The aim of this study is to assess changes  in practice amongst Pelvic Physical Therapists  in the United States regarding  their use of ultrasound (US) imaging and  education methods and over the past 10 years.

United States trained Pelvic Physical Therapists (PT) were invited to participate in a 52 question internet-based survey that was modified from a similar survey completed in 2007 (1). Questions were added to increase understanding of confidence and to reflect the increase in residency training (one residency program in 2007 and nine in 2017). Subjects were recruited through social media, professional organization website postings, journal clubs and members of the APTA Section on Women’s Health.   All students, PT assistants and international PTs were excluded from participation. Survey questions were related to the type of professional education received for pelvic floor muscle (PFM) dysfunctions at various levels of training including first professional, post-professional, residency, continuing education, and on-the-job.   Survey Questions also queried type of PFM assessment training (discussed versus performed)  as well as type of PFM assessment techniques utilized in current Pelvic PT practice. Preliminary analysis included descriptive statistics of key constructs. These results are presented alongside a similar study conducted 10 years ago for reference.

The survey was initiated by 403 PT’s that were trained in the United States. Three hundred and twenty three PTs completed the survey. Percent change was calculated by subtracting the 2017 value from the 2007 value, dividing the 2007 value, and multiplying by 100. Over the past ten years there has been a substantial increase in discussion of US imaging in both first professional (277% increase) and on-the-job training (153% increase) for Pelvic PTs. (Table 1) Practice of US imaging in on-the-job training has increase 503%. (Table 2)  Currently the most common place for Pelvic PTs to practice US imaging is during residency (30.4%) followed by on-the-job training (18.7%),  post professional university education (15.2%) and continuing education (13.3%). (Table 2) Self reported usage of US imaging often or almost always in patient care has not change from 2007 (4.4%) to 2017(4%). In 2017, 9.4% of United States Pelvic PTs surveyed felt confident in their skills in using US imaging in comparison to 85.9% who felt confident in their skills in examining the PFM through vaginal palpation.

Despite an increase in US imaging education, Pelvic PTs report low levels of confidence in psychomotor skills for its use in the clinic.  Additionally, there has not been a concurrent increase in the use of US imaging in the clinic, based upon the therapists surveyed.  Possible barriers to the use of US imaging in the Pelvic PT clinic include cost and space for equipment, lack of reimbursement, lack of training and confidence in its use.  
The PFMs can be evaluated in the clinic using a variety of measurements including vaginal digital palpation, biofeedback, and US imaging. Many professionals suggest a complete PFM assessment would include more than one type of test.   Trans abdominal US imaging of the PFM has been shown to have good intra- and inter-rater reliability (ICC 0.81 to 0.88) (2). Reliability in vaginal digital palpation studies varies (3).   Trans abdominal US is more sensitive than digital vaginal palpation to assess the lifting function of the PFM (3). However, US imaging cannot assess closure pressure like vaginal digital palpation (2).  US imaging has good clinical utility alongside vaginal palpation in the assessment of PFM function. 
Limitations of the study include the number of people that did not complete all questions, low number of therapists that reported using US imaging, and possible confusion in the meaning of the educational categories. Additionally, this was not a cohort study and results were compared to a study completed in 2007.

Over the past ten years there has been an increase in training in US imaging in United States PT education. However, despite its clinical utility, the results of this study suggest that US imaging for the assessment of PFM lifting in clinical practice has not increased. These findings should inform future education and training of Pelvic PTs so as to increase practice of US imaging, to teach practical skills needed to perform US imaging in a clinical setting and to increase therapists understanding of the importance of US imaging use in the clinic toward improving outcomes.

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