Spotlight on Women’s Rehab and Men’s Health

There is physical therapy for that?!

Sarah Kremer, SPT ’21

I think that is a fairly common reaction when it comes to the area of women’s rehab and men’s health (WRMH) physical therapy (or women’s health for short). This area of physical therapy is one of the more unique ones, and one that I have particularly grown to have a lot of passion for.  I could probably write a book on the different diagnoses that this area of PT can treat, but I am going to try and highlight the most common patient populations that WRMH physical therapists see. 

Pelvic floor dysfunction is one of the most commonly seen diagnoses in this subset of physical therapy. All of the so called “taboo” subjects like urinary and fecal incontinence, urgency, constipation, prolapse, pelvic floor spasm, sexual dysfunction are issues the physical therapy can treat! The underlying cause of a lot of these conditions may be pelvic muscle dysfunction and can be resolved with pelvic floor physical therapy paired with lots of education. These patients often benefit from both hip and core strengthening, as weakness in these areas can play a significant role in pelvic floor dysfunction.  Something imperative to note, is the importance of communication and establishing a very trusting patient-therapist relationship when treating pelvic floor dysfunction. It goes without saying that this is a sensitive and personal area of the body. It is crucial that the patient feels comfortable voicing any questions, concerns or discomforts they may feel during their treatment.

Breast cancer patients. Breast cancer is a diagnosis that unfortunately hits close to home for a lot of us, as it is the second most common cancer among women in the United States according to the CDC.[1]  The treatment that these patients undergo such as surgery (most commonly being lumpectomy, single/double mastectomy), radiation and chemotherapy can immensely alter these patient’s physical health. After a patient undergoes a mastectomy or lumpectomy along with radiation, the skin where the breast tissue was removed can become very tight and fibrotic. This condition will very likely be painful and limit their upper extremity range of motion (ROM).  Following lymph node removal, these patients may experience a condition called axillary webbing, which will also greatly restrict their upper extremity ROM ( gives a thorough overview of this condition). The goal of physical therapy is to use techniques such as instrument assisted soft tissue massage (IASTM), passive range of motion and strengthening exercises to break down the fibrosis, axillary webbing and scar tissue to improve overall ROM. 

If breast cancer spreads, the first place it typically will go to is the surrounding lymph nodes. After lymph node removal, these patients are at high risk of developing lymphedema.  Teaching these patient’s preventative techniques, particularly manual lymph drainage (MLD) and having them fitted for compression garments can assist in prevention of lymphedema according to the Clinical Practice Guideline from the Academy of Oncologic Physical Therapy of APTA.[2]  If the lymphedema is unable to be prevented, these patients will benefit from complete decongestive therapy (CDT). CDT is a technique that women’s health PT’s will likely be certified in and includes bandaging, compression garments, MLD and skin care. Lymphedema patients are at much higher risk for skin infections so education about skin care on the first visit is crucial.  Ensuring the skin is moisturized at all times will prevent any cracks/breaks in the skin that would allow bacteria or fungus to enter.  Bandaging is an important part of lymphedema treatment and includes the use of short-stretch bandages to reduce swelling and prevent fluid accumulation.[3]Unfortunately, supplies for bandaging can become extremely expensive for patients and they are not covered by insurance.  I have seen patients in the clinic who are unable to properly manage their lymphedema due to financial restrictions. Here is a link to the Lymphedema Act, in which you can contact your local legislators about the importance of insurance (particularly Medicare) coverage of compression supplies for these patients.

Head and neck cancer patients are also a part of the population that WRMH commonly sees. These patients may also struggle with lymphedema due to damage to the lymph nodes from radiation. So in some cases, they will need CDT and MLD techniques to manage their lymphedema or reduce their risk of developing it.  Another common issue that these patients come in with is extreme tightness and fibrosis from the radiation on the skin around their sternocleidomastoid (SCM), thyroid cartilage, scalenes and submandibular region.  These patients greatly benefit from manual techniques such as IASTM, thyroid/hyoid mobilizations and passive stretching to decrease tightness and increase overall ROM.  In many cases, the cancer and treatment will have caused issues with swallowing and/or speech, and many patients have to rely on feeding tubes as their main form of nutrition secondary to their issues with swallowing. The techniques utilized in PT can help to break down scar tissue/restrictions and hopefully assist these patients with their overall swallowing  and speaking abilities. This population has a high risk of aspiration when eating/drinking so it is absolutely crucial to decrease the risk of this occurrence.  These patients also greatly benefit from posture correction techniques due to the common presentation of forward head posture, due to tight anterior neck structures.

Finally, post partum patients are another very common subset of patients that come into women’s health PT.  Giving birth is a wonderful miracle of life but can be extremely physically taxing for the mom and cause lasting musculoskeletal issues. A common postpartum issue that women experience is a condition called diastasis recti abdominis (DRA), which is defined as a separation of the rectus abdominis muscle of more than 2 cm at one or more points of the linea alba.[4] Women can experience this during their pregnancy and also directly after giving birth due to delivery related trauma.  The combination of hormones released during pregnancy and the stress of the growing fetus on the abdominal wall results in this separation. Luckily, physical therapy can help with this condition. Focusing on deep core strengthening (especially the transversus abdominal muscle), pelvic/sacroiliac joint alignment and posture are all key components of treating DRA. Additionally, women commonly experience pelvic floor weakness/dysfunction and prolapse after delivering. Physical therapy can focus on strengthening and coordinating the pelvic floor muscles which will consequently help to address prolapse symptoms. In May of 2018, the American College of Obstetricians and Gynecologists (ACOG) embraced the concept of the “fourth trimester.[5] This concept addresses the importance of ongoing care for the mother and baby in the weeks following birth, especially physical therapy for the mother.  Advocating that physical therapy should be a standard of care for women postpartum will greatly increase the resources women will have available to them to improve their overall health and well-being.

This specialty area of physical therapy clearly has quite a diverse patient population and can treat many musculoskeletal issues affecting one’s day to day life.  Through my time in my WRMH clinical rotation thus far, I have experienced first hand how much this area of physical therapy improves patient outcomes and helps them achieve their own personal goals.

[1] Breast Cancer Statistics. (2020, June 08). Retrieved October 18, 2020, from

[2] Davies, C., Levenhagen, K., Ryans, K., Perdomo, M., & Gilchrist, L. (2020, July 19). Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA. Retrieved October 18, 2020, from

[3] Why Bandage? (n.d.). Retrieved October 18, 2020, from

[4] Thabet, A., & Alshehri, M. (2019, March 1). Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: A randomised controlled trial. Retrieved October 18, 2020, from

[5]OB-GYN Group Embraces ‘Fourth Trimester’ Concept, Acknowledges Role of Phys… (2018, July 11). Retrieved October 18, 2020, from

The Value of Interdisciplinary Care

Kimberly Berkovich, SPT

If you ask anyone in the field of Physical Therapy what they like about the profession or why they chose it as a career path, you will likely hear something to the effect of “I want to help people move better and optimize their function” or “I want to increase the quality of life my patients experience.”  One of the first lessons we receive in Physical Therapy school is the importance of treating the whole person and not just simply the diagnosis he or she presents with. This involves looking beyond the pathology and considering who our patients are fundamentally, what their day-to-day life looks like, what goals they have that are important to them, and what kind of activities and responsibilities they hope to return to. Understanding who our patients are helps us provide a more tailored treatment approach to achieve more meaningful goals. However, what people may not realize is that for many of our patients, Physical Therapy is just one piece of a larger healthcare puzzle. It is often through collaboration with our medical professional colleagues that we are able to provide the most holistic, comprehensive care.

Historically, medical care has been siloed, and when one specialist is not aware of what another specialist is doing with a patient, duplicate work or contradictory instructions may result. This can lead to confusion and frustration on the part of the patient, and quality of care suffers. Recently, there has been a push in healthcare to implement a more interdisciplinary approach to combat these issues.

Interdisciplinary care, as defined by the Victoria State Government, is an approach where individuals from various disciplines work together with a common purpose to “set goals, make decisions, and share resources and responsibilities.” [1] The disciplines involved in this approach can include any or all of the following: physicians, nurses, pharmacists, dieticians, occupational therapists, speech language pathologists, psychologists, social workers, neurologists, and more. The medical team, along with the patient and the patient’s family members or social support group, create a plan of care to best serve the patient.

This collaborative treatment effort is becoming increasingly utilized, and with good reason. Interdisciplinary care has been shown to reduce length of hospital stay and has been linked to improved patient outcomes and overall satisfaction of care, which is especially important in the midst of Covid-19. [1] Each discipline is specially trained to treat a unique aspect of a patient’s clinical picture, and in combination with one another, ensures that all of the patient’s medical needs are accounted for.

The best place to observe this in action is in an Inpatient Rehabilitation setting. In this setting, patients receive > 3 hours a day of intensive therapy that includes Physical, Occupational, and/or Speech Therapy, and 24-hour medical care is provided by an attending physician and nurse. Psychologists, pharmacists, and case managers are typically involved as well. The healthcare team meets at the beginning of each patient’s rehab stay to establish goals and a target discharge date, as well as to discuss any perceived barriers and how to address them. Later in the patient’s stay, another meeting is held to determine discharge criteria and the patient’s needs post-discharge. It is encouraging and heart-warming to witness this comraderie and observe how each discipline contributes their wealth of knowledge to optimize each patient’s health.

In the inpatient rehab setting, physical therapists are one of the first healthcare specialists to get patients moving after an acute life-altering event, such as a stroke, traumatic brain injury, or spinal cord injury. We have the opportunity to build relationships and rapport with these patients and witness firsthand the benefits from the interdisciplinary care they are receiving. There is something special about the moment when your previously nonverbal patient is able to communicate verbally with you thanks to the time spent with their Speech Therapist or the first time you see a patient brush their hair independently as a result of working with an Occupational Therapist. The most rewarding part about interdisciplinary care is celebrating a patient meeting all of his or her goals and getting discharged, knowing that each discipline played a part in the patient’s success.

As the U.S. population ages and the world continues to battle a global pandemic, it would be beneficial to see interdisciplinary car extended beyond hospital settings and incorporated into more outpatient practices. Hopefully we can see a bridging of the various disciplines in both the inpatient and outpatient setting going forward to provide patient-centered treatment and high-quality patient care for those who may benefit from a more holistic, comprehensive approach.

1. Department of Human Services 2008, Health independence programs guidelines, State Government, Melbourne.

Monday Memo Oct 5, 2020: The Importance of Return to Sport (RTS) testing in ACL Rehabilitation

Phil Forsythe, SPT ’21

Week two of the NFL came and went filled with injuries in one of the worst weekends for players and fantasy football owners alike. For Saquon Barkley of the New York Giants and Nick Bosa of the San Francisco 49ers’, their 2020 campaigns came to a halt with one of the worst injuries a professional athlete can suffer: torn ACLs.  In a review of Orthopaedic Surgeries effect on athletes’ careers in the NFL, the average rehabilitation period for ACLRs was 378.1 days or just over a year [1]. These are some of the most elite athletes in the country with some of the best professional surgeons, physical therapists, and strength and conditioning specialists, and yet, it still takes them on average a year to return to the field.

That raises an important question: how good are the outcomes for physical therapists treating high school and college athletes in the outpatient orthopaedic setting? Not great. In a 2014 study looking at the incidence of a second ACL injury two years after return to sport in 78 patients, they reported a second ACL injury rate of 29.5% with 20.5% occurring on the contralateral ACL [2]. Surgeons and physical therapists alike have made progress on recognizing some of the most important factors from the literature to reduce reinjury rates including symmetrical quadricep indices and time until return to sport. In general, it appears that every month RTS is delayed up to the ninth, the likelihood for reinjury is reduced by 51% compared to the previous month (3).

Every new graduate in the outpatient orthopaedic setting will eventually see the referral to evaluate and treat a post-operative ACL patient. Alongside that referral they will receive a protocol outlining the goals for range of motion, strength, jogging, jumping, running, cutting/pivoting, and finally return to sport. The problem with only adhering to your protocol is you are trying to eliminate the personal aspect from your athlete’s rehab. The protocol should serve as your guide, but it should never paralyze your ability to assess what your athlete is showing you on the day to day basis. Every athlete should earn the right to the next stage of their rehab until they are ready to step back onto that field. Otherwise, you are potentially doing them a disservice. At Pitt, one of the mantras we get taught is to test early and test often. While that doesn’t mean you start doing hopping tests before they are jogging, one of your goals should be to assess strength of the quadriceps compared to the uninvolved side before the patient earns the right to progress in their rehab. Communicating early with the surgeon to align recommendations with objective goals ensures there is no miscommunication during checkup visits.

What is the next step when nine months passes by, and your athlete feels that they are ready to start playing again? As physical therapists, we need options that will accurately assess the demands of their sport and provide an evaluation that clears an athlete for play. Researchers are still working on the most optimal battery of return to sport tests, but they have shown that meeting a comprehensive RTS criterion can significantly reduce reinjury rates in athletes who passed versus athletes who failed [3].

Here’s an example of the battery used in the Delaware-Oslo ACL cohort study (>90% symmetry for all tests is considered a pass) [3].

1. Quadriceps Strength Testing: Isokinetic Concentric (Biodex) – The Biodex is considered the gold standard for testing quadriceps muscle strength, but it is also extremely cost prohibitive for typical outpatient settings. A handheld dynamometer can produce a more cost-effective assessment, and even 1-rep maximum testing on the leg press is better than no strength assessment. Quadriceps symmetry is extremely important; this needs to be tested before you should be comfortable letting a patient return to sport.

2. Four Single Legged Hop Tests – There are many different options for single legged hop tests: single leg hop for distance, triple crossover hop, triple hop, 6 meter timed hop, lateral and medial single leg hops. Symmetry between involved and uninvolved in terms of distance or time is what you are measuring.

3. Two Objective Outcome Scores – KOS-ADLS and Global Rating Scale. These outcomes tell a lot about how the patient perceives their knee and overall function. Another great outcome score would be the ACL-RSI; this outcome gives a quick measure of the patient’s fears about returning to sport and the specific mechanism of injury for their knee [4].

RTS testing is an integral element to ensuring that you are providing the best possible opportunity to prevent a second ACL injury. While there are additional considerations on whether athletes should progress through a tapered return to live, full contact sport, RTS testing is the bare minimum we need to be doing as clinicians before signing off on our end.

Nine months minimum is one of the longest rehabilitation times in physical therapy. By making your RTS decision objective and measurable, you could prevent that athlete’s return to physical therapy for a second injury.

1. Mai HT, Alvarez AP, Freshman RD, et al. The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): The Effect of Common Orthopaedic Procedures on Football Careers. The American Journal of Sports Medicine. 2016;44(9):2255-2262.

2. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014 Jul;42(7):1567-73

3. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8.

4. Webster KE, Feller JA. Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Orthop J Sports Med. 2018 Apr 4;6(4)

Monday Memo 4/20/2020

The Monday Memo

April 20th, 2020                                                                       PITT DPT STUDENTS

Psychologically Informed Care

For many people across the globe, 2020 has been a particularly challenging year thus far.  With the COVID-19 Pandemic, a sequala of stressors are arising in conjunction with anxiety, depression, increased incidence of domestic violence, alcohol/substance abuse, PTSD, and other mental illnesses throughout the world.  With social distancing in effect in many areas of the United States, many people are feeling alone and fearful in the midst of uncertainty.  It is CRITICAL during this time to be aware of signs and symptoms consistent with mental illness when we are interacting with those around us.  Then, you must be aware of ways to support yourself, your loved-ones, and your patients through this challenging time. Although, as students, we are not seeing patients currently, these are key points to take with you as future clinicians.

Stress has many physical manifestations that mirror common impairments we see in the clinic such as muscle pain, fatigue, spasms, tightness, and high blood pressure.  It is important to be aware of psychological triggers for the pain the patient is feeling, as well as physical causes.  As physical therapists, we often see patients for longer durations over an extended period of time.  Due to this length of treatment, patients share information with us that they have not yet shared with other medical professionals.  Listen to each patient when they talk, because they could provide you with a wealth of knowledge regarding how to best support them.  For example, Mr. Covid is a 52-year-old man referred to you for chronic low back pain.  You evaluate him, and it appears that he has a standard flexion-preference.  You treat him for five visits, he misses a week of treatment, and when he returns for visit six, he states that his pain “just doesn’t seem to be getting any better.”  You start talking to him about his home exercise program, and he tells you:

“To be honest, I just have not found any time to do it.  I was laid off because of this pandemic and have been spending four hours a day sitting in front of my computer trying to find a new job.  My wife is an ER doctor who has been working 12 to 14-hour shifts, and we have four children that I am taking care of and homeschooling alone.  I just am not doing so well right now.  I’m stressed, I’m eating everything in my house, I miss my friends, family, and coworkers, I’m not sleeping enough; this back pain just makes it all so much worse!” 

This patient report, although fiction, doesn’t seem very unrealistic, right?  It could be easy to write “no progress noted.  Pt. non-compliant with HEP” on their chart and move on with your treatment plan as scheduled.  Using psychologically informed care, the information that Mr. Covid shared could be critical for his mental AND physical progress.  Being the skilled-PT you are, you say to Mr. Covid:

“I hear you are going through a lot right now between losing your job, caring for your children, and this back pain that just doesn’t seem to go away.  Unfortunately, the stress you are under could be contributing to your back pain.  I really would like you to start working on some mindfulness techniques at home to help you destress; I will show you them at the end of the session.  If your wife is feeling stressed as well, these could be great to teach her, and you could practice together!  Every thirty minutes that you are at the computer or homeschooling your children, I would love for you to integrate some sort of activity break in – such as dancing with your children, doing a lap around your house, or some other form of activity for 5-10 minutes to break up those long intervals of sitting.  Today in the clinic, let’s do some milder activities to calm your back down, and modify your home exercise program so they are activities that you will have time to complete throughout your day.  This pandemic is incredibly challenging for everyone, and I want you to know that you are not alone.  Do you think you want to talk to a mental health professional about your stress?  If so, I know someone great who I could refer you to!”

               As Pitt Physical Therapy students, we often discuss the term “psychologically informed care”, but what does that term mean to each of us future clinicians?  According to 2nd Year DPT student Paige Paulus, psychologically informed care means being aware of the patient’s perspective; “Sometimes it isn’t about pushing what you want to do on them, it is adapting their treatment so that they can heal to the best of their ability.”  Christina White, a 2nd Year DPT student stated that it means “being in tune with the psychological factors that could be a barrier to care, but also aware of aspects that could promote care.  For example, if someone is motivated and ready to go, that is psychologically informed, but so is the opposite side of that continuum where a patient is not motivated.”  To 1st Year DPT student Nikki Ray, it means “recognizing when a patient is struggling mentally and noticing when they have their guard up and not pushing them past their boundaries.  They could have their guard up because they don’t want to get reinjured, or something else may be going on.”  2nd Year DPT student Kalli Seibert stated that, “for me, the psychological piece of treating patients is one of the most important parts; if you aren’t listening to what the patient needs to be successful, your outcomes will not be as great.  You could heal their body, but you will not leave a lasting impact.  In Women’s Health, we get a lot of patients who have many factors affecting their physical and mental health.  In my experience in this area of PT, using psychologically informed care is a key part of every treatment.  Patients may not remember the exercises you gave them, but they will remember what you said to them and how you made them feel.  You are not just treating them so they get better musculoskeletal-wise, but that they are also getting better emotionally and have more confidence in themselves after each session.”  2nd Year DPT student Kara Kaniecki stated “to me, psychologically informed care means being an active listener. Listen to your patients when they talk and listen to the way they say things. Listen to your patient’s body language. Observing how they present themselves can be so important when trying to understand how your patient is truly doing. Psychologically informed care means that your patients may have so many things going on outside of your therapy session. Their spouse could have just passed away. They could have just been fired from their job. They might have just failed an important exam. We need to take into account how their mental health is affecting them and how our treatment sessions can improve their health both mentally and physically. We need to keep our patience and empathy at all times. We need to do what we can to make our patients feel comfortable with us. PT shouldn’t be another stressor in a patient’s life! We are trustworthy and great communicators. Let us show our patients that as well.”

The Pandemic will come to an end, and we as a society will move through this… but some of the psychological complications of COVID-19 could last a lifetime.  As future healthcare professionals, it is crucial to listen to our patients, support them, and make appropriate referrals as necessary.  Be open to talking to your patients about their mental health as well as physical health.  Use your motivational interviewing and listening skills early and often for each patient that you encounter.  Additionally, just as the SBIRT training suggests, screen each patient, provide a brief intervention, and refer to treatment (whether that be for alcohol/substance abuse or mental health resources) as necessary.

As far as what we can do RIGHT NOW to make a difference: reach out to those around you who may be feeling alone during this time, be kind to each other, and most importantly—take care of yourself and stay healthy.  Our future patients are counting on us.

Mental Health resources posted by the University of Pittsburgh Counseling Center:

-Mariah Callas, SPT

Special Thank you to Paige Paulus, Christina White, Nikki Ray, Kalli Seibert, and Kara Kaniecki for their valued input.

Monday Memo 04/13/2020

The Monday Memo

April 13th, 2020                                                                       PITT DPT STUDENTS

My Day In An Interprofessional Education Program

In the fall, I was lucky enough to be chosen to spend a day at UPMC Presbyterian engaged in an interprofessional educational program. Our own faculty member, Dr. Vicki Hornyak, is the director of this program. I have since reflected on this day and how I believe that it has helped me develop my professional skills in the clinic. I am truly so grateful for this experience and hope to relay some things I’ve learned to you all.

I was partnered up with a nurse on the 5G unit, which often has a lot of patients with neurological injuries. The patients were often medically complex, requiring a variety of specialty team members such as neurosurgery, orthopedic surgeons, physical therapists, and everything in between. We started off the day with introductions and learning about each other. We were around the same age – she was a younger nurse who had just started at Presby a few months prior and I was a second year DPT student who was just starting a clinical rotation at UPMC Mercy.

We chatted for a bit about her morning routines – checking in on the patients, giving out medications, talking to the physicians and giving updates on her patients. She gave me a quick run-down on what the drugs were as she administered them to patients and provided me her thought process for patient care every step along the way. I really appreciated how in-depth she explained everything to me. Not yet having pharmacology, I did not know a lot about medications. She was understanding of this and was excited to teach me. I was excited to teach her a little bit about physical therapy as well.

Throughout the day, we talked to occupational and physical therapists, speech therapists, neurosurgery physicians, medical students, medical residents, plastic surgeons, and so many others that I cannot even recall. Nurses are responsible for their patient’s entire plan of care and whoever may come along with that. I never realized how much of a nurse’s day is spent checking in with other professionals. I felt as though every few minutes she was answering her phone, whether it was patient call bells or physicians. Before I knew it, it was time for another round of medications. Even though we did not do physical work all day, we were constantly busy.

Something my nursing partner said to me that will always stick in my head is “I wish we could have done this when I was in school. I didn’t know half of the things you guys did in the hospital.” This is why interprofessional education while we are still in our schooling programs is so important. I was able to learn so much about what a nurse’s day looks like. I never even could have imagined half of it. Even though our day was pretty calm and uneventful (a good thing!), she was busy nonstop. I have come out of this experience with so much more admiration for our nursing coworkers.

Whenever I become a licensed therapist, I will now have a new perspective towards others in the inpatient environment. If I’m trying to clear the floor for PT and cannot get a hold of a nurse, I need to understand that they have so many other things on their plate and talking to me might be the last of their priorities at the current moment. Open communication and teamwork lead to better patient outcomes. We all want what is best for our patients, and together as a cohesive team, we can make that happen. I hope more people get the chance to have this opportunity, and if any of you reading this get the chance, please take it!

-Kara Kaniecki, SPT