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April 30, 2024/Pediatrics/Rehabilitation

Pediatric Pelvic Floor Therapy Program Offers Holistic Care

Novel program is life changing for patients and families

child using exercise ball

Traditionally, pediatric pelvic floor disorders are treated through medical management and education to establish healthy habits. But pelvic floor therapy is key to improving the quality of life for these children, says Erin Ramsey, an occupational therapist at Cleveland Clinic Children’s Hospital for Rehabilitation.


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“Children and their families deserve to have a therapist who understands their unique needs and can offer skilled services in a compassionate and creative way,” Ramsey says. “Bowel-bladder issues are incredibly common, and having a dedicated team to problem-solve ways to improve their condition is so vital for their physical and mental health.”

The need for a pediatric pelvic floor program

The impetus for developing such a program at Cleveland Clinic Children’s was an international outpatient that Ramsey treated several years ago. “She really needed this specialty, but there was nobody to refer her to in our area,” Ramsey recalls.

As Ramsey discussed this need with fellow occupational therapist Suzanne Messer, the pair were inspired to design and propose a pelvic floor therapy program. As a collaboration with urology and GI specialists, the program officially began in July 2023 as the first one of its kind offered in northeast Ohio.

Ramsey notes that often families come in who have felt extremely isolated, so they consider having someone to listen to them and work to solve their issues a victory. “The impact we’ve had so far on a wide variety of patients is honestly incredible,” she says.

For instance, a teenage patient was evaluated and treated for urinary incontinence and daily abdominal and pelvic pain that had been worsening over the past five years. Within four treatment sessions, her pain went from between eight and 10 on the pain scale down to two, and she is no longer taking pain medication or having urine leaks. “This is just one brief example of how pelvic floor therapy improved a child’s quality of life and ability to function daily,” Messer says.


A unique approach

Institutions that offer pelvic floor therapy programs are typically managed by physical therapists. However, the pelvic floor treatment program at Cleveland Clinic Children’s is run by Ramsey and Messer, both occupational therapists.

“Occupational therapy applies a holistic and child-centered approach to each patient’s evaluation and treatment, and our program is equipped to work with children who are neurodivergent and neurotypical.”

Like traditional physical therapy-based programs, Ramsey and Messer assess physical function, including posture and muscle strength and tone. “We use surface electromyography biofeedback to look at how the pelvic floor muscles are working and how we can change them to improve bowel and bladder symptoms,” Messer says.

Messer and Ramsey believe that occupational therapy offers a unique treatment perspective, in part because of the therapists’ ability to understand the specific goals of each child. “We have the skills to solve complex scenarios and make positive changes in all areas of daily life, but especially with bladder and bowel concerns,” says Messer.

Occupational therapists are also experienced in working with children who have sensory challenges. “We work on how to identify what the body is feeling and what that feeling means,” Ramsey says.“When interoception and sensory processing skills are out of sync, we’re well equipped to dive into all these self-care areas that impact the gut, bowel and bladder and figure out how to problem solve. It feels like occupational therapy is the perfect holistic profession to target the pelvic floor.”


Pediatric urologist Lynn Woo, MD, agrees, noting, “Bowel and bladder dysfunction are under-recognized, but extremely common in many otherwise healthy children that can lead to significant problems, including soiling, incontinence, and urinary tract infections.”

While prescription medications, surgery or other invasive procedures may be needed to address these issues, treating any underlying pelvic floor muscle and other behavioral components of the disorder are vital to being able to fully treat the problem, she explains. “Occupational therapy can provide an incredibly helpful adjunctive treatment modality in the management of elimination dysfunction and can effectively re-train a child’s body to function more normally.”

Individualized treatment

Along with determining each child’s physical function, their unique sensory needs are considered. “Can they tolerate wearing different types of clothing and textures? Does the smell of the bathroom impact their ability to sit for an appropriate amount of time? Are they fearful they might fall off the toilet even though they’re well supported?” Ramsey explains.

The team evaluates each child’s current coping strategies and whether they need to learn new ones. For example, if a child has an accident at school, are they able to calmly find a solution or are they so embarrassed that they are paralyzed and unable to deal with the situation?

Additionally, the team looks at every angle of the toileting process, from the child’s ability to independently manage their clothing in a reasonable amount of time, to their use of a proper wiping technique, to whether they feel the urge to eliminate at all. This includes evaluating all the child’s environments and what barriers might exist in each.


“We also assess if there’s any type of special equipment they might need to help them transfer on and off the toilet or maintain their balance safely while sitting on the toilet,” Messer says. “We’re really looking at all the pieces of the puzzle.”

Patients are usually seen for four to eight weekly sessions, with decreased frequency and follow-ups as needed. Each child receives a specialized home program at every session that includes applicable components such as exercises, positioning, breathing techniques, task modification, increased fluid intake and diet changes. The hope, says Dr. Woo, is that these tools become naturally incorporated into the child’s day-to-day functioning.

She also adds that motivation to seek treatment and adherence to a regimen are key when pursuing occupational therapy, as the approach aims to address an underlying chronic problem. When referring a patient, she says, “patient selection and being honest with what a family and child feels they are able to handle is important to getting a successful outcome.”

Addressing a wide variety of concerns

The most common reasons patients are referred to the pelvic floor therapy program include chronic constipation, urine or stool incontinence, withholding urine or stool, bed-wetting past age six frequent urinary tract infections, abdominal pain, pelvic floor pain or spasming and pain with bowel movements or urination.

Ramsey and Messer emphasize that they take any case, no matter how complex or challenging. “While we love to use the EMG biofeedback, we also have many patients for whom that is just not an option,” says Ramsey. This may be due to anxiety or because a child has had so many invasive bowel and bladder procedures, they don’t want to be touched.

Instead, the pair use dolls, crafts, models and developmentally appropriate books to interact with their patients, as well as to engage and educate them. “We’re meeting them where they’re at and then we’re peeling off the layers to look at what we can do each session to get to the end goal,” Messer says.

As mothers themselves, Ramsey and Messer find deep satisfaction in their vocation. “This work is incredibly valuable in improving family dynamics and relationships between the parents and kids,” Messer says. “We have found so much joy in helping these families that have been underserved work through these challenges.”

Messer and Ramsey say they are more than happy to consult with healthcare providers about their pediatric occupational therapy pelvic floor therapy program. “We would love to talk to anybody who has questions and let them know if we can make a difference and how we would accomplish that,” says Ramsey.


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