The Best Position(s) for Rectal Treatment

This podcast will help you to become more confident with your patients , more successful in your practice or business , and a leader in pelvic health . We're going to have some fun along the way . Join us as we rise together .

We're Jesse and Nicole Cozine , founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle , and this is Pelvic PT Rising .

We've heard about how transformational it is If you have been on the wait list or if you're just listening to this now and catching up . It is open today , so make sure you head to pelvicptrisingcom and check that out . In honor of that , we've been talking rectal treatment for the last couple of episodes . We're going to be talking today about rectal positions .

Before we do that , nicole , just a couple more details on the course . Give me that origin story . I know we've talked about this a little bit , but why did you feel like this was ? I know you have 100 ideas for courses . Why was this in your top ? Basically , three courses .

This one was exciting to put together because it's so needed and it's such an area that I observed for a very long , long time in our out of town patients that we treated at pelvic sanity and the remote consultations that I've done , hearing other patients' experiences about the ways that they've experienced pelvic therapy and , frankly , the things that have been missing

the rectal evaluation and treatment of the pelvic floor , muscles and the tailbone and everything has been a significant thing that I've been teaching those patients to go back and ask their practitioners to do .

And sometimes , when they would do that and I would have follow up calls with them , they would say , oh well , she didn't want to do it , or she did it once way back in the day and said that my quote pelvic floor was fine and doesn't think it's necessary .

I would hear back , oh , she said that we're getting the same muscles vaginally anyway , so there's no need to do that . And so I kept hearing these , these essentially these excuses as to why somebody wasn't getting rectal treatment . And then we actually posted we run a patient centered Facebook group that is all positive , practical information for patients .

It's called Finding Pelvic Sanity , and we actually posted in that group about hey , have you guys experienced rectal evaluation and treatment if you're going to public floor therapy ? And the amount of comments in there that were something like I asked my person to do it , I have pain right there . And then these same excuses were coming up .

And so it wasn't just that I observed that with a small number of patients albeit larger than most would have experienced , but it was also that we asked a ton of patients and then I got so many direct messages and messages in that Facebook group about that's where my pain is . I don't understand why somebody can't look there .

And so it was a combination of both practitioner stuff and patient centered stuff where I was like this just we just need to put together all of the things in one area and address all of it .

Address why someone's not doing rectal about , address what would be the implications to do rectal , how to talk to patients about it Because I would also talk to practitioners and they would say stuff like , oh , I just don't want to have to convince my patient to do it , and I'm like Whoa , you're not convincing anybody to do anything was not like coercion to do

rectal treatment . It's literally just presenting the reasons why it would be important and helpful information to add to your plan of caring . It might be a missing piece , and so we did a missing piece series on it and that got a lot of attention recently .

And when then we were like well gosh , when was the last time we actually did a little cohort of rectal ? And it was like , wow , I can't believe . It was like two years ago and that was like kind of nuts , and so that's like , as my dad would say , the long story short of it is that so details .

For those who are a CEU Obsessed , we have a whole nother podcast we probably need to talk about with that , but you will get a certificate of completion for that . So that's all that . Check it out . There's testimonials from people who have been through it and what it's done for them and their practice on that website . Again , that's pelvicpturizingcom .

Slash rectal .

There's not a prerequisite to take this course , so you can take the rectal evaluation and treatment course without having taken a rectal treatment course from any one of those other organizations . It just covers totally different stuff and it covers it in a very different way . So it's not meant to replace 2A . It's not . It's not an either or decision .

Yeah , yeah , yeah so you know in all of your incorporating there . So it's not either or it's not a prerequisite , you know . You just need to take a look at it . If it's something that you think that you need to add to your practice to be better for your patients , there's nothing holding you back , totally All right .

So , nicole , we're talking about rectal positions and I think one of the things that you said that was interesting to me is that the position that most people are taught rectal in is actually your least favorite .

I mean , essentially you're palpating somebody in the fetal position which is , by definition , like not functional . I mean , even if you're in the position like , it's not a functional position . Fetal position Right .

So if you think about one hand is being taken up by actually performing the rectal exam and treatment and assessing the pelvic floor , then if you're going to come up with a patient , then if you're going to commit to treating by manually , meaning using both hands for most , if not all , of your treatment , which is something that I am a huge proponent of I teach

that in essentials , I teach it again in rectal , I teach it in the IC course and basically any course you ever take for me is going to give you this lens to look through . Like what is your offhand doing ?

If you're sitting there treating your patient with internally and your other hand is doing anything but on the patient doing something else helping you to decide what's going on in the pelvic floor , then I mean I don't know what you're doing .

You can maybe treat the glute with the other hand , but it's just not a good way , and because your patient isn't fixed onto the table in some way , then even if you're going to treat , you can't put pressure anywhere , because then they're falling off the table . Yeah you got . You're pushing them .

They're pushing you back because they feel like they're going to fall off the table . It's just , it's not great . I mean , basically , the only reason why I would do sideline is , literally , if they can't lay on their stomach , if they also can't lay on their back and they can't get into quadruped trials . Pose or any other functional position or stand .

It's like if they're getting wheeled into your office .

And you guys know I freaking hate swirly's and I didn't really realize that there was another definition of swirly , with like the toilet or whatever . Yeah Right , so like if you're getting bullied or whatever and you get your head put . What is it you ?

So if you are treating with one hand only internally , vaginally or rectally and you are assessing let's say , your right hand , assessing their right side , if they're supine and transvaginal and then you don't change position and you literally just pronate and rotate your wrist and swirl your finger around to try to assess the other side , I call that a swirly and

it's just as bad as the other type . I mean , it is not good for your wrist , it's not good for your hand , it feels terrible . If you're the patient and you're not getting an accurate assessment and a reproducible assessment of the pelvic floor and I'll tell you , if no one has done this to you rectally , then you're not missing anything . It's like the worst .

It's even worse rectally than it is vaginally . It feels terrible . So if you are treating , let's say , the person's in right side lying and you're treating with your right hand , you're behind them and you're treating their left pelvic floor and you want to get to their right pelvic floor , if you do a swirly and go down towards the table .

That is going to feel terrible for your patient . You wonder why no one likes rectal treatments ? Because that's happening . So in side lying you almost have to do that .

So but yeah , I mean bottom line is that , honestly , that would be better and if your treatment table is up against a wall or something like that vaginal or rectal I would have your patient move Patient , have your patient flip to their other side , because that will allow you to treat with both hands so that you get accurate information and you're not putting your

wrist at a weird angle and then causing yourself like some freaking carpal tunnel or tendon or finger tendon problem and then you got to go explain that to the hand doctor

.

Is because it doesn't allow you a good assessment and it feels terrible to the patient and if you have not experienced somebody doing a swirly on you , like you need to feel it so that you never do it to a patient again . Honestly .

And then we have all the other functional positions that I think Trump sideline , which is quadruped , and child's pose , moving from quadruped down into child's pose . So like movement , even honestly standing with some functional movements like bending and squatting and stuff is also important to do that with .

So but let's go back to prone for a second , and there are some cons to prone . So I know that all of you that aren't regularly treating in prone you're going to be like , oh my gosh , you're going to have your patient with face down doing rectal . It's like yes , because I think that the pros far outweigh the cons in most patients .

There are exceptions , but to me it's like you want to get your patient's body in the position that it's closest to functionally , and when they're on the table that's not always easy , but at least in prone the hip is close to being an extension , the spine is very easy to see , palpate with your other hand , because that's what your idle hand is going to be

doing . You can treat the sacrum . The patient is they're laying on something , so that you , when you press on something , you can actually get a response in the pelvic floor . Or you can assess what's happening in the public floor . When you say , do a joint mode at the lumbar spine or at the thoracic spine , you can see their rib cage better .

You can treat all the way up into their mid thoracic spine With that . You can treat their glutes , you can treat their hamstrings All of that can be done simultaneously . While you're doing rectal evaluation and treatment , you can control the patient's internal , external rotation . You control the femur really well .

You can bring the patient's leg off of the table and get into like an asymmetrical position that to mimic more like walking .

The only thing that's not functional about is that it's non-weight bearing , but sometimes you don't want weight bearing forces to go through there right away as well , and so I feel like prone really is one of the most versatile ways that you can use bimanual treatment and also get an accurate assessment of the pelvic floor and the tailbone , which is so important to

do through their rectal evaluation , so transvectally .

Because if that's a problem , then I'm sure that there's some kind of work around or something .

However , if and when you're explaining that we're going to do rectal and we come to the agreement together that like this is going to give us really good information , and we're explaining the position that we're going to do it in , we can say that we have choices to do it in , but that the preferences is to do it in prone and this is how you're going to be

and you explain it really well . And then your patient's face doesn't have to be in the hole . It can be out where it can . You can put a pillow underneath their chest so that they can feel like they can still talk as well

. If you have your patient's face in a hole , if your table allows that , then a lot of times I'll just give somebody . I just say , hey , you can still talk through that . I talked to them before we do any internal stuff while they're in the rectal , the prone position , and so before we actually do the internal assessment .

I'm maybe assessing their spine that way and just getting them used to being in that position . I'm talking to them through that to allow them to see that like you can still talk to me , we can still have a full blown conversation . Like I'm moving their hip .

I'm going to move their hip in this way , I'm going to move their back in this way , I'm going to like , do some of the things I want me to do and then we add in the internal component and then I could just give patients another way to communicate with me .

So it's like if I'm doing something , if we're assessing in there and you feel some things weird , I want you to move your leg , I want you to tap the table . You can give them another nonverbal way to communicate with you In addition to just making sure that you're having an ongoing conversation with them . So , but it is a con that you can't see their face .

But as long as you do some things to address that and talk to the patient about it , then usually it's good to go and you can get just so much information from doing it in prone .

This is all predicated on the fact that you're doing some sort of bi-manual treatment and again , what that means is that during your internal assessment you're doing something else and it's really like looking to see does this , does locking the adductors change the tone of the rectum ? Does doing you can actually treat the psoas this way ?

Or you know , some of the hip flexors , does changing some of the hip flexor tension change the tension of the posterior pelvic floor ? That kind of stuff ? Supine , you can still manipulate the sacrum kind of , but it's a little bit more difficult . You can do bridging . You can do a lot of more ab recruitment type stuff .

So if you're trying to do some abdominal coordination activities and you want to see like , what's their pelvic floor recruitment , like posteriorly , are they over recruiting that ? Is it turning on too soon ? All that kind of stuff , is it over recruiting ? Are they post actively , post your pelvic tilting before ?

It's easier to see that because it's closer , mimicking some of their things that they might be doing like , say , at the gym . So I like supine , it also allows you to play around with hip flexion angles and non weight bearing positions really well . So , yeah , so I feel like there's a lot of good things about supine .

I just feel like for the most part , I'm looking at spine and sacrum and coccyx as I'm looking at the posterior pelvic floor , and I feel like those things are easier to assess and treat in prone . So I usually again default to prone versus supine , but supine is supine , but supine is still a decent choice .

So for different positions sometimes you have to just be cognizant of that so you're not biasing a pressure feeling in the canal or the hole that you're in , so that you're getting an accurate assessment of what's going on . But I really like this functional movement stuff .

So if , especially if somebody is like I have a problem when I'm I don't know working in the yard or something like that , well it's like well , what position do you normally in the yard ? Well , you're kind of in quadruped . Okay , cool , like let's get in quadruped and see what's going on , and then you can move into different angles of hip flexion .

It's weight bearing through at least the femur and so that's I like that as well . For quadruped Child's pose is can the patient relax ? Well , what happens when they go into , like , hip flexion ? What happens when they extend their arms and they're needing length in order to do that ?

That has connections all the way down to the posterior lumbar pelvic fascia , so , and thoracolumbar fascia , so that can influence , like how the sacrum and the and the coccyx are positioned and the posterior pelvic floor response to that . So I think that that's really important to do that .

And then , obviously , a lot of people don't think about doing standing rectal assessments . So we talk about doing standing vaginal assessments for people with prolapse and incontinence and stuff like that that are having those types of things in those functional positions . But you can also do this with a rectal assessment .

So either for a person where you just need to look at what the posterior pelvic floor is doing , where you do a transvaginal standing assessment and you find that there's some doing some sort of weird gripping thing with the posterior pelvic floor , you might want to add a standing rectal assessment as well .

It gives you a completely different picture about what's going on .

And if your patient only has one access point through the rectum to do stuff it's not like you get out of jail free card and not get to do a standing assessment you can still do standing , bending , lifting , twisting , all of the things that we would do with a transvaginal standing assessment Transrectly .

It's just that you have to change your position a little bit to accommodate for the angle at which you are going to be assessing that that area , got it and then so functionally .

So if you're saying , hey , you know , I think actually supine would be best for you , are they getting supine all the time ? Or is treatment usually a mix of these different things Like how does that work ? And do you have an example of you know , is it just one position or is it all of these what actually happens ?

So I do have a story actually about a patient that I treated them in multiple different positions . He was a cyclist and he was a relatively avid cyclist . He rode , like I think , over 100 miles a week .

He was constantly doing both mountain bike , trail riding and also road cycling and so he had symptoms of penenal nerve irritation and had golf ball on the rectum feeling and adductor tightness and numbness in the testicles and scrotum and also pain , testicular pain , intermittent leg groin pain , had history of a hernia .

So he's a relatively complex dude and he came in and he was like I'm not , not cycling . So if you're .

They all tell me I need to take a break . I don't want to do that . You came highly recommended , and if you're going to tell me not to cycle , then we're just going to . I'm going to . He , basically , was like I'm going to leave right now .

I think he would have stayed for the E-Val , but I was like okay , well , that's off the table , no problem , I just said so . What we're going to end up doing , though , is figuring out why . I was like what I said . This is going off a little bit of a tangent , but I was like so what if I told you have to do 50% , right ?

So now I'm bargaining with him . I'm figuring out like where's his line ? Would you be willing to pause for a week so we can get your symptoms down ? Would you be willing to cut your mileage in half . What was the deal ? So he ended up saying that he was not willing to do any stoppage at all .

So he still needed to ride the frequency , but he was willing to cut down on some of the mileage if we needed to do that , if we felt like that would give us some information . So long story short , as we ended up doing that . But he only had one access point .

So we were doing public floor assessments , rectally , obviously , and externally as well , in sitting . But there was a progression to him . So I usually do my assessments in prone .

So we started out prone , we started treating in prone and we found some pretty significant thoracic spine and sacral limitations as well that were influencing and his posterior public floor tightness and irritating the inferior rectal nerve , and so we got some of his symptoms down in prone . But if he's a cyclist , what's he doing ?

He's pushing off from a hip flexed angle . So you're at a significant angle of hip flexion and you're using your posterior chain from a lengthened position , essentially kind of , even though it's a two joint muscle , like I get it . But there's a significance in the amount of trunk and hip flexion that you're in when you're on a bike . And so what did we do ?

Then I moved him to supine and started to get well , non weight bearing what happens when we do each of your legs in hip flexion and varying angles of hip flexion and I know that in bike riders you're also using a little bit of internal rotation what was that doing to his penendal nerve pathway and stuff like that ?

So we're doing rectal assessment and treatment while we are looking at the non weight bearing positions of what would be needed to do a bike ride . And then we moved towards . Well , I know that I can't obviously do rectal when he's on his bike . That would be weird . That's where my line is drawn , folks .

So I ended up taking a Swiss ball and getting him on the floor , and just because we couldn't move our table in a way that wasn't going to make us move furniture but this is how much I'm trying to get to what we're doing right so I put a Swiss ball , I put a mat on the floor , I put a Swiss ball against a wall and I get in rectally and then have

him get into big hip flexion and then push against the Swiss ball , and then I can see some of his recruitment pattern .

And , sure enough , he was significantly doing I don't even know what he was doing , but I could feel it and it was like some weird , like pushing out , like almost , like his pressure management was not good , as he was like doing his force production on the ball , and so I was like well , does , is that the same if it's on a wall ?

Because I was like , if the Swiss ball is some sort of like non-malliable surface , what happens if he pushes against something stable and strong ? And it totally changed .

And so we ended up doing a lot of weight bearing work in a hip flex position against like an , starting from a stable surface , moving towards an unstable surface and getting that recruitment pattern better . So he wasn't over activating his pelvic floor and working on his breath pattern with his pedal strike and all this stuff .

And this is all coming from me not being a cyclist , you guys , I'm not like a cyclist specialist . So I mean , I took a look at him on his bike as well . I had him come in with his whole gear and then I'm bringing his padded shorts and all the things .

I'm sure that someone could have even done a lot better job with actually looking at the actual cyclist motion , but I was just looking at what are the piecemeal way that we can look at this from what functionally he has to do and get that as close as I can in the clinic and then check the hole that I need to get the best representation of what the public

floor is doing at that time , since we knew that he had pineal nerve like symptoms .

can't lay on their stomach because you're worried they're not going to be able to get up after then . Sure , but even then I'll try supine , you know , with like a wedge underneath them .

But if that's not going to work , then sidelining is sort of the next best thing and I'm always like so disappointed with like what I can feel there and you just have to take into account so many things that is hard for your brain to sort of wrap your head around . It's like okay , so the hip that's down is more fixed .

You know there's pressure on the greater trochanter , like there's the top leg is weird . The whole thing is just like not ideal .

So hopefully this gives you guys some different ideas on ways to be treating different positions for rectal . Obviously , I'm sure , nicole , you talk about all of this stuff in depth in the course , with models and demonstrations and all that stuff . So if this sounds interesting or sounds different than how you're usually treating , that might be something for you .

Doors are open now . They will be for the next three days on that , so don't delay . You're going to be very sad when you send me that email , inevitably on Friday , saying I'm so sorry , I forgot and life got in the way and I missed out and I wasn't able to do it . Can I get in ?

And the answer is going to be no , because we're honest about what we do and make sure you're getting in soon .

So , Nicole , takeaways I think one of the things that you said that was interesting is that checking your preference that a lot of therapists have if they are doing rectal , which is a big if to begin with , but if they're consistently doing rectal evaluation treatment , it's usually in one position .

Therefore , I'm a little bit nervous to try anything else , especially on a patient right , which is fair , but we also have to just do it , because sometimes what are you going to do ? Like ? You can't rope in your coworkers every minute , especially if they're not pelvic floor therapists . They're going to be like I don't want to do that , right ?

No one's going to sign up to get us early , right ? No Swirly's , and that's the other takeaway . Could you please stop doing Swirly's , please ? Can we figure out a way to treat one side with one hand , the other side with the other hand ?

You're going to yes , you're going to exit and insert more than once , but I'm telling you that is better for you to assess consistently , patient to patient and even within the same patient , like one day they come in and then the next week they come in .

You're going to be doing it most consistently all the time that way so that your hypothesis can be checked correctly . It just feels better . And if you don't believe me , ask somebody to give you a Swirly and you're going to see . It has to be compared to the non Swirly way .

And so if you don't listen to anything of this podcast , if you don't get the rectal course , if you don't do anything , please try to figure out a way to not give your patients Swirly's .

It's figuring out what's best for the patient , not necessarily what you're most comfortable with or what you were taught , but really deciding what you want to do for the patient . So that's something that you guys are interested in learning more on .

You certainly can join us for a cohort number two of the rectal course , but either way , I hope you got a ton out of this podcast . We are so grateful for each and every one of you who is listening would love to hear back from you . So if you want to send in , do you have a preference ? Which would you just treat inside line ?

Do you think that Nicole's totally wrong and it's amazing ? What is your preference ? Feel free to write in . We'd love to hear from you . We always want to keep this conversation going .