The Special Care Needs of the LGBTQ+ Community

Happy Pride Month!!!!

We are reposting an old post broadly discussing the LGBTQ+ community, with special focus on transgender individuals. Please keep checking back as we continue to discuss specific issues relating to the care of the LGBTQ+ community.  

Amy Stein PT, DPT and Fiona McMahon PT, DPT

rainbow flag

Who are LGBTQ+ individuals?

At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc.  They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.  

Never Assume. Listen, Ask.

We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community.  First rule of thumb:  with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.

 As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us.  Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.  

We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in trans care. Hormones, either testosterone, estrogen, lupron, puberty blocking, testosterone suppressing can be used in many patients, but are also used specifically to aid in transition in transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options.  There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration.  Hormones can be administered via injection, pellets, patches, creams, gels, and pill form.  It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc.  Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals.  Progression of hormones can be monitored for each patient and according to patients wants and needs.  

For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs.  Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that  can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.

How is care for the LGBTQ+ community funded and regulated?

Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.

How can physical therapy help?

At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction.  We also specialize in orthopedics and functional manual therapy.  We treat the LGBTQ+ community and we welcome any questions at desk@beyondbasicspt.com or call 212-354-2622. We are happy to help and look forward to hearing from you!
Resources: Center of excellence for transgender health.

WPATH center for care Endocrine Society

  • speaks on hormone therapy (however some information may be out of date).

 Adolescent Health Center

Questioning Childbirth Status Quo, Part One: Common Labor Positions

The following blog is a repost of Ashley Brichter’s original blog post. Ashley is a  birth educator, birth and post-partum doula, lactation counselor, and friend of the practice. She hosts many classes on childbirth, lactation, and much more. We will provide more information at the end of the post on how you can get in touch with Ashely and how you can sign up for her excellent classes. 


Ashley Brichter

Originally posted: January 22, 2019 

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Hollywood misrepresents a great deal about the childbirth process, but the fact that they show everyone delivering babies while lying on their backs in a hospital bed is accurate. As Ross clearly demonstrates above, lying down with knees apart is the most common way for someone in the United States to deliver. Here’s why you may want to question this:

A baby’s job in labor is to rotate and descend through the pelvis. If we can maximize the amount of space a baby has within the pelvis, we can not only speed this process along but minimize the stress on muscles and tissues within the pelvic bowl (and therefore minimize the risk injury).

How do you maximize the space in your pelvis to encourage the baby’s rotation and descent? The pelvis has four boney landmarks that determine the maximum circumference a baby has to fit through: the pubic bone at the front, tail bone or coccyx at the back, and two sitz bones at the bottom. Let me walk you through two very simple movements to see how you can create the most space between the pubic bone and tail bone and two sitz bones.

If you’re in a location where feeling around on your pelvis would be immodest, make a commitment to try it the next time you’re in the bathroom or back at home.

First, find the space between your pubic bone and tail bone: 

Place one hand on your pubic bone (it’s very low down under the belly, right between your legs. Isn’t it wide!?). Place your other hand on your tail bone. To find your tail bone, invite your hand to feel between the crease of your behind. It is often higher up than most people realize.  You can walk your fingers all the way down the bottom of your spine until you reach the end – and/or lean back on your fingers in order to feel it more.

Once you have fingers on the pubic bone and fingers on the tail bone, lean forward and feel the space between your fingers. Then lean back. In which direction to you have the most space between your fingers, between your pubic bone and tail bone?  When you are leaning forward or leaning back? Try this a few time before you move on.

 Then, find the space between your sitz bones: 

This is best done sitting down on the edge of a chair. Place your hands underneath your bum and your should feel your sitz bones protruding down. If you don’t feel them right away wiggle side to side a bit. You should feel boney points digging into your hands. 

Now, spread your knees out wide (like you’re having a baby!). Feel the space between your fingers. Then, bring your knees in close together (keeping your feet fairly separated). In which position do you have more space between your sitz bones? With your knees together, feet apart, or your knees and feet wide?   

Hopefully when you tried it you were able to feel that there is more space in your pelvis when you are leaning forward and that there is more space in the pelvis when your knees are closer together than your feet. 

WAIT. What? That’s right. I said it. 

Most people deliver their babies on their backs with their knees spread wide because this is the most convenient position for hospital staff. If you’re thinking about a physiological birth, looking for ways to possibly shorten your labor, or looking for ways to reduce the risk of tearing, give some serious through to positions that lend themselves to forward leaning and keeping feet wider than knees!

Let’s take one more look at the tail bone specifically: leaning backwards makes the tailbone stick in. It limits the amount of space a baby has to rotate and it asks your body to push a baby uphill!  Upright and forward leaning positions will allow the tailbone to get out of the way.   Granted, you have to deliver with a provider and in a location that is supportive of this. But that’s for another post!

You can learn more about Ashley on her website: http://overwhelmingmoments.com/

Her blogs are available here

Click here for a list of upcoming events with Ashley

 

 

PH101: I’m Pregnant – Help!

 

Having a baby is exciting, fascinating, and nerve-wracking. If you have never been through the process before, chances are you have a lot of questions and concerns about what changes your body will go through during your pregnancy, what the birthing process entails, and how your recovery will go once you’ve had your baby.

Join us and childbirth specialist, Ashley Brichter, in our Pelvic Health class to discuss the ins and outs of having a child.

Register at pelvichealth101.eventbrite.com   today.

Location:

110 East 42nd Street, Suite 1504

New York, NY

10017

Time: 7pm on  April 30, 2019

Pelvic Health 101 Spring 2019

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On March 19, 2019 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. 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 as well as the function of your bowel, bladder, and sexual muscles and organs. 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 Spring 2019

 

What To Do About Scars from Childbirth?

abdomen active activity belly button
Photo by freestocks.org on Pexels.com

Joanna Hess PT, DPT, PRC, WCS

No one told you that the pain of childbirth doesn’t end with that final push and it doesn’t matter if you had a vaginal or belly birth. If you are the roughly 10% of demigoddesses who delivered without a tear, bless you and your fairy child.* If you are a mere mortal, here are some secrets for post-partum “battle wound” care.

For many mamas, the scars from delivery heal without any intervention. However, in our clinic, we often see hypersensitive or immobile perineal and cesarean scars that affect other parts of the body and can be a reason for the loss of core stability mechanisms, pain with intercourse, and urinary and fecal incontinence.

Scars are the body’s glue and use a complex set of proteins. While scars are never as strong as the original (70% of the original strength), it usually doesn’t cause a problem. The healing process after cutting your finger on that dull knife is the same for a cesarean incision and perineal tear/cut. Immediately after the injury, lots of good inflammation comes into the area to clot and start a loose frame for new tissue to develop. In the first days, collagen and other healing buddies come in to pull the wound together. It’s not particularly organized, but that’s okay because really, priorities are to keep things from getting in. In the next weeks, the collagen fibers will start organizing according to the demands of that particular tissue resulting in a pinkish or red color to the scar. It’s about this time that you can tell if things aren’t going well, namely, the scar shouldn’t be painful. We don’t know for sure why some scars cause problems and others don’t. The best guesses have to do with genetics, tissue tension, hormonal glands, and blood supply. Within 7-12 weeks, not only should the scar not be painful, but it also should move as freely as the tissue around it—without tugging at other places. The scar should be flat and slightly lighter than skin color.

MOVEMENT AND ICE

In the first days, keep good blood flow to the area while managing the pain. For perineal scars, you can work by breathing gently into your pelvic floor and changing your position regularly so that blood doesn’t stagnate in the area. For cesarean scars, working on deep breathing is a safe way to gently move the area without disrupting the healing. You want to keep big movements limited (but really, you’re a mom and movements are a part of life). Use the pain meds as needed so that your muscles continue to function normally. Things like vagsicles (frozen maxi-pads) and support belts can also help with the pain. A regular ice pack for the c-section scar is also a good option. Make sure to place a thin towel between the ice or vagiscles and the skin.

SCAR MASSAGE

At the postpartum six-week appointment, have your physician or midwife check the mobility of the scar. If it is painful or stuck, ask if the scar healed enough to start gentle scar massage. The idea of the scar massage is to give a non-threatening stimulus for desensitizing the area and re-orienting fibers so that the tissue moves freely.

For both the perineal and cesarean scar, if the movement of the scar exceeds pain 2-3/10, start with just desensitization. This can be as simple as tapping the scar or rubbing the scar gently with a towel for 3-5 minutes/day.

For a perineal scar, use a clean finger to slightly push the scar along perineal body up towards the body to create some slack. Then, move the scar away from the center in all directions (north, south, east, west, and in between) to find out which direction is the least mobile. Hold the scar in the restricted direction for 30 seconds. The pain should not exceed more than 2-3/10. Repeat 3-5 more times. You should be able to steadily tolerate more movement within a month.

For a cesarean section scar before 3 months, lift the tissue around the scar in a generous pinch and move the scar up and down, then side to side. Continue along the length of the scar until you find an area of pain or restriction. At this point, spend a little more time and move that area of the scar 10-30 times and keep moving. Again, the pain should not exceed 2-3/10. For a cesarean section scar older than 3 months, you can mobilize the scar in the same movements by direct pressure or skin rolling—up and down, side to side, clockwise and counterclockwise and lifting with skin rolling.

For the new mama, this is easy to incorporate in the precious quiet moments in the shower.

SILICONE

The gold standard of stubborn scars is silicone with or without compression. For hypertrophic scars and keloids in other parts of the body, silicone sheets and gels are the primary non-invasive prevention and treatment. Silicone strips and gels are easily used over a cesarean scar. Silicone is used daily for 12-24 hours for 2-4 months to soften and decreases the height of the scar. The sheets and compression can also help with the hypersensitivity. Because of the proximity to the body cavities, silicone is not advised for perineal scars.

*If you want to try to avoid perineal tearing altogether, ask your birth team to help birth baby’s head slowly and use warm compresses during pushing, stay active during labor, deliver in a side-lying or upright position, and perineal massage in late pregnancy can all help reduce the risk of perineal tearing.

PHYSICAL THERAPY

If you have tried these simple interventions and still find your scar problematic or think your scar is related to pain in neighboring areas, find a women’s health physical therapist to help manage your care. Recent studies show that in 4-8 sessions, skilled physical therapy changes the mobility and thickness of old scars to decrease pain and improve function.

Scar management is widely promoted in post-operative care in orthopedics, plastics, and dermatology—we hope that scar care will soon be standard of care in post-partum care.

 

Joanna practices at our Downtown location

Joanna Lee Hess

REFERENCES

Aarabi S, Bhatt KA, Shi Y, Paterno J, Chang EI, Loh SA, Holmes JW, Longaker MT, Yee H, Gurtner GC. Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis. The FASEB Journal. 2007 Oct;21(12):3250-61.

Agha R, Ogawa R, Pietramaggiori G, Orgill DP. A review of the role of mechanical forces in cutaneous wound healing. Journal of Surgical Research. 2011 Dec 1;171(2):700-8.

Comesaña AC, Vicente MD, Ferreira TD, del Mar Pérez-La Fuente M, Quintáns MM, Pilat A. Effect of myofascial induction therapy on post-c-section scars, more than one and a half years old. Pilot study. Journal of bodywork and movement therapies. 2017 Jan 1;21(1):197-204.

Huang C, Murphy GF, Akaishi S, Ogawa R. Keloids and hypertrophic scars: update and future directions. Plastic and Reconstructive Surgery Global Open. 2013 Jul;1(4).

Lewit K, Olsanska S. Clinical importance of active scars: abnormal scars as a cause of myofascial pain. Journal of manipulative and physiological therapeutics. 2004 Jul 1;27(6):399-402.

Marshall CD, Hu MS, Leavitt T, Barnes LA, Lorenz HP, Longaker MT. Cutaneous scarring: Basic science, current treatments, and future directions. Advances in wound care. 2018 Feb 1;7(2):29-45.

Meaume S, Le Pillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines and use of silicones. European Journal of Dermatology. 2014 Jul 1;24(4):435-43.

Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound in Obstetrics and Gynecology. 2004 Mar 1;23(3):247-53.

Son D, Harijan A. Overview of surgical scar prevention and management. Journal of Korean medical science. 2014 Jun 1;29(6):751-7.

Wasserman JB, Abraham K, Massery M, Chu J, Farrow A, Marcoux BC. Soft Tissue Mobilization Techniques Are Effective in Treating Chronic Pain Following Cesarean Section: A Multicenter Randomized Clinical Trial. Journal of Women’s Health Physical Therapy. 2018 Sep 1;42(3):111-9.

Wurn LJ, Wurn BF, Roscow AS, King CR, Scharf ES, Shuster JJ. Increasing orgasm and decreasing dyspareunia by a manual physical therapy technique. Medscape General Medicine. 2004;6(4).

Pilates with Kierstin! Slingshot Lunges on the Reformer

Just in time for your New Year’s Resolutions, here’s another awesome exercise from Kierstin Elliot, Pilates Teacher at Beyond Basics Physical Therapy!

Goal: Strengthen the glutes and balance 

Exercise: Slingshot Lunges on the Reformer

Set Up: Standing on the floor with right foot near foot bar and left foot against the shoulder rest. Keep left knee straight and tilt upper body forward creating one long diagonal line from head to back toes. Use one blue spring as resistance. Belly button and chin are tucked in with neck lengthened and shoulders rounded back.

Execution: Inhale to send pelvis back into lunge bending the front knee 90 degrees while reaching arms forward and keeping the pelvis level and squared off to the front. Keep shoulders away from ears. Exhale to straighten the front knee, lower arms to sides, and return to your starting position.

Focus: Be sure to keep proper alignment throughout the spine. Lumbar spine should be elongated and supported throughout the entire exercise. Maintain core connection by dropping bottom ribs towards the top of your hips bones. Hips should also be level and squared off to the front- make sure there’s no pelvic rotation during lunges.

Importance: One of the best exercises for strengthening your glutes! This exercise also enhances your ability to stabilize the pelvis and lower back while connecting to the core for improved balance.

Modifications: Limit the range of motion in standard position, or drop back knee to the carriage. Dropping the back knee may draw more focus to the quad, making the exercise feel more like a stretch, however, the focus should still be held on standing glute. For an added challenge, grab a set of 3 pound free weights for your arms for added core control.

Bringing Things into Balance: The Relationship Between Low Back Pain and the Pelvic Floor

By: Katie Parrotte, PT, DPT, OCS, CFMT

Back Pain or Fitness (2)The Occurrence of Low Back Pain

Low back pain is the most common cause of disability and lost work time among working-age adults in industrialized countries (1). In fact, the worldwide prevalence of chronic low back pain has been estimated to be 11.9% of the population on a given day, and 23.2% of the population in a one-month period (2). That is a significant number of people! Determining effective treatments for low back pain can be challenging for various reasons: 1. there are no clearly defined risk factors that predict the development or outcome of low back pain; 2. most patients do not present with any significant findings physiologically or anatomically; 3. and pain can generate and spread at numerous locations within the nervous system, and can constantly change (1).

Treatment of Low Back Pain

There are many challenges associated with low back pain diagnosis and outcomes. Because of this, and the fact that so many people across the globe are impacted by it, there are many options out there for treating this condition. Some methods that have been proven to be effective are spinal manipulation (a high-velocity thrust applied directly on the vertebrae, or backbones, to improve movement and decrease pain), trunk coordination, strengthening, and endurance exercises (to target deep abdominal and back muscles that help to stabilize the spine), general fitness exercise, and patient education (1). These types of interventions are certainly helpful and have allowed many individuals experiencing low back pain to return to their daily lives. However, perhaps the areas that are being addressed with these interventions are not getting to the whole story… There is another area of the body that plays a significant role in the stability of the back but does not regularly get addressed with standard treatment to low back pain: the pelvic floor.

Treating the Pelvic Floor to Address Low Back Pain

Several studies have looked at incorporating pelvic floor-specific strengthening programs in the treatment of chronic low back pain. One study looked at women who were experiencing low back pain and urinary incontinence (the involuntary leakage of urine) (3), while two others looked at individuals experiencing chronic low back pain independently in men and women (4, 5). In all three studies, investigators compared “routine” physical therapy to routine physical therapy plus the addition of pelvic floor strengthening. Results revealed that incorporating pelvic floor strengthening decreased low back pain, decreased the incidence of urine leakage in the case of urinary incontinence, improved function based on specific questionnaires, and increased pelvic floor strength and endurance (3-5). This strengthening was completed by either performing isolated pelvic floor contractions (4, 5), or performing abdominal and pelvic floor muscle contractions while performing specific stabilizing exercises (3).

The Relationship Between the Pelvic Floor and the Low Back

Why did strengthening the pelvic floor make a difference in the above studies? This is likely because the pelvic floor is one of the muscle groups that contributes to overall spine stability; the others include the diaphragm, the transverse abdominis (a lower abdominal muscle), and deep muscles in the low back (3). Several studies out of Norway and Sweden have revealed that in women without pain, the pelvic floor activates just prior to arm or leg movement (6-8). This is important because it reveals that when the pelvic floor is working efficiently, it provides stability to the trunk and pelvis, allowing for functional postures and movements to occur.

Conclusion:

The pelvic floor is an important stabilizer of the spine and pelvis, and activates just prior to movement to allow for efficient function. When an individual is experiencing low back pain, not only do the abdominals and low back muscles require strengthening, focusing on the pelvic floor can help to eliminate pain and resume daily function.

If you or someone you know is struggling with unresolved low back pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!

Thank you so much for reading our blog.

K5 (2)

Katie Parrotte, PT, DPT, OCS, CFMT practices at our midtown location.

If you have questions about orthopedic, pelvic, or sports physical therapy, including back pain, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

Sources

 

1. Beattie PF. 2016. Current concepts of orthopedic physical therapy – the lumbar spine: physical therapy patient management using current evidence, 4th edition. (p. 3) Orthopedic Section – APTA.

2. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012; 64 (6): 2028-2037. doi:10.1002/art.34347.

3. Ghaderi F, Mohammadi K, Sasan RA, et al. Effects of stabilization exercises focusing on pelvic floor muscles on low back pain and on urinary incontinence in women. Urology. 2016; 93: 50-54.

4. Mohseni-Bandpei MA, Rahmani N, Behtash H, et al. The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain. Journal of Bodywork & Movement Therapies. 2011; 15: 75-81.

5. Bi X, Zhao J, Liu Z, et al Pelvic floor muscle exercise for chronic low back pain. Journal of International Medical Research. 2012; 41 (1): 146-152.

6. Sjodahl J, Gutke A, Ghaffari G, et al. Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the active straight leg raise in women with and without pelvic girdle pain: an experimental study. Clinical Biomechanics. 2016; 35: 49-55.

7. Stuge B, Saetre K, Hoff BI. The automatic pelvic floor muscle response to the active straight leg raise in cases with pelvic girdle pain and matched controls. Manual Therapy. 2013; 18: 327-332.

8. Sjodahl J, Kvist J, Gutke A, et al. The postural response of the pelvic floor muscles during limb movements: a methodological electromyography study in parous women without lumbopelvic pain. Clinical Biomechanics. 2009; 24: 183-189.