Pelvic floor. It’s totally a buzz word right now. And for good reason. Most people still do not understand the impact of the pelvic floor, that they are not alone in their problems, AND that they can get help. That’s what you’re ready to do. Help people suffering with pelvic floor dysfunction to reclaim their lives. There’s just one thing though… where to get started?!
Grad school didn’t prepare you for this. And when you’ve been practicing for a few years the path looks even more confusing. Which courses do you take? How many of them to take? When to take them?
I feel ya. I remember my excitement (and fear) about jumping into this specialty. I was ready to help people overcome their most intimate struggles, ready to teach other providers about pelvic health, to reach people before they had problems to prevent dysfunction in the first place.
But it was frustrating to figure out what would be the best way to get started. I spent soooo much time scrolling through Herman & Wallace and the Section of Women’s Health, hoping to figure out what was the best. I even reached out to other providers to figure it out. Should I do a residency? What if I don’t?
Even now, three years later, I still see these types of questions in the pelvic health groups I’m a part of and in my own inbox. I’ve had the conversation dozens of times. But if the question keeps coming up… then the answer must not be as clear. So I spent some time creating this guide to help you start on your journey. Consider me your sherpa as you embark on this adventure into the pelvic health specialty.
#1 Get to base camp
Before we can start this climb, we’ve got to set up camp. And in the PT pelvic floor world, that means taking pelvic 1. If you want to help people with pelvic floor dysfunction, regardless of whether they are men, women, or children - you’ve got to start with a pelvic 1 course.
Pelvic 1 is more than learning to do a vaginal exam. That is the specialized examination you will learn… but that’s not the whole enchilada! Pelvic 1 is going to blow your mind and open your eyes to a whole new world. You’re going to learn all about peeing habits, pelvic organ prolapse, urinary incontinence and the impact it has on women of all ages. It’s also going to offer you a safe space under supervision and guidance to learn how to do internal exams. I cannot stress this enough. The first person you do an exam on should not be a patient. This was how practitioners had to learn it decades ago when these courses didn’t exist. Now, the courses are there. And you should use these amazing resources.
As a pelvic floor PT, I take students and require them to take pelvic 1 before they start their internship. Why? Am I just that bad of a CI?
Uhm no! I want them to experience vaginal exams themselves and to perform exams on multiple women before they get started. I cannot guarantee 3-5 female volunteers in the clinic so that I can teach them the exam from scratch. That would be nice, but unrealistic. So they need to take Pelvic 1. Then I can coach them through their first exam on a real client. But what I want them to get from Pelvic 1 is so much more than the mechanics of the vaginal exam.
I want them to feel different people, see different bodies, and get feedback in the moment, in a safe space that takes the pressure off. And jumping into your first client and learning on the fly, even with an experienced mentor is NOT the same thing. There’s more pressure. You’ve got to appear comfortable for the patient. You lose out on the opportunity to ask questions like "Can you check and tell me what I'm feeling? How do I find obturator internus?"
The two main organizations that offer Pelvic 1 coursework are:
The next big question is: which course do I take?!
Short answer? Whichever one is closest/soonest/most convenient for you.
The underlying concern here is picking “the wrong course.” I remember that struggle. Here’s the thing though. Both organizations offer courses which are:
- Live 3 day courses
- Cost similarly ($6-800)
- Are taught by caring instructors and include lab assistants
Keep in mind that whatever organization you start with is the one which you should finish out the pelvic floor series with. The courses are meant to build on each other.
Neither pelvic 1 course will be “perfect” and answer all your questions. You will leave inspired, excited, somewhat nervous… and you’ll realize you have more questions. That’s normal. That’s when you reach out for help! Talk with clinicians, get mentoring (whether in person or virtual), take more courses, and keep learning.
And honestly, I’ve talked with/worked with pelvic floor PTs who went through the series from either and I’ve got to say that what distinguishes great clinicians is NOT whether they did H&W or SoWH. True specialists within our field have extensive patient care time under their belt (get it… pelvic health? Under the belt?), honed their skills (both technical and “soft skills”), are masters of anatomy, and have clinical reasoning skills so sharp that I’m not sure how their brains haven’t hemorrhaged yet. The pelvic series is simply what got them started and you should look at it the same way.
Now, if you aren’t sure about pelvic floor dysfunction, but are drawn to pregnancy and postpartum then a great way to get your feet wet is by taking courses in obstetrics.
Here are a few live courses:
There are also online courses for working with pregnancy clients, a couple of the popular ones I've heard good things about include:
- Girls Gone Strong Pre- & Postnatal Coaching Certification
- Brianna Battles Pregnancy And Postpartum Athleticism course
Note: I am not paid for listing these courses
Now when it comes to early postpartum (~1-2 years) even if you do not want to do internal exams, I would recommend you take a pelvic 1 course. Again, it will give you a much deeper appreciation for the pelvic anatomy and the tools to treat urinary incontinence and prolapse - which are the most common complaints postpartum. You can choose to do as much or as little of the internal work as you are comfortable with - but the knowledge you gain will be immensely valuable and allow you to help more women.
This leads perfectly into something we've gotta talk about:
Whatever your way in, odds are high that you will quickly realize you want more info about both pelvic health AND obstetrics (and them some). If you want to be able to see anyone walking through the door, then I recommend that eventually you take all of the pelvic series and ob series that are offered. Why?
Because you are training to be a pelvic floor generalist
We all agree that pelvic health education from PT school has quite a long way to go. So regardless of how long you've been practicing, if you are branching into pelvic health, you're going to need more training.
And the entire goal of the pelvic series and live OB courses is to prepare you to evaluate and begin treatment with anyone who walks in. It's important to understand how carrying and delivering a baby changes a woman's body. And what can be done to help her afterwards! Especially if you aren't sure exactly what area of pelvic health you want to work in, taking all these courses will help you to be a well rounded pelvic PT. Otherwise you don't know what you don't know!
A word about internal exams...
So you want to do pelvic health, but you aren't sold on the idea of doing pelvic exams. Can you still help people?
Absolutely! There are plenty of times when I do not start with an internal exam with a client. And we all know that you've got to look outside of the pelvis, at the whole person to provide the best care. Which means that there is quite a bit you can do for clients even without an internal exam.
But if you won't be doing internal exams... it also means you need to have a PT who does, to refer to. Because there will be clients who are not progressing and in these cases, an internal exam will give you information which you simply cannot get externally, especially when it comes to pelvic pain.
A couple things I'd like to point out to go along with this:
- There may not be anyone else in your area to refer to
- I still believe that taking a level 1 course will give you the best appreciation for the pelvic floor muscles, even if you choose not to use this skill (sorry external palpation!)
- And finally... I don't think any providers/patients enjoy internal exams. But the way I look at it is this: if I've already taken the time to hear this person's story, build rapport, and evaluate them, then I do not want to refer them to someone else to do the internal part of the exam and to repeat the process.
Ultimately it's all about your preference. If you do not want to do any internal work - then don't! But do recognize that in some cases your ability to help those clients will be limited.
#2 How far do you want to climb?
Okay, so to get a great map you gotta know where you’re going. Spend some time thinking about what you want to do in pelvic health. Consider what types of clients you’d love to work with. How quickly do you want to learn all the pelvic health basics? Are you looking to pursue certification? Are you going to open up a practice one day?
All I'm saying is that the climb extends beyond taking coursework. It's your end goal. And maybe you have several end goals, always finding a new peak when you conquer one summit. That's great too!
I won't speak to the business side of things quite as much here. Many of us PTs are Type A and like to have a specific goal - pursuing a certification is one way to do that (more on that below!) You can pursue pelvic health specific certifications to set yourself apart as a specialist. You can also become certified in biofeedback and/or lymphedema.
While the term "pelvic health" focuses specifically in on the pelvis, women's health is a more broad category which refers to female-specific conditions throughout the lifespan including lymphedema, relative energy deficiency syndrome (formerly female athlete triad) and osteoporosis. There are a wide variety of continuing education courses specific to disorders and populations, from pediatric to pudendal neuralgia, to coaching and hormonal health.
When you have an idea of your endpoint you can start to fill in the gaps. Remember, it's not set in stone! You can take a course, work with those clients and realize it's not your ideal situation. Also, pelvic floor physical therapy can and should be brought into settings other than outpatient physical therapy. It would be amazing to have pelvic floor PTs in skilled nursing facilities, more in home health, etc. There is such a need for this work that it can absolutely be incorporated into the area/population you love to work with.
And you do not have to "switch" and become solely focused on pelvic health. People are more than a pelvis so you certainly need strong MSK skills to provide the best care. But you can also carry a mixed caseload. Deciding to take all of the pelvic health courses does not determine what your schedule will look like. That's for YOU to shape!
Personally, I believe that this is the most important question to answer because it will help you to figure out where to go next with your coursework. Now before you panic - I’m sure there are more than a few of you reading this going “But what if I don’t know?! I just want to help people with pelvic floor dysfunction!!” Great! That’s an answer in and of itself. Continue on with the pelvic floor series and get more direct care under your belt. Continue to ask yourself this as you go; you'll find the answer!
#3 The climb
So you finally did the thing and signed up for Pelvic 1. Heck, maybe you just took pelvic 1 and are reading this to find out what’s next.
I recommend you begin planning when to take Pelvic 2 already. Why? Because once the floodgates open and you start seeing people, you’re going to realize that you don't even know what you don't know yet. And there is a TON that you still don’t know yet. Like what’s abnormal about someone’s poop? What to do you do for all these women who have pain during the vaginal exam? You’ll hear it in your first course - There are very few clinically “easy” clients with pelvic floor dysfunction.
There are definitely clients who have minimal to no comorbidities, high motivation, and relatively few problems. Enjoy working with these people! However, recognize that the majority of people will have more than one problem. Urine leakage? Oh ya, they’ve also got a life long history of constipation. Maybe some pelvic pain or pain during sex too. And multiple surgeries.
And once word gets out that you do this, others will come to you as well. So get ready for Pelvic 2. When I started practicing, I had a two month delay until I got Pelvic 2 and I was counting down the days until the course.
So now that you are past that point - what’s this hike like?
Well it's got it's own highs and lows. Some days you'll feel like an epic hero, fueled by the gratitude of the people you have helped. Some days you will feel like a PT student, overwhelmed and wishing for additional guidance and info.
By all intents and purposes, we are a new specialty (even though we’ve actually been around for 3+ decades). And like all of the rehab field - there are many questions we do not have the perfect answer to. So how are you going to make it?
Question. Learn. Apply. Integrate. Repeat.
I wanted to throw the word rinse in there, but it was totally going to throw the phrasing off.
Stay curious my friend! ASK all of the questions you have. The fact that you have questions is awesome! My most disliked phrase is “this is a dumb question but…” Are you a dumb clinician? Didn’t think so. You don’t have dumb questions. You have questions because you are a brilliant human being with brain cells that are firing away trying to comprehend everything that got tossed at you in a weekend, or what’s happening with this other equally brilliant but suffering human in front of you.
For the love of god, please remove that phrase from your speech patterns for the rest of forever. All you’re doing is cutting yourself down at the knees. It’s a protective mechanism because you do not want to appear stupid to the person you’re talking to, but when you say it, you are implying that you’re dumb because you have a dumb question… Like whut? Just ask your question!
OK, so I’m totally off my soapbox now, back to pelvic health talk!
There are TONS of awesome courses out there on specialty topics ranging from pudendal neuralgia to bowel dysfunction to visceral mobilization, mindfulness in pain treatment, etc… The list does go on and on.
Continue to expand your horizons and learn new information. The best part? You have so many more options for these courses! Unlike the pelvic series, you have way more continuing education courses to choose from and from a wider variety of sources! Like Pelvic Guru, Julie Wiebe, and PhysioDetective (AKA Antony Lo) just to name a few.
Beyond coursework, it's also important to develop your soft skills. I cover some of the most important skills I have learned in How to Become a GREAT Pelvic Health Provider.
#4 The fast track
Residency. This is taking the ski lift up the mountain. It’ll get you the basics and beyond much faster. That’s one of the main reasons I chose to do a residency. The other one was mentoring time.
Specifically, residency will fast track you to getting your WCS (more info on that below). It is usually 12 - 18 months of hard work. It’s a springboard for the rest of your career. Was it easy? NO. Was it worth it? Heck yes!
Some points to consider regarding residency:
- Each program is different!! Other than the requirements from ABPTRFE, everything else varies between programs including: length of program, start dates, pay, and additional focus areas. For example, not all programs offer lymphedema certification. The residency I completed (Brooks Rehabiliation) did not, however that was a plus to me as I am not interested in that area. You can find accredited programs here. (Scroll all the way to the bottom for Women’s Health!)
- Usually require relocation
- Include some type of pay cut (it varies from very small to a large cut)
- Work-life balance and residency are two different concepts. Are there slower times in the program? Absolutely. Do you have to miss every social engagement? No. Are you going to blossom as a social butterfly during this time? No.
There are many factors to consider when it comes to residency. Beyond the logistics of time/location/pay it's crucial that you find a residency which is a good fit for you. You are interviewing them as much as they are interviewing you! It might not feel like this, but you have to find the residency which matches your pace, interests, and get along with the people who will be your mentors/instructors. You're going to be spending a TON of time with these people, you better be able to at least tolerate them!
#5 Mount Everest: Certification
If you’re looking to set yourself apart and do something which few others have done, then you are after a certification. It's time to get some more initials after your name!
There are a few options:
- Section on Women's Health: Certificate of Achievement (in Pelvic PT or OB)
- Herman & Wallace Pelvic Rehabilitation Practitioner Certification (PRPC)
- American Board of Physical Therapy Specialties: Board Certification as Women's health Clinical Specialist (WCS)
The certificate of achievement is specific to SoWH courses only, so you would have to take their pelvic series and/or OB series. From what I could find online, it appears that you would take an exam after each course and write a case report.
PRPC and WCS are a bit different breed of certification. To qualify you have to provide proof of 2,000 patient care hours, submit a case report, then you take an exam. It doesn't matter where you did your coursework because the point is not to prove you did courses, but rather to test your knowledge base.
Another big distinction is that the PRPC is focused exclusively on pelvic health. The WCS requires extensive pelvic health knowledge but also includes content areas such as osteoporosis, REDS, and lymphedema.
Thankfully H&W created a chart which compares the PRPC and WCS certifications which you can check out here. One key missing point is that you can qualify for the WCS by completing or being enrolled in an accredited residency.
I'm not sure about PRPC, but for WCS there were only 381 board certified specialists as of June 2017. That's a pretty sweet marketing point! I did a residency and earned my WCS so I can give you a brief overview of that process.
Achieving the WCS
To earn the WCS initials you have to take an exam, much like the NPTE. A big difference from the NPTE is that the clinical specialist exams are only offered during 1 testing window in March each year. You have to apply in July the year before. For example, I applied July 2017 in order to take the WCS exam March 2018.
In order to sit for the exam, you have to quality for it. There are 2 ways to do this:
1. Have proof of 2,000 hours of direct patient care as a licensed physical therapist in women’s health, at least 25% of which must have been in the last 3 years. The other 75% can be from the past 10 years.
2. Complete (or be enrolled in) an accredited Women’s Health Residency within the last 10 years
When you meet either of these qualifications, you will fill out an online application, write a case study, and submit by July 1st. Your case study will undergo review and either be approved or submitted back to you within 1-2 months for revision. Once approved, you will be able to schedule your exam by Nov/December of that year.
The Section on Women’s Health has excellent information if you are prepping for the WCS this year. My co-resident and I used the study guide to create our weekly study schedule!
As mentioned above, it does not matter whether you did H&W or SoWH coursework for you to take the WCS or PRPC. Both certifications are good for 10 years and require taking another written exam to be re-certified. With a minuscule amount of specialists, it’s quite a way to set yourself apart! I have not taken the PRPC but I'd bet my money that it's also a difficult exam.
Currently these are the highest certifications you can earn in pelvic and women's health. To date, I do not know of any pelvic health specific fellowships (c'mon AOMPT!) however I can see that being an area we expand into.