Pelvic Organ Prolapse & Modification: An OT Perspective

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In the rehab world, pelvic health practitioners are leading the charge by teaching tools for integrating biopsychosocial approaches into clinical practice. These conversations overwhelmingly occur in discussions about pain. There is a TON of great research about pain!

What are our next steps for encouraging rehabilitation professionals to generalize these strategies to other outputs from the nervous system/symptoms that are distressing and that can be influenced by distress? For example, symptoms of Pelvic Organ Prolapse (POP)?

Teaching specific psychosocial tools (i.e. CBT, mindfulness) for supporting our clients with distress related to pain, POP, urgency, incontinence, Diastasis Recti…AWESOME!

But perhaps we are putting the cart before the horse and need to first consider looking at this symptom-related distress through a preventative lens. To do this, we have to get a bit vulnerable (growth necessitates vulnerability), do some soul searching, and take responsibility for the role that our language and treatments can play in creating or perpetuating distress.

A response that is unfortunately not uncommon from practitioners upon hearing of my involvement in their patient’s care…

“I am happy to hear that an O.T. is working with my patient/client. She needs to MODIFY her day to day movement to AVOID bending, squatting, and lifting heavy objects”…

So life then? She needs to avoid her life? Hmmmmm…..I have questions.

Such began some serious reflection on how I use modification in pelvic health practice and how I can be clear with other team members about the importance of doing so JUDICIOUSLY!

Fear Based Modifications

A VERY conservative and sadly a very common approach to POP is blanket recommendations to avoid activities that GENERALLY increase intraabdominal pressure (IAP). These blanket recommendations simply don’t hold any weight. There is an individuality to the pressures created with various movements in various bodies and we can learn strategies for managing pressure in different ways, with different movements, to feel safe and supported.

So…these restrictions aren’t super productive. More importantly, they can be very harmful. They often breed fear, undermine hope, undermine self-efficacy, strip people of meaningful activity and movement, create a sense of loss and grief, and have a detrimental impact on how they engage in their recovery journey.

Empowering Modifications

Yes! OTs are skilled at helping our clients to get creative and modify their meaningful activities and their environment to support continued engagement in their life.  An ethical question that we all need to be asking when we are considering modification as part of our treatment plan….

Am I creating restriction due to my own discomfort with uncertainty or am I promoting flexibility, adaptability, and participation?

Some reflections on hallmarks of modifications that create empowerment vs. breed fear…

Empowering Modifications Fear Based Modifications
Driven by client goalsImposed
Focus is on life/value engagement     Focus is on controlling/
eliminating symptoms
Reduces the cognitive load
involved in day to day movement
Increases the cognitive load
involved in day to day
Focuses on the HOW’s of
movement and learning new
Focuses on defining WHAT
movement is safe/unsafe
Reduces distress associated
with movement
Increases distress associated
with movement
Increased participation/movement
Creates fear-avoidance patterns
and a decrease in participation/
movement repertoire/flexibility
Necessitates tolerance of
Often fuelled by discomfort/
intolerance of uncertainty
Creating a toolbox of strategies to
manage flair ups (i.e. sensory,
cognitive, relaxation, movement,
dietary, etc.) is a part of the
treatment plan
Attribution of flair up is often
towards the restricted movement
Any restriction (if necessary)
is temporary and accompanied by a plan for scaling up to the activity if it is meaningful to the individual.
No time frame or plan suggested.

Have you noticed any others in your practice or in your recovery?

So how am I shaping my OT practice for addressing the impact of POP?

TASK ANALYSIS and EXPERIMENTATION (EMBRACING UNCERTAINTY)! We accept the unknown in service of creating an openness to challenge fear, beliefs, and expectation.

We search together for modifications or slight shifts in how, when and where we engage in these activities in order to promote feelings of strength, safety, and support AND promote the GENERALIZABILITY of these experiences to multiple contexts that are meaningful in the individual’s life.

Some necessary shifts that need to happen for clinicians to embrace a truly biopsychosocial approach to POP and really ALL pelvic health challenges…

  • Get vulnerable, and practice self-compassion…we are always learning!
  • Get comfy with (or at least tolerant of) the uncertainty
  • We need to place much more value on the client narrative as a strong source of evidence that should guide our treatment

OTs tend to have a hard time wearing the “expert” hat…I often joke that we are the Canadians of the health care world. A good friend recently proposed, “perhaps we, as OTs, are the experts at helping people to become their own experts?”

NOW THIS IS AN EXPERT ROLE THAT I CAN GET ON BOARD WITH! Thank you Sarah Thomas Rheinberger of Empowered Space!

Not that we always do it perfectly, but connecting with our clients in this way and working towards engagement and self-determination is a MASSIVE part of our education.

I am trying to call upon my confidence as an “EXPERT in self-efficacy” for the sake of my clients, when I must harness the confidence to challenge pelvic health practitioners (who have been doing this pelvic health stuff a heck of a lot longer than I have!) to reflect on their chosen approach and whether it bolsters or undermines self-efficacy…This is pretty freaking scary but also pretty freaking critical.