As a young child I remember that when my mother and I had a conversation about the area of the body that designated me as a girl, she would use the term “private parts.” I cannot even remember the time when I first heard, or read, the word vagina. It may have been in eighth grade when we were having our sex education class that lasted all of about one hour. And, since I was going to a parochial school, I don't recall that the nun teaching the class actually spoke aloud the terms for the relevant body parts. There may have been diagrams in the handouts but we were all probably too embarrassed to look at them. Indeed, I suspect that some of my classmates had their eyes squeezed shut and were perhaps uttering “la-la-la, I can't hear you, la,la,la!” Well… the times are slowly changing. When I recently “Googled” the term “vagina” it only took 0.03 seconds and I had 1,600,000 entries made available for my perusal. I could find information about the play titled, “The Vagina Monologues” as well as information about cancer research in the UK with the first page containing information “About the Vagina.” I also discovered that Brandeis University has a “Vagina Club.” And, there were entries that reminded me that the internet is not always “peer-reviewed.”
Still, not everyone is completely comfortable speaking or hearing about what is very simply an anatomical location. I recall an elderly woman coming to see me for treatment for incontinence and during her first visit she told me that she had very recently been having a lot of itching “down there.” Some of my former academic colleagues would avoid looking at one particular section of my book collection. When I would use the word as I taught physical therapy students, they would all of a sudden look down at their notebooks. I was informed by a friend who used to work in a library that she would find The V Book, authored by Dr. Elizabeth Stewart,1 in the most hidden away sections of the library where it had obviously been taken from the shelf to read. I, and several of the members of the Task Force who wrote the review published in this issue, did some chuckling when we were communicating via e-mail about the “Vulvar Pain” issue and received the following message, “Your mail message was deleted because it contained words that are considered as profanity by the Detroit Medical Center.” I am now beginning to wonder about the big black SUV that has been parked outside my house.
As I was reviewing the manuscripts for this issue, I was disappointed, yet not surprised, by the following facts from the data cited:
- “In a population-based study, cumulative incidence of chronic vulvar pain has been estimated at 16% of women between 18 and 64 years of age, nearly half of whom do not seek treatment…”2
- The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)3 does not include dyspareunia as a pain condition. It lists it as a sexual disorder.4
- When physical therapists who treat vulvodynia were asked about whether they used outcomes measures to assess the effectiveness of their interventions, only 55% confirmed that they did.5
I think that the reasons for my disappointments for numbers 1 and 2 above are obvious. Regarding number 3, I am disappointed because I believe this has ramifications for the future. There are clues arriving almost weekly in reimbursement updates that indicate that those who have no documented proof that their interventions are effective at improving the health of the patients/clients they treat are at risk for rejection of payment. Indeed, I was informed very recently that one insurance company has made the decision to not reimburse for iontophoresis because it has been deemed to be experimental.
The emphasis on outcomes measures became prominent in the 1990s as the health care practitioners were being asked to decrease the cost of care. I recall discussions when I worked in a hospital in which it was being predicted that insurance companies might begin to investigate which practitioners had the best outcomes and then their policy would be that they only cover the cost of treatment when patients would go to those practitioners. For insurance companies the best outcome might be defined in terms of number of visits required from evaluation to discharge. Health care practitioners might prefer another way to define “best outcome.” The National Quality Measures Clearinghouse defines an outcome measure as, “An outcome measure can be used to assess quality of care to the extent that health care services influence the likelihood of desired health outcomes.”6 The word that we read most often in the health care literature is “effectiveness.” Domholdt7 defines effectiveness as “…the usefulness of a particular treatment to the individuals receiving it under typical clinical conditions.” Medical disciplines, including physical therapy, are now being asked to document the “effectiveness” of their treatments/interventions. Personally, I think that this is a good thing. Patients/clients are now being required to submit “co-pays” for each visit and this, for many, can become an economic concern in these days where salary does not seem to keep pace with the increased cost of living. I believe that we must become more efficient with our care and this requires that we prescribe interventions that will be the most effective at decreasing pain, decreasing impairments, and increasing function. I think that we must strive to do this in a way that decreases the cost to those who come to us for our services. Our patients/clients must not be asked to pay while we “practice” our protocols to determine effective plans of care.
As we are specialists in women's health physical therapy, we have women (and men) that choose to come to us for pain that occurs in “private parts.” As you will read in the manuscripts included in this “special topic” issue of JWHPT, many women do not seek care for many years. Additionally, other medical care practitioners may not know that we can help their patients. When I was the Director of Research for the SOWH, I often would receive requests from members for articles that they could give to their physicians or nurse practitioners or other health care providers that would provide proof that our services could help their patients. Well…. that was sometimes a difficult task.
This issue is devoted to one of the topics for which there is a lack of written documentation for the effectiveness of the care that we can provide for women. The Task Force on Vulvar Pain, which was appointed by the Board of Directors in 2005, have completed a tremendous amount of work to accomplish the task with which they were charged. Their comprehensive review is the result of dedicated and steadfast work, and women's health physical therapists and their patient/clients will be the beneficiaries of this very successful effort. We now have a directed effort toward the goal of an evidence-based approach to the treatment of vulvar pain.
Also included in this issue is a reprint of the article published in the Journal of Reproductive Medicine that contains data collected by the Vulvar Pain Task Force. After a review of the information that had been submitted for this issue, an editorial decision was made to not simply summarize the information that was previously published. Rather, I elected to include the entire manuscript. As the Editor-in Chief, it is my job to always be careful to not duplicate material, knowingly or unknowingly, as is emphasized by the American Medical Association8 and the International Committee of Medical Journal Editors.9 Also, I believe that the SOWH members will benefit from reading the informative results.
With their paper included in this issue, Hummel-Berry, Wallace, and Herman have brought us toward the goal of having a valid and reliable tool to use in our clinics. They should be applauded for their efforts. However, research to develop outcome measurement tools is only useful to the field of physical therapy when the next step is taken. That is, clinicians must implement the use of the tools in the clinics in which they practice.
It is my hope with this issue of the JWHPT that the research will influence what we do in our clinical settings each and every day. Our patients/clients should not be paying for us to practice protocols for their “private parts” pain. They should be coming to women's health physical therapist practices because of our evidence-based effective and efficient plans of care for their “private parts” pain.
This is also the time of year when we publish our annual index. All of the papers published in this journal are peer-reviewed by volunteers who are considered to be experts in their designated specialties. Not all submissions are accepted for publication. The reviewers spend a considerable amount of time ensuring that the research is well-designed, that the writing is clear, and that the information included in the paper is new and relevant to the field of Women's Health Physical Therapy. I thank them for the dedicated work that they complete.
1. Stewart EG. The V Book
. New York, NY: Bantam Book; 2002.
2. Hummel-Berry K, Wallace,K, Herman H. Reliability and Validity of the Vulvar Functional Status Questionnaire (VQ). J Women's Health Phys Ther.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
ed., text revision. Washington, DC: American Psychiatric Publishing, Inc.; 2000.
4. Hartmann D, Strauhal MJ, Nelson CA. Treatment of women in the United States with localized, provoked vulvodynia: practice survey of women's health physical therapists. J Reprod Med.
5. Strauhal MJ, Frahm J, Morrison P, et al. Vulvar pain: a comprehensive review. J Women's Health Phys Ther.
7. Domholdt E. Physical Therapy Research: Principles and Applications.
Philadelphia, PA: W.B. Saunders Company; 2000.
8. American Medical Association. American Medical Association Manual of Style.: A Guide for Authors and Editors
ed. Baltimore,MD: Lippincott Williams & Wilkins; 1998.
9. International Committee of Medical Journal Editors. Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing forBiomedical Publication. Available at: http://www.icmje.org/
. Accessed October 10, 2007.