Pre-Licensure Inter-Professional Perspectives: Pelvic Health Physiotherapy

Purpose: In this study, we examined knowledge and perspectives pertaining to pelvic health physiotherapy among medical, midwifery, nursing, and physician assistant students at McMaster University. Moreover, we identified opportunities to improve knowledge translation to facilitate inter-professional education in urogynecological care. Method: A cross-sectional design was created to distribute an online survey to participants using a modified Dillman approach. The survey assessed areas of clinical interest in, knowledge of the scope of practice of, and regulations governing pelvic health physiotherapy in specific, in addition to clinical applications. Fisher’s exact and Kruskal–Wallis tests were used to assess statistical significance. Results: A total of 90% of the participants incorrectly indicated that internal digital exams could be delegated to physiotherapy assistants, and 50% believed that Kegel exercises were appropriate for all presentations of pelvic floor dysfunction. Moreover, when prompted to select conditions that could be treated by pelvic health physiotherapists, only 2% of the participants selected the correct conditions. Conclusions: Knowledge in all four programmes about the scope of practice, authorized activities, and application of pelvic health physiotherapy is inadequate. To foster the optimal integration of urogynecology into the relevant health science curriculums, enhanced inter-professional education, inclusive of pelvic health physiotherapy knowledge, appears to be needed. Key Words: interprofessional education, interprofessional relations, pelvic health physiotherapy, pre-licensure

Objectif : examiner les connaissances et les points de vue relatifs à la physiothérapie pelvienne des personnes étudiant pour devenir médecins, sages-femmes, infirmières ou auxiliaires médicales à l’université McMaster; établir des possibilités d’améliorer l’application des connaissances pour faciliter l’enseignement interprofessionnel en soins urogynécologiques. Méthodologie : les chercheurs ont créé un sondage transversal en ligne au moyen de la méthode de Dillman modifiée. Ce sondage évaluait les secteurs d’intérêt clinique, les connaissances sur le champ d’exercice et les applications cliniques de la physiothérapie pelvienne, de même que la réglementation s’y rapportant. Ils ont utilisé la méthode exacte de Fisher et le test de Kruskal-Wallis pour évaluer la signification statistique des résultats. Résultats : au total, 90 % des participants ont indiqué à tort que les examens digitaux internes pouvaient être délégués à des assistants-physiothérapeutes et 50 % croyaient que les exercices de « Kegel » convenaient à toutes les présentations des dysfonctions pelviennes. De plus, lorsqu’on les invitait à sélectionner des affections qui pouvaient être traitées par des physiothérapeutes pelviens, seulement 2 % des participants choisissaient les bonnes. Conclusion : les connaissances sont insuffisantes dans les quatre programmes à l’égard du champ d’exercice, des activités autorisées et de l’application de la physiothérapie pelvienne. Pour favoriser l’intégration optimale de l’urogynécologie aux programmes pertinents en sciences de la santé, il semble nécessaire d’améliorer l’enseignement interprofessionnel, y compris les connaissances sur la physiothérapie pelvienne. Mots-clés : : enseignement interprofessionnel, période précédant l’obtention de permis, physiothérapie pelvienne, relations interprofessionnelles The traditional unidisciplinary paradigm continues to be the standard in health care, but it remains ineffective in addressing complex patient needs.1 Isolated professional perspectives limit direct learning of the skills, clinical decision making, and patient interactions used in other professions.2 The World Health Organization recognizes inter-professional collaboration (IPC) as an expected standard of practice to improve the provision and quality of care.3 High-quality systematic reviews have substantiated the IPC approach by demonstrating improvements in patient satisfaction, teamwork, and the delivery of care while implementing inter-professional principles.4,5 IPC depends on a clear understanding of the role and scope of each discipline within the team to set comprehensive goals and make decisions.6,7 Inadequate integration of IPC into clinical practice can be attributed to the nature of pre-licensure health programmes, which encourage unidisciplinary environments and overlook the benefits of collaboration and inter-professionalism.8 To foster behaviours that are congruent with IPC, it is important to expose students to inter-professional education (IPE) at the pre-licensure level.9 A collaborative learning environment can facilitate positive educational interactions among pre-licensure students with the objective of improving patient outcomes and establishing an interdisciplinary approach.4 Pelvic health physiotherapy is an emerging area of practice that is primarily aligned with urogynecology. Pelvic health physiotherapists, among other practitioners, assess and treat pelvic floor dysfunction (PFD) in men, women, and children.10 PFD refers to impairment of the pelvic floor musculature and can result in urinary tract symptoms, bowel symptoms, sexual dysfunction, prolapse, and pain, thereby demonstrating the significant role the pelvic floor plays in the pelvic cavity.11 Central pain and pro-inflammatory mechanisms involved in persistent pain conditions, such as vestibulodynia, can affect pelvic floor function through hypertonicity and poor voluntary muscular control.12 Persistent pelvic pain is a common complaint among young patients, and more than 300,000 cases of endometriosis were surgically confirmed in Canada in 2009.13,14 Urinary tract symptoms affect both men and women, with 43% of men and 57% of women in Canada experiencing at least one urinary tract symptom in their lifetime.15 However, the development of PFD is strongly correlated with the female gender, aging, pregnancy, parity, and giving birth with the help of instruments.16 It is estimated that PFD will rise by 35% in the next 12 years, thereby greatly increasing the need for pelvic health physiotherapy to be readily accessible.17 PFD is best addressed using an evidence-based, multi-modal model that includes pelvic health physiotherapy.18 The current recommendations indicate that pelvic floor muscle training (PFMT) is the first line of management for stress urinary incontinence and pelvic organ prolapse.18,19 Most recently, clinical practice guidelines for persistent pelvic pain conditions have recommended using pelvic health physiotherapy to address the myofascial aspects that may contribute to an individual’s pain experience.20 To effectively address the complexity of pelvic health conditions from an integrative perspective, it is imperative to establish IPE and IPC within urogynecological care to optimize patient outcomes.21 To achieve this, an understanding of one another’s skills and relative scopes of practice is required. Based on the respective programme curriculums, all students in the undergraduate medicine (MD), nursing (NS) and physician assistant (PA) programmes at McMaster University in Hamilton, Ontario, receive some instruction in obstetrics and gynecology practices. However, at the time that the data for this study were collected, no instruction in pelvic floor disorders was being provided. The midwifery (MW) programme provides students with a single lecture on the topic and this is delivered by an academic pelvic health physiotherapist. In conjunction with the lack of education of the pelvic floor, the only recent introduction of pelvic health physiotherapy into health care may contribute to the reduced awareness of pelvic health physiotherapy among members of a urogynecological team. This study represents the first phase of a two-phase study that aims to evaluate the knowledge and understanding of pelvic health physiotherapy among pre-licensure MD, MW, NS, and PA students at McMaster University.

A cross-sectional survey design was used; ethics approval was granted by the Hamilton Integrated Research Ethics Board (Project 4666). Participants The study participants consisted of MD, MW, NS, and PA students at McMaster University. These programmes were selected for participation because they are regularly involved in obstetrics and gynecological care. Physiotherapy students were not invited to participate in this study because their knowledge of pelvic health physiotherapy is assessed in their curriculum in their last semester. Please refer to Table 1 for further participant demographics. Inclusion criteria consisted of answering a minimum of 80% of the survey questions and being enrolled in the target programmes during the study period. We recruited participants between April and June 2018 by means of emails from faculty programme administrators, advertising through McMaster student leadership groups and social media platforms, and in-class announcements. No financial incentive was provided. The modified Dillman approach was used to maximize potential recruitment,22 whereby follow-ups were completed at the 2- and 5-week marks. Table 1 . | Characteristic | n (%) | ||| |---|---|---|---|---| | Medicine | Nursing | PA | Midwifery | | | No. in programme | 5 (12) | 10 (25) | 11 (28) | 14 (35) | | Gender | |||| | Female | 1 (3) | 10 (25) | 10 (25) | 14 (35) | | Male | 4 (10) | 0 (0) | 1 (3) | 0 (0) | | Age, y | |||| | ≤ 18 | 0 (0) | 0 (0) | 0 (0) | 0 (0) | | 19–24 | 2 (5) | 8 (20) | 5 (13) | 7 (18) | | 25–29 | 3 (8) | 1 (3) | 6 (15) | 4 (10) | | 30–39 | 0 (0) | 1 (3) | 0 (0) | 1 (3) | | 40–49 | 0 (0) | 0 (0) | 0 (0) | 2 (5) | | ≥ 50 | 0 (0) | 0 (0) | 0 (0) | 0 (0) | | Programme year | |||| | First | 3 (8) | 4 (10) | 4 (10) | 6 (15) | | Second | 1 (3) | 1 (3) | 7 (18) | 3 (8) | | Third | 1 (3) | 3 (8) | N/A | 1 (3) | | Fourth | N/A | 2 (5) | N/A | 4 (10) | N/A = not applicable; PA = Physician assistant. Survey Instrument An online survey was developed through SurveyMonkey (San Mateo, CA) to assess the level of interest in clinical areas that constitute the breadth of pelvic health physiotherapy and the level of knowledge of the pelvic health physiotherapy scope of practice and regulations and its clinical applications through clinical vignettes. Participants were asked to determine appropriate referral to pelvic health physiotherapy and identify any red flags in the following scenarios: post-prostatectomy urinary incontinence and low back pain in pregnant woman with placenta previa. The survey presented 31 questions in a variety of formats: 5-point Likert scale, true–false, multiple-choice, and open-ended formatting. Clinical vignettes were included to effectively estimate professional performance and critical thinking.23 Pilot testing Using SurveyMonkey, we pilot tested the survey in February 2018 to optimize its function, readability, and clarity with participants outside the target population. Eight non-McMaster University students and four recent graduates of MD, MW, NS, and PA programmes in Ontario were recruited and participated with consent. After they completed the survey, the participants were prompted to provide feedback, and their responses mainly related to a lack of familiarity with terminology and the length of the survey. We then modified the survey to improve participants’ comprehension, such as providing definitions for unknown terminology and reducing the number of options for answering questions. Data analysis Data were transferred from SurveyMonkey into a password-protected document in Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA). To maintain anonymity and confidentiality, all descriptors (e.g., names and email addresses) were removed from the raw data. Descriptive analyses were performed to determine the response frequency for all questions. Fisher’s exact test was conducted to determine between-groups differences in response frequency, and a Kruskal–Wallis test was used to assess differences across the groups.

Participation and demographics A total of 40 participants answered 95% of the survey; this met the minimum completion rate dictated by the inclusion criteria. Two participants did not meet the inclusion criteria and were excluded. The overall response rate was 2.6% based on the estimated enrollment data from each programme. Demographic data are shown in Table 1. Clinical areas of interest Overall, obstetrics garnered the greatest interest among the participants, followed by pain science, urogynecology, and gastroenterology. We noted statistically significant differences in the level of interest in obstetrics and gastroenterology among the four programmes. The participants who were most likely to provide neutral responses were MD and NS students. Individual programme trends can be found in Table 2. Table 2 . | Area | Average rating by programme* | |||| |---|---|---|---|---|---| | Medicine; n = 5 | Midwifery; n = 14 | Nursing; n = 10 | PA; n = 11 | Total | | | Urogynecology | 3.6 | 4.3 | 3.3 | 3.7 | 3.8 | | Obstetrics† | 3.4 | 4.9 | 4.8 | 4.2 | 4.5 | | Pain science | 4.2 | 4.3 | 3.7 | 4.1 | 4.1 | | Gastroenterology† | 4.0 | 3.2 | 3.6 | 4.5 | 3.8 | PA = Physician assistant. Based on a numerical quantification of each choice on a scale ranging from 1 (strongly disagree) to 5 (strongly agree). Between-groups differences (p < 0.05). Knowledge of pelvic health physiotherapy scope and regulations Only 60% and 64% of the NS and PA participants, respectively, considered internal digital examination to be an authorized activity in pelvic health physiotherapy, compared with 100% of the MD and MW participants (p < 0.05). Moreover, 90% of the participants incorrectly indicated that delegating internal digital examination or treatment to physiotherapy assistants was appropriate. Refer to Table 3 for participants’ responses relating to the scope of, and regulations governing, pelvic health physiotherapy as well as the clinical applications and vignettes. Table 3 . | Question | n (%) of correct responses | |||| |---|---|---|---|---|---| | Medicine; n = 5 | Nursing; n = 10 | PA; n = 11 | Midwifery; n = 14 | Total | | | Clinical applications of PHP | ||||| | PHP definition | 5 (100) | 10 (100) | 11 (100) | 14 (100) | 40 (100) | | Pelvic floor muscles | 5 (100) | 9 (90) | 10 (91) | 11 (79) | 35 (88) | | PHP synonyms | 4 (80) | 6 (60) | 6 (55) | 12 (86) | 28 (70) | | Gender | 5 (100) | 10 (100) | 11 (100) | 14 (100) | 40 (100) | | Pelvic health referral | 4 (80) | 7 (70) | 8 (73) | 11 (79) | 30 (75) | | First line of treatment | 5 (100) | 9 (90) | 10 (91) | 12 (86) | 36 (90) | | Kegel | 3 (60) | 6 (60) | 2 (18) | 9 (64) | 20 (50) | | Interstitial cystitis | 2 (40) | 9 (90) | 8 (73) | 11 (79) | 30 (75) | | Internal exam benefit | 5 (100) | 10 (100) | 11 (100) | 13 (93) | 39 (98) | | PHP scope and regulations | ||||| | Conditions treated in PHP | 0 (0) | 0 (0) | 0 (0) | 1 (7) | 1 (3) | | Degree requirements | 5 (100) | 10 (100) | 11 (100) | 14 (100) | 40 (100) | | College rostering* | 5 (100) | 10 (100) | 11 (100) | 14 (100) | 40 (100) | | Authorized activity | 5 (100) | 6 (60) | 7 (64) | 14 (100) | 32 (80) | | Delegation of internal exam | 4 (80) | 9 (90) | 10 (100)† | 12 (86) | 35 (88) | | Pessaries | 3 (60) | 8 (80) | 9 (90)† | 13 (93) | 33 (83) | | Medications | 2 (40) | 4 (40) | 7 (64) | 3 (21) | 16 (40) | | Clinical populations | 2 (40) | 7 (70) | 8 (73) | 5 (36) | 22 (55) | | Clinical vignettes | ||||| | Protatectomy and UI | 5 (100) | 9 (100)‡ | 11 (100) | 12 (86) | 37 (93) | | Placenta previa and LBP | 5 (100) | 7 (78)‡ | 8 (73) | 9 (64) | 29 (73) | College rostering is a mandated process in which physiotherapists in Ontario must add their name to a list indicating completion of required training, education, and experience to safely perform an authorized activity.24 In this case, the authorized activity being referenced is internal assessment or internal rehabilitation of pelvic musculature. The college is a provincial regulatory body that oversees the physiotherapy profession to ensure safe and ethical care to the public.25 n = 10. n = 9. PA = Physician assistant; PHP = pelvic health physiotherapy; UI = urinary incontinence; LBP = low back pain. Clinical applications of pelvic health physiotherapy A total of 10% of the participants did not select lumbopelvic pain or bowel concerns as being appropriate to refer patients for pelvic health physiotherapy. When prompted to select conditions that could be treated by pelvic health physiotherapists, 2% of the participants selected the correct conditions; endometriosis, dyspareunia, and erectile dysfunction were selected the least. A full 60% of the MD participants did not believe that management strategies provided through pelvic health physiotherapy for interstitial cystitis were based on evidence. More than half the participants (59%) incorrectly believed that pelvic health physiotherapists had the ability to prescribe medication; 70% of the PA participants answered correctly, and 79% of the MW students answered incorrectly. In addition, 50% of the participants incorrectly identified strengthening the pelvic floor muscles, or performing Kegel exercises, as an appropriate treatment for all patients with PFD. Clinical vignettes Qualitative content analysis of the open-ended responses revealed that 60% of the MD, 69% of the MW, 82% of the PA, and 100% of the NS participants did not identify placenta previa as a contraindication for a digital vaginal examination in the prenatal population. In addition, 40% of the NS participants indicated lower confidence levels for both vignettes and responded with comments such as “Not sure” or “Just a guess.” Statistical analysis using a Kruskal–Wallis test determined no differences across the programmes.

To our knowledge, this is the first study to investigate pre-licensure students’ knowledge of pelvic health physiotherapy. Overall, there is a clear indication of inadequate knowledge across all programmes about pelvic health physiotherapists’ scope of practice, including the breadth of conditions treated and authorized activities. All programmes demonstrated limited awareness of the conditions that might involve myofascial pain and altered tone of the pelvic floor musculature, such as lumbopelvic pain, painful bladder syndrome, and dyspareunia.26 For well over a decade, clinical practice guidelines for managing persistent pelvic pain have highlighted how important it is that all relevant health care providers understand the implications of the myofascial system in relation to persistent pelvic pain.27 Our findings identify a potential educational opportunity for future pre-licensure students to understand the role of pelvic health physiotherapy as an initial conservative care strategy for numerous pelvic-related conditions.28 Our participants demonstrate limited knowledge of the scope of practice of pelvic health physiotherapy in regard to internal digital examination and medication prescription. This represents a significant barrier to facilitating IPC within urogynecological care because an internal digital examination is an integral part of assessment and treatment in pelvic health physiotherapy. It is well understood that a significant number of women do not contract their pelvic floor correctly and thus use compensatory strategies, such as holding their breath and contracting their gluteal muscles.20 This is counterproductive for improving pelvic floor strength and motor coordination.29 Consequently, health care professionals who are able to conduct an internal digital examination should assess the function of the pelvic floor and initiate PFMT principles and patient education as needed. Pelvic health physiotherapists are best brought in when additional expertise is required such as the progression of PFMT and a return to functional activity. A surprising finding was that participants incorrectly assumed the scope of pelvic health physiotherapists includes prescribing medication and delegating digital pelvic floor assessments or treatment to physiotherapy assistants. This limited understanding of the scope and associated competencies of pelvic health physiotherapists may lead to confusion among health care providers and individuals seeking care, thereby hindering the proper flow and quality of care.30,31 The perspective that performing Kegel exercises represents appropriate treatment for all pelvic conditions is not supported by evidence. Strengthening is only one component of training. The literature has demonstrated that PFMT is an effective multi-modal approach to addressing pelvic floor muscle capacity using many parameters, including strength, endurance, flexibility, responsiveness to pressure, and coordination.33–36 Thus, PFMT protocol needs to align with the parameters of fitness, and these parameters need to be developed. Establishing a protocol based on increasing the contractile properties of the pelvic floor through strengthening, for example, would be a misguided approach when increased pelvic floor muscle tone is the reason for lack of optimal function.34,35 A universal approach to treating PFD demonstrates a poor understanding of the etiologies of pelvic floor conditions. Instead, individualized PFMT programmes based on an internal assessment of the pelvic floor musculature are effective for addressing pelvic dysfunctions and considered best practice.29,37 Failing to recognize the appropriate treatment approach can exacerbate patients’ symptoms and limit function.38 The effectiveness of management strategies used in pelvic health physiotherapy in treating sexual pain and dysfunction may not be well known among health care professionals.42,43 Our findings provide further confirmation; our participants did not believe that dyspareunia was an appropriate reason for referral. This lack of knowledge can have significant implications for the sexual health and quality of life of individuals with pelvic conditions.43 Recent literature has stated that women with persistent pelvic pain, such as vulvodynia and endometriosis, are less likely to engage in sexual activity than healthy women in the same age group, and this situation can have a negative impact on intimate relationships, self-esteem, and quality of life.21,44,45 Women of middle and older age report that their health care providers are less likely to discuss the topic of sexual health management because they have limited training and time, have a low level of comfort, and believe that sex is not a priority for older patients.46 This can further limit patients’ options for addressing sexual pain conditions. Pelvic health physiotherapy can help address sexual pain and dysfunction by using a conservative multi-modal approach and targeting the physical, psychological, and emotional components that may be involved in their clinical presentation.19,44 This study demonstrates that knowledge of the scope of practice and clinical application of pelvic health physiotherapy is lacking across four pre-licensure health science programmes; this lack of knowledge may reduce the likelihood that patients will receive optimal evidence-based care in a timely and efficient manner. Primary care providers may not feel comfortable screening for PFD because it typically requires answering questions about bladder, bowel, and sexual function.36 Our findings provide further evidence of the importance of integrating IPE into all pre-licensure health science programmes to increase the likelihood of IPC in the health care system. Moreover, this study gave us the opportunity to increase awareness of the role of pelvic health physiotherapy in managing pelvic conditions within the urogynecological team. This study has a few limitations. The main limitation is the small sample size because recruitment was limited to one university; however, this approach was due to time constraints and resources. In addition, recruitment occurred during the undergraduate examination period, which could have deterred students from participating. Also, the true–false response option for certain survey questions may not reflect participants’ true knowledge because the likelihood of guessing the correct response was 50%. Finally, the MD students in their first year of study had recently been exposed to obstetrics content in their curriculum, which may have led them to respond more accurately to the survey questions.

The findings of this study demonstrate a knowledge gap among pre-licensure health science students at McMaster University regarding the emerging area of pelvic health physiotherapy. Implementing IPE with pelvic health physiotherapy can help foster the optimal integration of urogynecological care into relevant health science curriculums. Integration of IPE at the pre-licensure level may also improve practitioner engagement in IPC in clinical practice. Implementation of IPE can be provided through applicable workshops, combined lectures, and merging student urogynecological interest groups with the inclusion of pelvic health physiotherapy to improve knowledge of the conservative management strategies provided by pelvic health physiotherapists. Our study is based on knowledge from a limited sample of pre-licensure health science students from a single university. To increase the generalizability of our results, future studies should include a large sample size and students from various universities. To assess effective learning modalities to improve students’ knowledge of pelvic health physiotherapy, the curriculum could provide interactive workshops and lectures. A second phase of this study will be to explore the development and delivery of IPE workshops using a quasi-experimental design to improve the knowledge translation of conservative care strategies for pelvic disorders among pre-licensure students. Key Messages What is already known on this topic Based on Health Canada’s 2005 initiative, Interprofessional Education for Collaborative Person-Centred Practice, inter-professional patient education (IPE) is considered vital to achieving inter-professional collaboration in the health care system.43 IPE involves at least two professions collaboratively learning about one another to improve the quality of care.43 The literature on conservative care strategies for common pelvic floor dysfunction has discussed treatment such as pelvic floor muscle training as optimally being delivered by a pelvic health physiotherapist.19,21,46 Despite those findings, there appears to be a lack of knowledge about pelvic health physiotherapy scope of practice and its integration into the urogynecological team.47 What this study adds This study is the first to examine pre-licensure health science students’ knowledge of the emerging area of pelvic health physiotherapy. Our findings highlight the barriers in the current unidisciplinary learning approach and identify gaps in this approach that may be bridged by using enhanced IPE opportunities. Phase 2 of this study aims to improve this knowledge translation by developing and delivering IPE workshops.

- 1. Orchard C, Curran V, Kabene S. Creating a culture for interdisciplinary collaborative professional practice. Med Educ Online. 2005;10(1): 4387. 10.3402/meo.v10i.4387. Medline:28253153 [DOI] [PubMed] [Google Scholar] - 2. Barr H, Koppel I, Reeves S, et al. Effective interprofessional education: argument, assumption and evidence. Oxford (UK): Blackwell Science; 2005. [Google Scholar] - 3. World Health Organization . Framework for action on interprofessional education & collaborative practice [Internet]. Geneva: World Health Organization, Department of Human Resources for Health, Health Professions Network Nursing and Midwifery Office; 2010. [cited 2018 Nov 20]. Available from: http://www.who.int/hrh/resources/nursing_midwifery/en/. [Google Scholar] - 4. Reeves S, Fletcher S, Barr H, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016;38(7):656–8. 10.3109/0142159X.2016.1173663. Medline:27146438 [DOI] [PubMed] [Google Scholar] - 5. Reeves S, Perrier L, Goldman J, et al. Interprofessional education: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2013;3:CD002213. 10.1002/14651858.CD002213.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar] - 6. Baxter P, Markle-Reid M. An interprofessional team approach to fall prevention for older home care clients “at risk” of falling: health care providers share their experiences. Int J Integr Care. 2009;9(28):1–12. 10.5334/ijic.317. Medline:19513181 [DOI] [PMC free article] [PubMed] [Google Scholar] - 7. Dufrene C. Health care partnerships: a literature review of interdisciplinary education. J Nurs Educ. 2012;51(4):212–16. 10.3928/01484834-20120224-01. Medline:22356357 [DOI] [PubMed] [Google Scholar] - 8. Joseph S, Diack L, Garton F, et al. Interprofessional education in practice. Clin Teach. 2012;9(1):27–31. 10.1111/j.1743-498X.2011.00486.x. Medline:22225889 [DOI] [PubMed] [Google Scholar] - 9. Salfi J, Solomon P, Allen D, et al. Overcoming all obstacles: a framework for embedding interprofessional education into a large, multisite Bachelor of Science nursing program. J Nurs Educ. 2012;51(2):106–10. 10.3928/01484834-20111230-05. Medline:22201276 [DOI] [PubMed] [Google Scholar] - 10. Allina Health . Pelvic rehabilitation services [Internet]. Minneapolis (MN): Allina Health; 2019. [cited 2019 Nov 29]. Available from: https://account.allinahealth.org/services/643. [Google Scholar] - 11. Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the Pelvic Floor Clinical Assessment Group of the International Continence Society. Neurourol Urodyn. 2005;24(4):374–80. 10.1002/nau.20144. Medline:15977259 [DOI] [PubMed] [Google Scholar] - 12. Zolnoun D, Hartmann K, Lamvu G, et al. A conceptual model for the pathophysiology of vulvar vestibulitis syndrome. Obstet Gynecol Surv. 2006;61(6):395–401. 10.1097/01.ogx.0000219814.40759.38. Medline:16719941 [DOI] [PubMed] [Google Scholar] - 13. Levy AR, Osenenko KM, Lozano-Ortega G, et al. Economic burden of surgically confirmed endometriosis in Canada. J Obstet Gynaecol Can. 2011;33(8):830–7. 10.1016/S1701-2163(16)34986-6. Medline:21846438 [DOI] [PubMed] [Google Scholar] - 14. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):1789–99. 10.1016/S0140-6736(04)17403-5. Medline:15541453 [DOI] [PubMed] [Google Scholar] - 15. Herschorn S, Gajewski J, Schulz J, et al. A population‐based study of urinary symptoms and incontinence: the Canadian Urinary Bladder Survey. BJU Int. 2008;101(1):52–8. 10.1111/j.1464-410X.2007.07198.x. Medline:17908260 [DOI] [PubMed] [Google Scholar] - 16. MacLennan AH, Taylor AW, Wilson DH, et al. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000;107(12):1460–70. 10.1111/j.1471-0528.2000.tb11669.x. Medline:11192101 [DOI] [PubMed] [Google Scholar] - 17. Kirby AC, Luber KM, Menefee SA. An update on the current and future demand for care of pelvic floor disorders in the United States. Am J Obstet Gynecol. 2013;209(6):584–5. 10.1016/j.ajog.2013.09.011. Medline:24036399 [DOI] [PubMed] [Google Scholar] - 18. Abrams P, Cardozo L, Wagg A, et al. Incontinence. 6th edition. Bristol (UK): International Continence Society; 2017. [Google Scholar] - 19. Dumoulin C, Hay-Smith J, Habée-Séguin GM, et al. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a short version Cochrane Systematic Review with meta‐analysis. Neurourol Urodyn. 2015;34(4):300–8. 10.1002/nau.22700. Medline:25408383 [DOI] [PubMed] [Google Scholar] - 20. Vermandel A, De Wachter S, Beyltjens T, et al. Pelvic floor awareness and the positive effect of verbal instructions in 958 women early postdelivery. Int Urogynecol J. 2015;26(2):223–8. 10.1007/s00192-014-2483-x. Medline:25062656 [DOI] [PubMed] [Google Scholar] - 21. Engeler DS, Baranowski AP, Dinis-Oliveira P, et al. The 2013 EAU guidelines on chronic pelvic pain: is management of chronic pelvic pain a habit, a philosophy, or a science? 10 years of development. Eur Urol. 2013;64(3):431–9. 10.1016/j.eururo.2013.04.035. Medline:23684447 [DOI] [PubMed] [Google Scholar] - 22. Millar MM, Dillman DA. Improving response to Web and mixed-mode surveys. Public Opin Q. 2011;75(2):249–69. 10.1093/poq/nfr003. [DOI] [Google Scholar] - 23. Veloski J, Tai S, Evans AS, et al. Clinical vignette-based surveys: a tool for assessing physician practice variation. Am J Med Qual. 2005;20(3):151–7. 10.1177/1062860605274520. Medline:15951521 [DOI] [PubMed] [Google Scholar] - 24. College of Physiotherapists of Ontario . Controlled acts and restricted activities standard [Internet]. Toronto: College of Physiotherapists of Ontario; 2019. [cited 2019 Oct 24]. Available from: https://www.collegept.org/rules-and-resources/controlled-acts-and-restricted-activities. [Google Scholar] - 25. College of Physiotherapists of Ontario . About the College of Physiotherapists of Ontario [Internet]. Toronto: College of Physiotherapists of Ontario; 2019. [cited 2019 Oct 24]. Available from: https://www.collegept.org/about/about-the-college. [Google Scholar] - 26. Jarrell JF, Vilos GA, Allaire C, et al. No. 164 – consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2018;40(11):e747–87. 10.1016/j.jogc.2018.08.015. Medline:30473127 [DOI] [PubMed] [Google Scholar] - 27. Vilos GA. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2005;27(9):869–87. Medline:19830953. [DOI] [PubMed] [Google Scholar] - 28. Barbara G, Facchin F, Buggio L, et al. What is known and unknown about the association between endometriosis and sexual functioning: a systematic review of the literature. Reprod Sci. 2017;24(12):1566–76. 10.1177/1933719117707054. Medline:28558521 [DOI] [PubMed] [Google Scholar] - 29. Neels H, De Wachter S, Wyndaele JJ, et al. Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: a prospective observational study. Eur J Obstet Gynecol Reprod Biol. 2018;220:113–17. 10.1016/j.ejogrb.2017.11.019. Medline:29202394 [DOI] [PubMed] [Google Scholar] - 30. Boyle R, Hay-Smith EJ, Cody JD, et al. Pelvic floor muscle training for prevention and treatment of urinary and fecal incontinence in antenatal and postnatal women: a short version Cochrane review. Neurol Urodyn. 2014;33(3):269–76. 10.1002/nau.22402. Medline:23616292 [DOI] [PubMed] [Google Scholar] - 31. Sidani S, Fox M. Patient-centered care: clarification of its specific elements to facilitate interprofessional care. J Interprof Care. 2014;28(2):134–41. 10.3109/13561820.2013.862519. Medline:24329714 [DOI] [PubMed] [Google Scholar] - 33. Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362–71. 10.1002/nau.20232. Medline:17304528 [DOI] [PubMed] [Google Scholar] - 34. FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. II: treatment of the patient with the short pelvic floor. Int Urogynecol J. 2003;14(4):269–75. 10.1007/s00192-003-1050-7. Medline:14530840 [DOI] [PubMed] [Google Scholar] - 35. Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012;41(5):680–91. 10.1111/j.1552-6909.2012.01404.x. Medline:22862153 [DOI] [PMC free article] [PubMed] [Google Scholar] - 36. Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187–93. 10.1016/j.mayocp.2011.09.004. Medline:22305030 [DOI] [PMC free article] [PubMed] [Google Scholar] - 37. Nygaard IE, Kreder KJ, Lepic MM, et al. Efficacy of pelvic floor muscle exercises in women with stress, urge, and mixed urinary incontinence. Am J Obstet Gynecol. 1996;174(1 Pt 1):120–5. 10.1016/s0002-9378(96)70383-6. Medline:8571994 [DOI] [PubMed] [Google Scholar] - 38. Bump RC, Hurt WG, Fantl JA, et al. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991;165(2):322–9. 10.1016/0002-9378(91)90085-6. Medline:1872333 [DOI] [PubMed] [Google Scholar] - 39. Frass M, Strassl RP, Friehs H, et al. Use and acceptance of complementary and alternative medicine among the general population and medical personnel: a systematic review. Ochsner J. 2012;12(1):45–56. Medline:22438782. [PMC free article] [PubMed] [Google Scholar] - 40. Sundberg T, Halpin J, Warenmark A. et al. Towards a model for integrative medicine in Swedish primary care. BMC Health Serv Res. 2007;7(1):107. 10.1186/1472-6963-7-107. Medline:17623105 [DOI] [PMC free article] [PubMed] [Google Scholar] - 41. Somvanshi PR, Venkatesh KV. A conceptual review on systems biology in health and diseases: from biological networks to modern therapeutics. Syst Synth Biol. 2014;8(1):99–116. 10.1007/s11693-013-9125-3. Medline:24592295 [DOI] [PMC free article] [PubMed] [Google Scholar] - 42. Faithfull S, White I. Delivering sensitive health care information: challenging the taboo of women’s sexual health after pelvic radiotherapy. Patient Educ Counsel. 2008;71(2):228–33. 10.1016/j.pec.2007.12.011. Medline:18339512 [DOI] [PubMed] [Google Scholar] - 43. Sorensen J, Bautsita K, Lamvu G, et al. Evaluation and treatment of female sexual pain: a clinical review. Cureus. 2018;10(3):e2379. 10.7759/cureus.2379. Medline:29805948 [DOI] [PMC free article] [PubMed] [Google Scholar] - 44. Morin M, Carroll M, Bergeron S. Systematic review of the effectiveness of physical therapy modalities in women with provoked vestibulodynia. Sex Med Rev. 2017;5(3):295–322. 10.1016/j.sxmr.2017.02.003. Medline:28363763 [DOI] [PubMed] [Google Scholar] - 45. Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric. 2014;17(1):3–9. 10.3109/13697137.2013.871696. Medline:24423885 [DOI] [PubMed] [Google Scholar] - 46. Health Canada . Pan-Canadian health human resource strategy: 2007/08 report [Internet]. Ottawa: Health Canada; 2008. [cited 2019 Nov 29]. Available from: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/pdf/pubs/hhrhs/2008-ar-ra-eng.pdf. [Google Scholar] - 47. Davis KJ, Kumar D, Wake MC. Pelvic floor dysfunction: a scoping study exploring current service provision in the UK, interprofessional collaboration and future management priorities. Int J Clin Prac. 2010;64(12):1661–70. 10.1111/j.1742-1241.2010.02509.x. Medline:20946271 [DOI] [PubMed] [Google Scholar]