A total of 48 responses representing 58 individual practices (58/149 = 39% response rate) were collected (Table 1).

The mean number of therapists per practice was 3, although not all surveyed practices reported number of therapists. The majority of responding practices (n = 40, 83%) consisted entirely of female physical therapists (PTs). However, most practices (n = 43, 90%) accepted patients of all genders and gender identities, with only 10% (n = 5) only serving patients who identified as female. Portions of 17 distinct counties were included within the 50-air mile radius (Fig. 2), with approximately 8 counties with over 50% area included and 5 counties with over 90% inclusion (Cook, DuPage, and Lake Counties in Illinois, and Lake and Porter Counties in Indiana).

Map depicting 50-air mile radius (blue circle) from Dearborn and Jackson intersection in downtown Chicago (depicted by blue indicator) with included counties labeled

Regarding practice location, most surveyed practices were in Illinois within DuPage, Cook, and Lake counties (Fig. 3).

Density of all survey respondents in the Chicagoland area measured by number of surveyed providers per 100,000 individuals, by county

The highest respondent-patient ratio was present in DuPage County, at 1.30 providers/100,000 individuals, followed by Lake County (IL) with 1.00 respondent/100,000 individuals. Southern and Western counties within the Chicagoland area had low response rates (one PT each practicing west and south of Cook County where the city of Chicago is located). Although a small portion of the county was included within the 50-air mile radius (Fig. 2), DeKalb County in Illinois; Newton, Jasper, and LaPorte Counties in Indiana; and Berrien County in Michigan were excluded from Fig. 3 to improve the visualization of distribution of practices. There was a zero percent response rate from these counties, despite our protocol for 2 follow-up attempts.

Treatment modalities offered at surveyed practices varied. Nearly all PTs (n = 44, 92%) reported use of digital rectal exams within their practice. A large proportion (n = 39, 81%) endorsed reviewing ARM results, with the same proportion offering biofeedback. The most common type of biofeedback used was rectal balloon training (n = 26, 54%) followed by EMG-guided biofeedback (n = 22, 46%) and tactile/digital biofeedback (n = 13, 27%). Distribution of biofeedback and/or balloon training was similar to the overall distribution of surveyed practices (Figs. 3 and 4). Access to biofeedback of some form was primarily available in Cook, DuPage, and Lake Counties within Illinois (Fig. 4). Outside of Illinois, few practices (4%) offered biofeedback and balloon training.

Panels from L to R, top to bottom. a All surveyed practices in the Chicagoland area. b Availability of biofeedback and rectal balloon therapy in the Chicagoland area among surveyed practices. c Availability of formal or informal trauma training at surveyed practices. d Surveyed practices with formal PFPT certifications

Manual therapy, including visceral mobilization and massage, was offered by most practices (n = 30, 63%). Dietary and fluid intake recommendations, intended to supplement existing guidelines from referring physicians, were offered by nearly three-fourths of survey practices (n = 35, 73%); exercise counseling was offered by a much smaller proportion (n = 10, 21%).

Availability of PTs with specialist certifications varied widely among practices. The most common certification was the Women’s Health Clinical Specialist Board-Certification offered by the American Board of Physical Therapist Specialties (ABPTS), with 15 practices endorsing one or more PTs with this certification (31%), followed by the Pelvic Rehabilitation Practitioner certification offered by the Herman & Wallace Pelvic Rehabilitation Institute (n = 12, 25%). However, most practices reported having at least one PT with formal or informal trauma-informed training (n = 40, 83%). Most practices (n = 33, 69%) also offered telehealth as a potential appointment format.

Thematic analysis of select responses identified 3 major themes and 11 subthemes (Table 2).

The first major theme supported earlier adoption of PFPT as a parallel, adjunct treatment modality to medical therapy, including use for patients with complex co-morbidities. One practitioner stated: “I wish that referring providers… knew that even if the source of symptoms is more GI in nature, physical therapy can still provide patients relief of symptoms (especially pain, leakage, and hemorrhoids)” (Table 2).

The second major theme focused on the holistic approach of PFPT with scope of practice including lifestyle counseling and expanding beyond biofeedback. One provider stated, “Biofeedback machines are not the optimal way to teach patients how to relax their pelvic floors. It is easiest to be taught through rectal palpation. Failed anorectal manometry does not indicate a patient cannot relax his or her pelvic floor.” Another stated, “Biofeedback machines are not the end all, be all. There are a wide variety of techniques and a lot of important education to help support & empower patients to manage their conditions. PTs’ main job is to figure out how each patient learns best, what words they need to hear & what techniques work best for their unique situation.”

Regarding the scope of lifestyle counseling, one PT provided an example: “[We provide] recommendations regarding eating, including sitting, chewing food, breathing during meals, [and] avoiding tight pants all day as well as at mealtime.” Others mentioned expanding on over-the-counter recommendations provided by referring providers. Some practitioners also emphasized the potential benefit of PFPT before considering invasive surgical options, stating, “I wish referring providers knew how beneficial just even 1 or 2 sessions with a pelvic floor PT could be for a patient before they undergo more invasive treatment options such as surgery.” These two themes together provide context and specificity for a sentiment common among several PTs practicing PFPT that “providers don’t know we exist” and/or “don’t know what we do.”

The third theme explored barriers to accessing PFPT beyond geography/distance including lack of patient general health education, referral gaps, and psychosocial barriers to care including lack of mental health support and stress management. According to one PT: “Many times, constipated patients have poor education regarding healthy bowel habits… a lot of symptoms can be improved through proper education, not medications” (Table 2). Another concern among PTs was that many patients did not understand how the pelvic floor worked or did not establish a relationship in their minds between their bowel symptoms and pelvic floor dysfunction. One provider stated, “I often have patients complete a bladder and/or bowel diary to make correlations between symptoms and their diet.”

Regarding patient referral status, one PT stated: “PT does not typically have GI providers refer; usually patients self-refer or find us on google and present for other pathology,” and this potentially can lead to frustration among patients. Although distributions of practices were not found to be uniform (Fig. 3), it is evident that additional barriers exist for patients that can stem both from lack of information and provider referrals.

While our survey did not explicitly ask about suggestions for improving referral recommendations, several PTs commented on concomitant referrals to other team members for the integrated management of bowel disorders. The most common referral suggestion was for a dietitian or nutritionist (n = 9, 19%). Several (n = 6, 12.5%) suggested referrals to a behavioral health specialist, therapist, or psychologist, with one respondent stating “gastrointestinal psychologist” specifically.