A Pain in the Nut(s)

A quick note from Sarah: We’re pleased to present a blog post from a non-pelvic PT! We’ve had great chats with Steve at PT Pub Nights in the past, and were thrilled when he asked about sharing his experience. Of course, I’m personally always happy to see more support for my feelings that ALL physical therapists are pelvic health therapists is some small way. I’d also like to apologize to Steve, who wrote this blog quite sometime ago, and I have been slow to publish. Thank you for your post, and your patience!

A Pain in the Nut(s)

Steve Goostree, DPT, OCS, Cert. MDT, FAAOMPT
stevegoostree@gmail.com

I was inspired to write up and share a case I recently encountered after a conversation at PT Pub Night, sponsored by the lovely Sarah Haag and Sandy Hilton of Entropy Physiotherapy.

The patient was a healthy 24 y/o male that reported to PT with primary complaints of right testicular pain. He was referred by his PCP after a routine physical examination, which deemed his testicular pain as non-sinister. No imaging had been obtained, and the patient was not taking any medication. Past medical history was insignificant. He noted a recent gradual onset of right testicular pain after starting a new weightlifting regimen in the gym within the past month. The patient scored low on the Yellow Flag Questionnaire, indicating low psychosocial factors contributing to his pain. Special questions including bowel and bladder habits, swelling or change in structure were all negative. The patient did report a sedentary desk job, where he felt some lower back stiffness, which resulted in an increase in his testicular symptoms as th day progressed.

Being trained as an orthopedic manual PT, I was slightly uncomfortable performing a male pelvic exam, and was taught to always rule out the spine first as a primary source of referred pain. Before making this an uncomfortable experience for the patient and myself alike, I trusted my gut and screened the lumbar spine first. Having the patient actively cough was used as a symptom provoking baseline.

Lumbar AROM with overpressure was normal, except a positive right lumbar extension quadrant with overpressure, resulting in familiar right testicular complaints, rated 5/10 via NPRS. Sensation, myotome and DTR testing were all normal. Right unilateral passive accessory mobility pressures near L2-3 produced familiar symptoms radiating to the patient’s right testicle.

A repeated movement examination of the lumbar spine was performed next. After 30 repeated extensions in lying with clinician overpressure, the patient was asked to sit up and cough. He noted a decrease in symptoms. A right lumbar quadrant test with overpressure was reassessed, and the patient now noted a pain level of 2/10 via NPRS.

The patient was issued repeated extension in lying, using a belt for self overpressure 10 reps 5-6x/daily. The patient was seen for 3 visits, which included oscillatory mobilization targeting the right upper lumbar segments (Gr. III per Maitland) and a HEP following the lumbar extension principle with progression of forces as needed. Proper lifting technique in the gym was also reviewed as recovery of function. The patient stated he was ready for discharge after visit 3.

This brief case highlights the importance of a thorough spine screen for the orthopedic and pelvic health therapist, which is quick, easy and should be a day one priority for any neuromusculoskeletal complaint. The exact mechanism as to why this intervention was effective is unknown, but reviewing the photo may explain things anatomically. As always, further research is needed.

We the People of Physical Therapy (Part 2)

At the basis of providing competent care to all people, we must create inclusive means of communication within the clinical setting. All forms of our communication with patients should be respectful to all people seeking care so that everyone, including those within the LGBTQ+ population, receive equal quality of care. The following is a short, although surely incomplete, list of recommendations cited in literature to improve the inclusivity of communication constructs already in place in the clinical setting.

1.     Use informed, inclusive, compassionate language:

            It is important to note that “medical literature on culturally sensitive care” for marginalized groups in society “recognizes language and communication as fundamental to engendering trust with patients, positively influencing patient satisfaction and adherence, and ultimately improving engagement in care and health outcomes” (Goldhammer, 2018). With the shifting patterns of reimbursement and emphasis on patient outcomes, it makes sense that a move toward more inclusive terminology is beneficial for both all patients and clinicians. Hetero/cis-normative terminology and assumptions are seen as microaggressions, abolishing patient trust and contributing to decreased quality and continuity of care (Cahill, 2017).

            Language is important on medical intake forms, educational material, and exercise program prescriptions. Literature suggests that forms should offer qualifiers educating patients on why certain information is being collected (ex. legal name for insurance vs. preferred name), and offer ability to write-in or omit answers in order to limit heteronormative assumptions about the patient population (Wahlert, 2014 & Deutsch, 2014, Nadal, 2016). Medical documents can be made more inclusive by addressing legal name for insurance, preferred name, gender identity, gender expression, pronouns. And educational materials should be available in gender neutral terms, or available for various demographics of people, to avoid appealing solely to a heteronormative patient population (Goldhammer, 2018).

            Inclusive language in interpersonal conversations is also important. Reflection upon and correcting personal biases and heteronormative assumptions can improve patient interactions, prevent the clinician from asking insensitive or medically unnecessary questions/comments, and help prevent barriers to care that result from a clinician’s inappropriate or insensitive language (Colpittis, 2016). Adopting an attitude of respect versus tolerance for patients who are LGBTQ+ is also necessary and contributes to quality care, because clinicians who respect this population are more likely to provide equally competent care and advocate for their patients’ needs (Burch, 2008).

2.     Provide simple apologies, and then seek your own answers:

            Genuinely apologize to patients when terminology or culturally competent education is lacking, without offering excuses for mistakes. As one patient reported, “’Healing requires love’” and competent health providers “’push themselves to learn…so as to not compound the errors and terrors already endured [by the patient]. They apologize when they get it wrong. They work to make it right. They listen.’” (Cahill, 2017). It is understandable that terminology mistakes can happen in communication and/or cultural practices could be unknown to clinicians. Using Cognitive Behavioral Therapy concepts, the lapses in knowledge can be remedied by offering a simple apology, explaining your desire to improve cultural sensitivity, and taking steps to improve your own knowledge without tasking the patient to teach you (Goldhammer, 2018). Seeking and collecting resources for yourself and your patients is expected with quality care, so proactive and reactive efforts to attain such sources of information (ex. World Professional Association for Transgender Health, Human Right Campaign, etc.) is key to developing positive clinician-patient relationships.

3.     Promote more inclusive diversity education:

            It is common to complete training modules at the start of employment that require general competency in HIPPA/OSHA guidelines, hazard safety and infection control, sexual harassment and abuse training, diversity training, and so on. Based on the increased health risks and disparities reported in the literature, information regarding LGBTQ+ competent care should be included in the already existing training modules.

            Standardized health education regarding health risk/protective factors, socioeconomic barriers, and societal factors affecting the LGBTQ+ population should also be included in PT school curriculum, interwoven into diversity and ethics courses already in place (Jann, 2015). The Commission on Accreditation in Physical Therapy Education requires cultural competence education, and states that physical therapists should “Demonstrate verbal and non-verbal rapport in culturally competent practice that includes sensitivity to dimensions of diversity” including gender and sexual orientation (APTA, 2014). Despite this, standardized and comprehensive education on LGBTQ+ health is not yet taught across all PT programs, inadvertently negatively affecting quality of care for this patient population.

                        Despite several bigger barriers left to overcome within the healthcare system that limit inclusive care, we can begin achieving quality of healthcare for all patients by advocating for all people, including the LGBTQ+ population. Solutions come from the simple, underlying premise that our patients are human—humans who deserve to be treated as such, despite personal or societal biases. Because, why did you choose a career in physical therapy? To help people feel better.

If you missed Part 1, you can check it out here!

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Jordan is completing her final clinical rotation at Entropy Physiotherapy and Wellness before graduating from Old Dominion University this May as a Doctor of Physical Therapy. She will be starting her career as an outpatient pelvic physical therapist, following her passion to provide quality care for all people with pelvic health needs.

Update: Jordan has completed her rotation at Entropy and has passed her board exam!! Congrats!!

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Resources
Abramovich, A & Cleverley, K. A call to action: The urgent need for trans inclusive measures in mental health research. The Canadian Journal of Psychiatry. 2018;63(8): 532-537.

 American Physical Therapy Association (APTA). Blueprint for teaching cultural competence in physical therapy education. Retrieved from http://www.apta.org/Educators/Curriculum/APTA/CulturalCompetence/. August 2014. Accessed April 3, 2019.

 Burch, A. Health care providers’ knowledge, attitudes, and self-efficacy for working with patients with spinal cord injury who have diverse sexual orientations. Physical Therapy. 2008;88: 191-198.

 Cahill, S. LGBT experiences with health care. Health Affairs; Chevy Chase. 2017;36(4): 773-774.

 Colpittis, E, & Gahagan, J. The utility of resilience as a conceptual framework for understanding and measuring LGBTQ health. International Journal for Equity and Health. 2016;15(16): 1-8.

 Copti, N, Shahriari, R, Wanek, L, & Fitzsimmons, A. Lesbian gay, bisexual, and transgender inclusion in physical therapy: Advocating for cultural competency in physical therapist education across the United States. Journal of Physical Therapy Education. 2016;30(4): 11-16.

 Deutsch, MB & Buchholz, D. Electronic health records and transgender patients—Practical recommendations for the collection of gender identity data. Journal of General Internal Medicine. 2014;30(6): 843-847.

 Eisenberg, ME, et al. Risk and protective factors in the lives of transgender/gender noncomforming adolescents. Journal of Adolescent Health. 2017;61: 521-526.

 Glasper, A. Ensuring optimal health care for LGBT patients. British Journal of Nursing. 2016; 25(13): 768-769.

 Goldhammer, H, Malina, S, & Keurogblian, AS. Communicating with patients who have nonbinary gender identities. Annals of Family Medicine. 2018;16(6): 559-562.

Hayward, LM & Li, L. Promoting and assessing cultural competence, professional identity, and advocacy in Doctor of Physical Therapy (DPT) degree students within a community of practice. Journal of Physical Therapy Education. 2014;28(1): 23-36.

 Jann, JT, Edminston, EK, & Ehrenfeld, JM. Important considerations for addressing LGBT health care competency. American Journal of Public Health. 2015;105(11): e8.

 Mayer, KH, et al. Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health. 2008;98(6): 989-995.

 Nadal, KL, et al. Microaggressions toward lesbian, gay, bisexual, transgender, queer, and genderqueer people: A review of the literature. The Journal of Sex Research. 2016;53(4-5): 488-508.

 Reisner, SL, et al. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2015;92(3): 584-592.

 Taylor, AK, Condry, H, & Cahill, D. Implementation of teaching on LGBT health care. The Clinical Teacher. 2018;15: 141-144.

 Wahlert, L & Fiester, A. Repaving the road of good intentions: LGBT health care and the queer bioethical lens. The Hastings Center Report. 2014;44(5): S56-S64.

We the People of Physical Therapy (Part 1)

This article is for you. Well, not if you are a veterinarian, I suppose; but, even then I’m sure some similar argument could be made in regard to your client satisfaction. But, I digress. This article is for you. The healthcare provider. Specifically, the physical therapist who gives care to patients—to people, to humans—of all different backgrounds.

            Why did you choose a career in healthcare? What made you want to be a physical therapist? The common trend among responses, and the hackneyed answer that employers hear too often, is that you want to help people. You simply want to help humans feel better.

            So, what does it take to make a human feel better? All the science-y things we go through school to learn—duh! However, we cannot forget that quality healthcare requires us to consider the biopsychosocial influences on the health of our patients. Included in the biopsychosocial model of healthcare is the concept of cultural competence, which requires “acceptance and respect for difference” with “continuing self-assessment regarding culture, vigilance towards the dynamics of differences, ongoing expansion of cultural knowledge and resources, and adaptations to services” (Hayward, 2015 & Burch, 2008). In fewer words, cultural competence requires we treat all people like humans, each deserving equal respect and quality in healthcare regardless of personal or societal biases.

            Unfortunately, cultural competence and humility is often lost when it comes to providing care for the lesbian, gay, bisexual, transgender, queer (LGBTQ+) population. Despite growing efforts to create inclusive physical therapy (PT) school curriculums and clinical settings, the marginalization of this group is largely apparent. Additionally, uninformed attempts at inclusivity of this population sometimes serve to further stigmatize patients who are LGBTQ+ as atypical.

            It is well documented in literature and research that people who identify as LGBTQ+ have been historically marginalized, and suffer increased health risks in conjunction with the added stressors affecting healthcare services (Copti, 2016). Those who identify as LGBTQ are at increased risk for substance and tobacco use, sexually transmitted diseases, depression and anxiety, disordered eating, suicidal ideation or attempt, sexual abuse, chronic pelvic pain, low back pain, obesity (Copti, 2016, Mayer, 2008, & Eisenberg, 2017). Those undergoing hormonal therapies are also at further greater risk for various cancers, diabetes, cardiovascular issues, and osteoporosis (Copti, 2016). Additionally, a greater proportion of people who are LGBTQ+ face known negative determinants of health, such as homelessness, social isolation, and poverty (Colpittis, 2016).

            These risk factors are derived from and influenced by the disproportional victimization and discrimination by healthcare workers toward people who are LGBTQ+, as well as the “ignorance of LGBT health care needs” that “contributes to the misallocation and wasting” of health resources (Taylor, 2018, Nadal, 2016, & Goldhammer, 2018). Lack of cultural humility and sensitivity from healthcare workers and institutions creates physical and emotional barriers to receiving quality care, limits access to preventative care measures, and negatively influences health outcomes. The conscious and unconscious biases apparent in clinician-patient interactions cause people who are LGBTQ+ to endure lower quality of care, lose out on proper continuity of care, and avoid seeking necessary and timely medical treatment (Glasper, 2016).

            This invites conversation about how we can make changes in the clinical setting to help all humans feel better, without further stigmatizing or ignoring LGBTQ+ health issues. Cahill (2017) states that “one thing lacking in much of the analysis of this increased focus on LGBT health is the human element” (Cahill, 2017). Note the emphasis on human. So, the simple answer to this multifaceted issue? Just treat all patients like humans!

            Too simple? No. But, as with many things in life and healthcare, we make it complicated. Combatting the complexities and intricacies of societal discrimination, socioeconomic obstacles, political challenges faced by people within the LGBTQ+ community is beyond the scope of this blogpost, but we can discuss small changes we can take in the PT setting to make all patients feel human while in our care.

            In Part 2 of this blogpost, we will review some techniques and modifications cited in literature that we can use to help create a clinical environment that is competent in providing quality care to all humans who walk through our doors.

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Jordan is completing her final clinical rotation at Entropy Physiotherapy and Wellness before graduating from Old Dominion University this May as a Doctor of Physical Therapy. She will be starting her career as an outpatient pelvic physical therapist, following her passion to provide quality care for all people with pelvic health needs.

Update: Jordan has completed her rotation at Entropy and has passed her board exam!! Congrats!!

---

Resources
Abramovich, A & Cleverley, K. A call to action: The urgent need for trans inclusive measures in mental health research. The Canadian Journal of Psychiatry. 2018;63(8): 532-537.

 American Physical Therapy Association (APTA). Blueprint for teaching cultural competence in physical therapy education. Retrieved from http://www.apta.org/Educators/Curriculum/APTA/CulturalCompetence/. August 2014. Accessed April 3, 2019.

 Burch, A. Health care providers’ knowledge, attitudes, and self-efficacy for working with patients with spinal cord injury who have diverse sexual orientations. Physical Therapy. 2008;88: 191-198.

 Cahill, S. LGBT experiences with health care. Health Affairs; Chevy Chase. 2017;36(4): 773-774.

 Colpittis, E, & Gahagan, J. The utility of resilience as a conceptual framework for understanding and measuring LGBTQ health. International Journal for Equity and Health. 2016;15(16): 1-8.

 Copti, N, Shahriari, R, Wanek, L, & Fitzsimmons, A. Lesbian gay, bisexual, and transgender inclusion in physical therapy: Advocating for cultural competency in physical therapist education across the United States. Journal of Physical Therapy Education. 2016;30(4): 11-16.

 Deutsch, MB & Buchholz, D. Electronic health records and transgender patients—Practical recommendations for the collection of gender identity data. Journal of General Internal Medicine. 2014;30(6): 843-847.

 Eisenberg, ME, et al. Risk and protective factors in the lives of transgender/gender noncomforming adolescents. Journal of Adolescent Health. 2017;61: 521-526.

 Glasper, A. Ensuring optimal health care for LGBT patients. British Journal of Nursing. 2016; 25(13): 768-769.

 Goldhammer, H, Malina, S, & Keurogblian, AS. Communicating with patients who have nonbinary gender identities. Annals of Family Medicine. 2018;16(6): 559-562.

Hayward, LM & Li, L. Promoting and assessing cultural competence, professional identity, and advocacy in Doctor of Physical Therapy (DPT) degree students within a community of practice. Journal of Physical Therapy Education. 2014;28(1): 23-36.

 Jann, JT, Edminston, EK, & Ehrenfeld, JM. Important considerations for addressing LGBT health care competency. American Journal of Public Health. 2015;105(11): e8.

 Mayer, KH, et al. Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health. 2008;98(6): 989-995.

 Nadal, KL, et al. Microaggressions toward lesbian, gay, bisexual, transgender, queer, and genderqueer people: A review of the literature. The Journal of Sex Research. 2016;53(4-5): 488-508.

 Reisner, SL, et al. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2015;92(3): 584-592.

 Taylor, AK, Condry, H, & Cahill, D. Implementation of teaching on LGBT health care. The Clinical Teacher. 2018;15: 141-144.

 Wahlert, L & Fiester, A. Repaving the road of good intentions: LGBT health care and the queer bioethical lens. The Hastings Center Report. 2014;44(5): S56-S64.

EPIC Scholarship Winner: Natalie Kiefer

To start, I would like to thank the group at Entropy Physiotherapy and the EPIC Scholarship for the amazing opportunity to attend PAINWeek 2018. What a week! I had the pleasure of spending five days in Las Vegas learning about pain and its clinical management in a multidisciplinary setting. Among the group were physicians, nurse practitioners, physician assistants, pharmacists, psychologists, and many others. There were also a handful of other physical therapists attending and presenting at the conference.

The first thing that struck me about the conference was the thoughtful design and content presented. The halls of the conference were filled with creative and thought-provoking posters for each presentation. Some of my favorites that I attended (and just liked the design of) included:

As my own special interest, I was very much so looking forward to the lectures on pelvic pain. I now have some new tools in my toolbelt to treat this complex and intimate type of pain in our clinic. The International Pelvic Pain Society hosted a portion of the curriculum and addressed issues like endometriosis, dyspareunia, and vaginismus.

I was also encouraged to see the widespread education on opioid management. In the population that I work with through Indian Health Service (IHS), there has been a huge focus (like most other places) in addressing the overutilization of opioids for pain management. In particular, the Native American population has suffered from opioid abuse and addiction, with rates of overdose as high as three times greater than that of the general population. As a frontline clinician in pain management for this demographic, I am thrilled to have been provided with more education and insight on current best practices for managing those suffering from the opioid crisis.

It was a great week of learning with my colleagues and exploring such a fun city. With my infant daughter in tow, we were still able to see some of the beauty and excitement of Las Vegas, including attending a Cirque du Soleil show. It was a blast! Thank you again to all involved in the EPIC Scholarship. Your generosity serves not only individual clinicians but our profession as a whole as we move towards more evidence-based practice and clinical excellence through education!

Thank you to Natalie for writing about her experience at Pain Week 2018. My apologies for taking so long to post this!! Natalie was one of our TWO EPIC scholarship winners for 2018. Stay tuned for the next blog from our other recipient after the San Diego Pain Summit!

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Hard Flaccid Syndrome: Penetrating What We Know

Have you ever heard of Hard Flaccid Syndrome? Many clinicians and lay people have no idea what it is. If you try and search it on Dr. Google, all you find are message boards and blog posts. Not a single peer reviewed paper. Posts often cite that Hard Flaccid Syndrome involves things such as pelvic pain, pain on ejaculation, a retracted penis, a “rubbery” feeling to the penis, flaccid glans during an erection, symptoms reducing when laying down, and many others. 1,2 But, is it appropriate to call it a syndrome? One survivor speculates it as a symptom of Chronic Pelvic Pain Syndrome (CPPS) and not a condition itself. 3 Does it seemingly cause more catastrophization to comb this symptom out? Continuing with what the author of HF Unraveled cited, do we call one of the common cold symptoms “Runny Nose Syndrome”? Alas, this issue is still a somewhat common occurrence in males and often overlooked by healthcare providers. Pelvic health physiotherapists are the proverbial light at the end of the tunnel for many people. There is hope for individuals suffering!

First things first: there is nothing wrong with your/your client’s penis. Often, clients have been to many providers and have been given clean bills of health.4 He is shooed away with pharmaceuticals and no explanation why his friend is under the weather. Ruminating on the issue can precipitate a key ingredient to the problem: stress. 2,3,4 Stress causes activation of your sympathetic nervous system which in turn releases adrenaline throughout your body.5 This system is called the Fight or Flight response, and unfortunately your penis does not know if you are running away from a pack of rabid raccoons or wondering why you do not have the same erection you had before. Adrenaline acts by opening blood vessels more to things such as your muscles, heart, or brain and closing down smaller blood vessels, i.e. to your penis. This constant anxiety and stress can take a toll on your pelvic floor muscles too. While some of us hold stress in our jaws or stomachs, others hold their stress in their pelvic floor. They essentially forget how to relax their pelvic floor! Think of it like you have clenched your fist and you cannot extend your fingers back out to a resting position. It is stuck in a fist or you can only go part way. 

So, what can be done? As I mentioned before, a visit to your friendly neighborhood pelvic health physiotherapist may be in your interest. We can assess your pelvic floor muscles to determine how they are performing. What we find can help to direct your treatment. Here’s the catch: our assessment does not have to hurt. Neither does the treatment. Some people benefit from gentle self-massage to the area using a Z-Wand or other handy pelvic floor tool. 1 But, intensive internal manual therapy probably is not necessary, especially since Denneny et al concluded in their meta-analysis that evidence for trigger point manual therapy for chronic noncancer pain is weak and cannot be recommended. 6 We can also help you to employ relaxation techniques and constructive rest habits to help calm your sympathetic nervous system and increase your parasympathetic response. The parasympathetic nervous system releases nitric oxide (NO), the secret to the little blue pill, and causes smooth muscle to relax to allow more blood into your penis.5 Most importantly, we can help you get back on track with your exercise routine so you can increase blood flow to the entire body and help to increase endogenous endorphins! 

If you are a provider, get your clients to a pelvic floor therapist! If you are one of the many men suffering from CPPS and have this hard flaccid symptom, ask your primary care provider about what physical therapy can do for you and your penis. If you are in the Chicagoland area, come to Entropy Physiotherapy & Wellness and we will help get you back on track to healthy, normal erections! 

By Matt, Harville, SPT

Matt has been a student at Entropy Physiotherapy and Wellness since August, and will shortly be leaving us to complete his course work and help people with pelvises, with a focus on transgender care.

References

1. I have managed to recover from chronic pelvic pain syndrome. Medium. https://medium.com/@anonymous2016/i-have-managed-to-recover-from-chronic-pelvic-pain-syndrome-da4502b3a77. Accessed November 14, 2018.

2. Hughes K, Parnham A, Lucky M. Hard flaccid syndrome. Urology News. 2018; 23(1): 28-29. 

3. HF unraveled: A guide to understanding, coping, & healing. https://hardflaccid.org. Accessed November 14, 2018. 

4. Cure Hard Flaccid. Word Press. https://curehardflaccid.wordpress.com/. Accessed November 14, 2018. 

5. Spitz A. The Penis Book: A Doctor’s Complete Guide to the Penis—From Size to Function and Everything in Between. Emmaus, PA: Rodale Books; 2018. 

6. Denneny D, Frawley HC, Petersen K, et al. Trigger point manual therapy for the treatment of chronic noncancer pain in adults: A systematic review and meta-analysis [published online ahead of print Jul 17 2018]. Arch Phys Med Rehabil. doi: 10.1016/j.apmr.2018.06.019

Are we experts? Or Masters of anything?

Social media is amazing for so many things – staying up to date with research, reconnecting with people from high school, and forming amazing, international collaborations with people from all over the world.  It’s no longer weird or creepy to say ‘I met them online’.
 

With the good, comes the not so good.  There are obviously people selling things, which is fine.  I’ve never been a fan of the hard sell, or the oversell.  Just have a good product or service, tell me about it, and let me make my decision.  

As a physical therapist, it makes sense that my social media feeds are overflowing with physical therapy related podcasts, continuing education courses, products, and conferences.  I can generally scroll by quickly and still find the things that may be of interest to me. (Though to be honest, I usually email them to myself so that I can check them out later….  And then don’t.)

A growing trend in my feed are the terms and titles people are using to sell their services, courses and such.  These are self-proclaimed experts selling master classes or products.  This has always rubbed me a bit wrong.  so I sat down to have a think about why.

There are a few layers here, so stick with me…
First of all, I don’t know that you get to call yourself an expert.  I’ve been called an expert by others, but I can’t seem to say those words about myself.  Why? First of all, I don’t know that I am.  Every single paper I read has the potential to shed a little more light on a topic for me.  But it has equal potential to give me 30 other papers to read, because I now have more questions.  I have a sneaking suspicion that I will never know enough for me to call myself an expert.  I do call other people experts – but that’s my opinion of them and a sign of respect that I have for them, and really nothing more.

Second...

Now, on to the Masterminds and Master Classes that are now available….  These seem to be popping up everywhere!  While I’ve been told ‘this is how you market and get people to buy in’, it feels a bit like overselling or appealing to the insecurities of others.  I mean, who doesn’t want to be a ‘mastermind’?

I am in 100% support of evidence-based courses that are endeavoring to get clinicians thinking and asking more/better questions in order to better help their patients.  That being said, I don’t believe ANY of us are ‘masters’ of anything, and one course isn’t going to change that.   Lots of people are trying to do great things every day, but if we were ‘masters’, would our stats look like this?

There are many in the physical therapy community that I like and respect very much who are now promoting  ‘masterminds’ or ‘master classes’.  I firmly believe that they are trying to do good work.  However, I have a few questions for you….  Do you truly think you are ‘masters’?  Or did you choose that name as a marketing ploy?

Either way, I’d love to chat.  It’s very possible that I just don’t understand the meaning or your intention. 

Thanks for reading (& thanks in advance for the discussion),
Sarah

P.S.  Some more food for thought- instead of being a mastermind, what about having a 'beginner's mind'?  This sounds much more like what I'm aiming for!

An open letter to my patient’s previous therapist(s):

I’m currently seeing a patient of yours – a young person who is having some pain in their pelvis.  I am quite aware that often times our patients hear something different than what we say, and sometimes what they recall being told isn’t entirely accurate.

During the initial evaluation, the patient shared some past experiences and noted that there was short-term relief, some variation of symptoms which was taken as a sign of progress.  This made me very happy, as it was felt therapy in the past had made a slight, but positive, difference.

Then we spoke of what goals they had for therapy.  Other than to stop hurting, this patient wanted to run, do CrossFit, go to college and ride a motorcycle.  To me, these goals sounded amazing and perfectly achievable.

It broke my heart when they looked at me with surprise and disbelief.  They had been told to not to go to college but to stay close to home.  To sell the motorcycle and use the money for something that ‘wouldn’t make them worse’.  To not do CrossFit as that was too intense and would certainly increase the pain.

I don’t often share my feelings, but this outrages me.  Our only job as Physical Therapists is to help people do what they want to do.  That’s it.  We go to work every day to help people do the impossible – walk after a spinal cord injury, return to work after a stroke, regain independence after catastrophic medical or traumatic events.  If you don’t believe in the resilience and strength people have, and you don’t think people can get better, why on Earth are you in this profession?

But before me sits a young person, with no identifiable medical condition.  They just hurt.  And a colleague in my profession told them to give up. To be careful. To stop doing anything that might increase pain.  Remarks like that are the opposite of our job.

I can understand the desire to help and to protect people from more pain. However, that’s not how pain works.  Pain is an experience a person has.  We know that doing things you love can make people feel better.  And you’ve stolen that away from this person – by making them scared of the very things that could make them feel better.  Or at least feel more like them.

I wanted to bring to your attention that the people who don’t come back aren’t always ok.  That sometimes they’ve gone elsewhere because they want to do more than ‘not hurt more’, they want to live.  I’m not sure I can help this person recover, but I can promise you I’m unscaring them as best as I can, so they can get back to doing the things they love.

Thanks in advance for trying to stop scaring people in the future,

Sarah

Pelvic Health PHODA - What is it and how can it help?

Finding the “right” areas to address when working with any patient is a challenging task for a health care provider. What is important to that patient? In what area can we work to make progress so that there is a meaningful change and impact for that individual? When the patient is open, shares, and can pick out a specific activity or experience in which they would love to engage in again or for the first time all I must do as the provider is listen. But what can I do when the patient cannot articulate their goals because there are too many things, or it has been so long that all they want is for the dysfunction or pain to end?

That is when I use the Pelvic Health PHODA (Photographs of Daily Activities). Sandy first gave me the idea to create a PHODA for pelvic health after we discussed the original version during a course by Cory Blickenstaff. She had been wanting to have one for several years but had not yet found the opportunity to create the cards. A little while later I found myself stranded on my way back to the clinic from my home in Northern Michigan just after Christmas. My car broke down and instead of going to work for the next few days I headed back home until I could find an alternate route to Chicago. When I told Sandy about being stranded she said, “Work on PHODA”.

To begin I did some research on what versions of the PHODA exist and how they are used. It has been validated for use on patients with high and low levels of Kinesiophobia (Trost et al, 2008) where the modified version was used. This version has 20 photographs compared to the 100 in the original version. There is also a version that was recently validated for use with the pediatric population (Verbunt et al, 2015). This version looked at activities specifically important to youth with musculoskeletal pain and how harmful they perceived certain activities.

During my search I found the modified version, the original was by Kugler et al, for download on-line. My impressions after un-zipping, installing, and using the file were not positive. The background is a horrid mustard-yellow, the pictures are small and outdated, and you have to use all 40 images in order to complete the test. The experience was off-putting with the nauseating color scheme and the repetition of similar images that all had to be placed on a scale.

What I envisioned was a tool that would allow patients to pick images out that resonated with them, how ever many they would like, and then lay them out in terms of easiest to hardest. This then serves as a tool for the clinician to focus treatment and for the patient to zero in on what they are looking for from physical therapy. So I set about finding pictures of a variety of daily activities that patients have reported loving, hating, or wishing they could do that thing.

When I use them with patients I say, “Here are some photographs of activities. Please pick out ones that appeal to you. Then place them from no difficulty to very challenging based on your reason for coming to physical therapy. I don’t care how many you chose but I would like at least one at each end of the spectrum. Then we will talk about why you chose each card.” I want them to feel free to pick 2 or 54 cards. Then I can use their own choices as a guide for treatment.

Eventually I would love to validate these cards and their specific use for the treatment of pelvic dysfunction. Bronwyn Thompson, PhD, MSc (Psych) 1st Class Hons, DipOT, Registered Occupational Therapist has a great article on validating PHODA for use in New Zealand.  For now I use them in conjunction with other outcome measures using the photos to gain insight and target my treatments to best serve each individual who comes through the door.

Hannah Mulder is a 3rd year DPT student from Rosalind Franklin University, doing an amazing job of applying research to her practice, as well as making excellent snacks for the courses at Entropy.  If you're interested in a set of your own PHODA for the Pelvis cards, you can buy a set now!!

References:

Trost Z, France C, Thomas J. Examination of the photograph series of daily activities (PHODA) scale in chronic low back pain patients with high and low kinesiophobia. Pain (03043959) [serial online]. February 2009;141(3):276-282. Available from: CINAHL Complete, Ipswich, MA. Accessed January 22, 2018.

Verbunt J, Nijhuis A, Goossens M, et al. The psychometric characteristics of an assessment instrument for perceived harmfulness in adolescents with musculoskeletal pain (PHODA-youth). European Journal Of Pain [serial online]. May 2015;19(5):695-705. Available from: PsycINFO, Ipswich, MA. Accessed January 22, 2018.

Kugler K, Wijn J, Geilen M, de Jong J, Vlaeyen JWS: The Photograph series of Daily Activities (PHODA). CD-rom version 1.0. Institute for Rehabilitation Research and School for Physiotherapy Heerlen, The Netherlands, 1999

HealthSkills Blog

Variety is the Spice of Therapy

What do kettlebells, yoga mats, hula hoops, and a TRX system have in common?

They are all ways to challenge expectations about what you can or can not do!

Pain gets in the way of life when it changes how you sit, stand, move, do your daily things like taking a shower, having a poo, eating, and even being intimate! When these limitations happen, you are faced with the challenge of earning back your tolerance or skill! This is hard work.

It can be intimidating. You may have been told by healthcare professionals things we know to be wrong (out of date is a kindness to well-meaning providers/friends).  Things like:

“Running will damage your knees”

“Bending wrong will hurt your back”

“Your phone is ruining your neck”

“Pregnancy makes you hurt and leak and there’s nothing you can do about it”

“Too much sitting will create fascial torsions and Trigger Points that can never fully go away”

None of those things are reasonable beliefs – but they are catchy!  They scare you into needing help, they make you afraid to push your limits, they steal from you your resiliency.  They are great business models – and horrendously bad for health! The evidence is mounting against using such fearful words, and towards promoting resiliency and your natural health.

What then?  What is the key to getting out of pain and back to the things you love?
Hard work.  Repetition.  Challenge. Courage.  A helping hand when it’s rough.  An encouraging word when it feels too hard.  This is the essence of physical therapy! 

How does moving into discomfort or challenging your beliefs about movement help with pain?  A carefully set up program is matched to you, not taken from a pre-made sheet of exercises, but shaped by your priorities, your preferences, and starts right where you are.  This program uses common things, from balls to weights, maybe yoga, maybe the stairs in your house.  Creativity and play are important to include in any movement program, and joy is too often left out of therapy and self-care.

We play with these ideas in the course I teach to health professionals Pain, Science, and Pelvic Health with examples from acute pain episodes to persistent pain that hasn’t responded to care. If you’re in therapy and following sheet after sheet of boring exercises – consider shaking it up! If you’re a therapist looking to move past pre-programmed formulas so that you truly can individualize your care to your patient, come to my class where we explore graded exposure to all these things and more!

Sandy

Sandra Hilton, PT, DPT, MS
Doctor of Physical Therapy

Do Vaginas Need Rejuvenating?

Laser therapy for vaginal rejuvenation is a hot (and profitable) intervention.  

Lasers themselves are alluring.  They hold a promise of more power than anything we can do for ourselves. In health care, they have many uses – some with good evidence, others not.  The use of lasers for improving circulation and tissue health in the vagina is a growing trend.  Is it more than an expensive, flashy, placebo?

A British morning show did an expose with a live demonstration1.  What is the attraction and what bring women to pay roughly $1200/visit for vaginal laser treatments?  

Women are seeking help for:
Vaginal dryness
Painful intercourse
Vaginal skin irritation
Appearance

Some women experience uncomfortable symptoms from the hormonal changes that occur with peri-menopause and menopause. The lasers are promoted to women as a non-hormonal treatment to restore vaginal tissue hydration and mobility.  They are also promoted as a way to change the appearance of the labia and make the tissues “more firm” as a “Laser of Youth” for lady bits. 

I am left with many questions:
Is it beneficial for women to seek an eternal youthful appears to their labia for a self-esteem perspective?

What are the long-term effects for the tissues?

Does laser therapy live up to the claims? 

Is the effect the same or better as the hormonal therapy and/or topical ointments currently used to relieve these problems?

We don’t know the answers to these questions because there is no evidence supporting the claims, and there is evidence showing little change in the tissues following treatment.

Laser therapy as a treatment modality for genitourinary syndrome of menopause: A critical appraisal was published in January of 2017 on the current evidence on the treatment of vulvovaginal atrophy. 2 Neither the Mona Lisa (CO2 laser) or the Yr:YEG near infrared laser have undergone testing compared to a placebo and none of the studies found by the authors in their literature review used any control group.   The 220 women included in the review completed symptoms questionnaires as the measure of effectiveness.  There were no negative effects and the treatments are considered safe.  What we don’t know is if the laser treatment is the reason for the improvement.

I applaud the authors for recommending a placebo-controlled trial. 

They found no studies have been done on the lasers and that the term Genitourinary Syndrome of menopause (GSM) includes a variety of symptoms that have different causes and treatment options.  This paper addresses the older term “vulvovaginal atrophy” which included vaginal dryness and irritation – subjective symptoms most commonly treated with hormonal therapy and/or topical ointments.

Treatment typically is three 5-10 min sessions, administered 4 – 6 weeks apart.

The authors report that “some participants <in the literature> show improvement after one treatment procedure while some show improvement after 2 – 3 treatment procedures.” 2 It is important to note that what is improved, by how much, and how that is determined is not defined.

220 women are included in the review. There are no RCTs and the review included 3 case series without control groups.  The paper refers to “subjective cure rates” based on participant self-report on questionnaires.  The studies followed up for only three months, and no long-term data is available.  The authors concluded, “Lasers have become a very expensive option for the treatment of symptomatic GSM, without a single trial comparing active laser treatment to placebo”2

The two types of laser included in this review are Mona Lisa (CO2) and ER:YEG (near infra-red).  The Mona Lisa laser is ablative, and the ER:YEG is non-ablative. There are no other substatantive differences. This treatment is not covered by insurance (remember, there are no RCTs showing effectiveness and there is no long-term data) and costs between $1000 - $1500/visit.2 The Mona Lisa is a CO2 laser designed to stimulate and promote the regeneration of collagen fibers and to restore hydration and elasticity within the vaginal mucosa. The Er: YAG  is a laser with a wavelength of 2,940 nm, which emits laser energy in the mid-infrared region. This laser has 10 to 15 times the affinity for water absorption than the CO2 laser at a wavelength of 10,600 nm. This treatment approach enables a deeper secondary thermal effect and controlled heating of the target mucous membrane of the vaginal wall.

These lasers have been cleared for clinical use by the FDA and are being marketed both to healthcare practitioners and to consumers.  The women seeking this treatment for pain are desperate for help.  This puts the burden of proof of effectiveness and efficacy firmly on the providers. It is also important to point out that we do not know if it is effective long-term, or if it is more than an expensive placebo.  It MAY be effective!

What is the harm?  At this point, the harm is two-fold:

1)   The cost is a burden for the person in need.

2)   The person in need is IN Need.  This is not vanity treatment; this is to fill a need for comfort (in order to move without pain, rubbing, dryness) and self-confidence.

My hesitancy as a health care provider in promoting this option is that we do not have a placebo-controlled study, and we do not know the long-term effects.  It may be that this is a much-needed relief and a viable treatment.  Without a large, long-term, randomized, placebo-controlled study to assess safety and efficacy we do not know.  Is this better than low-dose local hormones for tissue health?  Is this better than a combination of hormones and moisturizers for dryness?  We don’t know. 
What role with the new selective estrogen receptor modulator play (SERM)?  We don’t know.

How many times can I say “We do not know”? One more!

An additional problem is with definitions and that leads to a challenge in determining effectiveness.

What is normal in the aging vagina? 

Is aging a pathology or something to be adapted to?

Define “improved” in these studies – would that carry over as a predictive value for another person?

My hope is that these authors continue to study and continue to push for the independent placebo-controlled randomized trial (a straightforward study design).  For women considering the procedure, I urge caution and clear discussions with your healthcare team for all your choices.  The jury is still out on this one.

Sandy Hilton, PT, DPT, MS

1. http://metro.co.uk/2017/09/20/woman-undergoes-designer-vagina-surgery-on-live-tv-its-visibly-different-6942159/ Accessed 15 January 2018.

2. Arunkalaivanan, A, Kaur, H Onuma, O. Laser therapy as a treatment modality for genitourinary syndrome of menopause: A critical appraisal.Int Urogynelcol J January 19, 2017.

Another EPIC story... Jilly Bond shares her experience from WCAPP 2017

From Entropy - Thanks to Jilly for sharing her thoughts on attending the 3rd World Congress on Abdominal and Pelvic Pain in Washington DC this past October. If you're interested in applying for an EPIC scholarship, please stay tuned for more details!  We have 2 events coming up in 2018 to support his fund.  We will have another EPIC event with Lorimer Moseley in Victoria, BC May 4, 2018.  We are also grateful and excited to announce that Paul Hodges has joined the party!  We will have an EPIC event with Professor Paul Hodges in Chicago at Entropy on March 2, 2018.  We hope to see you there!

Reflecting with distance

When I look back on my career I’m pretty sure that attending the World Conference on Abdominal and Pelvic Pain 2017 in Washington, DC, will have been a turning point for me. An idle conversation with a colleague about the wealth of international knowledge we wished we could access spurred me on to find out if there was funding available. I didn’t really consider that it might happen.

Without Entropy Physiotherapy’s EPIC scholarship in collaboration with Lorimer Moseley, it would have remained a pipe dream. I submitted my entry at the end of a long day in the clinic and crossed everything hoping that I’d get chosen. I was sure that I couldn’t appreciate the value of attending this conference until I was there, and I wasn’t wrong. The sheer volume of knowledge disseminated was vast; from presentations of evidence supporting concepts I was somewhat familiar with but in far greater depth and complexity, to basic brain science that was a real challenge to understand. At one point I asked a physio I was sat next to if this was a “normal” conference for her, or if she was also as blown away by the level of clinically relevant evidence presented and by such a wide array of experts in the field. “Oh yes, this is pretty normal for us. But I’m still amazed, isn’t the body incredible?!”. I’m a regular attendee at our national conferences, but this was truly a world-class event.

It was also an exhausting and exhilarating week – American conferences start early, and events go on late into the night. However, it was at the fundraisers and PT pub nights that I had the most fruitful conversations, where other clinicians and researchers as passionate about pelvic pain as I am shared how they had interpreted the day’s evidence into clinically useful ideas. Names that I have been reading since University were standing around me wanting to talk about what they’d heard, their thoughts, experiences within research and what they thought I needed to be thinking about and reading. These short interactions had a profound impact upon me. I grabbed breakfast with a keynote speaker, unawares, discussing the importance of psychoimmunology over our pastries. I had an amazing conversation whilst walking to the pub with Paul Hodges about how we can personalise treatment, and how we could begin to integrate that into an evidence-based model. At a coffee break, I discussed practical applications of interval training for vagal nerve stimulation with the team who had spent 15 years discovering how and why this could be useful to visceral pain. Over cocktails, I talked about how we could apply graded motor imagery and motor planning to bladder pain, with a researcher currently studying brainy changes who was also interested in the potential of this challenge. And I had a deeply impactful conversation with Shelly Prosko over Dim Sum on the importance of therapist self-care, that has made me take up Yoga. People were enthused, wanting to discuss pelvic pain, and were willing to share their knowledge. I’ve added countless people to my lists of those I follow online, those who I go to for help and solid evidence, and have benefitted from these supportive relationships already through professional mentoring.

A few months on I’m still returning to my notes to process all the concepts I’ve learnt and marveling in the access to experts that the conference provided. Putting together some blog summaries of the week for my colleagues in the UK and worldwide that couldn’t attend has really helped me to reflect and identify my learning points from the conference into the following themes:

-        There are complex changes in the motor cortex, sensory cortex, and salience network in those with chronic pelvic pain

-        Pelvic pain occurs with multiple and overlapping comorbidities, we have to think about them concurrently in treatment

-        The convergence of visceral pain creates a widespread pain state – the “widespreadedness” of pain is important and may denote a phenotype

-        Psychoimmunology is important - brainy pro-inflammatory pathways reduce downregulation of the distal inflammatory response in many pelvic pains

-        Autonomic changes are important – Bladder Pain Syndrome involves a vagal nerve dysfunction we can affect with interval training and myofascial pain involves a sympathetic vascular dysregulation

The harder part is then how you employ this knowledge. It’s all well and good having an intense learning experience and meeting some incredible members of our research community, but the important bit is how we apply this to clinical practice and help our patients. A few months on from the conference I can reflect now that it’s had a dramatic effect on my clinical work. I’m using tools I did before but with a greater understanding for the mechanisms by which they may work. I’ve started to play with different methods of creating motor and sensory retraining in patients with significant pain. Where I would previously have focussed on building a supportive, therapeutic relationship to allow me to get to the point where it was tolerable to perform manual therapies in order to affect change, I’m now working alongside my patients in the initial phases to build and modulate their motor and sensory awareness in order to produce a more meaningful response to manual treatments. It’s a subtle change but I’m already finding that my manual therapy feels more effective and efficient. All of my pain patients are also now completing interval training, to whatever level is appropriate for them. This has prompted me to engage them in physical exercise much earlier than I usually would in my treatment plans, challenging my previous ideas that it would limit the benefit of manual pelvic floor work by “getting everything tense again” using maladapted strategies – quite the opposite, they’re all improving and they’re enjoying themselves whilst they do! And finally, I’m explaining things more clearly to patients because I understand them more fully.

I’ve also spent some time going through the literature discussed and adding it into the professional development courses I run in the UK for physiotherapists so that the reach of this conference can be maximised. The conference has had a deep impact on my understanding of pelvic pain, the treatments I provide for my patients, and where I look for evidence and learning. I would encourage anyone interested in pelvic pain to attend the world congress, thankfully next time it may be closer to home for me in the UK. Without the EPIC Scholarship from Entropy Physiotherapy and Lorimer Moseley none of this would have happened, I can’t thank them enough for supporting me to attend what was a pivotal moment in my career. See you at the next conference!

Thanks again to Jilly for her blog!  You can find out more about her amazing work on her website, or find her hopefully attending more international conferences.  We are certainly excited to spend some time with her!

Goat Yoga - by Kelly Newman**

Though Kelly has left us, she's not forgotten...  Here's her blog on her (almost) experience with Goat Yoga.

Chronic low back pain is a huge problem in the United States, and despite our best efforts, we haven’t really found an effective treatment for it… until now.  Allow me to introduce the latest health and wellness technique: GOAT YOGA.  It is yoga… with goats.   

Why do so many people have chronic low back pain? It’s obvious.  It’s because they aren’t doing enough goat yoga.  “Can’t I do regular yoga?” you ask.  NO. NO. ABSOLUTELY NOT.  It’s not rocket science, people!  It’s clear that the health benefits are from the pitter patter of tiny goat hooves on your aching back. Trust me, if you don’t have a furry grass-muncher sniffing your ear while you down dog, you’re not doing it right. 

The theory is...

the goats have the perfect body weight to fur ratio to stimulate your muscles…and stuff.  And also relax them if that’s your problem.  While it’s true that nobody has checked out these claims “scientifically”, I can tell you that I am 100% certain that goat yoga will cure you.  If it doesn’t, you probably aren’t committed enough to goat yoga.  

To get the maximum healing properties out of goat yoga, you should go at least four times per week for the rest of your life.  Goats from the farms of Wisconsin are best, but any regular old goat will do in a pinch.  Just don’t expect as good of results.  Make sure the goats are in a healing mood.  If the goats aren’t in a healing mood, you need to come back later when they’re ready to radiate positivity.  

Make sure your instructor is GOAT YOGA certified.  If they are not, you will get nothing out of the class and probably feel worse for a long time, possibly forever.  Make sure you ask to see their Goat Yoga certificate for the 18 courses they had to take to become a Goat Yoga instructor.  If they try to tell you that they don’t need the certification to release a goat into a field while you’re doing yoga, they are SERIOUSLY MISLED and you need to get away before all of your discs slip.   

By the way, I am a certified Goat Yoga instructor and would love to take your money I MEAN CURE YOUR BACK.  Sign up now!

PS: Goat Yoga actually does not make any of these claims and I made this whole thing up.  Goat Yoga is probably really fun and silly!! Try goat yoga if you want, or don’t.

**It came to my attention today that I prematurely called her 'Dr. Kelly Newman'.  My apologies for this error.  I do know that Kelly has completed all of the didactic and clinical work for graduation, as well as passed her boards and secured her first job as a physical therapist with a clinic that will not disappoint her.  We're super proud of her ability to critically think, and not be seduced by things like certifications and 8-step training programs.  So, Kelly, we're really proud (even though you're not a doctor just yet) of what you're going to contribute to our profession.  Please continue to have fun, love what you do, and DTS. Love, Sarah and Sandy

Elvie has made me fall in love - for the first time ever with a pelvic floor device

Most people can agree that having a pelvic floor that does its job is desirable, many people struggle with knowing how to optimize their pelvic floor muscle function.

The opinions about how to do a pelvic floor contraction, how many you should do, and why you should do them vary dramatically.

So what is a lady to do?  There are an abundance of items that offer to help improve pelvic floor strength, cure incontinence, and give you better orgasms!  Sounds like a win-win-win !  So why aren’t we all continent and having fantastic orgasms?  This post will address the various products that are out there for ‘pelvic floor strengthening’.  These products range from vaginal weights, Ben Wa Balls, vaginal barbells, electrical stimulation machines, to biofeedback machines.

While some of these products work wonders, some women discover that the device they’ve chosen don’t work for them.  Why might this be?  I propose 3 simple possibilities:

1)   The device is not addressing the issue that needs to be addressed.

2)   The device is being used improperly.

3)   The device is not being used.

The pelvic floor muscles are just that:  muscles.  To function properly, the muscles need to be properly innervated, have good coordination ( the ability to contract and relax), and adequate strength. 

I’m skeptical by nature about ‘new’ products, and the idea that they can really help a woman improve her pelvic floor function. (Notice I said ‘function’, NOT strength).  I’m skeptical, but I have my reasons - I've been a pelvic floor Physiotherapist for over 10 years now. I've watched products come and go.  I've also helped clients sort through the products online, trying to find the one that would make working on their pelvic floor fun and effective.  I've also chatted with those people later, and even if their pelvic floor issues have resolved, they admit that they've not used the product that they had invested so much time and money in purchasing.

Any of the devices I mentioned, both the weights and the biofeedback, can be used improperly.  Weights don’t work well if you don’t know how to contract your pelvic floor properly.  Biofeedback typically works one of two ways – via EMG (electromyography ) or using pressure.  Both of these devices typically involve inserting a sensor (hard plastic or a air-filled balloon), which is then connected to a handheld monitor via a cord or tube.  If the set up already sounds a bit complicated, it can be.  Getting the sensor positioned properly, making sure all of the wires are connected, and get the monitor into a position where you can see it, and then start to actually do your pelvic floor contractions can be time and effort intensive for some people. 

Once everything is situated and you’re ready to work, you need to consider what information you’re actually seeing about your performance.  EMG biofeedback units will show you the relative change in the electrical activity in your pelvic floor muscles.  This sounds high tech, but unfortunately it’s not as scientific as it may sound.  These units utilize surface electrodes that are inserted into the vagina (or rectum).  This means that the information is general – it’s not necessarily the muscle activity of the pelvic floor, but a general report of the activity in the area.  There are several ways to get inaccurate readings, which may lead women to believe they are performing better (or worse!!) than they actually are. 

Pressure Biofeedback has challenges as well.  There are many variables that can skew the readings of a vaginal pressure biofeedback – holding one’s breath or pushing down (instead of contracting the muscles) can all give the appearance of a pelvic floor contraction.

Even if these devices were highly accurate in giving feedback regarding pelvic floor muscle function, the cumbersomeness of set up and multiple components to keep clean would challenge even the highly motivated consumer. 

So is there a product out there that I would recommend to my friends and clients?  There is now!  I’d like to introduce you to Elvie!

Again, I tend to be a skeptic.  I was given an Elvie to try from the brilliant ladies at the Women’s Health Foundation.

I opened the box, and I’ll be honest – it’s adorable.  Simple packaging, and the device itself is sleek and elegant.  Elvie comes in a little storage container, which is also the way you charge the device.  I was impressed so far…. 

But how does it work?

I charged it up, and downloaded the app to my iPhone.  There were just a few steps to set up the app, and I was ready to give this a go. 

I settled into a treatment room, and started to follow the instructions on my phone.  Once the Elvic is inserted, it sets about connecting to my phone via Bluetooth.  NO WIRES!!  I can move around comfortably without worrying about yanking anything out or breaking expensive equipment.  I can even stand up and move around a bit! 

I’d like to speak for a moment about the comfort of Elvie.  It’s covered with a medical grade silicone (so no latex!), and was so comfortable.  The size for me was comfortable, and many women would be able to accommodate the device as is.  However they also include a silicone ‘custom sizing’ sleeve in every unit.  More on that later.

Comfort and convenience?  Check

Not scary or hard to use?     Check

But does it actually work??  In my opinion – yes.  Very well, in fact.

I was taken through a set up phase, and then my first work out.  I appreciated the fact it was assessing both endurance holds, as well as ‘quick flicks’.  We were off to a good start, but it got better….

During the long holds, I tried to cheat.  When a contraction is done properly, there is a red gem that is lifted.  It sets your ‘goal’ during the set up, so you have a target to hit.  I wanted a good grade, so I did my best on the first few reps. Now to see if I could fool Elvie….  I squeezed my knees together.  I pulled in my ads.  I held my breath.  I pushed down.  The only way I could make that gem move was by doing a proper contraction.

I was further impressed when I moved onto the agility portion of the training.  Reminiscent of Space Quarks (a video game of my youth),  red gems streamed across the screen, and it was my job to contract at the right times to hit those gems.  It was a really good challenge, but the feedback I got was amazing….  Guess who wasn’t relaxing all the way between contractions?  This girl.  Guess who encouraged me to relax more?  Elvie. 

My most consistent complaint about pelvic floor contraction (or Kegels) is that the emphasis tends to be on the contraction.  The other units don’t really give accurate feedback on relaxation, and there are no norms.  I love that Elvie takes into consideration that the relaxation is just as important as the contraction in a healthy pelvic floor!

At this point, I was very impressed with Elvie.   So impressed that Sandy and I agreed to meet with a representative, Hannah, from Elvie.  What I learned about the product and the company only increased how excited I am about this product. My 2 favorite points? 1)   Elvie comes with a ‘custom sizing’ sleeve, for women who may need a slightly larger device to stay in place.  The sleeve is included with each unit.  The thoughtfulness of this almost brought me to tears.  Hannah explained that there were 2 women in the testing groups who were more comfortable with a slightly larger device.  They developed the sleeve, and decided to include it with every unit, rather than creating a situation where a woman would have to request a larger size.  Pelvic health can be awkward for some women, so I’m grateful they’ve removed one barrier for women to get a device that fits appropriately.

2)   During my attempts to cheat the results on Elvie, I did not know that if I cheated enough, Elvie would recommend consulting a pelvic health physiotherapist for some assistance before continuing the program.  How amazing that a device has been developed that not only figured out a different way to measure pelvic floor strength and coordination, but to also to recommend whom to seek help from.  You’re not sick if your pelvic floor doesn’t work well.  You just need a person who is an expert in pelvic floor function to help guide you, and that person should be a pelvic floor physiotherapist.

Has the Elvie been extensively studied in pelvic health?  Do we know long-term outcomes?  Not yet.  But they are gathering data, and working with health organizations in the UK to improve pelvic health on a larger scale.  The design is elegant, clean (literally and figuratively), the set up and use is intuitive, and the method by which the pelvic floor performance is assessed is advanced far beyond what  other pelvic floor biofeedback units have to offer.  I can say happily that is this is the first device for pelvic health that I’m truly excited about on every level!

You can learn more about Elvie on your own at their website.  If you'd like to see one in person, they were nice enough to give us a demo unit to have at Entropy!  Shoot me an email, and I'm happy to show you how it works!  A pelvic floor therapist can help you learn what you need to do to address any of your pelvic floor concerns, and if you need any other interventions before using Elvie.  We're happy to offer guidance, if you feel like you need some!  Good luck! 

Thanks for reading,

Sarah

Where do YOU find value in Continuing Education?

My opinion and views have changed quite a bit over the last 10 years about Continuing Education.  I’ve always loved learning, and for years I couldn’t tell you how many CEUs were required in Illinois because I attended every course I could.  I always had more than enough, and it was never about just ticking off a box.

It was a bit fortuitous this morning as I’m working on the schedule and website for Entropy Physiotherapy and Wellness’s Continuing Education offerings that 2 pertinent tweets popped up in my Twitter feed.

The first one was from David Pulter (@orth_DavidP), sharing this piece from the PT Journal published in 2001!  The Editor’s Notes by Jules M. Rothstein laments the quality of CE offerings, comparing CE purveyors as ‘modern-day revivalists, moving from community to community with zeal and a polished act that seduces the listener’.  What is the most depressing part of that statement (other than the fact it’s true in many cases) is that after each course, 40 disciples leave that course and spread information that is enthusiastic but often poorly researched at best, and implausible or misleading as a less beneficial outcome. 

I feel confident saying that, because Sandy and I have both experienced the process of getting ‘approval’ for courses we host at Entropy Physiotherapy.  We’ve attempted to get the courses approved through ProCert.  I was at first rather excited about what appeared to be a rigorous process.  However, my hopes were dashed as we looked over the example they gave to assist in filling out the complicated forms.  The example course?  Using therapeutic ultrasound.  Yep, ultrasound. 

While there are still administrative hoops to jump through to make the CE courses at Entropy ‘count’ towards fulfilling our licensure requirements, everyone needs to be aware that the ‘stamp of approval’ is NOT an indication of quality. The processes are in place to be sure that the therapists taking the courses understand what will be offered.  These processes have nothing to do with the level of evidence or plausibility or even quality of the course.  Those determinations are up to the individual therapist to make.

This leads me to the latest blog by Adam Meakins.  ‘Who is fit to teach?’.  It’s a great question.  In my time as a Physical Therapist, I’ve certainly gone through some phases here.  I started out as a wide-eyed believer.  Obviously if someone was able to get 40 people to pay $450 for a course, they must know what they’re talking about, right?  I didn’t question much back then. 

But now I’m old, and I question everything.  So what do I look for when I’m going to be spending my money on continuing education?  I’m looking for someone who is well versed in the latest evidence (even better if they’re involved in the research!), and someone who is willing to have an honest discussion about what we know and what we don’t know.  I’m not looking for someone who is a ‘guru’….  Because those don’t actually exist unless you suspend your ability to critically think. 

So who IS fit to teach?  Adam doesn’t limit it to the people with the highest degrees, the most publications, or largest social media presence.  The best teachers have passion, personality, respect, and are able to present their material while having fun.  The best teachers inspire challenging questions and critical thinking.  The best courses do not provide rigid protocols or elaborate rituals, instead they give the clinicians skills to thoughtfully evaluate and treat a person with unique goals.

So what is the point of this post?  Mostly to say learning is good.  But not all learning experiences are created equal, and sometimes all you learn is what not to do.

Entropy Physiotherapy has solved our continuing education frustrations by collecting clever speakers from all of over the world, bringing them to centrally located Chicago, and hosting small classes in a comfortable environment.  We would love to hear your thoughts on what we're doing, and how we could do better!

I didn't know what to expect - Nate's time at Entropy

Note from Sarah- Today is the first day in 2 months that Nate Mancillas won't be heading to work at Entropy.   We will miss him, and this post made my eyes water just a bit. Luckily Ryan Smith will be there to soften the blow...  Here are Nate's thoughts on his time with us at Entropy.  

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From Nate:

When I first began my clinical at Entropy Physiotherapy I didn’t know what to expect. If I had to guess before I began I would have thought my experience would just be anatomy, internal manipulations, and incontinence. While my time here did entail some of those things, it was so much more

I was able to attend continuing education courses that I felt were just as, if not more in some cases, beneficial than days spent in the clinic. I got to interact with world-class therapists and researchers and learn from them first hand. I was given the opportunity to network with them and connect with them outside of a clinical or conference setting.

I was given the best education on pain science a student could ask for. I learned the what, where, when, and why, and how of pain in my 10 weeks. I admit I still have a long way to go on pain science, but this clinic has taught me I need to educate others on pain, which is an awesome starting point.

Beyond all of these great things, I got to learn from two of the best physical therapists in the world. The way Sarah and Sandy run their business, treat their patients, and represent the profession of physical therapy is among the best I have ever seen. They treated me with respect and kindness. They were never condescending and always willing to answer my questions. I haven’t even mentioned how funny they are, but I never went a full day without a good laugh.

With all this glowing praise, you might think this was a cakewalk, but it was quite the opposite. I had my lines of thinking challenged and anything I would say had to be backed up by evidence. If I could not provide this evidence, I would need to do a bit of digging on the topic and come back with a suitable answer.

I would not trade my time at Entropy for anything. Even though I am sad to leave, I know that my time here has been invaluable and I am a better physical therapist walking out than I was walking in. Thank you Sandy, Sarah, and Ryan. I’m sure I will see you again.

Follow Nate on Twitter!  @NateMancillaSPT

Support for Pelvic Pain in Unexpected Places

When you are experiencing pelvic pain, or pain of any kind, you may go through a range of emotions and more than likely will have a lot of questions ranging from “Why am I in pain?” to “Is this going to get better on its own?”. These are not easy questions to answer, and finding support and the right person to ask them to can be very difficult. The following are great resources that you can use in a variety of ways. You can use them to vent about issues, get advice on a range of topics, or offer your support to others dealing with pelvic pain. Just remember that these websites are not run by health care providers so be sure to consult with a medical professional before beginning any sort of treatment recommended.

Reddit

Chronic Pain Subreddit

Pelvic Floor Dysfunction Subreddit

Reddit calls itself “The front page of the internet” and is described as a “social, news, entertainment network”. If you just browse the site casually you may not think it is the best place to share your experiences with pelvic pain. However, if you dig a little deeper you can find communities like “Chronic Pain” or “Pelvic Floor” full of supportive people who are happy to share advice on things such as tips for staying warm in cold weather to advice on post surgery recovery.

Facebook

American Chronic Pain Association

Chronic Pelvic Pain Network

You most likely have a Facebook page, and while it is great for staying up to date with friends and family it can also be a great way to connect with others living with pelvic pain. Like Reddit, there are many groups whose, members offer support and advice on pelvic pain related topics. Groups may even have meet-up events so you can connect face to face with others with pelvic pain.

Twitter

Twitter

Twitter is another social network that allows you to connect with others in similar situations. Using hashtags (the # symbol) you can see who is tweeting about things relating to your pelvic pain. Popular hashtags for those who have pelvic pain include #pelvicpain, #pelvichealth, #pain, and many others. You can reply to people who use these hashtags with advice, questions, or just to offer your support. Just make sure to keep it brief as 140 characters goes quick! Make sure to follow @SandyHiltonPT,  @SarahHaagPT, and @EntropyPhysio once you get set-up.

The internet is a great place to find support, if you find the right communities. The communities mentioned here is not an exhaustive list, but it does include places whose members are active and helpful. Make sure to contact Sandy or Sarah at Entropy Physiotherapy so they can answer any questions you may have and help you resolve your pelvic pain.

Nate Mancillas SPT, MS

Redefining Your New Normal

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  Warm red leather with great traction and no concern for rain or snow, my favorite boots sit in the corner of the closet, the soft tops sagging into pouty folds. They were benched last winter after a rough year of ankle sprains, soreness and nagging foot pain. “I’m good as long as I don’t wear heels or my boots.”

The new normal isn’t normal.

• Give up the favorite boots or heels and that foot pain is gone.
• Don’t turn your head as far and your neck doesn’t hurt.
• Move the dishes to the lowest shelf and reaching isn’t a problem.
• Take the elevator instead of the stairs and then you won’t be out of breath.
• Stop running and that little leak of incontinence is gone.

Clever adaptations and life can go on undisturbed. Silently and surely losing out on things you once did, things you loved to do that kept you feeling strong and healthy.

The signs of the inevitable decay with age?

NO! Absolutely not.

Let’s turn this around and create a NEW NORMAL where you take back the things you love!

What if….

When you notice that you’ve stopped doing something to avoid a pain, pinch, stab or ache you take that warning sign as a chance to change instead of to avoid? What if you design a plan that identifies the challenge and sets clear, measurable steps for reclaiming what you love to do?

What if you find the sore spots as opportunity to improve and erase them, while still doing what you love to do?

Run Climb stairs Play tennis Lift weights Reach the high shelf Get up and down from the floor Wear those gorgeous boots! Dance Laugh

Don’t give it up. Make a plan. If that’s hard, intimidating or if someone (including you) has told you it’s not possible, please give Sarah or Sandy a call… we’d love to help you change the story! Resilience is great… thriving is even better!

Thanks for reading,

Sandy

What to expect, and what to NOT accept, at Physical Therapy

Physical Therapy, or physiotherapy if you’re not from the United States, is a branch of healthcare that specializes in helping people have less pain, increase function and safety, and prevent injuries. If you’ve never experienced Physical Therapy in any way, it can be hard to guess what is in store for you. That’s not surprising, because the profession of Physical Therapy covers every age, and a number of settings. Physical Therapists work in outpatient clinics, hospitals, in people’s homes, and on sidelines at sporting events. Some of us use our hands, others use exercises, some even use needles! We use a multitude of techniques, for a wide variety of issues.  

So what do you need to know about going to Physical Therapy?

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What to Expect:

• For your first visit, you’ll have an evaluation with your physical therapist.
  • This will include a medical history, a history of the problem you’re there to address, as well as a physical exam.
  • You should feel like your physical therapist has listened to your concerns and beliefs.
  • Expect lots of thinking and learning!
    • You’ll learn about your condition, and what the plan of care will be.

• Your PT should be able to answer these five important questions:
  • What is wrong?
  • How long will it take to get better?
  • What can you do for yourself to help get better?
  • What can the PT do to help you get better?
  • How much will it cost?
  • Expect teamwork!
    • Your PT isn’t your boss. Your PT is your teammate in helping you reach your goals.
    • Expect to get better!
      • If you’re feeling worse or no change, make sure to communicate that to your PT.
      • Expect homework
        • Going to PT should be fun and productive! But you’ll need to be working more than 2-3x/week if you’re going to have lasting change!
        • Expect to feel empowered and independent!
          • Going to PT is about you getting back to your life, not becoming really good at coming to PT, or the program your PT came up with.

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What to NOT Accept:

• Do not accept coming to PT and then being left alone!
  • You should be under the care of a Physical Therapist or a Physical Therapy Assistant when you’re taking the trouble to attend (and pay!) for your visit.
    • If you can do all of your exercises on your own, you are either done with PT, can do them at home on your own, or need to be given the next exercise!
    • Do not accept confusion or a lack of understanding why you’re doing what you’re doing…
      • Whatever you do in therapy, or as part of your home program, should make sense to you!
        • If for any reason you don’t understand why you’re doing what you’re doing, it’s the job of your PT to help you understand!
        • Do not accept being bored.
          • If you’re doing the same thing over and over, and you don’t feel like you’re progressing – Say something!
          • Do not accept ‘Just lying there’
            • Manual therapy is great! But to regain function, you’re going to have to move!
            • Manual therapy can support movement and give you relief and confidence to move, but it is the movement that is the magic.
            • Do not accept getting WORSE!!
              • Lots of people come to PT for help with pain. It’s illogical to think you need to hurt more to hurt less, so if your PT tells you hurting more is ok, it’s perfectly acceptable to disagree! There are other PTs out there who can make you hurt less!

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Physical Therapists are not all the same, and sometimes you don’t meet your dream therapist on your first visit. It’s ok to ‘break up’ and look for that therapist that will make your dreams come true. The most important thing to remember about going to physical therapy is that your Physical Therapist is there for YOU.

The Joys of Motherhood

Having a baby is usually a joyous time of celebration.... We see it all the time in movies: a new mum wearing her skinny jeans with a perfectly happy baby perched on her hip, heading to the park or out around town. This is what it's supposed to be like, right? New mothers are all too aware that this isn't actually the way it is... Bits of you hurt that you didn't know existed. Picking up the baby, not to mention the diaper bag, can be a challenge! Holding your bundle of joy to feed him or her, as well as snuggle and comfort them can leave you with achy shoulders or tender wrists.

Getting back to exercise can also be a challenge! Once you manage to find time to go exercise, you may find that your muscles aren't working like they used to, or that maybe you feel a little pressure in your pelvis with exertion. Maybe you're noticing that little leak of urine that maybe your mom or your friends mentioned...  There is much of this that is common after having a baby, but it's not normal.

There is help.  Even if your doctor told you 'it's normal, and will get better on it's own', a Women's Health Physical Therapist can help you manage or eliminate any of the uncomfortable bits of motherhood.

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P.S.  It's never too late!!  Even if your baby has a baby of their own, if you've been dealing with issues since pregnancy or the birth of a baby, there is help!  Contact the Experts at Entropy Physiotherapy today!