PRPC - Chiropractor's Viewpoint

Deb Gulbrandson, PT, DPT has been a physical therapist for over 42 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. Dr. Gulbrandson frequently presents community talks on topics related to Osteoporosis and safe ways to develop Core Strength. She is a member of the APTA Geriatric and Private Practice Sections, a Certified Osteoporosis Exercise Specialist using the Meeks Method, and is a CEEAA (Certified Exercise Expert for the Aging Adult) through the Geriatric Section of the APTA.

Hello, my name is Deb Gulbrandson. May is National Osteoporosis Month, and my colleague, Frank Ciuba, and I are creators of the upcoming remote course Osteoporosis Management on June 12-13, 2021.

Did you know that approximately half of all women and a quarter of all men will break a bone due to osteoporosis? Equally disheartening, every year about one-third of adults in the US age 65 and older will fall. Many of these falls will result in broken bones.

Frank and I developed the Osteoporosis Management course to bring treatment protocols to practitioners in an organized and easily implementable format. This course is based on the Meeks Method created by Sara Meeks, PT, MS, GCS, with whom Frank and I taught for several years. With Sara’s blessing, we have branched out to add information on sleep hygiene, exercise dosing, and basic nutrition for a person with low bone mass. Knowing how to recognize signs, screen for osteoporosis, and design an effective and safe program can be life-changing for these patients.

In all likelihood, you are working with osteoporosis patients right now whether you know it or not. Osteoporosis affects all ages and stages of life including young and middle-aged men and women. Often we see patients with orthopedic or neurologic diagnoses who also have osteoporosis- known or unknown. Being able to address patients’ comorbidities helps ensure safety and quality of life. Many of the techniques we use can apply across several patient demographics. After all, who doesn’t benefit from postural alignment, back extensor/glute strengthening, and balance activities?

Working with this population has been extremely rewarding, because similar to pelvic health patients, these patients have been told there’s nothing you can do about it. They are incredibly grateful to find out that there IS something you can do about osteoporosis. They enthusiastically take an active role in their rehabilitation.

In addition, as a private practice owner for over 30 years, I’ve found osteoporosis to be a great business opportunity. An incredible niche practice, bringing in patients who have actively sought out my clinic with their self-referrals or by word of mouth.

We hope that you will join us this June 12-13 for our course Osteoporosis Management for an opportunity to experience posture, power, visual cueing, strengthening, and balance activities along with osteoporosis screening, evaluation, and evidence-based practice.

In this blog, instructor Heather Rader, PT, DPT, PRPC, BCB-PMD, discusses the concerns and fears therapists have when treating mothers recovering from childbirth and how her upcoming course can prepare therapists to confidently treat patients within hours to weeks after childbirth.

When is it OK for a new mom to start therapy?

When a new pelvic therapist asks me this question at courses, my answer begins by shifting the focus towards the birth itself. Childbirth is a mechanism of injury, not a “special population.” The real question then is when is it OK to start therapy after perineal or abdominal tissue trauma? When your clinical reasoning begins from this point of view, it removes biases you may have about childbirth and instills confidence in your skills as a trained clinician. Every therapist learns acute care skills - how to treat wounds, how to mobilize post-op patients, and how to screen for medical complications. Simply put, dear clinician, you know more than you think you do.

On average, 3.75 million women give birth in the US per year (1.) 100% will have some level of injury because of it. Those injuries will be perineal, abdominal, or both. There will be muscle strains and ligamentous sprains. There will be soft tissue bruising and swelling.

There are risks of immobility and re-injury without proper patient education. There might be stitches or staples in the abdominal or vulvar skin. There will be pain issues, mobility issues, safety issues, and definitely body mechanics and ergonomic issues. Given these obvious musculoskeletal and mobility impairments, I ask you to ponder this - what profession is better prepared to assess the acute and sub-acute needs of a new mother than rehab professionals?

Let’s imagine the same question posed to an acute care therapist about newly injured trauma patients.

Every lecture on the history of rehabilitation highlights the early days when bed rest was thought to be therapeutic.

Through research and clinical observations, we know immobility was, in some cases, deadly. Nowadays, it is considered standard of care to begin mobilization as early as medically possible, even in the ICU. And so should it be with new mothers. When should a person who was in an accident start rehab? What information would our therapist need to determine when to start and what early intervention is medically appropriate?

• Is the patient medically stable?
• Are the injured tissues structurally stable?
• Have any problems developed as a result of being immobilized in the hospital?
• Are there other co-morbidities to complicate the recovery?
• How is the patient’s mental status after the trauma?
• What social support is in place to assist with short-term and long-term needs?
• Can the patient function independently? Need home health? Benefit from outpatient therapy?

The clinical decision-making and critical thinking necessary to manage the care of an acute care patient is not much different than that of a pelvic therapist managing the recovery of a new or “acute” mother. More and more hospitals and birthing centers are incorporating acute care therapy within hours of birth. There are anatomical and physiological differences because of the effects of pregnancy itself that the clinician must learn, however. While the patient is recovering from childbirth, the body is returning to its pre-pregnancy state. Having a better understanding of the late pregnancy, birth, and the peripartum state has on healing can assist the motivated clinician in adding maternal-based therapy to their skill set.

The course Peripartum Advanced Topics covers medical screening, early exercise, patient education, hospital-based programming, and treatment strategies, as well as early outpatient care and fitness transition planning, such as returning to running.

If you are contemplating expanding your outpatient practice to see patients early in the “4th Trimester” or even earlier in the acute setting after the 4th stage of labor (recovery), consider signing up for the course.

• 1. https://www.cdc.gov/nchs/fastats/births.htm accessed 5/19/2021 10:30 AM

Mia Fine, MS, LMFT, CST, CIIP has written and instructing her remote course, Sexual Interviewing for Pelvic Health Therapists, with H&W on June 5-6, 2021. Mia (they/she) is a student of Queer Theory, Intersectionality, and Social Justice, and offers holistic, anti-oppressive, and trauma-informed therapy. This is a course intended for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit who work with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns.

Let’s talk terms: Dyspareunia and Vaginismus

• Vaginismus: involuntary contraction of vaginal muscles preventing insertion/penetration
• Dyspareunia: pain felt during penetration

Symptoms (not limited to): pain - painful penetration, painful orgasms, painful periods, painful pelvic exams, inability to use tampons/cups, urinary or bowel hesitancy, feeling “too tight”

Causes (not limited to): stress, relationship concerns, mood concerns (anxiety, depression), insufficient arousal/desire/interest, trauma, side effects of meds, negative attitudes towards sex, and other pelvic pain concerns such as a tilted uterus.

The deal is, when it comes to dyspareunia and vaginismus there’s a cycle that can be difficult to break. The cycle is: you feel pain, then you feel broken (shame about feeling pain), then anxiety that pain will happen again, then you tighten your pelvic floor, and the cycle repeats. It becomes a self-fulfilling prophecy.

Often unwanted sexual pain goes unaddressed. Why? Because we are not taught about the interactions between feelings, relationships, and our body. We are not taught that sex should not be painful; that pain is (likely) our body giving us information that something is going on (Hello crappy sex education and the stigma of sexual health and body awareness!). It’s not uncommon that most people who experience sexual pain often feel they are broken.

You are not broken

How to heal from unwanted sexual pain? There’s a trifecta! Effective healing comes from working with a sex-positive medical provider, sex therapist, and pelvic floor PT. We will all collaborate!

Sex is not supposed to be painful. You are not broken.

Mia ️

#therapy #sextherapy #wellness #health #awareness #mentalhealth #bodyawareness

Steve Dischiavi holds credentials as a licensed physical therapist and a certified athletic trainer. He also has a manual therapy certification from the Ola Grimsby Institute and is board certified by the American Physical Therapy Association as a Sports Clinical Specialist (SCS).

The blog you’re about to read is targeted at clinicians just like myself. I was taught in PT school to evaluate the sacroiliac joint (SIJ) via a movement-based analysis. I even went on for a certification in manual therapy nearly 2 decades ago, and again was taught the movement-based approach. Well, as the song goes… “times they are a changin”….

So… if you’re a clinician who will diagnosis the SIJ as being “unstable” from movement-based testing, using tests that evaluate the positional movement of the PSIS… then you need to begin to question the approach you’re taking.

There is a contemporary conversation taking place within the field of physical therapy. If you’re like me and learned to evaluate the sacroiliac joint (SIJ) through movement-based testing, you need to be involved in this evolving conversation.

A great place to start is with a “Perspective” article published in Physical Therapy in 2019. It is titled “Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area” written by Thorvaldur Palsson, et.al.1

The narrative dives into several areas pertaining to the treatment of this mysterious region of the body. It gives the reader a thoughtful and contemplative view of the contemporary conversation surrounding the evaluation and treatment of the SIJ.

The target audience should be the clinicians who continue to evaluate the SIJ solely on movement based analysis, attempting to diagnosis the SIJ with terms related to movement dysfunction. We have all heard terms like “upslip, downslip, or sacral torsions”. The narrative addresses why this is not the best approach to diagnosing the SIJ.

The article also touches on the concepts of “pain science” and how assessing how the SIJ “moves” tells the clinician very little about why the tissues about the SIJ might be sensitized. The article scratches the surface about the patient’s pain experience and how harmful terms such as “instability” and how the SIJ “goes out” are ways that can perpetuate and even heighten the pain experience for your patients.

The Perspective article gives the reader a great introduction as to why you might consider altering your approach to the SIJ. I’ll leave you with a quote directly from the article:
“If clinical decisions are based on a construct that lacks plausibility and clinical tests lacking in validity and reliability, the entire management paradigm must be questioned.”
The next question you might be asking yourself… ok, how do I learn a new management paradigm? A great start would be to take the 4-hour introductory webinar, Sacroiliac Joint Current Concepts - Remote Course - June 26, 2021, offered by Herman and Wallace… learn the evidence-based approach to the SIJ with Steve Dischiavi, PT, DPT, MPT, SCS, ATC, COMT who has been working closely on the hip and pelvis for over 20 years!

I hope to see you at the webinar!

1. Palsson TS, Gibson W, Darlow B, et al. Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Phys Ther. 2019;99(11):1511-1519.

Dustienne Miller is the creator of the two-day course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. 

I’m one of the small business owners who has survived this difficult time. Day after day I would mask up, put on the filtration systems, and be filled with gratitude that I could still safely do my work in the world. Despite being vigilant on sleep, eating lots of veggies from the local farm, exercising, and staying well hydrated I still carry a deep covering of stress and tension.

We have been holding our breath literally and figuratively with collective humanity for the past year. I realized when I had an acute flare of lumbopelvic pain that I had to melt away layer by layer of holding tension in both my back and ribs and go deeper into my breathwork and meditation practice.

I share this to acknowledge that as health care providers we are caring for more than just the physical concerns of our patients. We are honored to witness their grief, which could be from any type of trauma (physical, medical, etc). We are chosen to be their trusted source of advice which often goes beyond the rehab lens. We also need to notice when we as clinicians (and humans experiencing a global pandemic) experience burnout.

We teach our patients how breathing patterns inform our digestion, our spine, our emotional state, our pelvic floor, etc. It’s one of the most powerful tools we have to inform our system that we are safe. Despite this knowledge, we will often find ourselves holding our breath or breathing in non-optimal ways without even realizing it. When we don’t want to feel something we don’t breathe. When we are afraid we hold our breath. We might even find our ribs stay tight even when we feel relaxed.

Let’s pause to notice and soften.

Notice your body without “fixing” your posture. Where is your ribcage in relationship to your pelvic floor? What does it feel like when you breathe in? What does it feel like when you breathe out?

If you are sitting, slouch down. How does breathing feel in this position? Now imagine your head is getting magnetically pulled up towards the ceiling and sit in a more lengthened position. Take a breath with a taller spine. Does it feel different?

Now try this with your eyes closed: imagine the intercostal space widens with each inhale - then softens during each exhale. Do you have a habit of holding your ribs open with tension? Picture your shoulders softening, as if the tension from the upper traps was melting away. The jaw softens, the tongue softens, the center of the forehead softens.

Now take another long, conscious breath. What do you notice?

As practitioners, we give so much to our patients. It serves us to stay grounded in our bodies and as relaxed as we can be while we work. It’s a tall order and hard to remember but it might help decrease fatigue, exhaustion, physical pain, and burnout. Let’s all try and keep our breaths long, jaws soft, and pelvic floors pliable. I hope this pause was useful for you!

Dustienne Miller can be found teaching her course Yoga for Pelvic Pain online for 2021 on the following dates:
May 15-16, July 31-Aug 1, and Sept 25-26

;Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has co-authored the course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.

A few months ago a young woman with a diagnosis of dyspareunia was referred to me. She had been a gymnast through her teens and now worked out regularly. She reported being unable to use tampons throughout her life, experiencing difficulty with undergoing pelvic examinations, and inability to have intercourse with her partner all through her married years. She also had a history of long-standing constipation and urinary symptoms including increased voiding frequency and the feeling of incomplete emptying.

Her examination included significant overactivity of her abdominals. A very chest dominant pattern of breathing with very limited lower lateral costal expansion, limitations in thoracic mobility, a fairly rigid rib cage with a very narrow infra sternal angle, connective tissue restrictions of the abdominal, pelvic areas, decreased flexibility of her hamstrings, and weakness of her Glut Max muscles. There was significant guarding and an internal assessment of pelvic floor muscles was not performed initially due to associated discomfort.

Throughout the first few sessions, we worked on releasing her first rib, the scalenes, latissimus dorsi, and quadratus lumborum muscles, and worked on reducing the connective tissue restrictions in the abdominal and pelvic regions. We also spent time improving rib cage and thoracic spine mobility and reducing the chest dominant pattern of breathing; while trying to establish improved abdominal compliance and lateral costal expansion with inhalation. All this, along with techniques aimed at improving neuromuscular control of her Gluteus Maximus without excess compensatory pelvic floor muscular assistance led to enough improvement in a few sessions to allow for an internal pelvic floor muscle assessment to be performed.

The patient's job activities required constant vocalization and I found that she contracted her neck, her abdominal, and pelvic floor muscles very strongly with any vocalization and did not relax the muscles after she finished vocalization. The patient was educated on softening her vocalization, and on a more controlled release of air through the glottis with more gradual abdominal and pelvic floor contractions while performing glottal/vocalization exercises. The patient was very keen on continuing her fitness-related activities through all of her therapy. Manual internal pelvic floor muscle assessment performed with standing activities revealed that although she did not particularly find her workout routine very taxing she tended to exhale extremely forcefully with each repetition of the exercise. This forceful exhale was naturally accompanied by very strong recruitment of her abdominals and her pelvic floor muscles, and once again there was decreased relaxation after cessation of her exercises. The treatment process involved making the patient aware of breath patterns and her gripping, nonrelaxing quality of the contractions of the pelvic floor and the abdomen and how she could gain some relaxation by utilizing her breath.

In addition to continuing to receive pelvic therapy from me, the patient consulted with Leeann, a sports-trained therapist, for 2 sessions to set up a fitness program. Leeann set up a program for the patient to strengthen her core and gluteal muscles while monitoring the pelvic floor externally. The fitness program progressed with challenging exercises in non-weight bearing and quadruped positions which were then progressed to kneeling and then standing. An important focus during the development of this program was on monitoring the patient's strength of exhaling and ensuring pelvic floor relaxation with breathwork between repetitions ensuring that there was no reverting to the old habit of gripping.

The patient's complaints for which she initially sought pelvic therapy were completely resolved. The patient's pelvic pain symptoms were resolved with treatment directed at the thorax, the breath, vocalization and the glottis, and lower extremity muscle strength. Very little time was spent on conventional manual techniques applied directly to the pelvic floor musculature.

In the Herman and Wallace course, you will learn skills to effectively assess the thorax, the diaphragm, breathing patterns, thoracic mobility inclusive of joint mobility, and myofascial connections. Come and learn how postural changes can affect the biomechanics of how the body performs and in turn affect intra-abdominal pressure. Learn easy effective strategies that will help you in your care of patients with low back pain and pelvic floor dysfunction the very next day. Hope to see you in class!

;Aparna Rajagopal will be co-teaching Breathing and the Diaphragm: Pelvic and Orthopedic Therapists on May 15-16, 20201 with her colleague Leeann Taptich. This course instructs practitioners on breathing mechanics and their relationship to the pelvic floor.

Misbehaving Bladder - False Alarms

This is Part 2 of Tuesday's, April 27, 2021, blog Misbehaving Bladders and Cluster Drinking - A Novel Approach, Part 1.

Bladder capacity ranges from around 400-500ml (13-16 oz). The use of a measuring cup or water bottle can be very helpful to teach this concept. We certainly don’t have to strive for a full bladder volume, but it is important to illustrate that 2-3 ounces are in fact “just in case” voids. I explain to patients that in situations of overactive or irritated bladders, the receptors in their bladder walls are hypersensitive and sending “false alarm” messages when only a small amount of urine is present. The kidneys are always active and refilling the bladder, so it will never be totally empty per se, therefore it must be desensitized and retrained to be a viable, reliable, and reasonably comfortable storage vessel.

With the Cluster Drinking Approach, it is important to try and drink the fluid in a short enough period of time to ensure an increased rate of bladder filling for this to be effective, but you must be careful to monitor the bladder irritability with the training. A fuller bladder will experience more pressure, but this also helps with urine flow during voids. We then embark on this process of retraining and using their bladder diaries to help us with detective work to determine optimal amounts of fluid intake in each cluster and the optimal timing of fluid intake, number of clusters, etc. for their daily schedules. It may take some time to get used to the new habits. It can be hard for some patients who are used to sipping on their water bottle all day long, and they can feel dehydrated. This is a habit and learned response and can be retrained with some gradual investment in the process. Once patients experience the rewarding outcomes, they are usually willing to make the changes.

Based on diary findings, we modify types of fluids as necessary, my motto being: minimal disruption to achieve desired results. Why give up coffee and all favorite beverages if not necessary? Sometimes making modifications on timing and amount of intake works just fine, other times we tweak the beverage types. I also teach and integrate urge suppression strategies (USS) as well, to help with the process of retraining; and of course, address breathing, pelvic floor dysfunctions, connective tissue restrictions, and chronic constipation, but the variable which sets this approach apart is the cluster drinking.

According to Washington state urogynecologist Elizabeth A. Miller, MD FPMRS, a practitioner at Overlake and Swedish Medical Centers, the Cluster Drinking Approach works similarly to some OAB medications in training your bladder to hold more urine. She endorses the Cluster Drinking Approach as a viable first-line treatment option since it works naturally without harmful side effects. Results are often profound and rapid even for folks who have been struggling with these bladder issues for years. Likewise, leaking issues tend to diminish as the bladder training is mastered. Patients can structure riskier activities around this cluster program, i.e. plan their Zumba after cluster intake and output. The same goes for major outings where one will not be near a bathroom. Even my constipation patients have benefitted due to a more reliable intake of adequate fluid.

Nocturia is a bit of a different situation because of the role of kidney hormones, but I have found this approach to be quite effective for many patients whose lives and sleep are impacted by this problem. The Cluster Drinking Approach helps these patients to structure their fluid intake during daytime hours, and I teach them to heed the 1st overnight urge if it is within 2-3 hours after going to sleep. Then if they awaken again, I coach them to use the mantra “the bladder is a storage vessel”, analyze their last intake and output, and permit themselves to use the Urge Suppression Strategies, and go back to sleep without worrying that their bladder will explode. The other good news is after their bladders (and brains) are “retrained”, and you have done your PT magic, they can often return to more natural drinking patterns without negative consequences.

Fun Fact: Even Did you know that under anesthesia the amazing expandable bladder can hold over 1 liter?!

Kathy E. Golic, PT is a physical therapist at Overlake Hospital Medical Center in Bellevue, Washington.

There have been many constructive blogs about managing symptoms of overactive and misbehaving bladders, but I want to share an approach I have been using successfully for many years. Not only does this approach work for the majority of my patients in terms of addressing urgency, frequency, and urine leakage, but results are often quite rapid. After treating patients with modest success for many years with the traditional treatment approaches and noting that too often patients would plateau or results were just not effective or fast enough, I created my own approach to help these patients. I call it Cluster Drinking Approach and explain to my patients that cluster drinking begets cluster voiding.

When folks sip fluid, even water, all day long, it is hard for them to know when their bladder is full enough to warrant a trip to the bathroom. In patients with oversensitive or irritated bladders, the sensory receptors in the bladder wall are agitated and so often send false, unreliable signals,
when there is not much urine present. So they continue to struggle with urges and frequency and sometimes urine leakage. However, when they divide their fluid intake into 3-4, or sometimes even 5 or more, “clusters” then their bladders fill more predictably. They can sense it, and based on timing and amount of intake, they can reliably determine when the urges are accurate.

This requires a mindful and analytical approach to help retrain their bladders. The amount of intake and number of clusters are selected based on the level of bladder irritability, the patient’s schedule, as well as their weight, age, and level of anxiety. The variables can be modified according to their daily schedules, and their progress. Coupled with my mantra, “The bladder is a storage vessel, it is meant to hold urine!” this approach has been life-changing for many patients, and often in just a few visits!

Here is an example to illustrate what this might look like based on 60 fluid oz of daily intake. And important to share this pearl...In case you did not know...the adage of 8 glasses of 8 ounces of water was not based on research. So this will be quite individualized.

INTAKE
Cluster 1: 7:00 am-7:30am Consume 20 oz of fluid
Cluster 2: 11:30-12:00 Consume next 15 oz
Cluster 3: 4:30-5:00 Consume 15 more oz
Cluster 4: 7:00-7:30 Consume final 10 oz
Total Intake: 60 oz, plus sips for bedtime pills

OUTPUT
Void: Reliable urge 60-90 mins later
Possibly a 2nd void within the next 60 mins
Void: 1-2 times in next 60-120 minutes
Void: next 60-120 minutes
Void :next 60-120 mins
Final void: Bedtime
Total voids: generally 5-8, depending on actual intake



Kathy E. Golic, PT is a physical therapist at Overlake Hospital Medical Center in North Bend, Washington.

From a very young age, I had the passion to be a Physical Therapist, but it was only recently that a hidden passion was revealed, Pelvic Floor Physical Therapy. I graduated from Stockton University with my BS in Biology in 2007 and Doctorate of Physical Therapy in 2009. I have a history of pelvic health issues and had felt extremely uneasy about going to pelvic floor continuing education, so I focused on other areas early in my career like pediatrics, adult neuro, acute care, and wound care.

As a little girl, I dealt with Pelvic Floor Dysfunction due to tight pelvic floor muscles, with frequent urinary tract infections, and an overactive bladder. Then as a teen, I had pain with penetration, from tampons to speculums and later during sexual activities. Luckily, I was treated by a Pelvic Health Specialist who helped me to have a full and active lifestyle without pain and irritation but it took me a long time to find help with the right provider. I have experienced pregnancy (and most of the common complications including morning sickness, preterm labor & pelvic pain) and complicated childbirth that ended in a cesarean section. My daughter also experiences many of the common pediatric pelvic floor issues like constipation, post-void dribbling, and bedwetting.

When a coworker of mine was looking for someone to help her with our company’s Pelvic Floor program, I found the personal courage to go and take Pelvic Floor Level 1 with Herman & Wallace. I had always had the interest and the personal experiences, but I needed to find the right situation to delve into it all; enter Herman & Wallace. I cannot overstate how welcomed, safe, educated, and reassured I felt beginning my journey with Lila Abbate and Dustienne Miller. I signed up for my next course while still attending that first course, and there was no limit to the number of continuing education courses from Herman and Wallace I wished to attend over the next two years. Herman and Wallace had woken up a passion in me I didn’t even know I yearned for. I wanted to know anything, everything about pelvic floors. The next logical step to assure myself and my patients that I was an advanced practitioner in this area was to take my PRPC which I completed in May 2019.

My pelvic floor bestie, who happens to be someone I met on my first day of PF1, convinced me I was ready to be a Teaching Assistant in March of 2020. It was an amazing experience to be able to be the moral support for that next cohort of pelvic health practitioners and to share my years of tips, tricks, and experience. COVID shut things down for a bit the weekend after, but later in the year when Herman & Wallace was looking for TAs to help with their newly formatted hybrid classes, I was ready to lend a hand. Each time I TA, I learn new things and get to pass skills I have mastered on to new practitioners.

Herman & Wallace is wonderful at creating continuing education classes. I love their organization, adaptation, and ability to prepare practitioners to leave a course on Sunday and start using their new skills on Monday. Since taking a class with them, while other continuing education courses from other companies have provided information and opportunities, I find myself constantly comparing the field to Herman & Wallace, and I always find my way back to the company that has truly given me a renewed reason to love what I do.

Mora A Pluchino, PT, DPT, PRPC is a New Jersey based physical therapist and owns her own PT clinic, Practically Perfect Physical Therapy. She is a senior TA for H&W and can be found TAing courses in her area.

Fears about treating men’s health conditions are limiting access to care or are creating potential for harm in the field of pelvic health. Many cisgender women (women whose gender identify matches the sex likely assigned at birth) express concerns about working with cisgender men beyond a lack of knowledge about conditions related to prostate issues, urinary leakage, or genital pain. Are these fears warranted, are they fair? Rather than assert that ciswomen should simply move beyond their concerns, the field of pelvic health and the patients with whom we work may be better served by digging in and talking more openly about such fears. Following are some of the concerns or comments I have heard expressed by cisgender women within the context of treating men’s health matters:

• (Regarding palpation of the penis:) “Is that legal?”
• “I worry about being alone in a room with a man.”
• “What if he gets an erection?”
• “My husband doesn’t want me to work with other men for pelvic health stuff.”
• “I’ve never seen a man’s genitals before and I’m not comfortable with it.”
• “My religion teaches that I should not touch a man other than my husband.”
• “I don’t know what to say when men make suggestive comments.”
• “My supervisor is forcing me to do this work with men when I don’t want to.”
• “I only treat them in side lying because then I don’t have to see their stuff.”

Rather than a reader making a judgement about the above comments, we should ask ourselves as a profession if the above topics have been properly addressed in our training or if we are encouraged to work through this area of professional and personal intersecting concerns. We could view the concerns expressed through the lens of providing equal care, in other words, are we discriminating against someone based on their genitals? Or through a lens of safety- is there an actual (as well as perceived) threat from a cisgender woman who is alone in a treatment room with a cisgender man? If that’s potentially true, how are we mitigating this risk? Where does the anatomical line end between personal beliefs such as “I can touch another man’s shoulder, but not perineal area”? Are we practicing ethically if we are denying access to care or providing less than comprehensive care? Is a therapist truly worried about their primary relationship by doing this work because their partner does not approve? And more importantly, can we provide needed guidance or support to address some of the above obstacles?

I commonly have the opportunity to work with men who have seen other self-identified female therapists first. Here is what I often hear:

• “I could tell that they weren’t comfortable talking to me about this issue.”
• “It didn’t seem like they knew what to do with me.”
• “I got switched over to another therapist after asking some questions about using a penile pump.”
• “I felt really shamed about my condition because they would change the subject.”
• “I called many places and they rejected seeing me because I’m a man.”
• “When I asked if they were going to examine where the pain is [genital area] they said it would be a last resort.”
• “No one ever examined me, just gave me a biofeedback sensor to put in.”

This information is not shared to shame the caring professionals in our field. What needs to happen, however, for elevating the inclusiveness of care, is a continual dialogue and recognition of the support needed to work with sensitive conditions and the vulnerabilities of both patients and providers. It is potentially harmful to reject patients based on gender, or to provide lesser care based on genitals. To further this conversation, the Institute has partnered with author and educator Leticia Nieto, who holds a degree in psychology and who wrote Beyond Inclusion, Beyond Empowerment: A Developmental Strategy to Liberate Everyone. Join Leticia and me (Holly Tanner) for our first 3-hour discussion that emphasizes talking, feeling, and thinking through some of the above concerns and challenges. The class will focus on discussion more than lecture, and will aim to provide a space within which we can speak openly about how to move forward with the goal of improving comfort when working with men’s health issues and improving access to much needed pelvic health care. Note: this class is welcoming to all people with any gender identification, however, the emphasis will be on the topics discussed in this post.