Common Forms Section on Women’s Health

Section on Women’s Health
Certificate of Achievement in Pelvic Physical Therapy
Common Forms
These files are provided to enhance learning and provide resources for course participants. These
files will be reviewed in level 1 and referred to in the other levels. Please print them out and
bring them to the courses. Forms may be used by participants in their entirety without changes
and with credit to the SOWH.
Anatomy Charts
Hips
PFM – with pelvic nerves
Trunk
Anal
Clinical Forms
Bladder record
Bladder record assessment sheet
Voiding diary
Menstrual diary
PFM intake questionnaire
PFM initial evaluation
PFM examination consent
Bladder treatment program
Pelvic PT Outcomes measures
Continence Grading Scale
NIH-CPSI Female
NIH-CPSI Male
Pain Disability Index
Patient specific functional scale
PFDI 20
o PFDI 20 scoring
PFIQ 7
o PFIS 7 scoring
PSIQ 12
o PSIQ 12 scoring
Urogenital Distress Inventory
Vulvar Pain Functional Questionnaire
Other Resources
Documentation
Organizations and resources for Pelvic PT
Book list
Position statement on internal exam
JWHPT instructions for authors
Reporting Services to third party payors
1
1
1
Hip Muscles
Lower Limb
Muscle
Piriformis
Attachment
Attachment
Nerve
Segmental
Innervation
Function
Round pattern
lateral to lower
sacrum and
posterolateral to
hip, posterior
buttock, and thigh
External rotation
of hip when hip
extended; internal
rotation of hip
flexed; assists in
hip abduction
Medial: ventral
surface of sacrum
from segments
S2-S4;
sacrotuberous
ligament
Lateral: superior
aspect of greater
trochanter of
femur
Nerve to
piriformis
Obturator internus Medial: pelvic
cavity margin of
obturator foramen
and the surface of
obturator
membrane
Lateral: medial
aspect of greater
trochanter of
femur with
superior and
inferior gemelli
Nerve to obturator L5, S1, S2
internus
Round pattern
around coccyx,
upper half of
posterior thigh
External rotation
of femur
Femoral
Vertical band from
L1 to sacroiliac
joint along region
of transverse
processes; upper
middle 1/3 of
anterior thigh
Flexion of hip;
flexion and lateral
bending of lumbar
spine
Iliopsoas
Iliacus: iliac fossa, Tendon of psoas
ala of sacrum,
major
sacroiliac
ligament; anterior
inferior iliac spine
S1, S2
Referred Pain
(Travell and
Simons 1992)
L2, L3
L2, L3, L4
Psoas major:
Lesser trochanter
transverse process of femur
of L1-L5
2
Anatomy Tables: Hip Muscles
Lower Limb
Muscle
Attachment
Attachment
Nerve
Segmental
Innervation
Referred Pain
(Travell and
Simons 1992)
Function
Gluteus maximus Posterior iliac
crest, sacrum,
coccyx,
sacrotuberous
ligament
Iliotibial band,
Inferior gluteal
gluteal tuberosity
of femur
L5, S1, S2
Round pattern over
lower sacrum,
lower medial
buttock, and ischial
tuberosity; curved
band from lateral
sacrum to ischial
tuberosity
Extension and
external rotation
of femur; trunk
extension;
controls trunk
flexion
Gluteus medius
External ilium
below iliac crest
and between
anterior and
posterior gluteal
lines
Lateral aspect of Superior gluteal
greater trochanter
of femur
L4, L5, S1
Band pattern along
posterior iliac
crest, lateral
sacrum, and lower
posterior buttock;
round pattern over
sacrum, upper
lateral thigh, and
lower posterior
buttock
Abduction and
internal rotation
of femur; lateral
stability of pelvis
Gluteus minimus
External ilium
caudal to medius
and between
anterior and
inferior gluteal
lines
Anterior aspect of Superior gluteal
greater trochanter
of femur
L4, L5, S1
Round pattern in
lower posterior
buttock
Abduction and
internal rotation
of femur; lateral
stability of pelvis
3
Anatomy Tables: Hip Muscles
Lower Limb
Muscle
Attachment
Attachment
Nerve
Segmental
Innervation
Referred Pain
(Travell and
Simons 1992)
Function
Obturator
externus
External obturator Intertrochanteric
foramen and
fossa
obturator
membrane
Obturator
L2, L3, L4
Band pattern along External rotation
upper lateral thigh, of femur
upper posterior
thigh, lateral and
posterior knee, and
lateral and
posterior lower leg
Pectineus
Superior pelvic
ramus along
pectineal line
Pectineal line of
femur
Femoral
L2, L3, L4
Round pattern in
medial 1/3 of
inguinal region
extending into
upper most
anterior thigh
Flexion and
adduction of hip;
assists in medial
rotation
Adductor longus
Body of pelvic
bone
Middle medial lip Obturator
of linea aspera of
femur
L2, L3, L4
Oval pattern just
inferior to inguinal
ligament; round
pattern to anterior
knee just superior
to patella
Adduction of hip;
assists in flexion
and medial
rotation of hip
Adductor brevis
Body and inferior Pectineal line,
Obturator
ramus of pubic
proximal medial
bone
lip of linea aspera
L2, L3, L4
Same as adductor
longus
Adduction of hip;
assists in flexion
and medial
rotation of hip
4
Anatomy Tables: Hip Muscles
Lower Limb
Muscle
Attachment
Adductor magnus Inferior pubic
ramus, ischial
ramus, ischial
tuberosity
Attachment
Nerve
Gluteal tuberosity Obturator, L4 of
medial linea
tibial nerve
aspera and
supracondylar
ridge, adductor
tubercle
Segmental
Innervation
Referred Pain
(Travell and
Simons 1992)
Function
L2, L3, L4
Band pattern from
medial 1/3 of
inguinal region
along anteromedial
thigh; intrapelvic
area along anus,
rectum, and
bladder
Adduction of hip;
assists in hip
extension and
medial rotation
Gracilis
Body and inferior Proximal medial
ramus of pubic
tibial shaft, pes
bone
anserine
Obturator
L2, L3, L4
Band pattern in
middle 1/3 of
medial thigh
Hip adduction;
assists in knee
flexion and
medial tibial
rotation
Rectus femoris
Anterior inferior
iliac spine,
superior
acetabulum
Superior patella
by quadriceps
tendon, tibial
tuberosity by
patellar ligament
Femoral
L2, L3, L4
Band pattern in
lower 2/3 of
middle anterior
thigh, anterior
patella
Extension of
knee; flexion of
hip
Semitendinous
Ischial tuberosity
of femur
Proximal medial
tibial shaft, pes
anserine
Tibial
L5, S1, S2
Band pattern along Knee flexion; hip
all of
extension; medial
posteromedial
tibial rotation
thigh and upper
1/3 of
posteromedial
lower leg
5
Anatomy Tables: Hip Muscles
Lower Limb
Muscle
Attachment
Semimembranous Ischial tuberosity
of femur
Biceps femoris
long head
short head
Attachment
Nerve
Segmental
Innervation
Referred Pain
(Travell and
Simons 1992)
Function
Posterior aspect
on medial tibial
condyle
Tibial
L5, S1, S2
Same as
semitendinous
Knee flexion; hip
extension; medial
tibial rotation
Ischial tuberosity, Lateral tibial
sacrotuberous
condyle, lateral
ligament
side of fibular
head
Tibial
L5, S1, S2
Lateral lip of linea
aspera, lateral
supracondylar
ridge
Common peroneal
Band pattern along Knee flexion; hip
all of posterolateral extension; lateral
thigh and
tibia rotation
posterolateral
popliteal fossa
Travell J, Simons D. Myofascial Pain and Dysfunction Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992.
Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations
sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information.
6
Anatomy Tables: Hip Muscles
Pelvic Floor Muscles
Muscle Layer
Muscle
Attachment
Pelvic diaphragm Pubococcygeus
Levator ani
Puboperinealis
portion
Anterior: pubis
Pelvic diaphragm Pubococcygeus
Levator ani
Pubovaginalis
portion
Anterior: pubis
Pelvic diaphragm Pubococcygeus
Levator ani
Puboanalis
portion
Anterior: pubis
Attachment
Nerve
Segmental
Innervation
Posterior: perineal Nerve to levator
body
ani
Pudendal
S3, S4
Medial: midurethral vaginal
wall
Nerve to levator
ani
Pudendal
S3, S4
Posterior:
intersphincteric
groove
Nerve to levator
ani
Pudendal
S3, S4
Pelvic diaphragm Puborectalis
Levator ani
Anterior: superior Posterior: right
Nerve to levator
pubic ramus
and left
ani
puborectalis join Pudendal
to form a sling
around the
anorectal junction
S3, S4
Pelvic diaphragm Iliococcygeus
Levator ani
Medial: coccyx;
anococcygeal
ligament
Nerve to levator
ani
Pudendal
S3, S4
Sacral nerves
S3, S4, S5
Lateral: thick
tendinous arch
from obturator
internus fascia;
ischial spine
Pelvic diaphragm Coccygeus
Medial: lower
Lateral: ischial
Levator ani
(ischiococcygeus) lateral sacrum and spine;
upper coccyx
sacrospinous
ligament
S2, S3, S4
S2, S3, S4
S2, S3, S4
S2, S3, S4
S2, S3, S4
Function
Pulls perineal
body toward
pubis
Elevates midurethral vagina
Elevates anal
canal
Forms the
anorectal angle;
closes the pelvic
floor
Elevates pelvic
floor; supports
pelvic viscera
Stabilizes coccyx;
supports pelvic
viscera
Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves
7
Perineal
membrane
Sphincter urethrae Anterior: pubic
Posterior: trigonal Pudendal
arch and upper ⅔ ring
of urethra
S2, S3, S4
Constricts urethra
Perineal
membrane
Compressor
urethrae
Anterior:
Posterior: urethra Pudendal
ischiopubic ramus
S2, S3, S4
Compresses
urethra
Perineal
membrane
Urethrovaginal
sphincter
Medial: vaginal
wall
Posterior: urethra Pudendal
S2, S3, S4
Compresses
urethra
Lateral: ischial
tuberosity
Medial: perineal
body
Pudendal
S2, S3, S4
Supports perineal
body
Superficial genital Bulbocavernosus Lateral: fascia of
muscles
corpus
cavernosum
Medial: perineal
body
Pudendal
S2, S3, S4
Clitoral erection
Superficial genital Ischiocavernosus Anterior: crus of
muscles
the clitoris
Posterior: ischial
tuberosity
Pudendal
S2, S3, S4
Clitoral erection
Superficial genital Superficial
muscles
transverse
perineal
Ashton-Miller JA, Howard D, DeLancey JO. The functional anatomy of the female pelvic floor and stress continence control system.
Scand J Urol Nephrol Suppl. 2001;207:1–125.
Kerney R, Sawhney R, DeLancey J. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol. 2004;104:168–
173.
Wei JT, DeLancey JO. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004;47:3–17.
Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and
innervations sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information.
Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves
8
Pelvic Nerves
Nerve
Spinal
Level
Pathway
Innervation
Trauma
Iliohypogastric L1
Anterior to quadratus lumborum,
Skin above pubic bone
pierces internal oblique muscle and Lower abdominal muscles
travels between the internal and
Posterior gluteal region
external oblique muscles to the
superior pubic bone
Transverse incision with retractors
During closure of transverse
incisions
Sutures of needle urethropexies
Ilioinguinal
Anterior to quadratus lumborum,
Mons pubis
inferior to iliohypogastric, pierces
External genitalia
the transversus muscle and travels Upper medial thigh
between the transversus and internal
oblique muscles through the
inguinal canal to the mons pubis
Transverse incision with retractors
During closure of transverse
incisions
Sutures of needle urethropexies
Lateral femoral L2, L3
cutaneous
Anterior to quadratus lumborum,
posterior to psoas, inferior to
ilioinguinal, anterior to iliacus,
under inguinal ligament
Lateral and anterior thigh to
the knee
Positioning during gynecological
surgeries, especially extreme hip
flexion
Femoral
L2, L3, L4
Through psoas, anterior to iliacus,
under inguinal ligament
Quadriceps, sartorius
pectineus, iliacus muscles
Cutaneous medial anterior
thigh and medial lower leg
Knee joint
Hyperflexion of hip and knee such
as in labor
Diabetic neuropathy
Deep lateral retractors with
transverse gynecological incision
Genitofemoral
L1, L2
Through psoas, anterior to psoas,
under inguinal ligament
Upper anterior thigh: femoral Lateral retractors during
branch
gynecological surgeries
Mons pubis: genital branch Harvesting of external iliac lymph
nodes
L1
Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves
9
Obturator
internus
L2, L3, L4
Through psoas, exiting posterior to
travel just anterior to the sacroiliac
joint, anterior to obturator internus
muscle, and through the obturator
notch
Adductor muscles
Cutaneous medial thigh
Pelvic node dissection
Deep pelvic retractors
Dissection in the space of Retzius
Pudendal
S2, S3, S4
Through the greater sciatic notch,
around ischial spine, back in
through lesser sciatic notch, behind
sacrospinous ligament, curves
anterior along the medial ischial
tuberosity within Alcock’s canal,
turns superior to the ischioanal
fossa
Superficial perineal and
perineal membrane muscles:
perineal branch
External anal sphincter:
inferior rectal branch
Cutaneous perineal area and
clitoris
Pelvic diaphragm (?)
Chronic constipation and straining
Prolonged and difficult labor and
delivery
Deep mediolateral episiotomy
Nerve to pelvic S3, S4
diaphragm
Nerve root directly off sacral plexus Pelvic diaphragm muscles:
to muscle
levator ani and coccygeus
Chronic constipation and straining
Prolonged and difficult labor and
delivery
Possibly deep pelvic surgery
Barber M, Bremer R, Thor K, Dolber P, Kuehl T, Coates K. Innervation of the female levator ani muscles. Am J Obstet Gynecol.
2002;187:64–71.
Steege J, ed. Chronic Pelvic Pain: An Integrated Approach. Philadelphia, Pa: W B Saunders Co; 1998.
Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations
sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information.
Anatomy Tables: Pelvic Floor Muscles and Pelvic Nerves
10
Trunk Muscles
Trunk Muscle
Attachment
Rectus
abdominus
Pubic symphysis
and pubic crest
External
abdominal
oblique
Internal
abdominal
oblique
Attachment
Nerve
Xiphoid and
Intercostal
costal cartilage of nerves T6-T11
ribs 5, 6, 7
Segmental
Referred Pain
Innervation (Travell and Simons
1992*)
Function
T6-T12
Wide posterior band
across ilium, SI joint,
sacrum; wide band
across lower 4 ribs
and thoracic
vertebrae; oval
pattern between
umbilicus and pubic
Bilaterally forward
trunk flexion; posterior
pelvic tilt; stabilization
of pelvis and trunk
Bodies of ribs 5-12 Linea alba,
Intercostal
anterior iliac
nerves T6-T11,
crest, anterior
iliohypogastric
superior iliac
spine, pubic
tubercle by
inguinal ligament
T6-L1
Band pattern from
xiphoid to along
costal cartilage of
lower anterior rib
cage and along entire
inguinal region
Bilaterally forward
trunk flexion;
unilaterally lateral trunk
flexion to same side and
rotation to opposite
side; posterior pelvic
tilt; stabilizes pelvis and
trunk; supports the
viscera
Thoracolumbar
fascia, anterior iliac
crest, lateral
inguinal ligament
T6-L1
Same as external
abdominal oblique
Same as external
abdominal oblique
Costal surface of
ribs 9-12, linea
alba, superior
pubic ramus
along pectineal
line
Intercostal
nerves T6-T11,
subcostal,
ilioinguinal
iliohypogastric
Anatomy Tables: Trunk Muscles
11
Transversus
abdominus
Thoracolumbar
fascia, anterior iliac
crest, lateral
inguinal ligament,
costal cartilages of
ribs 7-12 into
diaphragm
Linea alba,
aponeurosis
fusing with the
fascia of the
obliques and
rectus, pubic crest
Intercostal
nerves T6-T11,
subcostal,
ilioinguinal
iliohypogastric
T6-L1
Same as external
abdominal oblique
Supports viscera;
decreases infrasternal
angle with exhale;
stabilizes SI and trunk;
synergistic with PFM
Quadratus
lumborum
Iliac crest lateral to Medial aspect of Ventral rami of
erector spinae,
rib 12, transverse L1-L4
iliolumbar ligament processes of L1L4
L1-L4
Band pattern along
iliac crest and lower
lateral buttock;
round pattern over
lower posterior
buttock and SI joint
Bilaterally extends
trunk; unilaterally
flexes to same side and
controls lateral flexion
to opposite side
Multifidus
lumborum
Posterior sacrum,
Spinous processes Dorsal rami of Lumbar
Round pattern over Bilaterally extends
posterior superior
of vertebrae 1-4 spinal nerves
levels
lateral ½ of sacrum trunk; unilaterally
iliac spine, posterior levels superior to crossed by
crossed by
and coccyx, SI joint, rotates and controls
sacroiliac ligament, first attachment
muscle
muscle
posterior iliac crest lateral flexion to
mamillary process
opposite side
L1-L5
* Travell J, Simons D. Myofascial Pain and Dysfunction Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1992.
Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations
sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information.
Anatomy Tables: Trunk Muscles
12
Anal Muscles
Muscle
Attachment
Attachment
Nerve
Segmental
Innervation
S2, 3, 4
Function
External anal
sphincter
(EAS)
Deep or upper
loop
EAS
Superficial or
middle loop
Superficial transverse
perineal muscle and
perineal body
Puborectalis
muscle
Inferior rectal
nerve branch of
pudendal nerve
Tip of coccyx via the
anococcygeal
ligament
Perineal body
Inferior rectal
nerve branch of
pudendal nerve
S2, 3, 4
Closure of the
anal canal: 20%
EAS
Subcutaneous
or basal loop
Internal anal
sphincter (IAS)
Involuntary
Circumferential
striated fibers
attached to the skin
Continuation of rectal
smooth muscle
Inferior rectal
nerve branch of
pudendal nerve
Inferior
hypogastric
plexus or pelvic
plexus
S2, 3, 4
Closure of the
anal canal: 20%
T12-L2
Provides 80% of
resting anal
pressure/tone
Closure of the
anal canal: 20%
Please note: The literature on anatomy varies. Ongoing research and discussion about muscle function, terminology, and innervations
sometimes results in conflicting information. The CAPP committee has tried to present the most accepted information.
Anatomy Tables: Anal Muscles
13
Bladder Record
Name: ______________________________________________________________
Date: __________________________ Date: ___________________________
Amount
Urinate
of leak /
in toilet
accident
Activity
during leak
Drink
type/
amount
Amount
Urinate
of leak /
in toilet
accident
Activity
during leak
Drink
type/
amount
6 AM
6 AM
7 AM
7 AM
8 AM
8 AM
9 AM
9 AM
10 AM
10 AM
11 AM
11 AM
12 AM
12 AM
1 PM
1 PM
2 PM
2 PM
3 PM
3 PM
4 PM
4 PM
5 PM
5 PM
6 PM
6 PM
7 PM
7 PM
8 PM
8 PM
9 PM
9 PM
10 PM
10 PM
11 PM
11 PM
12 PM
12 PM
1 AM
1 AM
2 AM
2 AM
3 AM
3 AM
4 AM
4 AM
5 AM
5 AM
Total
Total
Number of pads used: _____________
Number of pads used: ________________
2
14
14
Bladder diary assessment sheet
Patient name ___________________________________________________________
Date
Date
Daytime frequency
Nocturia
24-hour frequency
Average voiding interval
Minimum voiding interval
Maximum voiding interval
Average voided volume
Minimum voided volume
Maximum voided volume
Total incontinence episodes
Small leaks
Medium leaks
Large leaks
Cause of leakage
Total fluid intake
Irritant intake
Timing of fluid intake
Diagnosis
Proposed fluid changes
Proposed bladder schedule
3
15
15
Voiding Diary
Date:
Name:
Please keep track of your fluid and food intake and the amount of urine voided, amount of
leakage, the activity when the leakage occurred, and if an urge was present. Do this for 4 days.
Date /
time of
day
Type and
amount
of fluid
intake
Type and
amount
of food
eaten
Amount
voided
(small,
medium,
large)
Amount
of
leakage
(small,
medium,
large)
Activity
engaged in
when
leakage
occurred
Was an
urge
present?
(Yes or
No)
Change
of pad?
4
16
16
Menstrual diary
Patient name __________________________________
Month
Month
Symptom →
Day ↓
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Comments
5
17
17
Pelvic Floor Therapy Questionnaire
Patient name __________________________________ Date ______________________
Please fill in the following questionnaire to the best of your ability. The therapist will review the
answers with you at your appointment.
History
Number of pregnancies _______________ Number of vaginal deliveries ____________
Birth weight of largest baby ___________
Number of cesarean deliveries ___________
Number of episiotomies ______________
Date of last pap smear _________________
Did you have any trouble healing after delivery
Y
N
Do you have a history of sexual abuse or trauma
Y
N
Are you having regular periods/ menstrual cycles
Y
N
Do you have frequent urinary tract infections
Y
N
Pain
Do you have pain with:
Sexual intercourse
Y
N
Pelvic exam
Y
N
Tampon use
Y
N
Back, leg, groin, abdominal pain
Y
N
Test results
Urodynamics test
Y
N
Results: _______________________
Cystoscope
Y
N
Results: _______________________
Urine test
Y
N
Results: _______________________
Bowel test
Y
N
Results: _______________________
6
18
18
Bladder symptoms
Do you lose urine when you:
Cough/ sneeze/ laugh
Y
N
Lift/ exercise/ dance/ jump
Y
N
On the way to the bathroom Y
N
Have a strong urge to urinate Y
N
Hear running water
N
Other __________________ Y
N
Y
Do you wet the bed
Y
N
Have burning/ pain with urination
Y
N
Difficulty starting a stream of urine Y
N
Strain to empty your bladder
Y
N
Feel unable to empty bladder fully
Y
N
Have a falling out feeling
Y
N
Have pain with a full bladder
Y
N
Have an urgency of urination
(a strong urge to urinate)
Y
N
Urinate more than 7 times/day
Y
N
Strain to have a bowel movement
Y
N
Leak / stain feces
Y
N
Include fiber in your diet
Y
N
Have diarrhea often
Y
N
Take laxatives / enema regularly
Y
N
Leak gas by accident Y
N
Have pain with bowel movement
Y
N
Bowel symptoms
Have a very strong urge to move your bowels
Y
N
How often do you move your bowels: _____________ per day, week
Most common stool consistency
____ liquid ___ soft ___ firm ___ pellets ___ other ___________
Thank you for taking the time to fill out this questionnaire.
7
19
19
Pelvic Floor Physical Therapy Evaluation
Name:
Date:
DR:
Next visit with DR:
Family DR:
Medical DX:
PT DX:
Prescription:
HPI:
Tests:
PMH GYN:
PMH OB:
PMH:
SOC:
UI SX:
___ stress sx
___ urge sx
___ retention sx
___ prolapse sx
QOL results
SX score
Bowel SX:
___ constipation
___ leakage
___ pain
Pain:
___ dyspareunia
Pain:
___ low back, buttock
___ abdomen
___ other
Informed consent for internal evaluation consent given
External observation:
Introitus:
Resting position:
Voluntary contraction: … absent
Involuntary contraction: … absent
Involuntary relaxation: … absent
Perineal descent: rest … absent
Perineal descent: bearing
… absent
… present
… present
… present
… present
… present
Introitus clock:
Skin condition:
Scarring:
Other:
Skin condition:
Other: ___________________
scar +++,
pain x,
skin color ///
8
20
20
Pelvic floor:
Vaginal vault size:
Muscle volume:
PFM tone:
… decreased
… decreased
… decreased
… increased
… WNL
… increased
… WNL
… defect
… WNL
Pelvic floor clock:
scar +++
pain x
Contraction ability:
spasm ~
Voluntary contraction:
… absent … weak
… moderate
… strong
MMT: ____ R, ____ L
Voluntary relaxation:
… absent … partial
… complete
Muscle endurance: ______ seconds right, ______seconds left
Number of quick contractions in 10 seconds _____
Brink score: time ___ displacement ___ pressure ____
Tissue laxity test:
Anterior wall:
… min
… mod
… severe … WNL
Posterior wall:
… min
… mod
… severe … WNL
Urethra:
… min
… mod
… severe … WNL
Quality of contractions:
Overflow:
Treatment today:
__ Evaluation / examination
__ Bladder and PFM education
Bladder diary results:
__ Bladder diary given
__ PFM exercises
# large leaks / 24 hrs
# small leaks / 24 hrs
Minimum voided volume
Fluid intake / 24 hrs
# void / 24 hrs
# medium leaks / 24 hrs
Minimum voided interval
Average voided interval
Irritant intake / 24 hrs
SEMG evaluation: date
uV
Resting tone
Quality / rest: irregular, elevated, WNL
uV
5-second hold
uV
10-second hold
Quality of: Recruitment:
Derecruitment:
Holding:
Stability of hold:
Stability of rest:
Baseline b/t contract:
Overflow: … absent
… slow
… slow
… poor
… poor
… poor
… poor
… min
… fair
… fair
… fair
… fair
… fair
… fair
… mod
… good
… good
… good
… good
… good
… good
… severe
Assessment:
PFM dysfunction:
… non-contracting PFM
… non-relaxing PFM
… non-contracting, non-relaxing PFM
PFM condition:
… underactive PFM … overactive PFM
… non-functioning PFM
Rehabilitation potential: … excellent
… good
… fair
… poor
Symptoms of abuse:
… absent
… present ___________________________________
Learning barriers:
… absent
… present ___________________________________
Obstacles to rehabilitation: _______________________________________________________
9
21
21
Clinical Problem List
Joint dysfunction _________________________
Muscle spasm ___________________________
Abdominal / perineal scar adhesion __________
Poor trunk stability
Decreased PFM strength
Decreased PFM endurance ___ seconds
PFM trigger point / pain
_________________
Increased PFM resting tone ________________
Initial symptom index ___
Initial QOL index ___
Increased tissue laxity: anterior, posterior, urethra
Increased overflow with PFM contraction
Decreased relaxation ability
Decreased involuntary contraction / relaxation
____________________________________
____________________________________
Clinical Goals
____________________________________
____________________________________
Normalize scar mobility
Improve trunk stability
PFM strength: normal, strong
PFM contraction ___ seconds hold with good quality
Decrease PFM pain
Normalize PFM tone
Discharge symptom index: improved ____ points
Discharge QOL index: improved ____ points
Improved support of the PFM
Good isolation of PFM
Improved relaxation ability
Improved involuntary contraction / relaxation
________________________________________
________________________________________
Functional problem list
Decreased sexual activity due to pain
Decreased tolerance for vaginal penetration
Limited social activities due to UI or pain
Min
Decreased sitting ability
Min
Decreased standing ability
pain
Decreased sleeping ability
Sleep disturbed by nocturia ___ x / night
minutes / miles
Decreased walking distance
Decreased ability for basic ADLs leakage/ pain
Functional goals
Resume sexual activity with ____ / 10 pain
Able to insert # ___ dilator with ___ / 10 pain
Social activity not limited by UI or pain
Sitting ability minutes for work, travel, social
Standing minutes for work, home social
Sleeping hours per night
Nocturnal voiding ___ x / night for improved sleep
Walking
minutes / miles
Basic ADLs with ___ /10 pain / ___ % decreased
leakage
Advanced ADLs with ___ /10 pain / ____ %
decreased leakage
hour work day
Able to tolerate
___ hour voiding schedule
Good knowledge of PFM contraction
Good knowledge of PFM relaxation
PFM contraction before increased intra-abdominal
pressure
Good fluid intake
Good knowledge of posture and body mechanics
Good knowledge of self-help
Discharge functional index / QOL score ___
______________________________________
______________________________________
Decreased ability for advanced ADLs leakage/pain
Decreased tolerance for work
Urinary frequency
Poor knowledge of PFM contraction
Poor knowledge of PFM relaxation
Poor timing of PFM contraction with cough, etc
Poor fluid intake and irritant intake
Poor knowledge of posture and body mechanics
Poor knowledge of self-help
Initial functional index / QOL score ___
_____________________________________
_____________________________________
Treatment plan:
Frequency: ________________
__ Neuromuscular reeducation
__ Manual therapy
__ Therapeutic activities
__ Other
Duration: ___________________
__ Therapeutic exercise
__ Education
__ Modalities
__ Bladder training and fluid education
Signature: ____________________________ Date: _____________________________
10
22
22
PELVIC FLOOR CONSENT FOR EVALUATION AND TREATMENT
I acknowledge and understand that I have been referred for evaluation and treatment of pelvic
floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal
incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or
surgery; persistent sacroiliac or low back pain; or pelvic pain conditions.
I understand that to evaluate my condition it may be necessary, initially and periodically, to have
my therapist perform an internal pelvic floor muscle examination. This examination is
performed by observing and/or palpating the perineal region including the vagina and/or rectum.
This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance,
scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or
rectal sensors for muscle biofeedback.
Treatment may include, but not be limited to, the following: observation, palpation, use of
vaginal weights, vaginal or rectal sensors for biofeedback and/or electrical stimulation,
ultrasound, heat, cold, stretching and strengthening exercises, soft tissue and/or joint
mobilization, and educational instruction.
I understand that in order for therapy to be effective, I must come as scheduled unless there are
unusual circumstances that prevent me from attending therapy. I agree to cooperate with and
carry out the home program assigned to me. If I have difficulty with any part of my treatment
program, I will discuss it with my therapist.
1. The purpose, risks, and benefits of this evaluation have been explained to me.
2. I understand that I can terminate the procedure at any time.
3. I understand that I am responsible for immediately telling the examiner if I am having
any discomfort or unusual symptoms during the evaluation.
4. I have the option of having a second person present in the room during the procedure
and _____ choose _____ refuse this option.
Date:
Patient Name:
Patient Signature
Signature of Parent or Guardian (if applicable)
Witness Signature
11
23
23
Date
Name
BLADDER TREATMENT PROGRAM
Voiding Schedule
Fluid Intake
Increase intake of:
Decrease intake of:
Pelvic floor muscle exercises / Kegels
Short: hold ___ seconds
relax ____ seconds
repeat ___ times
Long: hold ___ seconds
relax ____ seconds
repeat ___ times
Other
Biofeedback / Electrical stimulation / Vaginal weights
Abdominal muscle exercises
Other
12
24
24
Continence Grading Scale: A Symptom Index (Jorge 1993)
Never
Incontinence for solid stool
Incontinence for liquid stool
Incontinence for gas
Alteration in lifestyle
Rarely
0
0
0
0
1
1
1
1
Sometimes
Weekly
2
2
2
2
3
3
3
3
No
0
0
0
Need to wear pad or plug
Taking constipation medicines
Lacking the ability to defer defecation
for 15 minutes
Daily
4
4
4
4
Yes
2
2
4
Never = no episodes in the past 4 weeks
Rarely = 1 episode in the past 4 weeks
Sometimes = more than 1 episode in the past 4 weeks but less than once per week
Weekly = 1 or more episodes per week but less than daily
Daily = 1 or more episodes per day
Scoring: add one score from each row
Minimum score: 0 = perfect continence
Maximum score: 24 = totally incontinent
Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum.
1993;36(1):77-97.
13
25
25
Female NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)
Center for Urologic and Pelvic Pain
Name: ____________________________
Date: _____________________________
Pain or Discomfort
1. In the last week, have you experienced
any pain or discomfort in the following
areas?
Yes
No
a. Area between rectum and
1
0
vagina (perineum)
b. Labia
1
0
c. Clitoris (not related to
urination)
1
0
d. Below your waist in your
pubic area
1
0
e. Below your waist in your
rectal area
1
0
2. In the last week, have you
experienced:
a. Pain or burning during
urination?
b. Pain or discomfort during or
after sexual climax?
Yes
No
1
0
1
0
6. How often have you had to urinate again
less than two hours after you finished
urinating, over the last week?
0 Not at all
1 Less than 1 time in 5
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always
Impact of Symptoms
7. How much have your symptoms kept you
from doing the kinds of things you would
usually do, over the last week?
0 None
1 Only a little
2 Some
3 A lot
8. How much did you think about your
symptoms, over the last week?
0 None
1 Only a little
2 Some
3 A lot
3. How often have you had pain or
discomfort in any of these areas
over the last week?
0
1
2
3
4
5
Never
Rarely
Sometimes
Often
Usually
Always
Quality of Life
9. If you were to spend the rest of your life
with your symptoms just the way they have
been during the last week, how would you
feel about that?
0 Delighted
1 Pleased
2 Mostly satisfied
3 Mixed (about equally satisfied
and dissatisfied)
4 Mostly dissatisfied
5 Unhappy
6 Terrible
4. Which number best describes your
AVERAGE pain or discomfort on the days
that you had it, over the last week?
0 1 2 3 4 5 6 7 8 9 10
NO PAIN
PAIN AS BAD
AS YOU CAN
IMAGINE
Urination
5. How often have you had a sensation of
not emptying your bladder completely after
you finished urinating, over the last week?
0 Not at all
1 Less than 1 time in 5
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always or always
Scoring the NIH-Chronic Prostatitis Symptom Index
Domains
Pain: Total of items 1a, 1b, 1c, 1d, 1e, 2a, 2b, 3, and 4 =____
Urinary Symptoms: Total of items 5 and 6
=____
Quality of Life Impact: Total of items 7, 8, and 9
=____
Adapted from Litwin et al. J Urol. 1999;162:369-375
26
26
NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) (for males)
Center for Urologic and Pelvic Pain
Name: ____________________________
Date: _____________________________
Pain or Discomfort
6. How often have you had to urinate again
less than two hours after you finished
urinating, over the last week?
0 Not at all
1 Less than 1 time in 5
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always
1. In the last week, have you experienced
any pain or discomfort in the following
areas?
Yes
No
a. Area between rectum and
1
0
testicles (perineum)
b. Testicles
1
0
c. Tip of the penis (not related to
urination)
1
0
d. Below your waist, in your
pubic or bladder area
1
0
2. In the last week, have you
experienced:
Yes
a. Pain or burning during
urination?
1
b. Pain or discomfort during or
after sexual climax (ejaculation)? 1
Impact of Symptoms
7. How much have your symptoms kept you
from doing the kinds of things you would
usually do, over the last week?
0 None
1 Only a little
2 Some
3 A lot
No
0
0
8. How much did you think about your
symptoms, over the last week?
0 None
1 Only a little
2 Some
3 A lot
3. How often have you had pain or
discomfort in any of these areas
over the last week?
0 Never
1 Rarely
2 Sometimes
3 Often
4 Usually
5 Always
Quality of Life
9. If you were to spend the rest of your life
with your symptoms just the way they have
been during the last week, how would you
feel about that?
0 Delighted
1 Pleased
2 Mostly satisfied
3 Mixed (about equally satisfied and
dissatisfied)
4 Mostly dissatisfied
5 Unhappy
6 Terrible
4. Which number best describes your
AVERAGE pain or discomfort on the days
that you had it, over the last week?
0 1 2 3 4 5 6 7 8 9 10
NO PAIN
PAIN AS BAD
AS YOU CAN
IMAGINE
Urination
5. How often have you had a sensation of
not emptying your bladder completely after
you finished urinating, over the last week?
0 Not at all
1 Less than 1 time in 5
2 Less than half the time
3 About half the time
4 More than half the time
5 Almost always
Scoring the NIH-Chronic Prostatitis Symptom Index
Domains
Pain: Total of items 1a, 1b, 1c,1d, 2a, 2b, 3, and 4 =____
Urinary Symptom s: Total of items 5 and 6 =____
Quality of Life & Impact: Total of items 7, 8, and 9 =____
Adapted from Litwin et al. J Urol. 1999;162:369-375 .
27
27
Name: __________________________________
Date: ________________________
Pain Disability Index
In order to determine how effective your treatment is, we need to know how much pain is interfering in your
normal activities. For the 7 areas listed below, please circle the number on the scale which describes the level
of disability you have experienced in each area OVER THE PAST WEEK. A score of “0” means no disability
at all, and a score of “10” indicates that all of the activities which you would normally do have been totally
disrupted or prevented by your pain over the past week. Circle “0” if a category does not apply to you.
Family/Home Responsibilities: This category refers to activities related to the home or family. It includes
chores or duties performed around the house (e.g. yard work, house cleaning) and errands or favors for other
family members (e.g. driving the children to school.
0
1
No Disability
2
3
4
Mild
5
6
Moderate
7
8
Severe
9
10
Total Disability
Recreation: This category includes hobbies, sports, and other similar leisure time activities.
0
1
No Disability
2
3
4
Mild
5
6
Moderate
7
8
Severe
9
10
Total Disability
Social Activity: This category refers to activities which involve participation with friends and acquaintances
other than family members. It includes parties, theater, concerts, dining out, and other social functions.
0
1
No Disability
2
3
4
Mild
5
6
Moderate
7
8
Severe
9
10
Total Disability
Occupation: This category refers to activities that are a part of or directly related to one’s job. This includes
non-paying jobs as well, such as housewife or volunteer worker.
0
1
No Disability
2
3
4
Mild
5
6
Moderate
7
8
Severe
9
10
Total Disability
Sexual Behavior: This category refers to the frequency and quality of one’s sex life.
0
1
No Disability
2
3
4
Mild
5
6
Moderate
7
8
Severe
9
10
Total Disability
Self-Care: This category includes activities which involve personal maintenance and independent daily living
(e.g. taking a shower, driving, getting dressed).
0
1
No Disability
2
3
4
Mild
5
6
Moderate
7
8
Severe
9
10
Total Disability
Life-Support Activity: This category refers to basic life-supporting behaviors such as eating and sleeping.
0
1
No Disability
2
3
Mild
Total Score: _____________________
4
5
6
Moderate
28
28
7
8
Severe
9
10
Total Disability
Pain Disability Index 03-07
PDI Scoring:
Scores for each item are summed.
Higher score = higher disability.
Tait RC, Pollard CA, Margolis RB, Duchro PN, Krause SJ. The pain disability index:
psychometric and validity data. Arch Phys Med Rehabil. 1987;68:438-441.
15
30
29
Patient Specific Functional Scale (PSFS)
Read at Baseline Assessment
I’m going to ask you to identify up to 3 important activities that you are unable to do or are
having difficulty with as a result of your _____________ problem. Today, are there any
activities that you are unable to do or have difficulty with because of your ________________
problem.
Try to be specific and descriptive eg. I have difficulty sitting for 15 minutes
Activity #1
Activity #2
Activity #3
Patient Specific Activity Scoring Scheme (Point to a number):
10
9
8
7
6
5
4
3
2
1
0
Able
Minimal difficulty Moderate difficulty
Severe difficulty
Unable
to
to perform activity to perform activity
to perform activity to perform
perform
activity
This is not a pain rating scale. The key is “how much difficulty”. This does not work with
urinary incontinence, fecal incontinence, or constipation. It is best to administer the PSFS
following the history but prior to the physical examination. It appears that when the PSFS is
administered following the physical exam, patients often select activities which are of more
(perceived) interest to the therapist rather than the patient. (trying to please) Minimal clinical
significant change is 3 points on any one activity scale.
For example:
I have difficulty sitting for 15 minutes
o Initial rating 6 - This would mean I can sit for 15 minutes but it is moderately difficult.
o Discharge rating 9 – I can sit for 15 minutes with minimal difficulty
I have difficulty lifting 25 pounds from the floor
o Initial rating 0 – This would mean I am currently unable to perform this task
o Progress rating 3 – I can lift 25 pounds from the floor but it is severely difficult
o Discharge rating 10 – I can lift 25 pounds form the floor without limitation or difficulty
I have difficulty with intercourse
o Intial rating 3 – I can have intercourse but it is severely difficult
o Discharge rating 8 – I can have intercourse with minimal difficulty – even if I do not
have desire for it (that would be another goal for another professional)
16
31
30
Read at Follow-up Visits and Discharge Visit
When I assessed you on (state previous date), you told me that you had difficulty with
________
(Read all activities from the Functional Goals)
Today, how would you rate your difficulty with those activities?
(Have the patient score each item and record on the Functional Goals)
Depledge J, McNair PJ, Keal-Smith C, Williams M. Management of symphysis pubis
dysfunction during pregnancy using exercise and pelvic support belts. Phys Ther. 2005
Dec;85(12):1290-300.
Jolles BM, Buchbinder R, Beaton DE. A study compared nine patient-specific indices for
musculoskeletal disorders. J Clin Epidemiol. 2005 Aug;58(8):791-801.
Pengel LH, Refshauge KM, Maher CG. Responsiveness of pain, disability, and physical
impairment outcomes in patients with low back pain. Spine. 2004 Apr 15;29(8):879-83.
Donnelly C, Carswell A. Individualized outcome measures: a review of the literature.
Can J Occup Ther. 2002 Apr;69(2):84-94. Review.
Pietrobon R, Coeytaux RR, Carey TS, Richardson WJ, DeVellis RF. Standard scales for
measurement of functional outcome for cervical pain or dysfunction: a systematic review.
Spine. 2002 Mar 1;27(5):515-22. Review.
Westaway MD, Stratford PW, Binkley JM. The patient-specific functional scale: validation of
its use in persons with neck dysfunction. J Orthop Sports Phys Ther.1998 May;27:331-8.
Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M.
The Patient-Specific Functional Scale: measurement properties in patients with knee
dysfunction. Phys Ther. 1997 Aug;77(8):820-9.
17
32
31
18
33
32
Scoring of PFDI-20 (POPDI-6 + CRADI-8 + UDI-6)
POPDI-6
#
no = 0
1
2
3
4
5
6
not at all = 1 somewhat = 2
moderately = 3
quite a bit = 4
Total scores = ____ divide by 6 = _____ x 25 = _____
CRADI-8
#
no = 0
7
8
9
10
11
12
13
14
not at all = 1 somewhat = 2
moderately = 3
quite a bit = 4
Total scores = ____ divide by 8 = _____ x 25 = _____
UDI-6
#
no = 0
15
16
17
18
19
20
not at all = 1 somewhat = 2
moderately = 3
quite a bit = 4
Total scores = ____ divide by 6 = ____ x 25 = ____
POPDI-6 score _____
CRADI-8 score _____
UDI-6 score ______
Add all scores for PFDI-20 score = _________
Higher = more dysfunction
Barber MD, Kuchibhatla M, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific
quality of life instruments for women with pelvic floor disorders. American Journal of Obstetric and Gynecology
Volume 185; Number 6, 2001
19
34
33
20
35
34
Scoring of PFIQ-7 (UQI + CRAIQ + POPQ)
UIQ-7 (bladder)
Question #
Not at all = 0
1
2
3
4
5
6
7
somewhat = 1
moderately = 2
quite a bit = 3
Total scores = ____ divide by 7 = ____ x 33.3 = ____
CRAIQ-7 (bowel)
Question #
1
2
3
4
5
6
7
Not at all = 0
somewhat = 1
moderately = 2
quite a bit = 3
moderately = 2
quite a bit = 3
Total scores = ____ divide by 7 = ____ x 33.3 = ____
POPIQ-7 (vagina)
Question #
Not at all = 0
1
2
3
4
5
6
7
somewhat = 1
Total scores = ____ divide by 7 = ____ x 33.3 = ____
UIQ-7 score ______
CRAIQ score _____
POPIQ-7 score ____
Add all score for PFIQ-7 score = ______
Higher = more dysfunction
Barber MD, Kuchibhatla M, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive
condition-specific quality of life instruments for women with pelvic floor disorders. American
Journal of Obstetric and Gynecology Volume 185; Number 6, 2001
21
36
35
22
37
36
Pelvic Organ Prolapse / Urinary Incontinence Sexual Function Questionnaire (PISQ-12)
Question #
1
2
3
4
Always = 0
Usually = 1
Sometimes = 2
Seldom = 3
Never = 4
Question #
5
6
7
8
9
10
11
Always = 4
Usually = 3
Sometimes = 2
Seldom = 1
Never = 0
Total scores = ____ divide by 11 = ____ x 10 = ____
Normal is high score – 44
Higher is better
37
Urogenital Distress Inventory (UDI-6 Short Form): UDI-6
… Yes … No
1) Do you usually experience frequent urination?
… Not at all … Somewhat
… Moderately … Quite a bit
If yes, how much does this bother you?
2) Do you usually experience urine leakage associated with a feeling of urgency; that is, a
strong sensation of needing to go to the bathroom?
… Yes … No
… Not at all … Somewhat
… Moderately … Quite a bit
If yes, how much does this bother you?
3) Do you usually experience urine leakage related to coughing, sneezing, or laughing?
… Yes … No
If yes, how much does this bother you?
… Not at all … Somewhat
… Moderately … Quite a bit
4) Do you experience small amounts of urine leakage (that is, drops)?
… Yes … No
… Not at all … Somewhat
… Moderately … Quite a bit
If yes, how much does this bother you?
5) Do you experience difficulty emptying your bladder?
… Yes … No
… Not at all … Somewhat
… Moderately … Quite a bit
If yes, how much does this bother you?
6) Do you usually experience pain or discomfort in the lower abdomen or genital region? …
Yes … No
If yes, how much does this bother you?
… Not at all … Somewhat
… Moderately … Quite a bit
If yes, then is your pain relieved after emptying your bladder?
… Yes … No
No= 0, Not at all= 1, Somewhat= 2, Moderately= 3, Quite a bit= 4
Add all scores and multiply by 6 then multiply by 25 for the scale score
Missing items are dealt with by using the mean from the answered items only
Higher score = higher disability
Also see scoring of PFDI-20.
Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl AJ. Short forms to assess life
quality and symptom distress for urinary incontinence in women: the incontinence impact
questionnaire and the urogenital distress inventory. Neurourol and Urodynam 1995;14:131-139.
Grade A rating for symptoms of UI for women
Donavan J, et al Symptom and quality of life assessment. In Incontinence vol 1 Basics and
Evaluation eds Abrams P, Cardozo L, Khoury S, Wein A. Health Publications Ltd Paris France
2005.
24
39
38
VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (VQ)
These are statements about how your pelvic pain affects your everyday life. Please check one box for
each item below, choosing the one that best describes your situation. Some of the statements deal with
personal subjects. These statements are included because they will help your health care provider design
the best treatment for you and measure your progress during treatment. Your responses will be kept
completely confidential at all times.
1.
Because of my pelvic pain
 3
I can’t wear tight-fitting clothing like pantyhose that puts any pressure over my painful area.
 2
I can wear closer fitting clothing as long as it only puts a little bit of pressure over my painful
area.
 1
I can wear whatever I like most of the time, but every now and then I feel pelvic pain caused
by pressure from my clothing.
0

I can wear whatever I like; I never have pelvic pain because of clothing.
2.
My pelvic pain
 3
Gets worse when I walk, so I can only walk far enough to move around in my house, no
further.
 2
Gets worse when I walk. I can walk a short distance outside the house, but it is very painful to
walk far enough to get a full load of groceries in a grocery store.
1

Gets a little worse when I walk. I can walk far enough to do my errands, like grocery
shopping, but it would be very painful to walk longer distances for fun or exercise.
 0
My pain does not get worse with walking; I can walk as far as I want to

3.
0
I have trouble sitting for very long because of another medical problem, but pelvic pain doesn’t
make it hard to sit.
Because of pain pills I take for my pelvic pain
 3
I am sleepy and I have trouble concentrating at work or while I do housework.
 2
I can concentrate just enough to do my work, but I can’t do more, like go out in the evenings.
 1
I can do all of my work, and go out in the evening if I want, but I feel out of sorts.
 0
I don’t have any problems with the pills that I take for pelvic pain.

5.
I have a hard time walking because of another medical problem, but pelvic pain doesn’t make
it hard to walk.
My pelvic pain
 3
Gets worse when I sit, so it hurts too much to sit any longer than 30 minutes at a time.
 2
Gets worse when I sit. I can sit for longer than 30 minutes at a time, but it is so painful that it
is difficult to do my job or sit long enough to watch a movie.
1

Occasionally gets worse when I sit, but most of the time sitting is comfortable.
 0
My pain does not get worse with sitting, I can sit as long as I want to.

4.
0
0
I don’t take pain pills for my pelvic pain.
Because of my pelvic pain
 3
I have very bad pain when I try to have a bowel movement, and it keeps hurting for at least 5
minutes after I am finished.
 2
It hurts when I try to have a bowel movement, but the pain goes away when I am finished.
 1
Most of the time it does not hurt when I have a bowel movement, but every now and then it
does.
 0
It never hurts from my pelvic pain when I have a bowel movement.
39
6.
Because of my pelvic pain
 3
I don’t get together with my friends or go out to parties or events.
 2
I only get together with my friends or go out to parties or events every now and then.
 1
I usually will go out with friends or to events if I want to, but every now and then I don’t
because of the pain.
 0
I get together with friends or go to events whenever I want, pelvic pain does not get in the way
7.
Because of my pelvic pain
 3
I can’t stand for the doctor to insert the speculum when I go to the gynecologist.
 2
I can stand it when the doctor inserts the speculum if they are very careful, but most of the time
it really hurts.
1

It usually doesn’t hurt when the doctor inserts the speculum, but every now and then it does
hurt.
 0
It never hurts for the doctor to insert the speculum when I go to the gynecologist.
8.
Because of my pelvic pain
 3
I cannot use tampons at all, because they make my pain much worse.
 2
I can only use tampons if I put them in very carefully.
1

It usually doesn’t hurt to use tampons, but occasionally it does hurt.
 0
It never hurts to use tampons.

9.
0
This question doesn’t apply to me, because I don’t need to use tampons, or I wouldn’t choose
to use them whether they hurt or not.
Because of my pelvic pain
 3
I can’t let my partner put a finger or penis in my vagina during sex at all.
 2
My partner can put a finger or penis in my vagina very carefully, but it still hurts.
 1
It usually doesn’t hurt if my partner puts a finger or penis in my vagina, but every now and
then it does hurt.
0

It doesn’t hurt to have my partner put a finger or penis in my vagina at all.

0
This question does not apply to me because I don’t have a sexual partner.

0
Specifically, I won’t get involved with a partner because I worry about pelvic pain during sex.
10. Because of my pelvic pain
 3
It hurts too much for my partner to touch me sexually even if the touching doesn’t go in my
vagina.
2

My partner can touch me sexually outside the vagina if we are very careful
 1
It doesn’t usually hurt for my partner to touch me sexually outside the vagina, but every now
and then it does hurt
 0
It never hurts for my partner to touch me sexually outside the vagina

0
This question does not apply to me because I don’t have a sexual partner.

0
Specifically, I won’t get involved with a partner because I worry about pelvic pain during sex.
11. Because of my pelvic pain
 3
It is too painful to touch myself for sexual pleasure.
 2
I can touch myself for sexual pleasure if I am very careful.
 1
It usually doesn’t hurt to touch myself for sexual pleasure, but every now and then it does hurt.
 0
It never hurts to touch myself for sexual pleasure.
 0
I don’t touch myself for sexual pleasure, but that is by choice, not because of pelvic pain.
For scorers (patient should not see these directions): To score the VQ, add numerical values assigned to each
response. These appear next to the check-boxes. The higher the score the greater the functional limitation. A
diminishing score represents improvement.
Hummel-Berry K, Wallace K, Herman H. Reliability and validity of the Vulvar Functional Status Questionnaire. JWHPT.
2007; 31:3.
40
Documentation and Forms
Types (Samples of these are available for down load on the SOWH web site)
Pre-evaluation questionnaire
Consent for PFM exam and treatment
Evaluation form
Bladder diary
QOL index
Symptoms index
General Recommendations for PT Documentation and Sample Goal Writing: Initial
Assessment / Plan of Care
Summarize the patient’s main problems: eg, underactive PFM with weakness and
impaired endurance contributes to symptoms of UI
Summarize patient’s history, symptoms, pertinent surgical history, chief complaints
Document objective findings (see examination section), goals, and plan
Use validated measures to report outcomes
Emphasize functional limitations caused by impairments
Critical Elements in Writing FUNCTIONAL Goals
PERSON
ACTIVE VERB
CONDITION
CRITERIA
Short-term Goals: Sample Documentation
Patient will verbalize an understanding of pelvic anatomy and causes of incontinence
Patient will verbalize rationale and purposes for exercises
Patient will be independent in the performance of a home program of PFM exercises
on a daily basis
Patient will demonstrate decreased overflow muscle activity during PFM contraction
Patient will demonstrate an increase in PFM contraction to normal grade as measured
by MMT
Patient will demonstrate an increase in PFM endurance from 3-second hold to 8second hold x 10 repetitions as measured by EMG
Patient will demonstrate use of functional PFM contraction by performing a precontraction (“knack”) to eliminate UI during a cough
Patient will incorporate a voiding schedule and urge strategies into his/her daily
routine to manage urgency, frequency, and incontinence with a goal of ____ minutes
of delay
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42
41
Organizations and resources for Pelvic PT
Organizations: Support Groups
Arthritis Foundation
PO Box 7669
Atlanta, GA 30357-0669
www.arthritis.org
Continence Restored, Inc.
407 Strawberry Hill
Stamford, CT 06902
1-914-285-1470
1-203-348-0601 (evenings)
E-mail: [email protected]
Endometriosis Assoc., Inc
8585 North 76th Place
Milwaukee, WI 53223
1-800-992-ENDO
www.endometriosisassn.org
Enu-Care Foundation Inc
100 Main-Sumner
Coos Bay, OR 97420
1-800-437-9233
www.essentialcontrol.com
Hysterectomy Education Resources &
Services (HERS)
422 Bryn Mawr Avenue
Bala Cynwyd, PA 19004
1-610-667-7757
www.hersfoundation.com
International Adhesions Society
David Wiseman, PhD
Synechion, Inc.
6757 Arapaho Road, Suite 711 #238
Dallas, TX 75248
1-972-931-5596
www.adhesions.org
International Foundation for Functional
Gastrointestinal Disorders (IFFGD)
PO Box 170864
Milwaukee, WI 53217-8076
1-888-964-2001
www.iffgd.org
International Paruresis Association
www.paruresis.org
The Interstitial Cystitis Network
www.ic-network.org
Interstitial Cystitis Association
PO Box 1553
Madison Square Station
New York, NY 10159
1-212-979-6057
www.ichelp.org
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43
42
Intestinal Disease Foundation (IDF)
1323 Forbes Avenue, Suite 200
Pittsburgh, PA 15219
www.intestinalfoundation.org
National Association for Continence
PO Box 1019
Charleston, SC 29402-1019
1-800-BLADDER
www.nafc.org
National Fibromyalgia Association
2200 N. Glassell St., Suite A
Orange, CA 92865
1-714-921-0150
Fax: 1-714-921-6920
www.fmaware.org
National Organization for Rare Disorders
(NORD)
PO Box 8923
New Fairfield, CT 06812
1-800-999-6673
www.rarediseases.org
National Vulvodynia Association (NVA)
PO Box 4491
Silver Spring, MD 20914
1-301-299-0775
www.nva.org
Share
National Kidney Foundation of Texas
1919 Oakwell Farms Pkwy, Suite 135
San Antonio, TX 78218-1725
1-888- 829-299
www.kidneytx.org
The American Fibromyalgia Syndrome
Association
PO Box 9699
Bakersfield, CA 93389
www.afsafund.org
The International Pelvic Pain Society
2006 Brookwood Medical Center Dr, Suite
402
Birmingham, AL 35209
1-205-877-2950
www.pelvicpain.org
The Fibromyalgia Network Newsletter
PO Box 31750
Tucson, AZ 85751
www.fmnetnews.com/
The Simon Foundation
PO Box 815
Wilmette, IL 60091
1-800-23SIMON
www.simonfoundation.org
The Vulvar Pain Foundation
PO Box 177
Graham, NC 27253
1-910-226-0704
www.vulvarpainfoundation.org
United Ostomy Association
19772 MacArthur Blvd, #200
Irvine, CA 927612-2405
1-800-826-0826
www.uoa.org
29
44
43
Support for Men
Impotence Information Center
10700 Bren Rd West
Minnetonka, MN 55343
1-800-843-4315
Impotence Institute of America, Inc.
2020 Pennsylvania Ave NW
Washington, DC 20006
1-800-669-1603
Man to Man
24600 Northwestern Hwy
Southfield, MI 48075
1-313-356-8870
The Prostatitis Foundation
1063 30th St, Box 8
Smithshire, IL 61478
1-888-891-4200
www.prostate.org
Us Too
Prostate Cancer Survivor Support Group
5003 Fairview Ave
Downers Grove, IL 60515
1-800-808-7866
www.ustoo.com
Professional Education
Texas Women’s University,
School of PT
PO Box 425589
Denton, TX 76204
1-940-898-2460
Long-distance women’s health education
www.twu.edu/pt
Rosalind Franklin University
Interprofessional Healthcare Studies
3333 Green Bay Rd
North Chicago, IL 60064
1-847-578-3310
Master of Science in Women’s Health
www.rosalindfranklin.edu
30
45
44
Professional Groups
ACOG
409 12th St. SW
PO Box 96920
Washington, DC 20090-6920
1-202-638-5577
www.acog.org
Alliance for Aging Research
2021 K Street NW, Suite 305
Washington, DC 20006
1-202-293-2856
www.agingresource.org
American Association of Sex Education
Counselors & Therapists
435 North Michigan Avenue, Suite 1717
Chicago, IL 60611-4067
1-312-644-0828
www.aasect.org
American Gastroenterology Assoc.
4930 Del Ray Ave
Bethesda, MD 20814
1-301-654-2055
www.gastro.org
American Medical Association (AMA)
515 North State St.
Chicago, IL 60610
1-312-464-5000
www.ama-assn.org
American Pain Foundation
201 North Charles St, Suite 710
Baltimore, MD 21201-4111
1-888-615-PAIN
www.painfoundation.org
American Urological Association
www.urologyhealth.org
American Urogynecologic Society
401 North Michigan Ave
Chicago, IL 60611
1-312-644-6610 x4739
www.augs.org
American Urological Society
1120 North Charles St.
Baltimore, MD 21201
1-410-727-1100
www.auanet.org
APTA/ Section on Women’s Health
PO Box 327
Alexandria, VA 22313
1-800-999-APTA
www.womenshealthapta.org
Association for Rehabilitation Nurses
ARN Publications Orders
5700 Old Orchard Rd, 1st Floor
Skokie, IL 60077-1057
1-708-966-3433
www.rehabnurse.org
International Association for the Study of
Pain
111 Queen Anne Avenue North, #501
Seattle, WA 98109-4955
1-206-283-0311
www.iasp-pain.org
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46
45
International Continence Society (ICS)
Dr. Werner Schaefer
Southmead Hospital
Bristol BS10 5NB
United Kingdom
+44 0 117 950 3510
www.continet.org
International Organization of Physical
Therapists in Women’s Health
www.ioptwh.org
National Institute on Aging
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD 20892
1-800-222-4225
www.nia.nih.gov
National Fibromyalgia Association
2200 North Glassell St, Suite A
Orange, CA 92865
1-714-921-0150
www.fmaware.org
The National Foundation for the Treatment
of Pain
1330 Skyline Dr, 21
Monterey, CA 93940
1-831-655-8812
www.paincare.org
National Kidney Foundation
30 East 33rd St
New York, NY 10016
1-800-622-9010
www.kidney.org
National Kidney and Urologic Diseases
Information Clearinghouse
Box NKUDIC
3 Information Way
Bethesda, MD 20892-3580
1-800-891-5390
www.kidney.niddk.nih.gov/index.htm
Prostate Health Council/ American
Foundation for Urologic Disease
1128 N. Charles St.
Baltimore, MD 21201
1-800-242-2383
www.afud.org
Society for Urologic Nurses and Assoc.
(SUNA)
East Holly Avenue, Box 56
Pittman, NJ 08071
1-888-827-7862
www.suna.org
Society for Pudendal Neuralgia
3 Shepherds Lane
North Hampton, New Hampshire 03862
www.spuninfo.org
Subgroup of World Physical Therapy
www.wcpt.org
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Additional Information and Links
Clearinghouse for health information from a
variety of sources – Diane Newman RN
www.seekwellness.com/phase/phase_data
base.htm
Dr. Howard Glazer
340 East 63rd St, Suite 1A
New York, NY 10021
www.vulvodynia.com
www.coccyx.org
Pelvic floor disorders and biofeedback –
Dr John Perry
www.incontinet.com
March of Dimes
Education and Health Promotion Dept.
1275 Mamaroneck Avenue
White Plains, NY 10605
1-914-997-4456
1-800-367-6630
www.marchofdimes.com
OSHA Publication Office
Room N3101
2000 Constitution Ave, NW
Washington, DC 20210
US Dept of Health and Human Services,
Public Health Service
Agency for Health Care Policy and Research
Publications Clearinghouse
PO Box 8547
Silver Spring, MD 20907
1-800-358-9295
Publications 96-0684, 96-0682:
Urinary Incontinence in Adults guidelines)
www.os.dhhs.gov
3M Center
St. Paul, MN 55144-100
1-800-228-3957
Preventing transmission of infectious agents
www.3m.com/us/healthcare/professionals/i
nfectionprevention
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48
47
Pelvic Floor Physical Therapy Booklist
Patient Books: Urinary Incontinence
Beyond Kegels, Janet Hulme; Phoenix Publishing Co, 1997
Drips, Leaks and Low Spirits: A Women’s Guide to Bladder Control, Infections and
Depression, Andre Alexander Kulisz; Bookstand Publishing, 2001
Geriatric Incontinence: A Behavioral and Exercise Approach to Treatment, Janet Hulme;
Phoenix Publishing, 1999
I laughed so hard I peed my pants, Kelli Berzuk; IPPC Publisher, Winnipeg, Canada. 2002
Managing and Treating Urinary Incontinence, Diane Newman; Health Professions Press 2002
Managing Incontinence: A Guide to Living with Loss of Bladder Control, Cheryle B. Gartley;
The Simon Foundation, www.simonfoundation.org
Overcoming Overactive Bladder: Your Complete Self-Care Guide., Diane K. Newman and Alan
J. Wein; Oakland, CA: New Harbinger Publications, 2004.
Overcoming Bladder Disorders, Rebecca Chalker and Kristine E. Whitmore; available from
NAFC, 1-800-BLADDER
Pelvic Power for Men and Women, Eric Franklin; Princeton Book Company, 2002
Staying Dry, Kathryn Burgio; Johns Hopkins University Press, Baltimore, MD, 1989
The Bottom Line on Kegels, Woman’s Hospital, Baton Rouge, LA,
www.womans.org/for_health_professionals/resources.pdf, 1997
The Female Pelvis Anatomy and Exercises, Blandine Calais-Germain; Eastland Press, Seattle,
2003
The Shy Bladder Syndrome: Your Step-By-Step Guide to Overcoming Paruresis,
Steven Soifer; www.paruresis.org
Women's Waterworks, Pauline Chiarelli; Health Books www.womenswaterworks.com
Patient Books: Bowel
Breaking the Bonds of Irritable Bowel Syndrome, Barbara Bradley Bolen; New Harbinger
Publications, 2000
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48
Conquering Irritable Bowel Syndrome: A Guide To Liberating Those Suffering With Chronic
Stomach or Bowel Problems, Nicholas J. Talley; Empowering Press, 2005
Continence With Biofeedback, Susan Trunnell; Advantage Publications, available from NAFC,
1991
Keeping Control: Understanding and Overcoming Fecal Incontinence, Marvin Schuster and
Jacqueline Wehmueller; Johns Hopkins Press, 1994
Prevent it! A Guide for Men and Women With Leakage From the Back Passage, Grace Dorey;
Mobilis Healthcare Group, 2004
No More Digestive Problems: A Leading Gastroenterologist Provides the Answers Every
Woman Needs--Real Solutions to Stop the Pain and Achieve Lasting Digestive Health, Cynthia
Yoshida; Bantam, 2005
The Good Bowel Habit: pelvic floor function and the bowel - managing constipation and
incontinence, 3rd Ed., Robyn Nagel and Shirley Owen; Beaconsfield Publishers Ltd, 2007
Patient Books: Male
Conquering Incontinence: A new and physical approach to a freer lifestyle. Peter Dornan; Allen
and Unwin, Australia, 2003.
Conservative Treatment Of Male Urinary Incontinence and Erectile Dysfunction, Grace Dorey;
www.desmitmedical.com, 2001
Living and loving after prostate surgery. Dorey Grace; www.desmitmedical.com, 2005
Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile
Dysfunction, Grace Dorey; Wiley 2006
Pelvic Floor Exercises for Erectile Dysfunction, Grace Dorey; Wiley 2005
The Prostate Book: Sound Advice on Symptoms and Treatment, Stephen Rous, W.W. Norton &
Company, Inc, 2002
Patient Books: Bed Wetting
Dry All Night, Allison Mack; Little Brown and Co, 1989
Waking up Dry: How to End Bedwetting Forever. Martin Scharf; Writer’s Digest Book, 1986
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50
49
Patient Books: Pelvic Pain
A Headache in the Pelvis: A new understanding and treatment for prostatitis and chronic pelvic
pain syndromes, 4th Ed. David Wise and Rodney Anderson; Center for Pelvic Pain Research,
2008
Fibromyalgia: A Handbook for Self Care and Treatment, Janet Hulme; Phoenix Publishing Co,
1995
Hysterectomy: Before and After, Winnifred Culter; Harper and Row Publishers, 1988
IC and Pain: Taking Control-A Handbook for People with IC and their Caregivers; Interstitial
Cystitis Association, 2004
Managing Pain Before it Manages You, Margaret Caudill, Rev ed., Guilford Press, 2002
Pelvic Pain and Low Back Pain: A Handbook for Self Care and Treatment, Janet Hulme;
Phoenix Publishing Co, 2002
Private Pain - It's About Life, Not Just Sex: Understanding Vaginismus and Dyspareunia 2nd ed.,
Ditza Katz and Ross Lynn Tabisel; Katz-Tabi Publication, 2005
The Endometriosis Sourcebook, Mary Lou Ballweg, The Endometriosis Association;
McGraw-Hill Professional, 1995
The Core Program, Peggy Brill; Bantam Books, 2003
The IC Survival Guide The Interstitial Cystitis Survival Guide: Your Guide to the Latest
Treatment Options and Coping Strategies. Robert Moldwin; New Harbinger Publishers, 2000
The Vulvodynia Survival Guide, Howard Glazer and Gae Rodke; New Harbinger Publishers,
2002
The Yeast Connection, William Crook; Professional Books Inc., 2002
When Movement Hurts: A Self-Help Manual for Treating Trigger Points 2nd Ed, Barbara J.
Headley; Innovative Systems for Rehabilitation, 1997
You Don’t Have to Live with Cystitis, Larrian Gillespie; Avon Books, NY, 1996.
10 Steps to Completely Overcome Vaginismus: Books 1 and 2, Mark and Lisa Carter;
www.vaginismus.com
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50
Patient Books: Gynecological
How to Give her Absolute Pleasure: Total Explicit Techniques Every Women Wants her Man to
Know, Lou Paget; Broadway Books, 2000
For Yourself: The Fulfillment of Female Sexuality, Lonnie Garfield Barbach; Doubleday, 1975
For Women Only, Jennifer Berman and Laura Berman; Henry Holt and Co, NY, 2001
Screaming to be Heard: Hormonal Connections that Women Suspect and Doctors Ignore,
Elizabeth Lee Vliet; M. Evans and Co. Inc., NY, 1995
Seven Weeks to Better Sex, Domeena Renshaw; Westcom Press, CA, 2004
The Five Love Languages, Gary Chapman; Lifeway Press, 2000.
The Sex-Starved Marriage: A Couple’s Guide to Boosting Their Marriage Libido, Michele
Weiner-Davis; Simon & Schuster, 2003
The V Book, Elizabeth Stewart; Bantam Books, NY, 2002
Physical Therapy Books
Clinical Application in Surface EMG: Chronic Musculoskeletal Pain, Glen Kasman, Jeffrey
Cram and Steven Wolf; Aspen Publishers, 1998
Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann; Mosby, 2002
Diagnosis Specific Orthopedic Management of the Hip. Omer Matthijs, Didi vanParidon, Phillip
S. Sizer, Jean-Michel Brismée, Valerie Phelps; International Academy of Orthopedic Medicine,
IAOM, US 2007
Examination in Physical Therapy Practice: Screening for Medical Disease, William G.
Boissonault, Ed.; Churchill Livingston, 1995
Evidence-based Physical Therapy for the Pelvic Floor, Kari Bo, Bary Berghmans, Siv Morkved,
Marijke Van Kampen; Elsevier Ltd, 2007
Fitness for the Pelvic Floor, Beate Carriere; Thieme, 2002
Introduction to Surface Electromyography, Jeffrey Cram and Glen Kasman; Aspen Publications,
1998
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51
Low Back Disorders: Evidence Based Prevention and Rehabilitation, Stuart McGill; Human
Kinetics, 2002
Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 2, Janet Travell and David
Simons; Williams & Wilkins, Baltimore, MD, 1992
Obstetric and Gynecologic Care in Physical Therapy, Linda O’Connor and Rebecca Stephenson;
Slack Inc., 2000
Pelvic Floor Disorders, Alain Bourcier, Edward McGuire and Paul Abrams; Saunders, 2004
Pelvic Power, Elizabeth Noble; available from New Life Images
Physiotherapy in Obstetrics and Gynecology, Margaret Polden and Jill Mantle; ButterworthHeinemann Publishers, Stoneham, MA, 1990
The Gynecological Manual, Elaine Wilder, editor, Section on Women’s Health APTA, 2002
The Pelvic Floor, Beate Carriere, Cynthia Markel-Feldt and Oliver French; Thieme, 2006
The Pelvic Girdle 3rd Ed., Diane Lee; Churchill Livingstone, 2004
Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain, Carolyn Richardson,
Gwendolen Jull, Paul Hodges, and Julie Hides; Churchill Livingston, 1999
Therapeutic Exercise: Moving Towards Function, Carrie Hall and Lori Thein Brody; Lippincott
Williams & Wilkins, 2005
Therapeutic Management of Incontinence and Pelvic Pain, Jo Laycock and Jeanette Haslam;
Springer Verlag, 2008
Ultrasound Imaging for Rehabilitation of the Lumbopelvic Region: A Clinical Approach, Jackie
L. Whittaker; Elsevier Publishers, 2007
Women’s Health: A Textbook for Physiotherapists, Ruth Sapsford, Joanne Bullock-Saxton and
Sue Markwell; WB Saunders, 1998
Other Professional Books
Atlas of Human Anatomy, 3rd Ed. Frank Netter; Ciba-Geigy Corporation, 1994
Biofeedback: A Practitioner’s Guide, Mark Schwartz; Guilford Press, 1995
Cognitive Behavioral Treatment of IBS, Brenda Toner, Zindel Segal, Shelagh Emmott, and
David Myran; Guilford Press, 2000
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Essentials of Health Care Marketing, Eric Berkowitz; Aspen Publishers, 1996
Irritable Bowel Syndrome and the Mind, Body, Brain, Gut Connection, William Salt; Parkview
Publishers, 1997
Masters and Johnson on Sex and Human Loving, Masters and Johnson; Little Brown Books,
Boston, MA, 1987
Marketing Public Health, Michael Siegel and Lynne Doner; Aspen Publishers, 1998
Strain/Counterstrain, Lawrence Jones, American Academy of Osteopathy, 1127 Mt Vernon
Road, Newark, OH 43055, available from the Upledger Institute, 1981
Textbook of Prostatitis, J. Curtis Nickel; ISIS Medical Media, 1999
Urogenital Manipulation, Jean-Pierre Barral; Eastland Press, 2003
Visceral Manipulation, Jean-Pierre Barral & Pierre Mercier; Eastland Press, 2003
Physician and Nursing Books
Clinical Urogynecology, Mark Walters and Mickey Karram; Mosby, 1993
Chronic Pelvic Pain: An Integrated Approach, John Steege, Deborah Metzger, and Barbara
Levy; WB Saunders Co, Philadelphia, 1998
Chronic Pelvic Pain: Evaluation and Management, Richard E. Blackwell and David L. Olive;
Springer-Verlag, New York,. 1998
Female Pelvic Floor Disorders, J. Thomas Benson, ed.; Norton Medical Books, 1992
Handbook of Pediatric Urology, LS Baskin, BA Kogan, and LW Duckett, Lippincott Raven,
1997
Incontinence: Volumes 1 and 2, Paul Abrams, Linda Cardozo, Saad Khoury, Alan Wein, eds.;
Health Publications Ltd, [email protected], 2005
Multidisciplinary Management of Female Pelvic Floor Disorders, Chapple CR, Zimmern PE,
Brubaker L, Smith ARB, Bo K, eds.; Churchill Livingstone, Elsevier, Edinburgh, 2006
Netter’s Obstetrics and Gynecology and Women’s Health, Roger P Smith; Icon Learning
Systems, NJ, 2002
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Pelvic Floor Re-Education, Bernhard Schussler, Jo Laycock, Peggy Norton, and Stuart Stanton;
Springer-Verlag Publishers, New York, 1995
Pelvic Pain: Diagnosis & Management, Fred Howard and Paul Perry; Lippincott Williams &
Wilkins, Philadelphia, 2000
The Female Pelvic Floor: Disorders of Function and Support, Linda Brubacker and Theodore
Saclarides; FA Davis Co., 1996
The Pelvic Floor: Its Function and Disorders, John Pemberton, Michael Swash, Michael M.
Henry, eds; Harcourt, 2002
Urinary and Fecal Incontinence: Nursing Management 2nd ed, DB Doughty, ed; Mosby, 2000.
Urodynamics Made Easy, Christopher Chapple and Scott A. MacDiarmid; Elsevier Health
Sciences, 2000
Voiding Function and Dysfunction, Allen Wein and David Barrett; Year Book Medical
Publishers Inc, 1988
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Instructions for Authors
GENERAL INFORMATION
The Journal of Women’s Health Physical Therapy (JWHPT) is the official publication of the
Section on Women’s Health (SOWH) of the American Physical Therapy Association. JWHPT is
a peer-reviewed publication that is focused on the clinical interests of physical therapists
practicing in women’s health, as well as those of other health care workers who interface with
physical therapists in the healthcare of women.
SUBMISSION REQUIREMENTS
Original manuscripts submitted for review must be accompanied by a cover letter with original
signatures of all authors. The cover letter must address copyright release, conflict of interest
disclosures, photographic releases, author(s) statement that written permission has been obtained
from persons named in the acknowledgment, subject protection, research or project
support/funding, and reprint permission for tables or figures. Contact information for all authors
must include mailing addresses, fax and phone numbers, and electronic mail addresses. These
must be updated as necessary during the review process. Manuscripts must be submitted in
triplicate along with one original and 3 copies of photographs and figures. An electronic version
of each manuscript is required on the initial submission, and additional electronic files may be
requested later in the review process.
The Editor-in-Chief reserves the right to return manuscripts without review that do not meet
minimal submission requirements. The Editorial Board adheres to the “Uniform Requirements
for Manuscripts (URM) submitted to biomedical journals. These are available from the
International committee of Medical Journal Editors (ICJME) at http://www.icmje.org/index.html
Authors should consult the most current edition (at this writing this is the 9th edition) of the
American Medical Association (AMA) Manual of Style, available from Lippincott, Williams and
Wilkins, 351 West Camden Street, Baltimore, MD 21201-2436, USA for detailed descriptions of
acceptable style and format, as well as specifics related to the preparation and submission of
manuscripts. Clarification of submission requirements can be obtained by contacting the Editorin-chief. Manuscripts previously published or currently under review for publication should not
be submitted. Authors who submit manuscripts that contain substantially similar content that has
been published or is currently being considered elsewhere for publication, must inform the
Editor-in-Chief of this and must provide the Editor-in-Chief with a copy of the other article.
The Editor-in-Chief will make the determination of the duplicative nature of the submitted
manuscript and may decide that the submitted manuscript is unacceptable for publication in
JWHPT. Published abstracts of oral presentations at scientific conferences or meetings will not
be considered duplicative.
All manuscripts accepted for review undergo blinded peer review. The Editor will assist authors
as necessary to make manuscripts acceptable for publication. Submissions that do not meet
essential requirements will be returned to the author without review. The Editorial staff reserve
the right to make literary and copyediting changes to manuscripts as necessary to meet
publication criteria and standards.
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Submit manuscripts (original, 3 copies, and electronic copy) to:
Nancy Rich, Editor-in-Chief
Journal of Women’s Health Physical Therapy
c/o Kathie St. Clair, Editorial Assistant
American Physical Therapy Association
1111 North Fairfax Street
Alexandria, Virginia 22314
[email protected]
MANUSCRIPT CATEGORIES
Research Report
A report of original research relevant to women's health research studies utilizing qualitative,
quantitative, and single subject design methods are all included in this category.
A research report must contain:
Abstract containing a maximum of 250 words divided into 6 sections with the following
bolded headings: Objective (specific purpose or research question, or hypothesis of the
investigation), Study Design (randomized controlled, blinded, case series, etc.)
Background (rationale for the study), Methods and Measures (subject/participants,
setting, outcome measures, interventions), Results (Main results with statistical
significance), Conclusions (those that are supported by the data, along with implications
for physical therapist practice). All abstracts must end with a Key Words section
containing 3 to 5 key words that are not contained in the manuscript title.
Manuscript text – the body of the manuscript must contain the following bolded
headings: Introduction (The purpose of the study as well as a rationale, with background
from the literature, for the importance of the research question, and the significance to
physical therapists) , Methods and Measures (selection and description of participants,
including inclusion and exclusion criteria, intervention(s), outcome measures, methods of
data collection, reduction and analysis in enough detail that would allow others to
replicate the study, statistical analyses), Results (most important findings relevant to the
research hypothesis), Comment (critical explanation for the findings, comparison to
previous studies, limitations and generalizability of the study), Conclusion (Brief
summary of the main findings, implications for clinicians, researchers, educators, or
others involved in women’s health physical therapy, possible directions for future
research). There may be any number of sub-headings that are appropriate to make the
manuscript easier to read.
Acknowledgements are placed after the Conclusion Section.
References must be cited numerically in the text, tables, or figures with superscript
numbers. The entire reference is listed in numerical order at the end of the manuscript.
The reference format must that which is outlined in the American Medical Association
(AMA) Manual of Style.
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Literature Review
A literature review is s comprehensive review and critical analysis of previously published
literature. The review should focus on a particular topic in women's health and include justifiable
conclusions and recommendations that are relevant to the practice of physical therapy in
women's health. The purpose of the literature review may be to provide readers a summary of
what is currently supported by the literature. It may be that there are several competing theories
about your topic and you wish to complete a critical review to determine if there is support for
one particular theory, or to identify gaps in the literature. They may also be systematic reviews or
meta-analyses. Manuscripts in this category must be invited by the Editor-in-chief. Selfnominations for an invitation to submit a literature report for review are welcome. Literature
review proposals must be sent to the Editor-in-Chief. A current curriculum vitae must also be
enclosed.
The format for a literature report submission is as follows:
Title page
Abstract with the identical guidelines as for research reports
Manuscript text with the identical guidelines as for research reports
References as outlined above
Clinical Commentary
A scholarly paper addressing a specific clinical approach or intervention of relevance to the
practice of physical therapy in women's health. Clinical experiences may be reported to support
rationales and approaches, however, references from the published research literature must also
be utilized.
The format of a clinical commentary is as follows:
Title Page
An abstract of no more than 250 words. The abstract for a clinical commentary is
unstructured.
The abstract ends with a Key Words Section, containing 3 to 5 key words that are not
contained in the manuscript title.
Following the Introduction Section, the text is separated into relevant sections with
appropriate bolded headings.
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Case Report
Brief reports describing evaluation and treatment of one to three patients that illustrate or critique
an approach or aspect of the clinical management relevant to women's health. References must
be utilized to support rationale and approaches.
The format of a case report is as follows:
Title Page
Abstract of no more than 250 words with the following bolded headings: Background,
Study Design, Case Description, Outcomes, Discussion.
The text must have the following bolded headings: Introduction or Background, Study
Design, Case Description (Examination (History, Systems Review, Tests and Measures,
including Outcome Assessment tools) Evaluation/Diagnosis, Intervention, Outcome,
Discussion, Conclusions.
Tables
Each table must be organized and formatted according to the AMA Manual of Style, section 2.13
Figures
Each figure must be prepared according to the AMA Manual of Style, section 2.14
Additional Documents Required For Submitted Manuscripts:
1. Photograph Release Statement. This statement must contain the manuscript title, names
of all authors, a statement granting the Journal of Women’s Health Physical Therapy the
royalty-free right to publish the photographs and/or videos of the participant for the
JWHPT and the manuscript in which the participant appears, as well as on the journal’s
website (http://www.womenshealthapta.org/). The statement must be signed by the
participant who is on the photograph and/or video.
2. Protection of Human Subjects. The name of the Institutional Review Board that
approved the research protocol must be placed on the title page. In addition, The
Methods section must contain a statement that informed consent was obtained and that
the rights of the subjects were protected.
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Reporting Services to Third Party Payers
Medical billing is complex and variable. It is important to contact each payer’s provider service
representatives for specific payment policies and benefit language related to the services that
will be provided. The following is a general list and should not be considered a substitute for the
full narratives included in CPT.
97001 PT evaluation
97530 Therapeutic activities
97110 Therapeutic exercise
97112 Neuromuscular re-education
97140 Manual therapy
97014 Electrical stimulation – unattended
Medicare: G0283 unattended electrical stimulation
97032 Electrical stimulation – attended
Includes the cost of a vaginal or rectal electrode
Must document that patient has tried and failed pelvic floor muscle exercises for 4 weeks
before Medicare will reimburse for e-stim
Must use a modifier code to charge for both NMES and BFB in the same treatment
session
Check with local fiscal intermediary and it’s interpretation of Medicare guidelines
97535 Self care home management
97010 Hot / cold pack
97035 Ultrasound
64550 TENS
90911 Biofeedback training
Addresses the sphincter specifically
Not a timed code
Includes the cost of a vaginal or rectal electrode
Must document that the patient has tried and failed pelvic floor muscle exercise for 4
weeks before Medicare will reimburse for biofeedback or electrical stimulation.
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Medicare Ruling on Report Services Related to:
HCFA (CMS) ruling on biofeedback for urinary incontinence October 6, 2000 (effective 7/01)
“Biofeedback therapy is covered for the treatment of stress and/or urge incontinence in patients
who fail a documented trail of pelvic muscle training or who are unable to perform pelvic muscle
exercise. Contractors may decide whether or not to cover biofeedback as an initial treatment
modality.”
HCFA (CMS) defines a failed trail for pelvic muscle exercise:
“A failed trail of pelvic muscle training is defined as not clinically significant improvement in
urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercise
designed to increase periurethral muscle strength.”
HCFA (CMS) ruling on electrical stim for urinary incontinence Oct 6, 2000 (effective 7/01)
“Pelvic floor electrical stimulators, inserted into the vaginal canal or rectum, are covered as
reasonable and necessary as a treatment for stress and/or urge urinary incontinence. The patient
must have first undergone and failed a documented trail of pelvic muscle exercise training.
There devices are not covered as an initial treatment modality for SUI or UI.”
Coverage of Electrodes
Electrodes are considered part of the practice expense for the procedure. Separate reporting of
electrodes would be considered “unbundling” and is not permitted. It is recommended that you
contact other insurance companies regarding payment policy before attempting to report the
following HCPCS codes.
E0740 – Incontinence treatment system, pelvic floor stimulator, monitor sensor and or trainer
(home units are listed here)
A4335 – Incontinence supply and miscellaneous
Out of Pocket Patient Expenses
Co-payment(s) and Deductibles – make sure you collect these at the time of the visit.
Equipment: CPT code 99070 – supplies and materials provided by the provider over and above
those utilized during an office visit or other services rendered.
Do not under any circumstances charge Medicare patients for electrode(s) as it is considered an
essential supply for the performance of the procedures of BF or ES.
Check payers for payment policy, i.e., if a payer pays on an RBRVS system, then any supply
used in the office cannot be unbundled from the procedure charge.
For other insurances, single patient use vaginal or anal electrodes: depending on the
number ordered
Surface electrical stimulation electrodes
Individual snap leads for surface EMG
Pressure EMG insert
Vaginal weight set
Dilators
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Most Common ICD 9 Codes
728.2 Muscle Dysfunction / disuse atrophy / Muscle weakness – PFM,
abdominal this code is currently being recommended for best
reimbursement and Medicare coverage for pelvic floor weakness
781.3 Muscle incoordination – PFM, abdominal
728.85 Muscle spasm – PFM, abdominal, trunk, hip
724.2 Back pain
724.3 Sciatic pain
729.1 Myofascial pain syndrome, myalgia, muscle pain
847.3 Sacrococcygeal strain – coccygodynia
Other ICD 9 Codes Included in Pattern C
564.0 constipation
569.42 anal and rectal pain
618 genital prolapse
623 non-inflammatory disorders of vagina
624 non-inflammatory disorders of the vulva and perineum
625 pain associated with female genital organs
625.6 stress incontinence – female
Miscellaneous ICD 9 Codes
596.51 hypertonicity of bladder (overactive bladder – OAB)
618.8 relaxation of vaginal outlet
623.4 old vaginal laceration
624.4 old laceration or scaring of vulva
625.0 dyspareunia
625.1 vaginismus
788.2 retention of urine (733.21 – incomplete bladder emptying)
788.3 incontinence of urine
788.31 urge incontinence
788.32 stress incontinence – male
788.33 mixed incontinence
788.41 urinary frequency
788.43 nocturia
617
endometriosis
787.6 fecal incontinence
724.7 disorders of the coccyx
724.79 coccygodynia
709.2 adherent scar
789.0 abdominal pain
Also check the “Practice” page on the web site of the Section on Women’s Health for more
information on billing and coding.
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