Physiotherapy for Survivors of Sexual Violence

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Original Editor - Jeniffer Chepkemoi from The Center for Victims of Torture as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell and Rishika Babburu  

Physiotherapy for Survivors of Sexual Abuse

Victims of sexual assault therefore present with unique health care needs. Given the prevalence of sexual assault, physiotherapists are likely to encounter sexual assault patients and are often on the frontline of caring for these patients. Consideration for physiotherapy interventions that recognizes the complex impacts trauma can have on a person’s well-being is paramount. Trauma-informed care appreciates how a person’s life history may have impacted their development, their behaviors, and their current situation.

A Trauma-Informed Approach to Sexual abuse care is important. The power differential between the health care professional and the patient, as well as an invasive physical examination, can cause victims of sexual assault to re-experience the trauma of an assault during health care interactions. In particular, the medical forensic examination and interview are invasive by nature and therefore have high potential for traumatization. Trauma-informed care is a framework that recognizes the impact of trauma and the role of health care providers in addressing trauma with their patients. Trauma-informed care advocates for patient safety and control by building patient-provider collaboration, with the long-term goal of supporting trauma recovery, making it essential to quality care for sexual assault patients. As rehabilitation professionals who frequently encounter clients who have experienced or are experiencing traumatic events, physiotherapists are in an excellent position to foster positive health care experiences and holistic rehabilitation by working from a trauma-informed perspective and supporting the health and resilience of both patients and therapists.

Table.3 Five Key Principles of Trauma Informed Care

Safety	The physiotherapist creates a therapeutic environment in which patients feel safe (physically and emotionally), respected, validated and understood. Safety is so vital that people usually can’t start processing their trauma until they feel safe. It is important for people to feel as safe as possible, so it is crucial that physiotherapists build a relationship of trust before they start the examination process,
Trustworthiness	It is often hard for survivors of trauma to trust people, and being touched can be very difficult, particularly for survivors of physical or sexual abuse. In situations where the treatment process involves touching the body and manipulating the joints, it is critical that physiotherapists not touch patients without permission. Therefore, the physiotherapist should work with a patient to develop a trusting relationship prior to undertaking any physical treatments.
Choice	The choice of the patient and the ability to control their physiotherapist treatments is important. Decisions about their treatment plan are not made for them, but with them.
Collaboration	Treatment effects are maximized by working with what the patient is already doing/knowing what works best for them.
Empowerment	Physiotherapists should priorities treatments that empower and build the patients skills and coping mechanism in managing their own health. Survivors often come from a place of being disempowered so it’s very important that they have major say input into their physiotherapy intervention, and that they have choices.

Physiotherapist should have a good understanding of pelvic anatomy and neurophysiology as this is critical to accurate diagnosis and management with appropriate physiotherapy techniques.

Goals of Physiotherapy for Survivors of Sexual Abuse

Main goals of physical therapy are to:

1. Increase patient awareness and proprioception of the affected musculature,
2. Improve ability to discriminate between muscles and to relax them,
3. Normalize muscle tone,
4. Increase elasticity at the vaginal opening and desensitize areas that are painful, and
5. Decrease fear of vaginal penetration.

Examples of other types of physiotherapeutic treatment recommended for relieving chronic pain and other physical complications in GBV survivors:

• Pelvic Floor Exercises
• Joint Mobilization Exercises
• Massage
• Vaginal Cones Exercises
• Biofeedback
• Hydrotherapy
• Thermotherapy 
• Myofascial Therapy
• Dance Therapy

Dyspareunia and Vaginismus

Dyspareunia is characterized by pain during sexual intercourse or vaginal penetration. Vaginismus is characterized by spasm of the perineal musculature which makes vagina penetration difficult.

Pelvic floor physiotherapy is an important treatment strategy in the multidisciplinary approach to dyspareunia and vaginismus as it improves muscle relaxation, normalize resting muscle activity, increases vaginal elasticity, muscle awareness and proprioception.

Methods such as manual therapy, Kegel exercise, posture, core stabilization, stretching, strengthening, flexibility and coordination exercises should also be included in the rehabilitation programme.

In males, instructing patients to isolate and identify the various trunk and pelvic muscles, as well as pelvic floor isometric strengthening exercises, biofeedback, and electrical stimulation can help with erectile dysfunction and improve control of the ejaculatory reflex.

In females, pelvic floor muscle training has been shown to improve quality of life and sexual function in women with urinary stress incontinence. This connection has prompted the recommendation that women with urinary problems should be asked about their sexual function.

Few physiotherapy studies have been done to explore treatment options for sexual abuse survivors. More research is needed about the topic areas below:

• Pelvic Floor Dysfunction
• Urine and Fecal Incontinence
• Vulva Hygiene
• Pelvic Inflammatory Disease
• Uterine Proplase
• Dyspareunia

When treating both male and female patients who are experiencing pain with sexual intercourse, there are a several guidelines to keep in mind for optimizing your patient’s well-being.

Take a thorough history of your patient presenting with pain during sexual intercourse

• Facilitate a therapeutic alliance that allows the patient to feel comfortable sharing with you.  Start with open-ended questions to give the opportunity for the patient to direct the conversation.
• Use close-ended questions to gain a more detailed understanding of the source of the pain. It may be a nearby mechanical or structural issue in the low back, hips, or legs.
• Asking the patient about specific positions in which their pain is evoked is essential to understanding the mechanism of their pain.
• Work to understand the role psychosocial factors and fear may be playing in the patient’s pain.

Your physical examination of the patient should allow you to gain an understanding of mechanical and soft tissue limitations that may affect the patient during sex. Always explain why you need to touch a patient in sensitive areas and gain their consent before proceeding with your exam. If possible, patients should be referred to a physiotherapist who specializes in pelvic physiotherapy. An internal physiotherapy examination (of vagina or anus) should NOT be conducted by physiotherapists without advanced training in pelvic floor physiotherapy. However, even when there are not qualified pelvic floor therapists available and thus an internal examination or even detailed external palpation of genital musculature is NOT conducted, physiotherapists can still provide skilled evaluation and treatments.

Provide a treatment plan consistent with the patient’s goals. Example areas to focus treatment goals:

• Increase patient awareness and proprioception of the affected musculature
• Improve ability to discriminate between muscles and relax them
• Normalize muscle tone
• Increase elasticity at the vaginal opening and desensitize areas that are painful
• Decrease fear of vaginal penetration

Treatment tools that may be utilized are:

• Education: providing anatomical and physiological information to improve patient’s understanding of their own body.
• Cognitive behavioral: vaginal dilators
• Rehabilitative: pelvic floor muscle strengthening and relaxation, (with tools to facilitate biofeedback if available).
• Palliative: to decrease pain and improve mobility

Manual techniques such as stretching, massage, soft tissue and joint mobilisation may be utilised as appropriate in order to achieve patient goals.

Chronic Pelvic Pain (CPP)

Chronic pelvic pain (CPP) in women is a complex condition, with a high prevalence globally. CPP is defined as “chronic or persistent pain for at least 6 months, perceived in structures related to the pelvis, and often associated with negative cognitive, behavioral, sexual and emotional consequences and symptoms of lower urinary tract, sexual, bowel, pelvic floor or gynecological dysfunction” (34).

Compared with the general female population, women with Chronic pelvic pain report poorer total health, a higher number of surgeries in the pelvic area, and more incidences of physical, sexual, and psychological abuse. Altered movement and respiratory patterns are observed, and pain-related fear of movements among other issues are often present.

Sexual Dysfunction in Men

Much of the research on male sexual dysfunction has previously been focused on neurological or vascular causes. More recently, studies have turned their focus to the involvement of the pelvic floor (35). The pelvic floor helps to stabilize the internal organs and gives bowel and bladder control. Research has shown that physical therapy intervention in treatment of the pelvic floor musculature is a safe and conservative method for treatment of male sexual dysfunction and pelvic pain. The causes of sexual dysfunction and pelvic pain that can be managed by physical therapy include erectile dysfunction, ejaculatory/orgasmic dysfunction, and chronic prostatitis/chronic pelvic pain syndrome.

Erectile Dysfunction

Muscles involved are bulbospongiosus and ischiocavernosus. Both of these muscles contribute to increased engorgement and expulsion of seminal fluid. These muscles need strength and coordination in order to properly contribute to erection. Pelvic floor exercise has been found to be effective in men with mild to moderate veno-occlusive dysfunction. Literature has suggested that voluntary contraction of the ischiocavernosus can increase penile pressure, thus increasing penile hardness. Literature has suggested that relaxation techniques of the pelvic floor muscles may resolve erectile dysfunction caused by high resting muscle tone.

The following are exercises that can be done with patients to help them gain strength of the pelvic floor muscles and are recommended for treating erectile dysfunction (www.medicalnewstoday.com, “Do Erectile Dysfunction Exercises Help?)  

Knee Fallouts:

• Have the patient lay supine with their knees bent, feet flat on the floor, and arms by their sides; instruct them to keep their back in a neutral position
• Have the patient contract their pelvic floor muscles while exhaling. Then have them slowly lower one knee out to the side, keeping the pelvic floor muscles contracted. The muscles or letting their pelvis lift off the floor.
• Next have the patient bring their knee back to where it started while inhaling and relaxing the pelvic floor muscles.
• Repeat with the other knee.
• Have the patient start with 4-5 reps on each side, working towards a goal of 10 reps per side.

Supine Foot Raises:

• Have the patient lay supine with their knees bent, feet flat on the floor, and arms by their sides
• Instruct the patient to contract the pelvic floor muscles while exhaling, then lift one foot in the air and straightening their knee
• Next the patient will lower their foot back to the floor while inhaling and relaxing the pelvic floor muscles
• Repeat on the other side
• Start with 4-5 reps on each side, working towards 10 reps on each side

Pelvic Curl

• Patient lies supine with the knees bent, feet flat on the floor, and arms by their sides
• Make sure the patient keeps their spine in a neutral position
• Have the patient contract their pelvic floor muscles and exhale
• The patient next will push their back flat against the floor
• They will then slowly lift their buttocks off the floor while pushing their heels into the floor
• Patient contracts their buttocks as they lift it off the floor; they should lift until they are in a bridge position
• While keeping their buttocks in the air, have them take 3 breaths in and out and contract the buttock and pelvic floor muscles
• Next have the patient slowly lower their buttocks to the floor, rolling one vertebrae at a time.
• Start by doing 3-4 reps, and work towards doing 10 reps as the patient gets stronger

Constipation

Constipation is a condition where bowel movements become difficult, painful, and infrequent. Normal bowel movements can occur anywhere from 3 times/day to 3 times/week. Constipation affects multiple aspects of a person’s health, including health-related quality of life. Constipation is influenced by a multitude of factors including an overactive pelvic floor, a diet low in fiber, improper hydration, and certain medications. Other risk factors associated with constipation include history of trauma, history of depression, females, lower socioeconomic status, regular use of constipation medications, and decreased activity (36).

An overactive pelvic floor hinders normal bowel movement. The pelvic floor surrounds the colon and rectum, aiding in the conscious control of elimination of feces. If the pelvic floor muscles are hyperactively contracting, passing a bowel can be difficult leading to pain, straining, hemorrhoids, anal fissures, fecal impaction, or rectal prolapse. Someone with a history of trauma, postural problems, and psychological/emotional factors can experience an overactive pelvic floor. While this handout can help to teach ways of relaxation of the pelvic floor, it will also be important to treat the underlying causes.

Physiotherapy is a very effective way of reducing the symptoms of constipation and optimising your recovery. Physiotherapists are equipped with knowledge and skills to do a thorough assessment and treatment programme specific to patient needs and goals.

Diaphragmatic Breathing

Diaphragmatic breathing is a good way to bring about general relaxation of the mind and body as well as relaxation of the pelvic floor. It stimulates the parasympathetic nervous system (rest and digest) and relaxes the sympathetic nervous system (fight or flight). The parasympathetic system promotes movement of the GI tract, and relaxation of the sympathetic system aids in relaxation of the surrounding back, pelvis, and trunk muscles which may be tense and causing pain. Teaching diaphragmatic breathing can be easy using DASS–Deep, Abdominal, Slow, and Smooth.

• Have patients lie comfortably with eyes closed. Have them focus on their breathing and eliminate any outside or stressful thoughts.
• Have them place one hand on their abdomen and the other on their chest, and have them observe which hand moves more with breathing. Guide them to focus on breathing primarily with the abdomen.
• Breathe in slowly through the nose, deep to the abdomen so it expands with inhalation. Hold for a second or more, and then exhale slowly through pursed lips, allowing the abdomen fall inward.
• The entire movement should be smooth instead of choppy. If they are experiencing choppy breathing, it may be helpful to breathe more slowly. Try having patients breathe in for 2 counts, then out with three. Numbers can be changed as needed but generally exhalation should be longer than inhalation.
• This can be done for 3-4 minutes at a time, multiple times each day.

Abdominal Self-Massage

Teaching patients to massage themselves at home can be an effective way to move stool along in the colon. The massage will follow the path of the colon.

• Have patients lie in a comfortable position on their back either with knees flexed or extended.
• Direct patients to the right side of their abdomen just above the iliac crest of the hip. Gently massage the abdomen, moving straight up from the hip until reaching the ribcage.
• Next, have patients move straight across the abdomen until reaching the left side of the ribcage.
• Then massage down the left side of abdomen from the ribcage until reaching the left iliac crest of the hip.
• Finish massaging by moving from the left hip until they reach you reach the center of the abdomen where the 
• Repeat this pattern for about 10 minutes at a time.

Tips for Massage:

• Use fingertips to move in a circular motion. The pressure can be gradually increased as tolerated.
• Spend about 1 minute moving through each direction
• Always start on the right side and go in a clockwise direction, as the direction that feaces travels through the colon.

Additional Lifestyle Tips for Reducing Constipation:

1. Diet;
   • Drink lots of water and tea to help soften stool for easier bowel movements
   • Limit consumption of drinks like soda, coffee, and alcohol. These can remove water fromyour bowels and cause stool to harden. 
   • Eat food rich in fiber like vegetables, ripe fruits, grains, and nuts.
2. Toilet Posture
   • Use a step-stool or box under your feet to bring your knees higher than your hips. This will put the body in an easier position for passing bowel movements.
3. Exercise
   • Moderate aerobic activity such as walking, biking, and swimming can help stimulate the bowels to move.

Feacal Incontinence

The Role of Physiotherapy in Treatment and Management. Information about fecal incontinence is included as this can be common sequelae for those who have experienced anal rape. Fecal incontinence or accidental bowel leakage (ABL) is defined as the inability to control bowel movements resulting in the loss of liquid or solid stool. The cause is often multifactorial including factors such as damage to muscles or nerves, rectal changes, aging, medication and child birth. This condition can have detrimental effects on the quality of life, daily activities and social interactions of those affected. Fecal incontinence is a complex issue often associated with psychological effects and can be a sensitive topic for many. Physical therapists have the ability to reassure their patients that they are not alone and implement accessible, evidence-based interventions and recommendations to help manage their patient’s condition and increase their quality of life (37) (38).<div