Infection prevention and control
Assessment and treatment techniques used when performing pelvic health internal examinations or treatments involve contact with mucous membranes and, therefore, necessitate the use of clean technique. Clean technique reduces the risk of infection and includes the use of hand hygiene, non-sterile, clean gloves, and clean work surfaces.5 Hand hygiene may be performed using either soap and water or alcohol-based hand sanitizer (60% alcohol content) and should be performed within the treatment room, immediately prior to donning gloves.6
Equipment and devices such as vaginal probes, cones, and pessary fitting rings are classified as semi-critical items according to the Spaulding Classification, due to their contact with mucous membranes.6 Physiotherapists employing these devices must be aware of and compliant with manufacturer directions regarding device use (e.g., single use, single patient use, or reusable). Reprocessing of reusable pelvic health physiotherapy devices must be consistent with the Spaulding Classification for the item, the manufacturer’s directions, and employer policies and procedures (when such procedures exist). In cases where there is a discrepancy between the Spaulding Classification of the device and manufacturer’s directions for reprocessing, physiotherapists are directed to use the higher level of disinfection/sterilization.6
Physiotherapists are directed to familiarize themselves with the Infection Control Standard of Practice,3 and with the Infection Prevention and Control Resource Guide for Alberta Physiotherapists.6 Additional information regarding device reprocessing can be found in the Guide.
Treatment risks and adverse event management
All aspects of physiotherapy practice include some risk. Pelvic health physiotherapy is no exception. Risks related to physiotherapy practice with this patient population include, but are not limited to:
- Skin irritation or allergic reactions
- Psychological trauma
Risks may vary depending on the patient population served and the specific treatment techniques employed by the physiotherapist. Consent conversations must include a discussion of material and special risks related to the assessment and treatment techniques proposed.
Physiotherapists are also required to identify real and potential risks to patient safety relevant to their practice and to develop critical event management plans to address each of the identified risks.3 A critical event management plan documents:
- The patient safety risk considered.
- Education provided to patients and families about treatment risks and how to respond to a critical event occurring after the patient leaves the physiotherapy site.
- The appropriate response to a critical event or near miss occurring at the physiotherapy site.
- The respective roles and responsibilities of all individuals (physiotherapists, non-physiotherapist staff, patients and families) in responding to a critical event.
- The type and location of resources to be used in response to a critical event.7
More information about Critical Event Management Plans can be found here.7
Sensitive practice is a routine practice
The risk of psychological trauma bears special consideration when working with this patient population. It is estimated that 33% of females and 16% of males will experience sexual assault within their lifetime. Other estimates indicate that 50% of girls and 33% of boys will experience sexual abuse by the time they are 16 years old.8 With these statistics in mind, the assertion that “all health care practitioners – whether they know it or not – encounter adult survivors of interpersonal violence in their practices”9 and sexual violence in particular, is well founded.
Survivors of sexual abuse generally demonstrate increased health-care utilization and are more likely to experience headaches, migraines, and chronic pain - conditions physiotherapists commonly treat.10,11,12 Physiotherapists working in the area of pelvic health may be even more likely to encounter survivors of sexual abuse as pelvic pain and acute gynecological injury are common consequences of sexual abuse. A significant proportion of individuals who have been sexually abused exhibit symptoms of PTSD, even years after the abuse occurred,10,11,12 and this may affect their response to seemingly innocuous procedures or interventions.
With such a high proportion of people having a history (whether recent or remote) of sexual abuse, all physiotherapists are advised to adopt sensitive practice as a routine practice in their patient interactions. Physiotherapists working in the area of pelvic health must also keep in mind that “examinations and procedures that health-care providers might consider innocuous or routine can be distressing for survivors of sexual abuse, because they may be reminiscent of the original trauma.”9 Physiotherapists working in the area of pelvic health need to be thoughtful and intentional in their interactions with patients, giving consideration to how their actions or comments could be misinterpreted or misunderstood.
Applying sensitive practice in clinical interactions
Applying the principles of sensitive practice as a routine practice means assuming every patient you encounter may have a history of sexual abuse and then acting accordingly. Some ways that physiotherapists can exhibit this include:6
- Slowing down, and taking the time to listen to the patient, to engage with them and develop a therapeutic relationship by being present and attentive to their concerns.
- Explaining what you are planning to do and why it is important, before you begin and with each step of the assessment or treatment process.
- Remembering that patients with a history of sexual abuse demonstrate non-linear healing, meaning that what they can tolerate one day may be different the next. Physiotherapists can demonstrate an awareness of this fact by reaffirming patient consent for different treatment procedures at each appointment, rather than assuming past consent remains valid. This is not only consistent with sensitive practice; it is also an expectation outlined in the Standards of Practice3 and Consent Guide.13
- Including an explicit statement of your intent to provide a safe environment for survivors of sexual abuse such as the one below:
XYZ Clinic strives to foster an environment where patients feel safe and supported. Survivors of past trauma should be aware that experiencing an internal exam may be difficult and triggering for some people. In order to help you feel safe and avoid possible triggers, we ask that you tell your physiotherapist about any history that may make the assessment or treatment hard for you. This information helps your physiotherapist to work with you to find approaches to treatment that feel safer and less challenging for you. Your private information will be kept confidential.
- Discussing the option of having a third party/chaperone/support person present for the assessment/treatment or any portion thereof.
- Sharing control with the patient, by
- Ensuring the patient has provided informed consent.
- Being alert and sensitive to non-verbal signs that the patient may no longer be comfortable with the assessment or treatment procedures, such as:
- Physically withdrawing
- Tensing hands or body
- Shallow breathing
- Decreased responses to questions
- Checking in with the patient to confirm ongoing consent to assessment and treatment.
- Making it clear to the patient with both words and actions that they can withdraw their consent at any time. Patients with a history of sexual abuse may need to be encouraged to advocate for themselves and may need to be “given permission” to say no.