This is the second of a three-part series regarding the benefits of physical therapy after treatment for anal cancer, focusing specifically on pelvic floor. The Anal Cancer Foundation is thrilled to have licensed physical therapist Dr. Allison Palandrani lend her expertise on this subject matter.

See our latest update to this series which was posted August 26, 2020 on the blog.

Featured Contributor: Allison Palandrani, PT, DPT

For many people, when they think of physical therapy their mind goes to ankle sprains and joint replacements. So when they’re prescribed physical therapy (PT) for a pelvic floor-related problem, such as pelvic pain or incontinence, after anal cancer treatment, they simply do not understand how physical therapy—something they may have done before in a gym-like setting—will help them.

In my previous blog post, I explained how pelvic floor PT can help those who have undergone treatment for anal cancer address pelvic pain, fatigue, incontinence, lymphedema, and loss of range of motion/stiffness. In this post I’m going to cover exactly what he or she can expect from a pelvic floor PT appointment.

Evaluation Appointment 

The purpose of the evaluation appointment is to ascertain your needs and identify how physical therapy can help.

At the evaluation appointment, the first thing we do is have a detailed conversation in order to obtain a patient’s full medical history and any other relevant information. Among the questions we ask are:

When did your treatment start/end? Are you experiencing pelvic girdle/floor pain with physical activity or at rest? What does it feel like? Where is it located? What exacerbates your symptoms? What alleviates your symptoms? Are you feeling fatigued? How does it affect these three functions: Urination? Bowel movements? Sex? Are you experiencing urinary or fecal incontinence? What kind of work do you do? Which physicians are following you regularly? What medications are you taking?

After we’ve gathered all of the relevant info, we will ask the patient to disrobe from the waist down so that we can begin the hands on portion of the initial evaluation.  The physical therapist will typically leave the room for a moment to give the patient privacy and time to get situated and comfortable.

During the hands on part of the evaluation, the goal is to begin to develop an understanding of what is going on with the patient’s tissues, joints, and muscles and determine what the primary impairments are that we need to treat first in order to be both efficient and therapeutic with the treatment.

We choose where to begin this part of the evaluation based on what we’ve already learned from the patient. The evaluation appointment is only a one-hour appointment, so we’ll selectively tackle the areas that are causing the most significant symptoms first.

While every patient’s case is unique, we will always try to evaluate the pelvic floor muscle tone and function on evaluation day. During the internal exam, physical therapists are assessing muscle tone and integrity (muscles too tight or weak?), and a gauge of the patient’s pelvic floor motor control and function. They will also evaluate the connective tissue around the pelvis and lower extremities, because radiation is so often a component of anal cancer treatment the connective tissue surrounding the pelvic girdle tends to become very stiff and painful. The physical therapist will evaluate the internal pelvic floor muscles by inserting one finger into either the vagina or rectum with our female patients and into the rectum of our male patients.

In case you’ve never gotten an explanation for how connective tissue contributes to pelvic pain or you need a refresher, this is my spiel: Connective tissue (which is the tissue that lies between the skin and the muscle) becomes tight as a result of underlying dysfunction in muscles, nerves, organs, or joints. With radiation the connective tissue often becomes very dense and stiff. As a result, there is reduced blood flow and the tissue becomes hyper-sensitive. Therefore, it becomes difficult and painful to manipulate. If we don’t fix it, it’s going to continue to contribute to the underlying impairments in corresponding muscles, nerves, organs, or joints, and the pain cycle will continue.

Often because the pelvic floor muscles and tissues have become so stiff from the radiation the muscles are unable to function properly which can contribute to urinary, fecal, and gas incontinence. This is overwhelmingly common for people that have gone through treatment for anal cancer and although we cannot always cure this, it is often possible to make some improvement. We need to address the pelvic floor muscle tone and focus on neuromuscular control. Essentially, bringing the brain’s focus back to the pelvic floor muscles and re-educating these neural pathways.

In the evaluation appointment, we examine the patient’s connective tissue mobility and their pelvic floor muscle tone and function, plus other areas we are able to get to that we believe are contributing factors to their symptoms. Ultimately, between this first appointment and the next appointment or two, all areas on the patient will be evaluated from the ribs to the knees, back and front.

Typical Pelvic PT Sessions After Evaluation

At the beginning of a typical follow up PT session, the physical therapist will walk into the room with the patient dressed. The physical therapist will take a few minutes to discuss with the patient how they tolerated the previous session, how they are feeling overall, and to address any questions that may have come up so far.

After a brief chat, the physical therapist will leave the room so that the patient can disrobe from the waist down and get situated on the table.

The exact treatment plan will vary depending on each person’s symptoms and presentation. However, if pain is an issue, the first thing that we will typically do during therapy is treat any connective tissue restrictions in the area through connective tissue manipulation. The reason we do the connective tissue manipulation first is that it makes it easier to treat any underlying trigger points or excessive muscle tightness and it calms the nervous system down some; it increases blood flow to the area and it relaxes the pelvic floor a bit.

Typically we spend about half the appointment on connective tissue manipulation and external trigger point release (external work), and half the appointment on internal trigger point release and muscle lengthening (internal work). An appointment lasts for one hour and patients typically see us one to two times per week.

Your physical therapist will also often give you an individualized program to do at home, based on the areas that need improvement. In order to get the most out of your physical therapy treatment, it is important to be diligent about the given home program. Although physical therapy appointments are typically occurring 1-2 hours per week, it is imperative to continue to attend to the areas of involvement/impairment to elicit the desired changes.

It is important to understand that physical therapists don’t use a cookie cutter, one-size-fits-all approach to pelvic floor rehabilitation. Not only will every patient’s treatment be different, but also a specific patient’s treatment will change and evolve from appointment to appointment. It’s also important to know that we will not leave our patients alone in the room hooked up to a tens unit or to a biofeedback machine or performing exercises with an aide.

Before I wrap up, I’d like to stress the importance of PT/patient communication in pelvic floor rehab. As a pelvic floor PT, it’s vital to my treatment approach that my patient knows what I’m doing and why I’m doing it. That’s why throughout the treatment session, I clearly explain to him or her what we’re doing and why it’s being done. On the flip side, it’s equally as important for patients to communicate their questions/concerns to me. When it comes to successful pelvic floor rehab, PT/patient communication is a key to success.

My third installment in the series will focus on how to find the right pelvic floor physical therapist for you.

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