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  • Writer's pictureNicole Cozean

The 10 Most "Controversial" Things We've Said

Updated: Sep 11, 2022

What's sparked the most conversation and discussion in pelvic health after 250 'sodes of the Pelvic PT Rising podcast

We've certainly shared our opinions about a lot of different topics in pelvic health. They've sparked conversation, debate and some disagreement.

But ultimately, these are the conversations we need to be having in order to push our field forward. You don't need to agree with all of these (or any of them!), but we hope it makes you examine your beliefs, challenge your thinking and become a better clinician.


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Without further ado, here are the 10 most 'controversial' things we've said over the years. Have a favorite? Shoot us an email or DM and let us know!

1. Biofeedback is not the best use of your time

Check out the full 'sode we did (one of our all-time best!) for all the details. But with the inherent limitations of biofeedback, we challenge whether it is the best use of our time with patients. Not whether it works (which we know it can), but whether it's the absolute best option.

2. We are (or should be) primary care providers

To live up to our doctoral-level education, we should be guiding patients through their care and a trusted resource. We should be the 'quarterback' of their medical team. But to take on this responsibility, we need to understand all of their different options and what we can be recommending (this is why we created the Medical Procedures for Pelvic Pain Masterclass!)

3. Don't be the evidence police

We did a whole series on this and it's gotten so much better! This refers to when a pelvic health provider challenges another publicly to 'prove' or provide evidence for a social media post. We believe this harms our specialty by making clinicians afraid to put out education content (and frankly is just a jerk thing to do). If you really have a problem with someone's post, either 1) just keep scrolling! (recommended), 2) create your own content the way you want, or 3) let them know privately if you think it's a big enough deal (it usually isn't).

4. Voluntary strength testing in the evaluation sends us down the wrong road

This was big when Nicole first said she doesn't evaluate voluntary pelvic floor strength in her initial evaluation. Even if it's 'just a part' of your eval, it focuses both you and the patient on voluntary strength. And because we never find anyone with 'perfect' (pun very much intended) pelvic strength, it always seems like something that can be worked on and improved, even if it's not the cause or driver of symptoms. We talk all about this in the Essential Pelvic Strengthening: Not Your Mama's Kegels! course

5. If we're not routinely doing rectal, we aren't thoroughly assessing the pelvic floor

We still think this is one of the most underutilized skills in pelvic health. Some muscles of the pelvic floor are simply best assessed rectally. And not just for 'obvious' symptoms like rectal spasms, tailbone pain or constipation. We believe rectal evaluation and treatment needs to be in your toolkit for all different diagnoses (and that's the basis of the Rectal Evaluation & Treatment course!).

6. You don't need more clinical skills, you need to better utilize the ones you have

When we aren't feeling confident in our clinical skills and practice, what do we usually do? We think we need to take yet another skills-based course. That will certainly make us more confident with a complex patient or someone who plateaus - despite the fact that none of our previous skill-based courses have helped.

We are physical therapists, ortho therapists, and pelvic floor physical that order. We have a ton of skills and knowledge to help patients. We just need to be confident to use it (and the basis of the Pelvic PT Essentials course I have all my staff take before seeing patients).

This course was so good! I learned so much about myself and how I want to treat. It has reignited my confidence and love of pelvic PT. -Brittany H. (Pelvic PT Essentials)

7. The pelvic floor is more like a trampoline than a biceps

This is a metaphor we flesh out in the Essential Pelvic Strengthening course, but the biceps metaphor has some serious limitations. It leads to a more voluntary strength thought process and doesn't accurately represent the function, shape or complexity of the pelvic floor. The trampoline metaphor works - in our opinion - much better to provide a true representation of what the pelvic floor is like. We're excited to see more and more of you starting to use it!

8. You can't always trust research

We all want to provide evidence-based care, but we also need to realize the limitations of published research. Research always lags (often at least 5-10 years) behind clinical practice. It's often over-simplified into a protocol to make things easier to study. Many times the inclusion/exclusion criteria rule out the majority of patients. And sometimes (often!) the conclusion doesn't actually match what the results show.

This isn't saying research is bad or not incredibly important. It absolutely is. But we have to understand the limitations of research and also vet it by our clinical experience and other information to truly utilize it well.

9. The isolationist strength approach (eg Kegels) is outdated

For more than 80 years the pelvic rehab specialty has focused on the voluntary aspects of the pelvic floor (eg Kegels). We've seen incremental changes in how we implement voluntary contractions, but have never questioned they were critical to how we treat.

We believe the pelvic floor functions in a system. And if we replace an isolationist strength approach (Kegels) with an Adaptive Strength Approach(TM) we can be more functional, more individualized and more tailored to our patients. We can get better results, faster. Get our patients up off the table and back to doing what they love. This is what we go over in the Essential Pelvic Strengthening: Not Your Mama's Kegels course, and something we've been thinking about for more than 10 years!

"Absolutely changed the way I practice, how I evaluate, and how I THINK about the pelvic floor. Pelvic strengthen in the system and for function!" - Sarah P. (Essential Pelvic Strengthening)

10. Cash physical therapy is the future of our specialty

We believe change and progress in our specialty is being driven by cash-based practices. This doesn't mean insurance-based practices are bad, or unnecessary. And it certainly doesn't mean you shouldn't work in one.

But cash-based practices are starting to change the game for both clinicians and patients. There are places where you can work and see patients for a full hour (or more) at every session. With minimal documentation and paperwork. While being able to focus on 'wellness.' Where wages can grow and what we make is determined by our skill level and value we provide.

We all benefit when there are more choices available. We know insurance reimbursement for physical therapy services is only going to decline. Cash-based pelvic health practices offer both patients and providers a different choice and are essential to the landscape of pelvic health.

Make sure to catch the full 'sode on the 10 Most "Controversial" Things We've Said About Pelvic Health for the full discussion!


Nicole Cozean, PT, DPT, WCS

Founder of Pelvic PT Rising and PelvicSanity Physical Therapy in Southern California.

Dedicated to forever changing pelvic health with online clinical courses to help you be more confident in your practice and business resources to help start and grow pelvic health businesses.

Jesse Cozean, MBA

Co-founder of the Pelvic PT Rising and the Rising Podcast.

Jesse uses his business experience to help pelvic health business owners start and grow their practices so they can build a practice that truly works for them. From website design, SEO, conversions, marketing, finance and money mindset, he wants to make the process of owning your own practice easier and fun.

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