive therapy and quick healing in women with pelvic floor issues and complications associated with transvaginal mesh.
On the podcast, Robinson discusses what women can expect from pelvic physical therapy and how it can help ease complications from transvaginal mesh implantation and removal and even help women avoid surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP).
For most women, the thought of a pelvic examination is uncomfortable. Pelvic floor physical therapy may sound even more daunting , especially for women experiencing pelvic discomfort from multiple surgeries associated with transvaginal mesh.
At Clear Passage, Robinson and the other therapists are aware it is a very sensitive issue. They encourage women to tell their stories and even involve the patient’s partner in a safe and supportive environment. Most importantly, they take the time to listen.
The therapy itself usually consists of a thorough internal and external pelvic exam to assess the extent of the symptoms and damage to the tissue. The external exam includes checking a patient’s posture. According to Robinson, this alone can clue a therapist in to problem areas, and unlike a woman’s yearly gynecological exam, the internal exam does not use a speculum or stirrups.
“Of course, if a woman isn’t interested in an internal pelvic exam, we wouldn’t make them do that,” she said. “However, the internal pelvic exam – especially for women who have experienced mesh issues – is a very critical part of the exam procedure.”
The internal and external exams help the therapist locate adhesions that may have formed after surgery. Adhesions are bands of scar tissue that form between two surfaces in the body, such as muscles or organs. This tissue is very tight and binding, which can cause discomfort and pain.
If adhesions form between organs, they can cause organ dysfunction. Pelvic physical therapy loosens these adhesions and breaks them up naturally, to restore function and mobility.
During the course of therapy, it is also possible that the therapist may locate pieces of mesh that might have been missed during surgery. Unfortunately, many of the mesh products were not designed to come out of the body once implanted and prove difficult for even experienced surgeons to remove.
Many people think of physical therapy as a treatment after surgery or after an injury, but it can also be used as a preventative measure or as a first-line treatment. Before surgery for incontinence or prolapse, women may wish to consider pelvic physical therapy.
Not only can it prevent costly surgery and possible complications, but it can also decrease the likelihood of recurrence of incontinence or prolapse.
Robinson cited studies on the effectiveness of pelvic physical therapy for SUI and POP. She referred to one study that showed 79 percent of patients receiving pelvic floor training improved significantly and avoided surgery.
“A lot of times, physical therapy is skipped in the beginning,” she said. “But if patients are given the option, and the prolapse is not severe, they can avoid surgery for prolapse.”
Unfortunately, some women who had mesh surgery later suffered serious complications such as infection, erosion, organ perforation and inability to have intercourse. Thousands of women – including Linda Gross, Christine Scott and Donna Cisson – filed lawsuits against several manufacturers.
Avoiding unnecessary surgery and transvaginal mesh implants may save a lot of pain and suffering and is definitely worth looking into. Women suffering from mesh issues should ask their OB-GYN or urogynecologist about pelvic floor physical therapy or research it online.
Anyone who wants to learn more about Clear Passage and pelvic floor physical therapy can visit the Clear Passage website or call the office.
Today we're talking about non-surgical options for women who might have suffered complications of transvaginal mesh. I'm very happy to have Amy Robinson with me today. She is a physical therapist and director of the Indiana clinic Clear Passage Physical Therapy. Amy has had almost two decades experience as a physical therapist, and more than half of that has been spent dealing with pelvic health issues. She's joining us today via telephone from Indiana. Welcome to the show, Amy.
Thank you so much for having me.
I'm going to ask this because I'm sure people are probably thinking, when they think of physical therapy they're thinking of moving body parts around. But we're dealing with a very sensitive area and a sensitive subject. And some women might be a little apprehensive about going to physical therapy. Can you tell us how invasive the therapy is and what kind of external or internal techniques you might use?
There are a whole host of techniques that we use, and we do not use any cookbook methods, which means that we do not use the same techniques over and over on patients. We always do a very thorough evaluation and we always start with checking a patient's posture because looking at a patient's posture can clue you into where a lot of restrictions lie in the body. We also take a lot of time checking pelvic alignment, because the pelvis is like the foundation to your house. If you have any alignment issues in the pelvic region it can affect virtually the whole body. We also do internal pelvic exams. Of course, if a woman says she is not interested in an internal pelvic exam we would not make her do that. However, the internal pelvic exam, especially for women who have experienced mesh issues, is a very critical part of that exam procedure. And with the internal exam it is different than what you would experience at the gynecology office. We don't use stirrups or a speculum. The speculum actually covers the muscles up, and we're very interested in working with the muscles and seeing if they are functioning properly. And so, with that being said, at times there is also wrestle work that is required in order to access some of the posterior structures such as the tailbone and some of the ligaments to systems that are on the backside of the pelvis. It's a very thorough exam. We usually take about an hour to do the examination and then we move right into treatment.
How do you loosen up the organs and all the things you do to help people?
There are several manual therapy techniques that we utilize. And manual therapy just means a hands-on therapy. We utilize several different techniques, like connective tissue manipulation which is meant to decrease connective tissue tension. We utilize myofascial release; we use sustained pressure to release fascial restrictions which also then reduces pain. We use visceral manipulation which is manipulation of the organ system to improve their movement and the health of the organs and decrease pain. We use cranial sacral therapy which focuses on the cranial sacral system. The cranial sacrum system consists of membranes that are present from the brain down the spinal cord. We use very light pressure techniques to address imbalances in the cranial sacral system. We can also utilize manual lymph drainage. And that is to assist in increasing lymphatic flow which removes harmful substance from the tissues. And most importantly, we also utilize a Wurn technique which is a protocol of over two-hundred manual therapy techniques that were created by Larry and Belinda Wurn, owners of Clear Passage.
Wow. This is a big system we're talking about here.
Yes. It's a very big, extensive system. Larry and Belinda have studied with physicians and physical therapists in the U.S. and abroad. Belinda was diagnosed with cervical cancer in 1984, so she has a unique perspective and unique experiences as a physical therapist. All these manual therapy techniques that I mentioned, they helped her to a degree, but she never really felt she could get her total function back. Larry is a licensed massage therapist. Larry and Belinda work together to create therapy techniques for addressing areas that had not previously been addressed in her healing process. With that, we use a lot of hands on therapy to help these women heal. A lot of women don't understand exactly what pelvic physical therapy means.
Go ahead and talk more about that.
Pelvic physical therapy actually consists of an internal pelvic examination. We use one lubricated, gloved finger to assess all of the pelvic muscles. There are three layers of pelvic muscles. The first two can be felt directly through the skin. And the third layer you need to assess either vaginally or rectally. It's a very extensive exam, but it is necessary to allow for total healing to occur.
You work with urogynecologists and all kinds of specialists as well. How does the therapy that you do for these women compliment the care they are already getting with their physicians?
We work right alongside the physicians to give the patients the care that they deserve to get and to make sure they meet their goals. Whether it be that we need to talk with the physician and ask the physician to help with trigger point injections in the pelvic floor, or to suggest possibly estrogen to help with beefing up the tissues to help the patient progress a little bit quicker. We're in constant communication with the physician as needed in order to help the patient heal.
You've treated some women who have suffered complications, or that are going through additional ones after surgery to remove the mesh. Can you tell us about some of the complications you've seen in your practice?
Sure. When a patient comes to physical therapy they've often been to multiple physicians because they are having issues, and often times it seems such as back pain and pelvic pain, inability to sustain intercourse either because there is too much pain or they just cannot even attempt full penetration. You're looking at pain as a whole with these women. A lot of them complain that they cannot sit and that they have horrendous abdominal pain. There's a whole realm of issues that go together when women have complications with mesh. It's not, a lot of times, just in the pelvic region itself.
It kind of radiates, right? I think it also has some nerve damage attached to it, all kinds of other things. You mentioned back pain. A lot of people wouldn't even think that they'd have back pain because of something that was in their pelvic area.
That's exactly right. However, if you have mesh that's actually come through, and let's say it has actually punctured the bowel that, in and of itself, creates a problem with the bowel, but that also can contribute to back pain. As a therapist you have to look at the anatomy in the surrounding structures to see the co-relation as to the other diagnoses and the other complaints that these patients are having. Very often with patients who have had mesh puncture the bladder or the bowel we also have to do bowel and bladder retraining to help those organs function again.
That's another thing you wouldn't expect a physical therapist could help you with. I think a lot of people sometimes will just assume that it's going to have to be a surgical fix or maybe a drug related issue. When a woman has had mesh implanted and still has it in her, and then has had it removed, those are two different situations too, right, where the treatment can change? Could you talk a little about how you can help both types of women?
If the mesh is in and they are having pain very often you can do techniques that can help with the pelvic alignment, because the pelvic alignment often during those surgeries becomes dysfunctional. And that needs to be fixed because that, in and of itself, will have an effect on the pelvic musculature and on the organ system. Sometimes those women just need help with freeing up the pelvic muscles themselves, allowing them to contract and relax and move as they should. A lot of times you are having to do work with the organs and with the ligamentous system in order to allow the pain to improve. Often we'll get referrals from women who have had the mesh implanted and they are reporting pain and everything is fine with the mesh. The surgeons have checked it out, but they will say that they cannot have intercourse. There are specific manual techniques that we can use to help relax the musculature, and techniques to improve the accessibility to the vaginal canal and tissues to allow them to have the adequate size necessary to reduce pain during intercourse.
This is the sort of thing you can do for both types of women. Obviously it is more complicated if the mesh is still in and they're having issues with the mesh. Then they've got to have surgery first, right?
If there is a problem with the mesh typically what will happen is they will come to us after the mesh has been removed. Now, I have had instances where physicians have referred patients to me – let's say the mesh has been removed but they are still having pain – they come for therapy. There have been times where I actually have identified mesh that has been left within the pelvis, so they actually have to go back and have the rest of the mesh removed. So every once in a while I will have a patient who has been referred who, the mesh has been removed but their still having pain. Typically they come in, the mesh has been removed, and we, as therapists, have a lot of work to do on decreasing those connective tissue restrictions and restrictions of the muscles to help them get their life back and help them regain normal function.
We were just talking about adhesions and some of the things that could happen after surgery that physical therapy can help with. That is something that probably not a lot of people know about. How do adhesions, and the pain and tightness in there, how are they all related to having surgery?
Adhesions form just with the natural inflammatory response of the body. So anytime you have damaged tissues within the body, the body walls off that area in order to protect it. Adhesions are made up of collagen bonds that are bound by cross links and they can create growths, curtains or blankets of tissue to contain that area, but what happens is they have a scar-like bond and they form between two surfaces of the body. For example, it can form between the bladder and the bowel. It's those two surface areas in the body that get bound together. And that can happen anywhere in the body, they can bind organs, nerves, muscles, any neighboring structure. And that, in and of itself, causes pain and dysfunction. There are four major causes of adhesion formations: which would include infections, inflammation, trauma, and of course any surgery. Abdominal surgeries are the most common cause of abdominal adhesions. Any surgery will create adhesions.
So even if the mesh is functioning well in the patient adhesions can form after the mesh is placed because of the surgery, right? And that would be something that you would have to help them out with, to loosen up?
That is correct.
And I think they also talk about going in surgically and cutting adhesions which, if you talk about adhesions forming from surgery and trauma to the tissues, it seems like more surgery on an adhesion makes it worse.
Yes. Very often physicians will go in and cut adhesions, but they will forewarn the patient that it may not solve their problem because whenever you go in and cut, whenever you open someone up, you are affecting those tissues which then sets them up for adhesion formation.
The kind of therapy and the complications involved with transvaginal mesh are obviously a little hard for some people to talk about. And some people might even say that they are taboo topics. When a patient comes to you with this, and say maybe she has her partner with her, how do you get them to open up and get more comfortable about talking about these issues?
I think it is very important first and foremost you sit down and ask the patient to tell you their story. Once they start telling their story they tend to open up, because really they're there because they want help. When you ask a patient to help you understand what they have gone through they are more than willing to open up and share the issues that they have been having. And the partner is included in that. Often when a partner comes along with the patient the partner will also add to that story, and from their perspective as well which is very important.
Especially if there are any sexual issues involved or anything like that. Their partner is definitely intimately aware of what their partner is going through. So I think that's wonderful that you have both people involved in the situation. And obviously you pay attention to how the patient is feeling, the comfort of the patient and things like that. So it seems to me you are very sensitive to these issues.
Yes, we're always very sensitive. And we always tell our patient up front that it is their body, they are the boss of their body. If they want to stop, that's all they have to say. If a woman comes in and says, “I don't really feel comfortable with having this pelvic work done, can we do other things?” We'll certainly try other options. In all honesty, once the patient gets used to the therapist most often they come back and say, “OK, I'm ready to have that internal work done. I'm feeling so much better already from the things you've done externally. I know working internally is going to help me feel so much more.” We are always paying attention to body reaction, and the patient's general sense of well-being. We're always paying attention to how they are healing because if they're not comfortable with what we are doing, then we need to stop and let them have a break and make sure that that's what they want to continue doing. We are very sensitive.
You talked a little about the beginning of how the Wurn technique came about and what pelvic floor therapy is. What is the difference between the Wurn technique and traditional pelvic physical therapy, what are the advantages?
In traditional physical therapy, typically you'll be seen once or twice a week for anywhere between eight and 12 weeks, depending on the severity of the diagnosis when we're talking about mesh issues. But with the Wurn technique, it is a very intensive therapy where patients will come in and they will have usually 20 hours of therapy within one week. If it is someone who is local they may have 10 hours in one week and 10 in the second week. It's intensive, so you're working through the process much quicker. So you can help people get back to their life and function much quicker.
Oh, yeah. And if people are in pain and obviously suffering a lot of different complications – like in the case of mesh sometimes – the faster the better. In my opinion, I wouldn't want to be suffering from this for quite a while. So, I think that's great. We talk about a core surgery and personally if I can get a treatment that doesn't involve more surgery or more drugs I'm all for it. When you have conditions, though, like prolapse and incontinence, a lot of people might not know the options they have for treating it that are non-surgical or that don't involve drugs. How can physical therapy, specifically pelvic floor physical therapy avoid worsening prolapse of incontinence or even surgery for it?
Our main goal for women who are having stress incontinence issues is to improve the strength of the pelvic floor muscles, help to improve closure of the urethra via that contraction. With prolapse our goal is to improve the strength of the pelvic floor muscles in order to support the organs better because organs are attached to the pelvis by ligamentous systems and if the pelvic floor muscle is weak then those organs are just hanging on the ligaments. That worsens the prolapse over time. Another thing with stress incontinence and prolapse is for women who have constipation we need to teach them the right way to sit on the toilet, the right way to push if they are having to push to initiate the bowel movement. And then often times we are working with them on the correct way to get up out of a chair, what to do when you cough or sneeze. There are different techniques we have in our toolbox that allow us to really help these women learn techniques that help them. There are a few studies out there. There was a study done by Wilson in 2005 that stated that women with stress, urge or mixed incontinence should be offered a conservative program as a first line treatment for primary incontinence. There was another study done, by Bond in 2009 in the UK. that said that seventy-nine percent of patients receiving pelvic floor physical training improved significantly and they avoided surgery. A lot of times therapy gets skipped in the beginning, but if patients are given options, and the prolapse is not severe, very often they can avoid surgery. And, quite frankly, if a woman has prolapse and she doesn't go through pelvic physical therapy and they have very weak pelvic floor muscles the recurrence rate to have a second surgery seven to nine years later is fairly high.
You brought up something really interesting that I think most people don't think about that is therapy as a preventative as opposed to therapy after something bad has already happened. You can use it in both instances, not just after a problem has occurred.
Correct. And I would like to see the U.S. change. I wish that every woman would be required to go through pelvic physical therapy prior to having a surgery. I think that would really help in decreasing surgery rates. And for those women needing surgery I think it would help in decreasing second surgeries down the road.
And probably some of the complications that could happen after, right?
And the thing too about incontinence is that we've had some women call us and say that they never knew that that was an option, and their incontinence was really mild, but then they ended up having surgery for it and then having a mesh put in that kind of caused them problems after. There are some things that preventative care would be so much better for. I actually had a question from one of our listeners, she emailed us. Her situation is she had a partial mesh removal and has attended twelve sessions of pelvic physical therapy and she has homework to do at home, too. She is now starting to try and work with the muscles at the entrance to her vagina. She says she's having a lot of discomfort with that. But her question is, would you recommend pelvic floor therapy while a bladder sling is in place? And if you have any recommendations or restrictions she wants to know.
Yes. We see patients who have bladder slings all the time, and unless her physician gives any specific restrictions there are no restrictions as long as you're working within the constructs of what is typical physical therapy.
Alright. Then a bladder sling is not something that you cannot work around?
Yes. And we will very often get referrals just simply for women who are having pain after a bladder procedure. So she should be fine.
Awesome! She also mentioned something interesting too, homework exercises. Is that something you will end up telling your patients to do, they've got some home therapy that they might follow up with, or is this all something they do in your office?
No. They do have homework to do because we can do an extensive amount of work and yet if their muscles have been holding tight for a long time and then we're going in and releasing those muscles we want them to do exercise to remind those muscles that they need to contract and they need to release. And we have homework to help women who have issues with vaginal stenosis, where the vaginal canal is shrinking. We give them homework where they can work with dilators in order to help them open that tissue back up along with some manual therapy. Yes, our clients do have homework, and even after a patient leaves our office – because a good majority of our patients travel from very far distances for treatment – even after they are done with Clear Passage treatment we do follow up with those patients four to six weeks out. And often at that time, if a patient is advancing well, or if they are not advancing as quickly as we think they should, we will send additional homework to them and have a very long phone conversation with them. And we are always available to them via email. So they will have homework.
So even if they've got homework, though, they're not alone. You're still there to help them through any questions they might have if they get home and start doing their exercises and they're like, “Hey wait a minute. I don't know if I'm doing this right, or this feels a little funny, or it hurts a little bit.” They can actually talk to you and make sure they're doing it correctly?
Yes, that is correct.
Tell us a little about Clear Passage and how you started in the field of pelvic floor therapy.
I started in the field of pelvic floor therapy in 2000. I had an interest in women who were having an issue with incontinence and pelvic pain and bowel dysfunction, things that they were having issues with but were embarrassed or afraid to talk with people about. And I saw such a need and lack of service for these women, especially in Indiana because it is a mid-west state. So at that time I began going through an extensive education process because unfortunately in physical therapy school you get very little education in the form of pelvic health.
Not a lot of people know about it, that's probably because it is hard to talk about.
That's correct. And what you will find out is that there's a lot of research out there that shows that unless a patient is specifically asked by a healthcare provider if they have an issue they will not come forward and admit they have that issue because they are embarrassed.
A lot of the issues are incontinence and prolapse and, I mean, what woman really wants to talk about leaking or having to go to the bathroom too often or discomfort. And I think also included in that is sexual dysfunction. So you talked about it. How you got into it because you saw a need. What made you choose Clear Passage?
I chose Clear Passage because I am always looking for that missing link, the thing that maybe didn't get my last patient to meet their functional goals. I'm always looking for that next piece and Clear Passage was actually that perfect fit. The way the insurance companies manage care these days makes it very difficult a lot of the time to for a therapist to have an adequate amount of time to treat a patient. They are looking at the number of visits you are spending with a patient. So it makes it difficult to listen to the patient because that is actually the most critical part of the evaluation because often a patient can tell you where the problem is just by listening to them. Then going forward, you have to treat the whole body. When you're working within an insurance frame of mind they want you to treat the specific body part the patient is being referred for. Clear Passage allows us to be able to take the time to fully listen to the patient, to do a thorough evaluation of the entire body and then have the time to treat that patient.
And that's so important. And like you said too, the communications aspect, because you really want to take the time and really listen to find out what's really going on. And that could also take time, to be comfortable with each other, and really get the patient to open up. I've heard some ladies who've called us or written to us and they're dealing with some really difficult complications. For women who are interested in learning more about the Wurn technique or Clear Passage or anything like that, how can they schedule treatment?
There are a couple ways to find out more about Clear Passage, the first is to go online to ClearPassage.com, the second way is to call the office directly and talk with the director of patient resources. So those are the two ways you can request additional information about clear passage.
OK, pretty easy to find out. And how many clinics do you have around the country?
We do have six clinics. We have our national headquarters in Gainesville, Florida. We have a metro Denver, Colorado clinic, a metro Washington, D.C. clinic, a clinic in Miami, Florida, one in Orange County, California, and my clinic in Indianapolis, Indiana.
Gotcha. So pretty much if you're on the west coast, mid-west or the east coast there's going to be a Clear Passage that's closer to you. So that's good. Six clinics. That's nice, and available nationally to anybody that's definitely interested in checking this out. Of course, if you have any questions for me or anything that we talk about on the show you can email me at: [email protected]; you can give me a tweet at: @drugwatchradio. If you've got questions for Amy or on anything we've talked about please let us know. So Amy, thank you very much for being on the show. I know that I learned a lot and I definitely appreciate you talking about some more options that women with mesh issues can take advantage of, and that it's not always going to be surgery if they're concerned about it. So thank you so much.
Thank you for having me.
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