Pelvic Health 101 is back! Come to Our First Class on September 20th

On September 20th, at 7pm we will be kicking off our fall semester of pelvic health education class, we call Pelvic Health 101 (PH101). In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health and function of your bowel, bladder, and sexual functioning. We will also be covering how things such as alignment, posture, muscle tone and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes

Pelvic Health 101 Fall 2018

LGBTQ+ Topics: Special Considerations for People with Prostate Cancer in the LGBTQ+ Community

blue and orange light projeced on left hand of person
Photo by Valeria Boltneva on Pexels.com

Fiona McMahon PT, DPT (pronouns: She, Her, Hers)-practices in our midtown office

We have talked about prostate cancer many times on this blog. It is an exceedingly common condition and represents 26% of new cancer cases in cis-men, second only to skin cancer, and 14% of cis-men will experience it within their lifetimes. Prostate cancer can affect one’s life dramatically in terms of sexuality, continence, and even their self perception. Even though prostate cancer can have such a dramatic effect on sex and sexuality, there is little information out there on prostate cancer that is not heteronormative. It is estimated conservatively that 3-12% of America’s population self identifies as lesbian, gay, trans, bisexual, queer, or questioning (LGTBQ+). For people in this community navigating a heteronormative healthcare system can be alienating, frustrating, and downright dangerous. Today, we are going to take some time to discuss what is known about prostate cancer specifically in men who have sex with men as well as trans women.

Prostate Cancer Basics

Prostate cancer typically occurs later on in life. It is extremely common and its incidence is rising, likely due to a rise in prostate specific antigen (PSA) testing. Prostate cancer is a very survivable cancer with the 5 year survival rate being estimated at 84-92%. Treatment may include radiation, chemotherapy, removal of the prostate, or some combination thereof. That being said, common side effects of prostate cancer treatment include bowel and bladder incontinence, sexual dysfunction and pain. These side effects can be improved with medication, physical therapy, and lifestyle changes. People who are at risk for prostate cancer are people who have advanced age, African ancestry, live in certain geographic locations, and those who smoke.

Are Men who Have Sex with Men at Increased Risk?

This is the first out of many examples in this blog where we need more research. There are certain conditions that have been associated with men who have sex with men that may be a risk factor or protective against prostate cancer. Men with HIV seem to be an increased risk factor for prostate cancer, however the antiretroviral therapy for it may be protective. See how this is super confusing? Additionally use of supplements, steroids may increase risk for prostate cancer.

These are all pretty strong “mays”. What we do know is that men who have sex with men are less likely to have up to date PSA testing. Black men who have sex with men are even less likely to be up to date with their PSA’s. This fact can be correlated to the subjective experience many men who have sex with men express when navigating a heteronormative healthcare field. We will talk more later about barriers to healthcare in the LGBTQ+ community and ways clinicians can work to reduce these barriers for their patients.

What About Transgender Women?

There is very little reported about trans women with prostate cancer. Prostate cancer in transwomen is relatively rare especially after removal of the testicles. That being said, it can occur if a transwoman has her medical transition later on in life. In the case study cited below, the authors posit that it may be possible for androgen receptors to become more sensitive to androgens when androgens are at a low level. Androgens are produced by the testicles and are thought to contribute to the development of prostate cancer. If small amounts of cancerous or precancerous cells were present on the prostate prior to testicle removal, they may have continued to develop in the presence of the small amount of testosterone produced elsewhere in the body.. All this being said, prostate cancer is a rare condition in transwomen, but it does beg the important questions like, do we remove a woman’s prostate when she is transitioning, which can be a source of pleasure and erotic function for some transwomen. Most experts agree that transwomen with prostates should be screened for cancer. This is an area where more research is definitely needed.

Why One -Size Fits All Fits None

Men who have sex with men and transwomen have different sexual roles and expectations than the hetero and cis-gender community, and applying heteronormative treatment approaches in the sexual rehabilitation of people recovering from prostate cancer can leave a lot to be desired. The prostate can be a huge source of sexual pleasure for some men who have sex with men and  some transwomen. Men who have sex with men are much more likely to report that the prostate as a pleasure center than their hetero and or cis counterparts. A prostatectomy can represent a loss, and should be respected as such. Also for men and trans women participating in penetrative anal sex, the erection requirements are different than those required to participate in vaginal penetration. The penis requires much more rigidity to penetrate the anus than it does the vagina, ( We should keep in mind the requirement to be able to participate in penetrative anal sex may be important for men who have sex with women exclusively.) Detailed sexual histories should be taken for every patient.

Tips for Providers

Only 68% percent of LGBTQ+ patients are “out” to their clinicians. This is an important stat to keep in mind when performing an intake and subsequent treatment with patients. Avoiding heteronormative assumptions, like assuming a man with a wedding ring is married to a woman, can be a helpful step in the right direction. Displaying a rainbow flag somewhere in your office can also set the stage for a more open conversation that can help you better address the needs of your patients. To learn more about this population check out our resources below. For people who are used to viewing the world through a heteronormative lense, this can take a concerted effort, but it is well worth it in the name of improving patient care for all of your clients!

We have offices in both midtown and downtown locations. If you are dealing with prostate cancer, please give us a call at

212-354-2622 (Midtown)

212-267-0240 (Downtown)

Fiona McMahon PT, DPT practices at our midtown location

fiona2018

Blogs: 

The Special Care Needs of the LGBTQ+ Community

Resources:

Gay & Bisexual Men Living with Prostate Cancer from Diagnosis to Recovery https://www.amazon.com/Gay-Bisexual-Living-Prostate-Cancer/dp/1939594251

A Gay Man’s Guide to Prostate Cancer

https://www.amazon.com/Prostate-Journal-Psychotherapy-Monographic-Separates/dp/1560235527

Malecare https://malecare.org/

Healthcare Equality Index: A tool to find hospitals with established and effective policies for improving LGBTQ+ care http://www.hrc.org/hei/search

Sources

Ussher J, Perz J, Simon Rosser B. R. Gay & Bisexual Men Living with Prostate Cancer from Diagnosis to Recovery. New York: Harrington Park Press, 2018. Print

Quinn G, Sanchez J, Sutton S, et al. Cancer in lesbian,gay, bisexual, transgender/transexual and queer/questioning populations (LGBTQ). CA Cancer J Clin. 2015;65(5):384-400

Rosser S, Merengwa E, Capistrant B, et al. Prostate cancer in gay, bisexual, and other men who have sex with men: a review. LGBTQ Health(3)1. 2016; 32-41

Turo R, Jallad S, Prescott S, et al. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy.

Lace up or Feet up? Running During Pregnancy

Running and exerciseJoanna Hess PT, DPT, PRC, WCS

Exercise in ever tightening spandex while making frequent public toilet stops, or binge on Netflix and cronuts? Pregnancy is a great equalizer. Not even Kate Middleton can escape the hormones that can cause pregnant women to suffer from mood swings, fatigue, nausea, and achiness. Those symptoms—and modern culture—frequently encourage pregnant women to decrease movement and everyday activities. However, there is resounding support in academic literature that recreational physical activity during pregnancy is beneficial to both mother and baby.

While the pregnant woman is best suited to monitor what is beneficial for her body and baby during pregnancy, adequate information to make that decision is not always readily available. Yet around 600 studies published between the mid-1980s and mid-1990s corroborate that exercise during pregnancy is not harmful by measure of fetal birth weight, mode of delivery, preterm delivery, Apgar scores, and acute fetal well-being (1-3). What’s more, the American College of Obstetricians and Gynecologists (4) removed the limitations for intense exercises back in 1985 (5) and a literature review showed that bed rest was not beneficial for pregnancy complications. Still, 95% of ob-gyns continue to prescribe activity restrictions to certain pregnant mothers (6).

Clearer guidelines are needed for how pregnant women can decrease injury while maintaining performance and the well-being of mother and baby. While running is only one mode of boosting fetal and maternal health, many women, especially here in New York, embrace it as a key part of their overall wellness. As a recreational runner myself, I was disappointed during my first pregnancy with the foggy information regarding how to run safely during pregnancy. I found myself as a self-case study, correlating the physiological and biomechanical pregnancy changes with a shift in running mechanics. At the third trimester, I had a suspicion that I should replace running with the elliptical and restorative yoga.

The scientific literature specific to running during pregnancy is extremely limited, and in its absence, I’ve used findings for “moderate to strenuous” physical activity, in addition to clinical knowledge of pregnancy related changes in the body and running patterns to develop the recommendations below. Recently, a group of researchers published a series of five papers and combined recent literature about higher level physical activity during pregnancy for application in appropriate populations (7-8).

Pregnancy and exercise:

Pregnancy may seem like a counter-intuitive time to start an exercise program. However, research shows that 150 minutes/week of moderate exercise (9) for inactive and relatively sedentary women, and moderate to strenuous exercise for active women, has strong health benefits for both fetus and mother. Moderate exercise is recognized as 5-6 on the Rate of Perceived Exertion (RPE), 40-59% HRR (Heart Rate Reserve = Heart rate max – Heart rate resting). Moderate to strenuous is described as 7-8 RPE, 60-84% HRR (1). So while growing a baby is not a good time to start a running program, it is a good time to increase an appropriate level of physical activity or continue an established running program. Some of the benefits of appropriately prescribed exercise are correlated to (10-16):

· Improved cardiovascular function

· Lower risk for gestational diabetes

· Improved strength and lean muscle mass

· Improved sense of wellbeing

· Improved sleep

· Decreased bone density loss

· Decreased physical discomfort – low back pain, pelvic girdle pain

· Healthier gestational weight gain, which protects against complications like cesarean delivery, hypertension, preeclampsia, and gestational diabetes

· Improved general healthy behaviors

· Improved psychological wellbeing – reduction in depression and anxiety, improved self-esteem, particularly for women who were previously inactive

· Improved ability of the placenta to deliver oxygen

· Increased amniotic fluid

· Healthier fetal birth weights that correlate to changes in leptin levels that continue to correlate with a healthier body fat and muscle ratio at the age of 5

· Increased gestational age

· Decreased rate of pregnancy complications, although one study showed higher use of physician assisted delivery (10)

· Faster delivery and decreased chance of Cesarean delivery in a setting that supports natural birth (11)

· Higher Apgar scores

· Lower fetal heart rate and increased fetal heart-rate variability

· Improved neonatal orientation

· Higher general intelligence and oral language skills at the age of 5

· Improved ability of baby to self-soothe after birth, (i.e. longer stretches of night sleep)

Precautions:

Strenuous activity is correlated to a higher rate of miscarriage during the implantation phase of pregnancy—about 20-23 days after the last menstrual cycle. Elevated body core temperature (above 103 degrees Fahrenheit), which can be caused by strenuous activities like marathon running or exercising in hot and humid weather, can increase the risk of fetal neural tube abnormalities during its development, 35-42 days after last menstrual period. Exercising for 60 minutes in a comfortable environment will not raise core temperature above 100 degrees Fahrenheit.

The pregnant woman’s heart rate should not exceed 90% of her maximal heart rate. Because of physiological changes, the pregnant runner will underestimate her heart rate based on the typical rate of perceived exertion or talk test. For this reason, the pregnant runner should modify the run intensity knowing that her heart is working harder than she perceives or wear a heart rate monitor using the HRmax = 220-age, unless she has access to laboratory equipment that can calculate HRmax without full exhaustion.

The American College of Obstetrics and Gynecology, (ACOG) has set absolute and relative contraindications to aerobic exercise during pregnancy (4).

Absolute contraindications:

· Hemodynamically significant heart disease

· Restrictive lung disease

· Incompetent cervix or cerclage

· Multiple gestation at risk of premature labor

· Persistent second or third trimester bleeding

· Placenta previa after 26 weeks of gestation

· Premature labor during the current pregnancy

· Ruptured membranes

· Preeclampsia or pregnancy-induced hypertension

· Severe anemia (different than mild anemia)

Relative contraindications:

· Anemia

· Unevaluated maternal cardiac arrhythmia

· Chronic bronchitis

· Poorly controlled type 1 diabetes

· Extreme morbid obesity

· Extreme underweight (BMI <12)

· History of extremely sedentary lifestyle

· Intrauterine growth restriction in current pregnancy

· Poorly controlled hypertension

· Orthopedic limitations

· Poorly controlled seizure disorder

· Poorly controlled hyperthyroidism

· Heavy smoker

Warning signs:

Low back and pelvic girdle pain/instability, knee/hip pain, pelvic heaviness, sharp pains in the pelvic floor, urinary leakage, and regular ankle sprains are all signs that it may be time to modify running as exercise. In the clinic, I am often asked about pelvic floor symptoms, particularly urinary leakage during pregnancy, and specifically with running.

I like to think of these warning signs as a force transfer problem—something in the system is not working well. For stress incontinence and pelvic heaviness, it’s the inability of the pelvic floor to generate enough force to keep things up against the up-chain forces of running (2.5x while accepting weight after the flight phase) and down-chain forces of steadily increasing body weight + baby’s weight (around 20% of pre-pregnancy weight). But post-partum is not as simple as the forces that are generated from running or the ability to do a Kegel. Elite athletes and non-exercisers have about the same rate of post-partum incontinence. However, postpartum symptoms are more likely if exercise also caused urinary leakage during pregnancy (16).

The pregnant body is a little more complicated:

It needs to taken into account, that the 10-fold increase of relaxin and progesterone that might be responsible for more instability as forces from the ground traveling up into the falling arches of the feet, adduction of the knee, internal rotation of the hip, through the pelvic floor and gapping of the sacroiliac joint. As the fetus and breasts grow, the body’s center of gravity shifts forward, the ribs flare, and the pelvis tilts forward. While the gluteus maximus and calf muscles are getting stronger to propel the pregnant body forward, the front of the body gains significantly more mass. When this happens, the front of the diaphragm and the front of the pelvic floor are positioned so more forces are going through the front of the pelvic floor than the back. This requires more support of the bladder through the pelvic floor. As the pelvis widens, foot step width increases in walking (17), but decreases in running during the single stance phase, requiring more pelvic control. In other words, the pregnant runner’s leg strength, particularly the hip stabilizing muscles, gluteus medius and minimus, need to be exponentially stronger than in the non-pregnant runner to account for additional weight, forward weight shift, and ligamentous laxity. I primarily talk about the deficit of the gluteus group because of what I see clinically, but depending on when the woman is experiencing pain or pelvic floor instability symptoms, other muscles may also need attention.

The usual period of pain experienced by pregnant runner’s initial strike to single stance, corresponds with the biomechanical gapping of the sacroiliac joint. Alleviating such issues will require force absorption and muscle activation through the quadriceps, medial hamstrings, calf muscles, tibialis anterior, TFL, adductor magnus, iliopsoas, and gluteus medius/minimus. Symptoms of lower extremity and lumbopelvic pain, pelvic heaviness, or sharp pains in the pelvic floor have similar biomechanical and physiological causes as urinary leakage. They should be treated in a similar manner whether controlling the upward and downward loads by:

· decreasing speed of running – correlated to double flight phase, which increases upward pressures

· decreasing vertical displacement

· landing with a midfoot strike to increase shock absorption (18)

· increasing arm swing/thoracic movement – dispersing upward forces and facilitating the respiratory and pelvic floor piston

· decreasing daily physical exertion that causes increased abdominal pressure

· increasing external support with (sacroiliac joint) SIJ belts or foot orthotics – decreasing the body’s instability

· improving glute strength in functional positions – tandem lunges, close chained glute isometrics

· improving dynamic single leg pelvic stability – star excursion

· maintaining hip flexor mobility – controlling forward pelvic tilt, movement throughout the day out of sitting posture, hip flexor stretches, shifting weight back through heels, diaphragmatic vs. back breathing

An orthopedic physical therapist specializing in pelvic floor dysfunction and in prenatal and postpartum care will be able to give more specific recommendations, since each woman’s symptoms are a little different.

Expected running changes in pregnancy:

For previous recreational to elite runners, about 70% will continue to run at some point in the pregnancy with only 1/3 continuing into the third trimester. They usually cut the running volume and intensity by 50% compared to non-pregnancy training. For those who stopped running during pregnancy, over half elected to do so because of self-monitoring symptoms of wellness, about one quarter stopped due to physician’s advice, and the remainder stopped for fear of a miscarriage. Whether choosing to continue or stop running during pregnancy, most women had returned to running by 2 months postpartum, and without negative impact on breastfeeding (19).

Speed will decline as instability increases, so that the body has less time with both feet off the ground. Ankle sprains may happen intermittently because of changes in foot position, possible increased swelling, and laxity in the ankle ligaments. Resting heart rate increases 15-20%. Breathing might be more labored during running because of increased sensitivity to carbon dioxide (particularly in early pregnancy) and decreased lung capacity/rib excursion (in late pregnancy). Pregnancy-related mild anemia, which decreases available blood oxygen, affects more than 40% of pregnant women and may show up as accelerated fatigue and increased respiratory rate during running. Be sure that fatigue is not related to severe anemia or hypothyroidism, particularly in persistent symptoms. The pregnant body will improve its ability to thermoregulate with increased sweating to dissipate more heat.

Clothes won’t fit like they once did, especially the spandex. Find some appropriately fitting, breathable, loose exercise clothing that does not excessively compress around the stomach. Urinary urgency and frequency are common limitations in running as the pregnancy progresses, which requires some planning and increased water intake.

Running during pregnancy presents an opportunity to do something overwhelmingly beneficial for both mother and baby, with the added incentive of tuning into the body’s remarkable capacities. While physical activity, running or otherwise, will look different during pregnancy, the goals are similar for a healthy lifestyle. Be kind to yourself—body, mind, and spirit. You and your baby will be thankful. Happy trails. Please leave any comments or questions here!

Joanna is currently taking new patients at our downtown office.

Irene &amp; Joanna treatment 4
Joanna keeping fit with personal trainer, Irene Donahue at our Downtown location

Phone: (212)- 267- 0240

 

 

1. Szymanski LM, Satin AJ. Exercise during pregnancy: fetal responses to current public health guidelines. Obstetrics and gynecology. 2012 Mar;119(3):603.

2. Physical Activity Guidelines Advisory Committee. Physical Guidelines Advisory Committee Report, 2008. Wasington, DC: U.S. Department of Health and Human Services: 2008.

3. Barakat R, Stirling JR, Lucia A. Does exercise training during pregnancy affect gestational age? A randomised controlled trial. British Journal of Sports Medicine. 2008 Aug 1;42(8):674-8.

4. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol. 2015;126(6):e135-142.

5. Artal R, O’toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British journal of sports medicine. 2003 Feb 1;37(1):6-12.

6. Bigelow C, Stone J. Bed rest in pregnancy. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011 Mar 1;78(2):291-302.

7. Bø K, Artal R, Barakat R, Brown W, Davies GA, Dooley M, Evenson KR, Haakstad LA, Henriksson-Larsen K, Kayser B, Kinnunen TI. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant. Br J Sports Med. 2016 May 1;50(10):571-89.

8. Bø K, Artal R, Barakat R, Brown W, Dooley M, Evenson KR, Haakstad LA, Larsen K, Kayser B, Kinnunen TI, Mottola MF. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2—the effect of exercise on the fetus, labour and birth. Br J Sports Med. 2016 Sep 22:bjsports-2016.

9. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Department of Health and Human Services. Washington, DC: 2008.

10. Kuhrt K, Harmon M, Hezelgrave NL, Seed PT, Shennan AH. Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy. BMJ open sport & exercise medicine. 2018 Mar 1;4(1):e000296.

11. Erdelyi GJ. Gynecology survey of female atheletes. J Sports Med Phys Fitness. 1962;2:174-179.

12. Prather H, Spitznagle T, Hunt D. Benefits of exercise during pregnancy. PM&R. 2012 Nov 1;4(11):845-50.[Ine

13. Hoeg TB. Baby on Board: Long Distance Running During Pregnancy – iRunFar.com [Internet]. iRunFar.com. 2017 [cited 2018May7]. Available from: https://www.irunfar.com/2017/12/baby-on-board-long-distance-running-during-pregnancy.html

14. Clapp JH, Capeless E. The VO2max of recreational atheletes before and after pregnancy. Med Sci Sports Exerci. 1991;23:1128-33

15. Gjestland K, Bø K, Owe KM, Eberhard-Gran M. Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med. 2012 Aug 1:bjsports-2012.

16. Bø K, Sundgot‐Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life than non‐athletes?. Scandinavian journal of medicine & science in sports. 2010 Feb 1;20(1):100-4.

17. Gilleard WL. Trunk motion and gait characteristics of pregnant women when walking: report of a longitudinal study with a control group. BMC pregnancy and childbirth. 2013 Dec;13(1):71.

18. Nicola TL, Jewison DJ. The anatomy and biomechanics of running. Clinics in sports medicine. 2012 Apr 1;31(2):187-201.

19. Tenforde AS, Toth KE, Langen E, Fredericson M, Sainani KL. Running habits of competitive runners during pregnancy and breastfeeding. Sports health. 2015 Mar;7(2):172-6.

What Pelvic Floor PT is and What it is Not

 

PelvicTrigger Warning: This piece briefly discusses sexual assault.

Fiona McMahon PT, DPT

Last summer, a reporter came to our office. This is usually not a tremendously unusual circumstance at Beyond Basics Physical Therapy. We often have reporters come to our office to research conditions like dyspareunia (painful vaginal intercourse), endometriosis, painful bladder syndrome/interstitial cystitis, prostatitis, and the many other conditions we treat. This time was different. This reporter was researching legitimate medically necessary pelvic floor physical therapy to put into context what was currently happening in USA gymnastics and the Larry Nassar story.

The Larry Nassar story rocked the pelvic floor world to our core. Larry Nassar was a USA Gymnastics Team physician who sexually abused girls for decades, under the guise of providing “pelvic floor treatment”. For those of us who have spent our lives promoting, educating, and treating both men and women with pelvic floor dysfunction, to see pelvic floor treatment perverted into a way to systematically abuse women and girls, it was truly heartbreaking.

We at Beyond Basics PT feel it is imperative to ensure that every patient knows his or her own rights and what to do if they feel uncomfortable. Although we are writing this in the context of pelvic floor physical therapy. Keep in mind, that much of what we talk about applies to interactions with other healthcare professionals.

Before we get started, let’s discuss why one might need to have their genital region examined in the course of physical therapy treatment. Pelvic floor dysfunction refers to a whole host of symptoms mainly felt in the pelvis, although they may appear in other parts of the body. These symptoms may include and are not limited to both male and female pelvic pain, urinary, bowel and sexual issues. Treatment may include external manipulation of the pelvic floor and genital region as well as manipulation of the pelvic floor muscles by inserting a gloved finger into the anus or the vagina. These techniques are used in combination with other osteopathic techniques to improve muscle length and strength, as well as reducing spasm within the pelvic floor and surrounding areas. To read more about what pelvic floor physical therapy is, click here. Pelvic floor physical therapy can be life changing when performed appropriately. It can allow an individual to go back to work or back to school, or the tolerance to sit on a plane to visit family, when doing so would have been too painful prior to physical therapy. It can allow an individual to have painless sex (male and female, same sex or opposite sex sex), and it can allow someone to regain continence who before was socially isolated. Pelvic floor physical therapy is a legitimate means of improving the health and quality of life of an individual. We will include peer reviewed articles below if you would like to read more.

Given the intimate nature of the treatment as well as the power dynamic that sometimes may exist between patient and clinician, it is important to discuss what rights you have as a patient in order to make yourself feel more comfortable. The following outlines your rights as a patient receiving any type of medical treatment.

Consent

When you step through the door of any medical office for the first time, you get handed what feels like fistfuls of paperwork. In that paperwork, there should always be a consent form. This form must be signed before you are treated, the exception being in medically emergent situations, when you become unconscious and consent is implied for life saving medical intervention.

Remember, just because you signed the form before treatment, doesn’t mean you consent to any and all treatment. You may always revoke your consent by saying you don’t want to participate in a procedure or intervention by saying so.

We want you to feel comfortable. If a treatment course makes you uncomfortable, tell us. Gritting your teeth and tolerating an uncomfortable treatment can sometimes do more harm than good. It is also appropriate to revoke consent to be treated if you are unsure why a treatment is being done or suspect it may not be necessary. Our jobs as clinicians are not only to treat but to educate. If you don’t know why we are doing a certain technique, we need to take time to educate you in order to do our job correctly. Revoking consent can be as simple as telling your practitioner you do not want to engage in a certain activity. Practitioners may take time to explain why they feel that intervention is necessary; however they should never make you feel ashamed for revoking consent. Remember, you are not in the clinic to please us. You are there for yourself. To get better. That is it.

Even if you truly need a pelvic floor treatment, often times there are other parts of the body that should be addressed to aid in certain pelvic conditions. Skilled practitioners can delay pelvic floor treatment by treating other parts of the body until you are ready. This can often be done while still maintaining forward progress.

Chaperone

Chaperones are individuals who accompany you to medical and physical therapy exams and treatments. If having a chaperone attend a visit or visits would make you more comfortable, you should be allowed to bring one. You should be able to bring a family members, or a friend into treatment. If you don’t have someone to fill this role, you can ask the facility to supply you with one, (usually asking ahead of time will ensure a staff member is available). In very few cases, such as surgery or trauma interventions, is it appropriate for a patient to be denied a chaperone if he or she requests it.

Second Opinion

What if your clinician gives you a diagnosis or suggests a treatment that doesn’t sound right? This is where a second opinion really comes in handy. Getting a second opinion is not “cheating” on your doctor, it can allow you to explore other options or be more confident in your original provider’s course of action.

Respect and Comfort

Feeling respected by your clinician is essential to healing . If you feel that you are not getting the respect you deserve or even if you are not connecting with clinician for whatever reason, you have the right to change clinicians. You don’t have to feel obligated to explain why you are changing clinicians if you don’t want to. Most healthcare providers realize that we might not have the right clinician for every person, and we are trained to not take it personally. It is okay to put yourself first.

Red Flags in Pelvic Floor Physical Therapy

  1. Feeling coerced, bullied, or shamed into a pelvic floor treatment
  2. Therapist does not wear gloves for treatment
  3. Therapist insists on not allowing chaperone
  4. Therapist fails to offer adequate reason for treating the pelvic floor
  5. Therapist is not licensed
  6. You therapist acts in a way to make you feel unsafe or uncomfortable

The truth is, there are so many wonderful physical therapists out there who treat the pelvic floor. Being a physical therapist is one of the greatest jobs in the world, because we get to help people do things that before were difficult or impossible. Pelvic floor physical therapy changes lives. We sincerely hope this article helps you feel empowered to go to physical therapy and know what your rights are and what to expect.

Further reading on pelvic pain:

Association

International Pelvic Pain Society: www.pelvicpain.org

International Society of the Study of Women’s Sexual Health: www.isswsh.org

 

Books

Heal Pelvic Pain

By: Amy Stein DPT

http://www.healpelvicpain.com/

Healing Pelvic and Abdominal Pain DVD

By: Amy Stein DPT

http://www.healpelvicpain.com/

When Sex Hurts

By: Andrew Goldstein, MD and Caroline Pukall, PhD

Healing Painful Sex

By: Deborah Coady, MD and Nancy Fish, PhD

 

Scholarly Articles

Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60

Anderson R, Sawyer T, Wise D, Morey A. Painful myofascial trigger points and pain sites in men with chronic prostatitis/ chronic pelvis pain syndrome. The Journal of Urology, 182;6 2753-58

Fitzgerald M, Kotarinos R. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J 2003; 14:261-8

Fitzgerald M, Kotarinos R. Rehabilitation of the short pelvic floor. II: Treatment of patient with the short pelvic floor. Int Urogynecol J 2003;14: 269-72

King H. Manual Therapy May benefit women with interstitial cystitis and pelvic floor pain. J Am Osteopath Assoc. 2013;(113)4: 350-61

Morin M. Bergeron S. Pelvic floor rehabilitation in the treatment of dyspareunia in women. Sexologies. 2009; 18:91-4

Shafik A, Shafik I. Overactive bladder inhibition in response to pelvic floor muscle exercises. World J Urol. 2003 May; 20(6):347-7. Epub. Apr 4

Wurn B, Wurn L, Patterson K. Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual therapy: results from two independent studies. 2011;3(4)

Beyond Basics is Visting Brooklyn!!!!

Brooklyn

 

Fiona McMahon PT, DPT

Have you got pelvic floor questions? Have you desperately wanted to go to one of our PH101 classes, but can’t swing 7pm in midtown in the middle of the week? Well, I have great news and GREATER news. I know, right… how much great news can you handle? The first bit of awesome, is that Beyond Basics’ Physical Therapists’, Dr. Fiona McMahon and Dr. Sarah Paplanus are hosting a forum and open discussion on pelvic floor health and treatment on Saturday, April 28th at The Floor on Atlantic (310 Atlantic Avenue in Brooklyn) at 12 noon. We will be there to explain the ins and outs of the pelvic floor, what can go wrong with it, and best yet, how you can heal it. It is a must go to event. RSVP here. Also, it’s FREE!

So what’s the other news, Fiona? Well, it’s that although we are not in Brooklyn, we have opened another office just across the river from Brooklyn, Beyond Basics Physical Therapy Downtown. In enlarging our footprint we hope to expand access and convenience to patients living downtown and in Brooklyn. We will be hosting a Grand Opening and 15 year anniversary celebration at our new location: 156 William St, Suite 800 New York, NY 10038 on Thursday, April, 26th from 4pm – 7pm. Come and enjoy food, drinks and meet our Physical Therapists. RSVP here.

 

 

How a Birth Doula Can Help Make Labor a More Intimate Experience

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Chantal Traub, CD, CCCE, LCCE,

Pregnant mothers may be unsure if they want to work with a doula because they would like their labor and birth to be an intimate experience between them and their partners and wonder whether having a doula would encroach on their intimacy.

The role of the doula is to help ensure a healthier, safe and positive birth experience for the whole family. She will provide emotional support, physical comfort and the information needed to make informed decisions as they arise in labor at home or at the hospital. She will present reassurance and perspective to the birthing woman and her partner, offering various positional ideas for relaxation and labor progression and hands-on comfort measures like touch, massage, counter pressure and breathing techniques.

One may wonder how an intimate experience can be enhanced with the presence of a doula and the medical staff. Intimacy refers to the feeling of being in a close personal association and belonging together. It is the familiar and very close affective connection with a bond that is formed through knowledge and experience of the other. This intimate experience can be created by having the partner taking a role in the birthing process. The experienced doula will include the partner.

The doula’s presence offers a great sense of relief for both of you, especially for your partner who may begin to feel concerned with the responsibility of supporting you and may not know what normal is in this situation. If you’re having an intimate moment with your partner, an experienced doula will know when to step in and when to step back. She will encourage and allow you both to have that moment. In fact, she will look out for and suggest opportunities for you to be together. She will gently pull your partner back if your partner is feeling overwhelmed or feels worried seeing you in pain and give your partner the tools to help support you. If your partner needs a break or a breath of fresh air, the doula will be there, so that the partner can take care of themselves knowing the doula will take care of you.

The role your partner takes depends on the two of you. If your partner would like to roll up their sleeves and offer physical support or prefers to remain emotionally present from a distance, your doula will guide you. The doula may suggest ways for your partner to hold you or breathe with you. She can show your partner ways to massage and apply pressure while you are laboring. If a partner cannot participate physically for various reasons, they may choose to assist in other ways like getting ice and water while the doula manages the physical part, or merely remain emotionally present in the room. The intimacy is in the experience, allowing your partner to remain confident and emotionally present with you.

Whether your birth is unmedicated or medically complex, every family can benefit from the guidance and support of a doula at this often vulnerable and overwhelming time in their lives.

Chantal is originally from Cape Town and after years of working in film she began teaching yoga in 1996 and in 2003 she became a Certified Doula and has been assisting women in labor ever since. She is also a Certified International Childbirth Educator and a Certified Pre/Postnatal Yoga teacher. Her Prenatal classes are informative and educational and are designed for Labor and Delivery. Chantal has been teaching and assisting families in the New York Metro area for over 15 years and she combines her wisdom and knowledge to help families prepare for a positive birth experience

Chantal Traub, CD, LCCE, CCCE

 www.chantaldoula.com

Certified Doula (CD)

Lamaze International Certified Childbirth Educator (LCCE)

Certified Cooperative Childbirth Educator (CCCE)

Chantal Traub is a certified doula with over 15 years of experience and is a board member for the Childbirth Education Association of Metro New York. Originally from Cape Town, South Africa, Chantal received her BA of Fine Arts and after working for many years in film as an art director, she began teaching Yoga in 1996. Chantal is a White Lotus Foundation Certified Yoga Teacher, Pre/Postnatal certified Yoga teacher and Certified Traditional Ayurvedic Bodyworker. Chantal started her Birth Doula practice in 2003 after receiving her certification from A.L.A.C.E. In 2007 She became a Certified Childbirth Educator by Lamaze International and by the Childbirth Education Association of Metropolitan NY. Chantal is trained with Kate Jordan Pregnancy and Postpartum Massage Therapy and with The Julie Tupler Maternal Fitness Technique. She’s also Certified Kangaroula by Dr Nils and Jill Bergman. She lives in Brooklyn with her husband and two children, Naomi and Noah.

Endometriosis as a Feminist Issue

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Fiona McMahon PT, DPT

March is endometriosis awareness month. March is also women’s history month. It seemed like the perfect time to discuss how poor detection and treatment of the disease affects the welfare, social, economic health, physical health,  and quality of life of women. Endometriosis is a feminist issue.

Here, at this blog, we have extensively discussed treatment and various options for endometriosis. Although there are many treatments available for managing endometriosis, the time it often takes to get a proper diagnosis and referral to competent clinicians is often so long, that the disease may progress to a point where pain is a lot harder to treat and fertility is impacted. Endometriosis is a gynecological disorder, that according to the Women’sHealth.gov currently affects more than 11% of women in the United States.

Older material, in fact, posts on this page used to define endometriosis as a condition in which endometrium (the lining of your uterus) grows outside the uterus. Now, in most of the recent literature referring to the tissue growing outside the uterus, call it endometrium like, because the tissue bears some resemblance to endometrium but isn’t quite the same. Endometriosis can show up clinically in a whole host of ways. It is estimated that up to 59% never have symptoms and may only discover that they have endometriosis, if they have abdominal surgery and legions are spotted. Infertility may also be the only symptom. For those who do have pain symptoms, it can be really bad and debilitating. If you have heard of endometriosis before, you are probably aware that it can make periods intolerable, but that’s not the whole story. Endo, as it is called for short, can cause pain that extends well beyond menstruation, it can cause issues with constipation, low back pain, urination, bowel movements, and fertility. Pain with endo can be severe. It can keep you from work, and school, or even land you in the hospital. The time a woman spends trying to get a diagnosis for the pain caused by endometriosis can take up to 11 years according to the American College of Gynecology fact sheet cited below.

What Causes Endo?

As you may have gleaned from the intro to this story endo is poorly understood and frequently misdiagnosed. Up until recently, we weren’t even entirely sure what the deposits left by endometriosis were. The research community is divided on what causes endo and have offered many different theories to its origin, but the specific cause of endo is unknown.

We do know endometriosis is an estrogen dependent disease, which is why it affects mainly women. One common theory of how endometriosis is caused is the theory of retrograde menstruation. This theory posits that endometriosis is caused by shed endometrium that escapes the uterus and deposits itself in the abdomen. This theory is supported by animal studies that have produced endometriosis like legions when endometrial tissue was deposited in the abdominal cavity. The theory fails to explain cases in which endometriosis deposits are found far away from the uterus in tissues like the lung. It also fails to explain the rare cases of men who develop endometriosis with estrogen therapies. In many circles, this theory is falling out of favor and is completely disregarded by others. Another similar theory is the lymphatic vascular theory. This theory hypothesizes that endometrium travels to outside spots via the lymphatic system. Again, this theory doesn’t explain the rare cases of male endo nor does it explain that the tissue found in these outside sites. It also fails to explain that the tissue found outside the uterus is “endometrium like” and is different than normal endometrium within the uterus.

The theory of coelomic metaplasia is based on the fact the both endometrium and peritoneal tissue comes from the same embryonic ancestor, coelemic epithelium. The theory posits that certain immunologic or hormonal factors may transform this tissue into the implants we see in cases of endometriosis. The third theory is the embryonic rest theory. It purposes that endometriosis caused by stem cells derived from the embryonic müllerian system become transformed in endo deposits. This theory is supported by the rare cases of men with endo, as they, as embryos, have the same embryonic müllerian system, before it regresses as the male embryo develops.

What’s kind of crazy is the level of pain a women experiences is not directly related to the amount or size of the endo deposits she has. One theory of why a women with very little endo found surgically can have a lot of pain, is the concept of centralization, where the brain becomes more likely to perceive stimuli as painful. Read more about this process in our blogs  Navigating Life with Chronic Pain 1, and Navigating Life with Chronic Pain 2 here.

One, all, some, or none of these theories could explain how endo is formed and maintained. The truth is we don’t fully understand the pathogenesis of this disease, yet. We need to know the cause. If we know the cause we may be better able to design treatments to ease the pain of endo and optimize the fertility of its suffers. Knowing the cause of endo will at least, aid in diagnosing the disease earlier or possibly curing or preventing it all together, which brings us to our next section.

 

Why does it take so long to get an endo diagnosis?!

Here’s the deal. The gold standard for endometriosis diagnosis is laparoscopic exploratory surgery with pathological biopsy confirming a lesion. Before laparoscopic surgery was a mainstay of medical practice, it was often believed that endometriosis was a disease that did not affect adolescent girls, as it was only seen in laparotomy, a more invasive technique reserved for more severe symptoms and conditions. When laproscopy became widely available in the 1980’s the diagnosis of endometriosis grew rapidly in all women and especially adolescent girls.

There are other tools available to detect endo but they are not definitive like surgery and may miss cases. Even laparoscopic surgery can miss endo especially in adolescents, because the endo deposits may be better disguised because of its color, usually clear or red in younger girls. Endo is also not suspected often until after the start of a girl’s first menses, new recommendations suggest that abdominal and pelvic pain complaints in girls be investigated for endo at the start of breast bud development (Brosens) as endo was found in between 50- 62% of adolescent girls undergoing laparoscopy for chronic pelvic pain ( Agarwal and Chaichian).

Doctor’s need better, less invasive tools to detect endo and get women out of pain. Although laparoscopic surgery is considered non invasive, the recovery from it can be difficult, dissuading patient and physician alike from using it as a diagnostic procedure. There is emerging science working on less invasive ways to screen or even detect for endo. More research dollars should be spent to develop early diagnosis and treatment in order to save women the years, lost work and education secondary to pain, and infertility from prolonged endometriosis.

Conversely, women without true endo are undergoing surgery needlessly, sometimes sustain hysterectomies to “cure” endo that is in fact not even there (also hysterectomy does not cure endo, Endo by its definition is a disease that occurs outside of the uterus). 25% of 4000 women studied who underwent hysterectomy for suspected endometriosis pain, were found to not actually have endo, which is outrageous on so many levels. 1. Hysterectomies do not cure endo. 2. Infecting infertility and the risks of major surgery on a woman who does not need it, regardless of whether she has endo or not, is awful. 3. Those 25% of women who had their hysterectomy likely have more pain and were not given a proper diagnoses so they can pursue the proper intervention for their pain.

Why is Endo Such a Big Deal as Feminist Issue?

Endo is a disease the effects women and only in very rare cases, men. If you get 10 of your gal pals in a room, statistically 1 of them will have the condition. Before I start in with this next argument, I want to make clear, that a diagnosis of endo does not necessarily impair one’s success later on in life; however, it can make achieving life’s milestones a lot more challenging.

Girls with painful endo symptoms miss more school a month than girls without endo (Brosens), setting them up for a harder battle to succeed academically and potentially limiting college options. In the workforce, they may continue to miss more days limiting their chances for raises and advancement. These missed opportunities have the ability to compound and further place women with endo at an economic disadvantage.

As women, it is sometimes harder to have our pain taken seriously. In a shattering article in the Atlantic, Joe Fassler, describes the ordeal his wife had to go through to have her potentially life threatening ovarian torsion taken seriously. He recounts how many times his wife was told to buck up, while she was actually in the process of losing her ovary. He also sites the disturbing statistic that women wait approximately 25% longer than men in the ER for pain relief. There is evidence to support that if you are a woman of color, you are even less likely to be given an analgesic at all when you go to the ER for pain. The fact our pain, as women, is taken less seriously means that in order to get a timely diagnosis women may have to scream louder and longer just to be heard.

The longer women wait for diagnosis, the more likely the pain is likely to enter a centralized state in which stimuli that were previously not painful are perceived as pain. Centralized pain is a lot harder to treat and will take longer to resolve than non centralized pain, possibly leading to more time out of the workforce, and requiring more money spent on treatments. Women with endo must be taken seriously. Our financial independence and personal lives require it.

What Can I Do If I am In Pain?

So we talked about the larger systemic issues affecting women with endometriosis. But what are some realistic steps you can employ to help with your pain?

  • Get moving! A review by Bonocher and colleagues, found exercise may help women who are already suffering from endometriosis related pain. The pain caused by endometriosis is thought to occur because of inflammation caused by endometriosis implants outside of the uterus. Exercise has been shown in repeated studies to increase anti-inflammatory chemicals in the blood and therefore reduce pain caused by inflammatory processes.
  • Stretch it out. Zahra Rakhshaee, published a 2011 article that found yoga could ease painful periods and may be helpful in managing the symptoms of endometriosis. In this study, a yoga routine consisting of daily 20 minute sessions had a significant effect in reducing pain in the study participants.
  • Put a pin in it, or you! Acupuncture is an ancient Chinese healing practice and can be used to treat many conditions. In a review by Leong in 2014, acupuncture reduced painful periods in 92% of study participants. The review also cited an article in which 73% of participants reported an improvement in their symptoms versus 42% receiving a placebo (fake) treatment
  • Physical therapy treatment can be helpful in treating many of the issues associated with endometriosis. In a study by Wurn in 2011 , physical therapy was shown to have a significant effect on reducing pain and improving sexual function in women who have endometriosis. Physical therapists are trained healthcare practitioners who can guide you in strengthening and stretching programs to help ease your pain, apply hands-on techniques to restore mobility lost due to endometriosis and other conditions, as well as guide you through lifestyle modifications you can make to ease your pain symptoms.

If one or all of these methods of pain management strategies sounds like they will work for you, Beyond Basics Physical Therapy, as well as other specialized clinics can help guide you. We at Beyond Basics, have an excellent team of physical therapy practitioners who are experts in the field of pelvic health, who do one on one, hands on work, who can develop an appropriate exercise plan tailored to your needs, and can guide you through other lifestyle modifications to help reduce your pain. We also partner with acupuncture and yoga professionals who offer services on site at our Midtown clinic. We hope to see you soon as you begin your journey of healing.

For more on PT and how it can help endo pain, check out Amy’s Video

What do we do for everyone affected by endometriosis or pelvic pain?

Seems pretty bleak, doesn’t it? It’s not. Collectively women and endo specialists are working to advance the awareness, diagnosis, and multidisciplinary approach to treating endo. It is an exciting time with new discoveries being presented in the literature, and more women and doctors becoming outspoken about this condition. But we have a heck of a long way to go to help out our sisters with endo.

The first thing you can do is speak up. If you feel you have not been diagnosed correctly, seek a second opinion. Also feel free to share the articles below with your doctors in order to broaden their exposure to endometriosis, I particularly like Brosen’s article. Share this blog and others on endo so more women and practitioners know about it. For those of you with the resources to do so, consider donating to an organization like the Endometriosis Association or the International Pelvic Pain Society (IPPS). Both are organizations that study and advocate for effective diagnosis and treatment for people with pelvic pain, including those with endo, as well as advocate for a multidisciplinary approach to healing. Together, we can improve society’s awareness of this disease and reduce the challenges that endo has on women.

 

ACOG. Endometriosis Fact Sheet. https://www.acog.org/about_acog/news_room/~/media/newsroom/millionwomanmarchendometriosisfactsheet.pdf. Accessed March 12, 2018

Agarwal N, Subramanian A. Endometriosis- morphology, clinical presentations and molecular pathology. J Lab Physicians. 2010; 2(1)-19

Bonocher C, Montenegrow M, Rosa e Silva, et al. Endometriosis and physical exercises: a systematic review. Reproductive Biology and Endocrinology. 2014, 12:(4)

Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Human Reproduction. 2013; 28(8) 2-26-31

Dickasen M, Chauhan V, Mor A, et al. Racial Differences in opiate administration for pain relief at an academic emergency department. Western Journal off Emergency Medicine. 2015; 16(3) 372-80

Chaichian S, Kabir A, Mehdizadehkashi A, et al. Comparing the efficacy of surgery and medical therapy for pain management in endometriosis: A systematic review. Pain Physician. 2017; 20 185-95

Fassler, Joe. How Doctor’s Take Women’s Pain Less Seriously. The Atlantic. October 15 2015

Leong F. Complementary and alternative medications for chronic pelvic pain. Obstetrics and Gynecology Clinics of North America. 2014, 41:(3): 503-10

Mowers EL, Lim CS, Skinner B, et al. Prevalence of endometriosis during abdominal or laparoscopic hysterectomy for chronic pelvic pain. Obstet Gynecol. 2016 Jun;127:1045–1053.

Rakhshaee Z. Effect of three yoga poses (cobra, cat and fish) in women with primary dysmenorrhea: A randomized clinical trial. Journal of Pediatric Adolescent Gynecology. 2011;24(4):192-6

Sasson I, Taylor H. Stem cells and the pathogenesis of endometriosis. Ann N Y Acad Sci. 2008; 1127: 106-15

Stratton P, Khachikyan I, Sinaii N, et al. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obset Gynecol. 2015; 125(3) 719-28

Womenshealth.gov. https://www.womenshealth.gov/a-z-topics/endometriosis . Page last updated: March 05, 2018. Accessed March 12 2018

Sources:

Wurn B, Wurn L, Patterson K. Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual therapy: results from two independent studies. 2011;3(4)