Pelvic Health Content in Canadian Entry-To-Practice Physiotherapy Programs: An Online Survey

Abstract

Purpose:

Pelvic health physiotherapy is an emerging and sensitive area of practice that offers effective conservative treatment for pelvic health conditions. Canadian entry-to-practice curriculum guidelines accord programs considerable flexibility regarding incorporating pelvic health content, which may lead to differences between programs and diverse levels of competence among new graduates. The purpose of this study was to determine the nature and extent to which pelvic health content is incorporated in entry-to-practice physiotherapy programs in Canada.

Method:

We conducted a descriptive cross-sectional e-survey of representatives from Canadian entry-to-practice physiotherapy programs.

Results:

Ten out of 15 Canadian programs participated. Programs incorporated pelvic health content throughout the required curriculum (n = 9) and in optional courses (n = 6). All participating programs covered musculoskeletal-related conditions, urinary incontinence, and pelvic pain conditions, and included anatomy and physiology, clinical reasoning, subjective assessment and pelvic floor muscle training topics. Three programs trained students in internal pelvic floor techniques in elective courses. All programs covered cisgender women populations, however, transgender populations were seldom covered.

Conclusions:

This study provides an understanding of pelvic health curricular content that can serve as a first step towards standardizing and improving entry-level pelvic health training in Canada.

Pelvic health conditions such as incontinence and pelvic pain can lead to decreased health-related quality of life for individuals of all genders and ages and place a significant economic burden on the healthcare system.^1–3 Fortunately, pelvic health physiotherapy (PHPT) is a field that is well positioned to address these clinical problems through prevention and conservative treatment.⁴ PHPT is a growing field in Canada as seen by the 46% increase in the number of physiotherapists registered to practice PHPT in Ontario between 2020 and 2022.⁵ Additionally, a recent survey found that the Canadian Women's Health Division of the Canadian Physiotherapy Association (CPA), an organization joined voluntarily by practitioners interested in women's health and PHPT fields, had 700 physiotherapist members and 1,285 student members, suggesting a substantial interest among physiotherapy students in Canada.⁶

PHPT is considered sensitive due to the intimate nature of assessing and treating conditions related to the pelvic region, which requires privacy, sensitivity to emotional and cultural considerations, and a compassionate approach to address the physical and psychological well-being of patients.^7,8 One particularly intimate practice that distinguishes PHPT from other fields is the use of internal assessment and treatment of the pelvic floor (per vaginum or per rectum).⁷ As a result, PHPT training has traditionally been delivered in post-graduate settings.^7,9,10

Although PHPT training typically occurs after graduation, incorporating PHPT content into entry-to-practice curricula can have several benefits. For example, pelvic health conditions commonly co-occur with conditions that physiotherapists treat regularly such as low back pain or lumbopelvic pain,^11,12 or may be present in populations seen in general practice including, but not limited to, women or elderly populations. Given that the majority of Canadian physiotherapists practice in the areas of musculoskeletal or general practice,¹³ new graduates educated on PHPT would be well positioned to identify, treat, or refer patients to pelvic health physiotherapists or other healthcare professionals, thus providing more holistic care. Including PHPT content in university curricula can also increase students’ awareness of the field and reduce or eliminate the financial barrier associated with enrolling in post-graduate courses,^14–16 leading to more trained physiotherapists. Despite the benefits of including PHPT content, pelvic health physiotherapists, including those working in Canada, have been dissatisfied by the paucity of PHPT content in their entry-to-practice programs.^8,17,18 This incongruity may be due to national- or program-level curriculum factors.

In Canada, entry-to-practice physiotherapy education is delivered through professional Master's programs with academic and clinical components. The National Entry-to-Practice Curriculum Guidelines specify the recommended knowledge, skills, and common conditions to be covered in academic curricula of 15 Canadian university programs.¹⁹ Each program is responsible for designing and delivering a curriculum that covers the guideline's learning topics.¹⁹ Currently, the guidelines only recommend covering a few PHPT-specific conditions and topics (e.g., urinary incontinence, perinatal conditions, subjective assessment including questions about continence).¹⁹ They also identify “pelvic floor assessment/management/interventions” as an “emerging topic in entry-to-practice” and encourage programs to discuss and determine whether and what PHPT content to deliver.¹⁹ This suggests that there is likely variation in the amount and type of PHPT content covered, as well where content is incorporated in the curriculum across Canadian programs because programs may incorporate this content in required or elective portions of the curriculum. This may lead to diverse levels of PHPT knowledge and skills among new graduates, which could negatively impact patient care.

Currently, it is unknown what PHPT content is included in Canadian entry-to-practice curricula. The only study of Canadian programs focused on urinary incontinence, providing limited insight into other potential pelvic health conditions or topics.²⁰ Furthermore, the survey was conducted in 1998 when entry-to-practice programs were at the undergraduate level and programs have evolved since then. Identifying which PHPT content areas are covered and how they are incorporated into Canadian entry-to-practice curricula will help inform decisions by education stakeholders (e.g., program faculty, policy makers) on how to improve entry-level pelvic health training for future physiotherapists. Therefore, the objective of this study was to determine the nature and extent to which PHPT content is incorporated in entry-to-practice physiotherapy programs in Canada.

Methods

Study design and participants

We conducted a cross-sectional e-survey among representatives from Canadian entry-to-practice physiotherapy programs between May and June 2022. Participants were eligible if they were affiliated with an accredited Canadian entry-to-practice physiotherapy program and had knowledge about the pelvic health content in that program's curriculum. Our methodology was informed by web survey guidelines.²¹ The University of Toronto Research Ethics Board approved this study. The Checklist for Reporting Of Survey Studies (CROSS) guided our reporting.²²

Sampling and recruitment

The sampling frame included all 15 accredited entry-to-practice physiotherapy programs (10 English, 5 French) in Canada. We emailed a personalized survey invitation and 2 weekly reminder emails to each program director asking them to forward the recruitment email to the person with the greatest knowledge of PHPT content in the curriculum. The recruitment emails and questionnaire were available in English and French to enhance participation. We also used a snowball sampling approach,²³ by allowing participants to nominate one or more individual from their institution if needed (e.g., if they were unsure about content areas or if another individual had additional knowledge about how pelvic health content was incorporated). Participants received a $25 e-gift card.

Questionnaire development and survey administration

We developed a current and comprehensive list of PHPT-related curriculum content areas to populate the questionnaire by synthesizing items from international PHPT competency⁷ and curriculum¹⁰ frameworks, and curricula from post-graduate PHPT courses delivered as of November 2021 by three education companies^24–26 endorsed by the Women's Health Division of the CPA. We mapped the questionnaire items to the 2019 Canadian National Physiotherapy Entry-to-Practice Curriculum Guidelines¹⁹ to help organize the items and to identify what PHPT content areas were present in the guidelines (Supplemental File 1). The curriculum guidelines also informed definitions presented in the questionnaire, such as the degree to which conditions are covered in entry-to-practice programs (i.e., basic or comprehensive level). Additionally, we found that some topics (e.g., biomechanics, pain science, and shared-decision making) could not be distinctly conceptualized as pelvic health-related (see Section 5 in Supplemental File 2 for all general topics). As such, we wanted to identify programs that taught these topics in the context of pelvic health. Table 1 contains the definitions used in the questionnaire.

Table 1.

Definitions

Term	Definition
Covered	A condition, topic, or population is considered to be covered if information is provided didactically (e.g., discussed verbally), practically (e.g., discussed through practical skills in a lab setting), or through self-study (e.g., assigned readings, self-study module)
Condition is covered at the basic level*	Entry-to-practice physiotherapists are expected to be aware of these conditions and understand the condition type/category and general clinical presentation
Condition is covered at the comprehensive level†	Entry-to-practice physiotherapists are expected to know and understand the etiology, pathophysiological mechanisms, natural history, typical clinical presentation (signs/symptoms, impairments), differential diagnoses, prognosis, current physiotherapy management and basic non-physiotherapy management (medical, surgical)
Covered in the context of pelvic health	The topic or population is taught or discussed in a pelvic health course or lecture or linked to specific pelvic health condition (e.g., anatomy of the thoracolumbar/pelvic/hip region or pain science is taught or discussed in a pelvic health lecture or as it directly links to pelvic health conditions such as chronic pelvic pain or dyspareunia)
Not covered in the context of pelvic health	The topic is not taught or discussed in the context of pelvic health (e.g., anatomy of the thoracolumbar/pelvic/hip region or pain science is taught generally, but NOT specific to any pelvic health conditions)
Portion of the curriculum
Elective	Courses or units delivered to some students (e.g., elective, selective, or optional course)
Required	Courses or units delivered to all students
Sex & gender terminology ‡
Sex	Biological attribute associated with physical and physiological features (e.g., genes, hormones, and reproductive/sexual anatomy)
Gender	Socially constructed roles, behaviours, expressions, and identities
Cisgender	Gender identity aligns with sex assigned at birth
Transgender	Gender identity does not align with sex assigned at birth
Gender diverse	Individuals who have diverse gender expression(s)
Intersex	Individual who does not fit typical binary notions of male or female bodies

^* Analogous to Level 2 from the Canadian curriculum guidelines.

^† Analogous to Level 1 from the Canadian curriculum guidelines.

^‡ Canadian Institutes of Health Research definitions for sex and gender.

The final questionnaire contained nine sections. Sections 4–8 addressed the study objectives. The section titles, number of items, and response scales for the sections that addressed the study objectives are presented in Table 2. Each response scale also had a “Don’t know/unsure” option to avoid inaccurate or missing responses.²¹ If participants responded “No” to any of the eligibility or consent questions in Section 1, the survey would terminate. There were open-ended comment boxes at the end of each section. See Supplemental File 2 for the full questionnaire (English and French versions).

Table 2.

Questionnaire Characteristics

Section	No. of items	Response scale for sections that addressed the study objectives
1-Eligibility and consent	3	-
2-Contact information and institution	3	-
3-Professional experience and sociodemographic information	11	-
4-Pelvic health conditions	13	Categorical: Yes (comprehensive level) Yes (basic level) No, not covered
5-General topics covered in the context of pelvic health	24	Dichotomous: Yes (specific to pelvic health) No (general or not covered)
6-Pelvic health topics covered in the curriculum	24–26
7-Clinical populations	6
8-Incorporation of pelvic health content in the curriculum	3–4	Dichotomous: Yes No
9-End of survey/follow-up	4	-

The survey was administered through REDCap.²⁷ The questionnaire's comprehensibility and face and content validity were first evaluated by two PHPT content experts, and its comprehensibility, face validity, and ease-of-usage were then evaluated by two end-users.²⁸ Given the volume of items and the complexity of curricula, all participants verified their responses prior to finalizing the data for analysis. During this verification step, the sub-sample of representatives from programs that offered elective courses in PHPT were also asked to (1) report the level of coverage for pelvic health conditions in both the required and elective portions of the curriculum, and (2) to identify topics that were only covered in the elective course, to the best of their knowledge.

Data analysis

Data were exported into Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA) and summarized using descriptive statistics (frequencies and percentages). We reviewed participants’ comments within each section for commonalities to supplement the quantitative data.

Results

Of the 15 Canadian university programs, 11 representatives from 10 programs in three provinces participated (66.7% program response rate). One program had two representatives participate (i.e., one representative completed the survey and a second representative participated in the verification step). Seven participants reported that they instructed PHPT content; four reported that they did not instruct the content but were familiar with it. Six participants had PHPT clinical experience. Table 3 presents participant characteristics.

Table 3.

Participant Characteristics (n = 11 Participants Representing 10 Programs)

Characteristics	n (%)
Age, years
<40	3 (27.3)
40–50	3 (27.3)
51–60	3 (27.3)
>60	2 (18.2)
Gender
Cisgender woman	10 (90.9)
Cisgender man	1 (9.1)
Faculty position
Assistant or Associate Professor	4 (36.4)
Lecturer	3 (27.3)
Professor	3 (27.3)
Program Director	1 (9.1)
Number of years of faculty or teaching experience in an entry-to-practice program
<5	1 (9.1)
5–10	2 (18.2)
11–15	3 (27.3)
16–20	1 (9.1)
≥20	4 (36.4)
Entry-to-practice physiotherapy degree
Bachelor's	7 (63.6)
Entry-level Master's	4 (36.4)
Highest degree obtained
Entry-level Master's	1 (9.1)
Research Master's	1 (9.1)
Research PhD	8 (72.7)
Post-doctorate	1 (9.1)
Number of years of clinical experience in pelvic health physiotherapy
0	5 (45.5)
5–10	1 (9.1)
11–15	1 (9.1)
16–20	1 (9.1)
≥20	3 (27.3)
Number of years of clinical experience in any clinical area or setting
5–10	1 (9.1)
11–15	3 (27.3)
16–20	3 (27.3)
≥20	4 (36.4)

Pelvic health content delivery in required and elective curricula

All 10 responding programs reported covering pelvic health content in the required and/or elective curriculum. Nine programs reported delivering PHPT content in the required curriculum (one representative was unsure). They did so in non-PHPT-specific courses or units (n = 9, 100% programs) and PHPT-specific courses or units (n = 3, 33.3% programs). Six programs also delivered PHPT content in a PHPT-specific elective course.

Pelvic health conditions

Table 4 presents the frequency and percentage of programs covering pelvic health conditions at the basic level, comprehensive level, and any (i.e., comprehensive or basic) level in the required and elective curricula. Musculoskeletal conditions associated with pelvic floor dysfunction, urinary incontinence, and pelvic pain conditions were covered in the required curriculum by all nine programs that were certain that PHPT content was delivered in the required curriculum. Pelvic skin conditions were covered least frequently in programs’ required curricula (n = 2 programs). Urinary incontinence, perinatal-related conditions, and other genitourinary conditions (e.g., overactive bladder, menopausal syndromes) were covered in all six PHPT elective courses. Furthermore, urinary incontinence was covered at the comprehensive level in all six of those courses.

Table 4.

Level of Coverage of Pelvic Health Conditions in the Required (n = 9 Programs that Were Certain that Pelvic Health Content Was Delivered in the Required Curriculum) and Elective Curriculum (n = 6 Programs) of Physiotherapy Programs, Organized by Coverage at Any Level within the Required Curriculum

	Required curriculum (n = 9 programs)			Elective curriculum (n = 6 programs)
	Covered			Covered
	Basic level (a)	Compre-hensive level (b)	Any level (a+b)	Basic level (a)	Compre-hensive level (b)	Any level (a+b)
	n (%)			n (%)
Musculoskeletal conditions associated with pelvic floor dysfunction	3 (33.3)	6 (66.7)	9 (100)	1 (16.7)	2 (33.3)	3 (50.0)
Urinary incontinence	5 (55.6)	4 (44.4)	9 (100)	0 (0)	6 (100)	6 (100)
Pelvic pain conditions	7 (77.8)	2 (22.2)	9 (100)	1 (16.7)	2 (33.3)	3 (50.0)
Diastasis rectus abdominis	3 (33.3)	5 (55.6)	8 (88.9)	0 (0)	3 (50.0)	3 (50.0)
Perinatal-related conditions	4 (44.4)	4 (44.4)	8 (88.9)	2 (33.3)	4 (66.7)	6 (100)
Other genitourinary conditions	7 (77.8)	1 (11.1)	8 (88.9)	2 (33.3)	4 (66.7)	6 (100)
Ano-rectal dysfunction	7 (77.8)	0 (0)	7 (77.8)	1 (16.7)	1 (16.7)	2 (33.3)
Gastrointestinal conditions*	7 (77.8)	0 (0)	7 (77.8)	3 (50.0)	1 (16.7)	4 (66.7)
Sexual or genital conditions	7 (77.8)	0 (0)	7 (77.8)	0 (0)	0 (0)	0 (0)
Pelvic organ prolapse	4 (44.4)	2 (22.2)	6 (66.7)	2 (33.3)	3 (50.0)	5 (83.3)
Cancer (pelvic)	6 (66.7)	0 (0)	6 (66.7)	1 (16.7)	0 (0)	1 (16.7)
Other body system-related conditions associated with pelvic floor dysfunction*	3 (33.3)	2 (22.2)	5 (55.6)	0 (0)	0 (0)	0 (0)
Skin conditions (pelvic)	2 (22.2)	0 (0)	2 (22.2)	0 (0)	1 (16.7)	1 (16.7)

^* Required curriculum – Don’t know/unsure: n = 1 (11.1% of nine programs).

General topics covered in the context of pelvic health

All 10 programs covered anatomy and physiology of the abdominal wall and pelvic floor, autonomous professional practice (e.g., recognizing components for physiotherapy treatment and need for referral), and clinical reasoning for establishing a diagnosis and treatment planning (Table 5). The least frequently covered topics were anatomy and physiology of other systems (e.g., endocrine, immune, cardiopulmonary) and telehealth (n = 2 programs each). Supplemental Table 1 in Supplemental File 3 presents the frequency and percentage of programs that reported covering general topics in the context of pelvic health only within the elective curriculum.

Table 5.

General Physiotherapy Topics Covered in the Context of Pelvic Health Anywhere within the Curriculum (i.e., Required and/or Elective) of Physiotherapy Programs (n = 10 Programs)

	Covered n (%)
Anatomy and physiology
Abdominal wall	10 (100)
Pelvic floor	10 (100)
Thoracolumbar/pelvic/hip region	8 (80.0)
Urinary tract	8 (80.0)
Gastrointestinal tract	7 (70.0)
Neurophysiology	6 (60.0)
Other systems	2 (20.0)
Related sciences
Biomechanics	9 (90.0)
Exercise science	8 (80.0)
Pain science	7 (70.0)
Therapeutic alliance
Shared decision-making	8 (80.0)
Trauma informed practice	8 (80.0)
Cultural competence	7 (70.0)
Autonomous and ethical practice
Autonomous professional practice	10 (100)
Ethics and laws	8 (80.0)
Informed consent	8 (80.0)
General and other professional practice areas and topics
Clinical reasoning – establishing a diagnosis	10 (100)
Clinical reasoning – treatment planning	10 (100)
Communication	9 (90.0)
Biopsychosocial approach	8 (80.0)
Collaborative practice	7 (70.0)
Hygiene and infection control	6 (60.0)
Research and critical appraisal	6 (60.0)
Telehealth	2 (20.0)

Pelvic health topics

Subjective assessment and pelvic floor muscle training topics were covered by all 10 programs (Table 6). The next most frequently covered topics were abdominal wall and orthopaedic assessments, behavioural techniques, breathing and pressure management techniques, and movement and exercise, each covered by nine of the programs. Insertion devices were covered least frequently (n = 2 programs). Online Table S2 in Supplemental File 3 presents the frequency and percentage of programs that reported covering pelvic health topics only within the elective curriculum.

Table 6.

Pelvic Health Topics Covered Anywhere within the Curriculum (i.e., Required and/or Elective) of Physiotherapy Programs (n = 10 Programs)

	Covered n (%)
Pelvic health physiotherapy assessment topics
Subjective assessment	10 (100)
Abdominal wall assessment	9 (90.0)
Orthopaedic assessment	9 (90.0)
Outcome measures	8 (80.0)
External pelvic floor assessment	7 (70.0)
Internal pelvic floor assessment – vaginal	6 (60.0)
Internal pelvic floor assessment – rectal	6 (60.0)
Pelvic floor reflex testing	5 (50.0)
Pelvic health physiotherapy management and intervention topics
Pelvic floor muscle training	10 (100)
Behavioural techniques	9 (90.0)
Breathing and pressure management techniques	9 (90.0)
Movement and exercise	9 (90.0)
Education	8 (80.0)
Psychological techniques	8 (80.0)
Manual therapy	7 (70.0)
Relaxation techniques	6 (60.0)
Electrophysical agents	5 (50.0)
Other modalities	5 (50.0)
Pessaries	4 (40.0)
Scar management	3 (30.0)
Insertion devices	2 (20.0)
Non-physiotherapy pelvic health management and intervention topics
Medical investigations	6 (60.0)
Pharmacological interventions	5 (50.0)
Medical interventions – non-surgical and surgical	4 (40.0)

Six programs reported covering internal vaginal and rectal pelvic floor assessment. Since our definition of a topic being “covered” included verbal description, these respondents were asked to identify the degree to which students perform these techniques. Students did not perform the techniques in three of the programs; only students enrolled in the PHPT elective course performed them in the remaining three programs.

Clinical populations

All 10 programs covered cisgender women populations in the context of pelvic health. Cisgender men and elderly populations were covered by eight programs, paediatric populations and patients with neurological pathologies were covered by five programs, and transgender, gender diverse, or intersex populations were covered by one program (see definitions for sex and gender terminology in Table 1). Comments from two programs indicated that content related to transgender health would be added or enhanced in the following academic year.

Discussion

Overall, the majority of Canadian entry-to-practice physiotherapy programs that participated in this survey delivered PHPT content in non-PHPT-specific areas of the required curriculum or in PHPT-specific elective courses. All programs covered musculoskeletal conditions, urinary incontinence, and pelvic pain conditions, and included anatomy and physiology and clinical reasoning in the context of pelvic health, as well as pelvic health subjective assessment and pelvic floor muscle training. Less than one-third of programs taught students how to perform internal pelvic floor techniques. While all programs covered PHPT in relation to cisgender women populations, transgender populations were rarely covered.

The finding that the majority of programs incorporate content in non-PHPT-specific required courses is consistent with research from Brazil and the USA that identified that physiotherapy programs most frequently incorporate women's health topics in compulsory courses⁹ and across the curriculum²⁹ compared to separate women's health courses. This may be because PHPT is not typically viewed as a core or entry-level area of physiotherapy practice compared to musculoskeletal, neurological, and cardiorespiratory fields,^7,19 and therefore developing separate courses is not as common as integrating content within existing courses or units. However, programs also delivered content in PHPT-specific elective courses. We found that musculoskeletal-related conditions were frequently covered comprehensively in required curricula and urinary incontinence and other genitourinary conditions were more frequently covered comprehensively in elective courses. This may be because curriculum decision-makers consider it more feasible or desirable to cover emerging topics in-depth in non-required offerings. The result of this, however, is that students within and across programs may be graduating with different levels of competence in PHPT. Overall, more research is needed to explore curricular decision-making and to support standardization of entry-level PHPT education. This will promote the advancement of the field and provision of high-quality patient care.

Since there are few PHPT-specific topics in Canadian curriculum guidelines,¹⁹ the large number of content areas that were covered by all or most programs was surprising. Results from a recent qualitative study⁸ showed that pelvic health physiotherapists working in Canada reported receiving little to no PHPT education in their entry-level training. Since the guidelines were published in 2019 and the majority of the participants in the qualitative study⁸ graduated more than 10 years prior, this discrepancy may be indicative of the rapidly evolving nature of PHPT education. Indeed, our findings support the overall international trend that certain PHPT content areas are being increasingly incorporated in entry-to-practice curricula. For example, surveys of physiotherapy programs conducted in 2002 (USA),³⁰ 2015 (Brazil),⁹ and 2019 (Australia),³¹ and 2022 (Canada, current study) identified that pelvic floor anatomy topics were taught in 78.1%, 90.9%, 100%, and 100% of participating programs, respectively. Similarly, pelvic floor muscle training was delivered in 83.3% of Canadian programs prior to 1998²⁰ and 74.8% of American programs in 2002,³⁰ compared to 100% of the Canadian programs in this current study.

Conversely, only a third of Canadian programs in the current study taught internal pelvic floor techniques, and previous surveys identified that 14.6%, 16.3%, and 35.7% of programs taught this skill in 2002 (USA),³⁰ 2014 (USA),³² and 2019 (Australia),³¹ respectively. Programs may choose not to teach this skill because of the belief that it is not an entry-level skill,³³ or because of challenges associated with managing the privacy and sensitivity associated with using a peer-to-peer model of teaching,³⁴ or acquiring funding for standardized patients.¹⁵ Currently, performing internal pelvic floor techniques is designated as a restricted or controlled act by three Canadian provincial regulatory bodies,^35–37 meaning that physiotherapists require specific authorization to perform the skill. Because of this, regulations regarding the use of internal pelvic floor techniques by students and new graduates in clinical practice differ between provinces, which may influence programs’ decisions to teach these skills. In addition to internal pelvic floor techniques, another noteworthy omission from the majority of programs was education related to PHPT for non-cisgender populations, given that there is a growing role and need for PHPT in post-gender affirming surgery recovery.³⁸ Overall, understanding what factors influenced Canadian programs’ decisions about what content to include or exclude could increase understanding of how programs approach training students in this, and potentially other, emerging areas. Future qualitative research should explore these factors in depth, as it was outside the scope of this survey.

Our study had several limitations. Given that 10 of the 15 existing programs from 3 provinces participated, information is missing from the remaining 5 programs and 4 provinces, which may limit the generalizability of the findings. This is especially important given that regulatory requirements for performing internal pelvic floor techniques differ between provinces. Additionally, curricula are complex and faculty may not have detailed knowledge of content delivered across the curriculum, which could lead to incomplete or inaccurate responses. Response bias was also possible whereby participants might have over-reported what PHPT content is delivered. However, we increased the accuracy of the results by enabling participants to nominate additional representatives and by conducting a data verification step. Furthermore, we did not measure the amount of time dedicated to delivering PHPT content.

A strength of this study was the development of a comprehensive list of PHPT conditions, topics, and populations. Past research in this area has had a greater focus on women's or men's health compared to pelvic health,^9,16,29,31 which include topics that are not necessarily specific to pelvic health. We chose not to categorize content based on gender so as to avoid imposing a gender binary on conditions and topics that may be relevant to many or all patient populations. We did, however, present many conditions and topics in categories rather than individual items to mitigate response burden (e.g., pelvic pain conditions could include dyspareunia or bladder pain syndrome; behavioural interventions could include bladder training or lifestyle interventions). Future research may aim to explore these categories in greater depth. Given that this was the first comprehensive survey of PHPT content in Canadian programs, our results can be used to understand of how entry-level PHPT education changes in the future.

Conclusion

Many Canadian physiotherapy programs teach PHPT content in the academic curriculum that is beyond what is outlined in Canadian curriculum guidelines. Programs include content in the required, elective, or both portions of the curriculum. Content areas such as musculoskeletal-related conditions, anatomy and physiology, subjective assessment, clinical reasoning and recognizing the need for referral, and cisgender women populations were covered by all programs. Programs that teach internal pelvic floor techniques do so only in elective courses. Future research is recommended to understand the factors that influence what PHPT content programs decide to include and where they incorporate it, as this is an area that may continue to evolve in entry-to-practice education.

Key Messages

What is already known on this topic

PHPT is a growing and complex area of practice that has traditionally been taught at the post-graduate level. Entry-to-practice physiotherapy programs are afforded considerable flexibility regarding the incorporation of PHPT content.

What this study adds

Canadian entry-to-practice physiotherapy programs deliver PHPT content (e.g., musculoskeletal-related conditions, anatomy and physiology, subjective assessment, clinical reasoning, and recognizing the need for referral) that is required for all students, and some programs deliver additional content through elective courses. Programs place a greater emphasis on teaching certain topics, such as musculoskeletal-related PHPT content, in the required curriculum compared to internal pelvic floor techniques, which are only taught in elective courses. This study provides a baseline understanding of PHPT curricular content that can serve as a first step towards standardizing and improving PHPT training in entry-to-practice physiotherapy programs in Canada.

Dr. Nancy Salbach is a Professor in the Department of Physical Therapy at the University of Toronto, a Senior Scientist at the KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, and the Toronto Rehabilitation Institute Chair at the University of Toronto, in Toronto, Canada.

Dr. Salbach is a physical therapist and world-renowned implementation scientist. She has obtained almost $14 million in grant funding and published more than 145 journal articles.

Research in Dr. Salbach's Knowledge-to-Action Mobility Lab is advancing the integration of task-oriented exercise programs for older adults with balance and mobility limitations in community and parks settings. Dr. Salbach's research highlights the value of toolkits and the role of physical therapist practice leaders in facilitating the standardized assessment of walking in stroke rehabilitation settings. The iWalkAssess app, with close to 18,000 downloads from the App Store and Google Play worldwide, is a clinical tool designed to promote an evidence-informed approach to using the 10-metre walk test and 6-minute walk test among physical therapists.

Dr. Salbach is a leader in guideline development in Canada. Since 2017, she has co-chaired writing groups to update the Canadian Stroke Best Practice Recommendations and Canadian Stroke Community-based Exercise Recommendations, and develop new recommendations for virtual stroke rehabilitation.