Defending a Legitimate Therapy
Posted February 12, 2018 6:06 p.m. EST
The case of Lawrence G. Nassar, the former doctor for the U.S. gymnastics team who was sentenced in January for systemic sexual abuse of his young patients, raises many uncomfortable questions. One of the more troubling is the way the team doctor duped patients, parents and other physicians into believing that his “treatments” were medically appropriate, even after complaints were lodged.
It wasn’t entirely implausible. A form of physical therapy called pelvic floor physical therapy uses internal vaginal soft tissue manipulation, or massage, to relieve pelvic pain by accessing muscles that cannot be reached any other way. The therapy has been tested and found effective in several small studies and clinical trials published in peer-reviewed medical journals.
But medical professionals use pelvic floor physical therapy primarily for conditions like persistent pelvic pain, bowel and bladder problems like incontinence, and painful intercourse. It is not the first line of treatment for problems that typically afflict gymnasts, such as lower back and hip pain, which are less likely to require internal vaginal manipulations, experts say.
Furthermore, physicians generally do not perform the therapy themselves, even if they are, like Nassar, osteopathic physicians who are trained in hands-on techniques that use stretches and pressure to relieve muscle pain. Doctors who recommend pelvic floor physical therapy usually refer patients to physical therapists who specialize and are certified in it. And most of those therapists are women.
“It’s not a requirement they be female, but from the standpoint of patient comfort, we only use females,” said Dr. Sangeeta Mahajan, an obstetrician-gynecologist and division chief for Female Pelvic Medicine and Reconstructive Surgery at University Hospitals Cleveland Medical Center, who often refers patients for the therapy.
Unlike Nassar, practitioners of pelvic floor physical therapy always wear gloves, which prevent infections but also make patients more comfortable. They manipulate muscles to release and elongate those that are tense and shortened or to strengthen weakened muscles. They often assign patients exercises to do at home.
“There is nothing sexual about it,” said Rhonda Kotarinos, a physical therapist in Chicago who specializes in the pelvic floor and is an author of several studies on the therapy.
She, like many other practitioners, now worries that women with pelvic problems who could benefit from the treatment will be reluctant to seek help for fear of being abused.
“There could be a backlash from this,” Kotarinos said. “But if people decide physical therapists should not do this work, a lot of women will suffer with pain and a markedly compromised quality of life.” (Men also develop chronic pelvic pain that can benefit from the treatment; in this case, massage is typically performed through the anus.)
Many cases of muscle-based pelvic pain remain undiagnosed or undertreated, experts say, and patients often turn to medication or surgery instead of trying more conservative approaches such as physical therapy. “Much of the general public doesn’t realize what we as physical therapists have to offer them,” said Lori Mize, director of education for the section on women’s health of the American Physical Therapy Association and an assistant professor of physical therapy at Lynchburg College in Virginia.
Some patients who come to a physical therapist will say they aren’t comfortable with transvaginal manipulation, and therapists say they use it only if the patient understands what’s involved and freely consents. Furthermore, they generally offer it only after other interventions have failed.
Karen Connor, a physical therapist also with University Hospitals in Cleveland, said she uses three-dimensional anatomical models of the pelvis to explain to patients what’s entailed.
“I’ve had patients who say, ‘I’m just not ready for it yet,'” Connor said. “I say, ‘That’s fine, we can work on hip weakness and tightness in the back, and that can impact the pelvic floor.’ The patient is always in control.”
Kotarinos helped design the protocol for trials comparing pelvic floor physical therapy to other treatments. She is one of the authors of a 2013 study, published in the Journal of Urology, that randomly assigned 81 women with pelvic floor tenderness and painful bladder syndrome to either 10 sessions of pelvic floor physical therapy involving targeted internal and external muscle manipulation or 10 sessions of full body massage.
Women who received the targeted pelvic floor therapy were more likely to respond to therapy, with 59 percent experiencing improvement in symptoms compared with 26 percent in the full body massage group, though both groups had easing of pain and urinary problems. (A limitation of these studies is that patients cannot be “blinded” to their form of treatment, which can influence results.)
Another small study by Mahajan that examined patient charts from her clinical center found pain scores improved after patients started getting pelvic floor physical therapy and improvement increased in direct proportion to the number of sessions patients had. Of the 75 patients whose cases were examined, 63 percent reported significant pain improvement. Though many women develop pelvic problems after childbirth or later in life, Mahajan said gymnasts are prone to pelvic floor problems because they land hard and slam on to the floor repeatedly. She said it was “not inconceivable” the therapy might be appropriate for them under certain circumstances.
But several physical therapists said they would suggest the therapy to girls younger than 18 only as a “last resort” in extreme cases of severe injury, and once other treatments had failed. And it should always be done with safeguards in place.
“I use this every day in my own practice,” Mahajan said, “but it’s always with gloves, by a female therapist, with consent, and supervised. When they’re in my office, we have a chaperone. These safeguards must be in place.”