During your first visit you can expect the following:

• All paperwork (patient intake forms, etc) will be submitted by you through the client portal prior to the appointment
• Intake forms will be reviewed by your provider.
• You will be seen either in-person or virtually through our client portal for your appointment.
• The therapist will begin the appointment with you, your child, and whomever else you wish to be present.

The therapist will further discuss and clarity the following with you:

• Your child’s medical history.
• Your child’s current problems/complaints.
• Toileting habits, previous attempts to help previous challenges.
• How this is impacting your daily activities or your functional limitations.
• Your goals with physical therapy.
• Medications, tests, and procedures related to your health.

The therapist will then perform the objective evaluation. Virtually, this will be completed with verbal instruction from the therapist, and visual observation of how your child is able to complete certain tasks (such as squatting, skipping, and belly breathing). The objective section may include some of the following:

1. Palpation - hands on assessment, touching, and firm pressure. This is done to check for the presence of tenderness, swelling, soft tissue integrity, tissue temperature, inflammation, etc.
2. Range of Motion (ROM) - the therapist will move the joints throughout the body to check for the quality of movement and any restrictions.
3. Muscle Testing - the therapist may check for strength and the quality of the muscle contraction. Pain and weakness may be noted. Often the muscle strength is graded.
4. Neurological Screening - the therapist may check to see how the nerves are communicating with the muscles, sensing touch, pain, vibration, or temperature. Reflexes may be assessed as well.
5. Special Tests - the therapist may perform special tests to confirm/rule out the presence of additional problems.
6. Posture Assessment - the positions of joints relative to ideal and each other may be assessed.

The therapist will then create a list of areas of potential improvement of your child and how those areas will be addressed. A plan of action is developed with your input. This includes how many times you should receive therapy services per week, approximately how long the therapist things you will need therapy, home exercise programs (homework to practice between therapy sessions), patient education, short-term/long-term goals, and what is expected after discharge from therapy.

A referral from your child's physician is not needed on day one. Payment will be completed prior to scheduling. Prepare your child by talking about physical therapy, that we will be talking about poop and pee, and doing exercises.

Your child should wear loose fitting clothing in order to allow easy mobility to complete various movements. The therapist will likely complete an abdominal and possibly pelvic assessment.

Initial evaluations are scheduled for 2 hours. Unconstipated Kids typically provides 45-minute treatment sessions, though these may vary based on an individual child's needs.

This is highly variable and depends both on your child's level of toileting dysfunction, as well as how long the dysfunction has been present. Unconstipated Kids has seen children with a complex history require therapy for more than 2 years. However, we have also seen children make a 100% recovery in one session, though this is atypical. Most children require therapy services for 9-15 months.

Physical therapists are experts of movement, muscles, and looking at the body as a whole. Toileting challenges are may times rooted in impairments that are related to muscles and body movement. Physical therapy is a great option to address challenges related to toileting!

Resource:

• Physical Therapy for Fecal Incontinence in Children with Pelvic Floor Dyssynergia

Who is better to see, a PT that works for a physician or a PT that owns a private practice? We leave it up to you to draw your own conclusions but here are some facts. The studies indicate there were more treatments (visits per patient were 39% to 45% higher in physician owned clinics) and the cost was greater for those patients that attended a physician owned physical therapy practice (both gross and net revenue per patient were 30% to 40% higher)¹.

Another study indicated that licensed and non-licensed therapy providers spent less time with each patient in physician owned clinics and physical therapy assistants were substituted for physical therapists.²

Another older study concluded that "Therapists who had treated patients through direct access were significantly more likely to believe that direct access had benefited them professionally and benefited their patients than were therapists who had not practiced through direct access."³

We believe that we can provide you with the highest quality of care available and do it in a cost-effective manner.⁴ You will work closely with your physical therapist and in most instances, your case will be managed by the same physical therapist from the beginning to the end of your experience with us.

1. Mitchell, J., Scott, E., Physician Ownership of Physical Therapy Services: Effects on Charges, Utilization, Profits, and Service Characteristics, Journal of the American Medical Association, 1992.
2. "Joint Ventures Among Health Care Providers in Florida," State of Florida Health Care Cost Containment Board, 1991.
3. Domholdt E, Durchholz AG. Direct access use by experienced therapists in states with direct access. Phys Ther. 1992 Aug;72(8):569-74.
4. Federal Office of the Inspector General May 1, 2006 - This report calls into question billing processes done by non-physical therapist owned practices.

Physical therapists working for Unconstipated Kids LLC are considered out-of-network and are cash-based providers. Unconstipated Kids has chosen to be a cash-based provider because without the overhead and restrictions placed by insurance companies, we are able to provide more flexible, individualized care for you and your child. This allows ample time for evaluation and treatments that would otherwise be restricted by insurance reimbursement requirements.

You and your child will be evaluated by one of our licensed and highly trained physical therapists and he/she will also treat you during subsequent visits. Unlike some clinics, where you see someone different each visit, we feel it is very important to develop a one-on-one relationship with you and your child to maintain continuity of care. Since only one physical therapist knows your problems best, he/she is the one that will be working closely with you to speed your recovery.

There are dozens of different types of treatment interventions, and there are many unique to pediatric pelvic floor physical therapy. Here is a list of possible treatment interventions:

Abdominal Assessment - while your child is laying on their back, the therapist will use their hands and pressure to assess for tension, adhesions, and stool build up in their digestive tract. Manual work done by the therapist may also be completed to release areas of tension and adhesions. Your therapist will work with your child, will not complete this if your child is uncomfortable, and will use several techniques to bypass ticklishness if your child is giggly!

Active Range of Motion (AROM) - your child moves a body part through their maximum range of motion against gravity. AROM is may help your child gain movement, especially related to the trunk, to increase mobility in the digestive tract.

Coordination - your child moves their body in a certain way to improve how their brain and muscles communicate. This can be done through gross motor tasks like skipping, or specifically in one part of the body, such as the pelvic floor. Pelvic floor coordination can be assessed and practiced with or without clothing, though admittedly is best when the therapist can see your child's pelvic region to assess how much control they have over the muscles around the holes that pee and poop exit from their body. Unconstipated Kids strongly values bodily autonomy, and strongly refuses to participate in any type of treatment if you or your child is not agreeable. Please see "Pelvic Assessment" for more details.

Gait or Walking Training - the analysis of how your child walks and runs. How your child moves, walks, runs, and completes other tasks can indicate to a therapist how your child is or is not appropriately using their muscles and alignment. Any negative variation found in gait can contribute to pelvic dysfunction and impairments of toileting tasks.

Soft Tissue Mobilization - hands-on therapeutic procedures intended to increase soft tissue or joint mobility. Mobilization is usually prescribed to increase mobility, delaying progressive stiffness, and to relieve pain. In children with toileting dysfunction, this may be applied to the abdomen, rib cage, and hips.

Pelvic Assessment - the therapist will use a variety of methods to assess how your child moves their pelvic floor, and what control they have over the muscles of the pelvic floor. The amount of movement your child is able to bulge or contract their pelvic floor may also be assessed

Proprioceptive Neuromuscular Facilitation (PNF) - a system of manually resisted exercises performed in diagonal patterns that mimic functional movements. PNF was initially used in developmentally and neurologically impaired patients but now is used in almost every aspect of neuromuscular retraining, which is used in assisting children learn improved toileting mechanics.

Posture Training - instruction in the correct biomechanical alignment of the body. Therapists educate children and their family about the importance of improving posture with daily activities, and how less-than-ideal posture can contribute to pelvic dysfunction and toileting challenges.

Progressive Resistive Exercises (PRE) - exercises that gradually increase in resistance (weights) and in repetitions. PRE is usually prescribed for reeducation of muscles and strengthening. Weights, rubber bands, and body weight can be used as resistance.

Passive Range of Motion (PROM) - the patient or therapist moves the body part through a range of motion without the use of the muscles that "actively" move the joint(s).
Seated Toilet Mechanics Assessment - while sitting on a chair or other surface, the therapist will palpate and assess your child's pelvic floor (typically felt at the perineum, through your child's clothing) as they attempt various tasks, including breath work, bulging as for defecation, and pelvic tilting. Please see "Pelvic Assessment" for more details.

Stretching/Flexibility Exercise - exercise designed to lengthen muscle(s) or soft tissue. Stretching exercises are usually prescribed to improve the flexibility of muscles that have tightened due to disuse or in compensation to pain, spasm or immobilization.

Toilet Training - while the patient participates in the task of toileting, the therapist assessed posture, breath work, and other techniques used in order to urinate or defecate. Please see "Pelvic Assessment" for more details.

Unconstipated Kids values your time, money, and efforts done with therapy services. We will never recommend therapy services longer than they are needed. Often, when a child gets "ninety percent" better, they and the family can continue therapy homework to achieve the last "ten percent." However, sometimes a child may have symptoms that return shortly after ending therapy, or after a longer period of time. Just contact Unconstipated Kids. We may suggest you come back to see us, return to your doctor, or simply modify your current therapy homework and toileting activities.

You have the right to choose any physical therapy provider if you are paying as "self-pay," meaning you pay cash, out-of-pocket for physical therapy services. Our practice does not accept insurance and is cash only.

In most states, physical therapists cannot make a medical diagnosis. This is something that your child's medical doctor will provide for you.

Physical therapists are important members of your medical team. At this point in time, physicians are typically the health care providers that will provide your child with a medical diagnosis.

Billing for physical therapy services is with Unconstipated Kids is very straight forward. Unless otherwise agreed upon with your provider, services must be paid in full prior to the service provided. Your client portal is easy to navigate, and through the portal, you are able to book and pay for future services.

WHAT WILL I HAVE TO DO AFTER PHYSICAL THERAPY?

Most therapy sessions will include a review of your "therapy homework," as well as what is recommended you do with your child for "therapy homework" prior to your next appointment. It is important that you communicate your goals to your therapist, so he/she can develop a custom program for you.

Physical therapists (PTs) with Unconstipated Kids are licensed through the state of Texas. In order to provide services to states outside of Texas, PTs are required to pass a state specific jurisprudence exam, as well as pay an additional fee; the Physical Therapy Compact allows PTs to practice in other states for the same duration as their home-state license, and the additional states' licensing expires at the same time the home-state license expires. All providers with Unconstipated Kids have additional specialized training in pediatric physical therapy, as well as pelvic health physical therapy.

These are some things you may consider when looking for a provider for your child related to their toileting difficulties:

• Your provider should trust that you and your child know your child better than the physical therapist.
• Your provider should teach your child about pelvic health and toileting in an age-appropriate manner with age-appropriate words.
• Your provider should review pelvic safety with you and your child and acknowledge who does and does not have permission to discuss things related to their pelvis and toileting.
• Your provider should communicate all aspects of care with you, including objective findings, goals, and plan of care.