August 11, 2019

A Pain in the Nut(s)

August 11, 2019/ Entropy Physiotherapy

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.

Screen Shot 2019-08-11 at 12.37.05 PM.png

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.

May 08, 2019

We the People of Physical Therapy (Part 2)

May 08, 2019/ Entropy Physiotherapy

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!

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.

May 01, 2019

We the People of Physical Therapy (Part 1)

May 01, 2019/ Entropy Physiotherapy

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.