NewYork-Presbyterian is at the forefront of diagnosing and treating female-specific pelvic floor, neurological, and musculoskeletal conditions as a burgeoning subspecialty within physical medicine and rehabilitation. Physiatrists and physical therapists in the Department of Women’s Health Rehabilitation at NewYork-Presbyterian, Weill Cornell Medicine, and Columbia provide a full spectrum of services for complex women’s health conditions that often have been misunderstood or neglected.
The Pelvic Pain Nexus
One in four women between ages 17 and 75 experiences pelvic pain. Of those, 5% to 10% of women have chronic pelvic pain, which can significantly diminish their quality of life. Jaclyn H. Bonder, MD, a physiatrist and medical director of Women’s Health Rehabilitation at NewYork-Presbyterian and Weill Cornell Medicine, is one of the few physiatrists in the nation dedicated to diagnosing and treating female pelvic pain and pelvic floor dysfunction. However, teasing out the etiology of women’s pelvic complaints can be challenging. “Patients with pelvic pain can mean different things,” says Dr. Bonder. “Some people complain of pelvic pain, and it means bladder pain and lower abdominal pain. Some people will say pelvic pain, and it means vaginal pain or pain with intercourse. This broad definition makes figuring out where that pain comes from complicated because there are many overlapping symptoms.”
Some people complain of pelvic pain, and it means bladder pain and lower abdominal pain. Some people will say pelvic pain, and it means vaginal pain or pain with intercourse. This broad definition makes figuring out where that pain comes from complicated because there are many overlapping symptoms.
— Dr. Jaclyn H. Bonder
A common finding is hypertonic pelvic floor muscles—tightness in the pelvic floor muscles that contributes to symptoms of the GI system like constipation, pain with intercourse, bladder pain, and urinary urgency and frequency. “Often there isn’t an obvious structural cause of the pain or a positive diagnostic test to diagnose it,” says Dr. Bonder.
Shame and stigma are a barrier to care, particularly for intimate conditions like painful intercourse. Problems often start when patients experience pain when they first become sexually active or after a lingering infection. “They are told that their pain is normal, it will get better on its own, or that since tests are negative, there’s nothing wrong,” says Dr Bonder. She emphasizes the importance of validating patients’ pain and explaining what is causing it as the first step toward healing.
The program’s physiatrists assess patients’ gait, posture, spinal and pelvic alignment, and neurologic status of the lower extremities by conducting muscle and reflex testing. Dr. Bonder also evaluates the sacroiliac and hip joints, pubic symphysis, and abdominal muscles. Most importantly, she conducts a thorough musculoskeletal pelvic floor exam.
“Pelvic floor physical therapy is a mainstay of treatment,” says Dr. Bonder. “This is provided by specialized physical therapists who have received additional training to help treat women with these conditions.” Adjunctive therapies used can also include muscle relaxers and nerve pain or anti-inflammatory medications, trigger point and Botox injections for pelvic floor muscles, and nerve blocks.
Treating Musculoskeletal Problems Throughout the Female Life Span including Pregnancy and Postpartum
At NewYork-Presbyterian and Columbia, the Women’s Rehabilitation Program are pioneers in treating musculoskeletal problems associated with pregnancy and postpartum and bone health. “One in two patients will have some amount of back pain during pregnancy,” says Farah Hameed, MD, a physiatrist and medical director of Women’s Health Rehabilitation at NewYork-Presbyterian and Columbia. “And one in four will experience back pain following childbirth in the postpartum period.”
Dr. Hameed works together with obstetricians, orthopedists, and endocrinologists, to treat common and rare musculoskeletal problems, such as disc herniation during pregnancy as well as pregnancy and lactation-associated osteoporosis. Treatments include physical therapy, strengthening exercises to stabilize the core and pelvis, and supports like maternity bands, belts, and pillows. These treatments can help improve the function and quality of life of women during the peripartum period and can help make their journey into motherhood less painful.
In addition to pregnancy and postpartum, Dr. Hameed takes a multidisciplinary approach when treating problems associated with overtraining or having low bone mass, including stress and insufficiency fractures. Her work encompasses the lifespan of young female athletes, perimenopausal women, and women past menopause. “I also see younger women who are active and get recurrent stress fractures, which may be from the pressures of a sport where they are watchful of their weight or have an eating disorder,” she says. “We know that if you are altering any of your hormonal milieu when you’re in a period of life when you should be building bone, you can have lower bone density.”
Such problems often follow women into perimenopause and post-menopause or present for the first time in these later life stages. Dr. Hameed approaches these issues by quickly identifying the problem, such as a biomechanical cause, and/or screening for nutritional deficiencies and bone health disorders which may warrant further investigation and workup by an endocrinologist.
Women’s Health and Cancer
The Women’s Rehabilitation Program at New-York Presbyterian also recognizes and supports the needs of women with cancer. Kristen de Vries, DO, a physiatrist at NewYork-Presbyterian and Weill Cornell Medicine, has specific expertise and training in treating functional impairments related to cancer and its treatment “Breast and gynecologic cancers and their treatment are known to have long-term effects and impact on quality of life,” says Dr. de Vries. Treatment may include surgery, radiation, and/or systemic treatments, including chemotherapy or hormonal therapies, and each of these interventions can lead to functional changes. “With advancements in cancer care, there is a growing need to recognize the potential adverse effects of treatment, address these early, and ultimately improve both survivorship and quality of life for patients.” She adds that starting rehabilitation as soon as symptoms present can make a difference.
Dr. de Vries treats patients with a variety of diagnoses, including radiation fibrosis, axillary web syndrome, lymphedema, joint pain, neuropathies, plexopathies, and pelvic floor dysfunction. “The rates of pelvic floor dysfunction are higher in the breast and gynecologic cancer populations as compared to the general population, and can present in a number of ways,” she says. An underactive pelvic floor can lead to incontinence or pelvic organ prolapse, while an overactive pelvic floor can lead to difficulty emptying the bladder and/or bowel and pelvic pain. Bowel and bladder changes can also be related to neurologic changes from chemotherapy, surgery, radiation, and/or the cancer itself.
“Given the complex nature of cancer and its treatment, a comprehensive physical examination is critical. This allows for creating an individualized treatment plan based on a patient’s symptoms and functional goals,” says Dr. de Vries. Treatment may include lifestyle modifications, physical, occupational or pelvic floor therapy, bracing, medication management, and/or interventional procedures. She also works in close communication with the oncology teams to coordinate care, especially when patients are undergoing active treatment.
Given the complex nature of cancer and its treatment, a comprehensive physical examination is critical. This allows for creating an individualized treatment plan based on a patient’s symptoms and functional goals.
— Dr. Kristen de Vries
This advice applies to all women who need rehabilitation. “As more providers begin caring for these patients, diagnosis, and treatment may happen sooner, which is prognostically better for patients to improve, feel better, and have more pain control,” says Dr. Bonder.
