Why PT Needs More LGBTQ+ Affirming Pelvic Floor Specialists

By: Serra Shelton, SPT

I am a 2nd year physical therapy student about to start my clinical rotations, and I have been interested in pelvic floor PT since the beginning of my academic journey. However, since it is a somewhat niche specialty, my general coursework provided only 2 lectures on pelvic floor therapy in the entire program . Despite seeking out exposure to pelvic floor education in other ways, such as taking a courses with the Herman and Wallace Institute and a pelvic health elective at the University of Washington, I wanted to learn more than the brief glimpse I had seen so far—and that is how I found myself creating an independent study course with Dr. Brianna Durand, an LGBTQIA+ pelvic floor/outpatient orthopedic physical therapist. Let me give you a sense of what this experience was like.

It was the first day of my independent study in which I would shadow Brianna as she practiced.

We started off the day with a returning patient, and Brianna began by asking for updates on her symptoms. As the patient recounted her status since her last session, Brianna typed away at her computer, asking for more details here and there.

When the patient had finished, Brianna turned away from her computer, made eye contact, and said “So to recap, since our last session you had a nasal endoscopy with negative findings, you saw an endocrinologist for the first time who ordered new tests, you had another biopsy, and you had a particularly stressful week at work.” The patient nodded emphatically. I was impressed—

I had never observed a physical therapist summarizing the patient’s words back to them. It seemed like a simple yet highly effective technique for the patient to feel fully seen and heard, and to make sure no important information had been missed.

Brianna sat back in her chair, her expression concerned, and said, “It sounds like you’ve been through an incredible amount of medical stress since our last session. No wonder you weren’t able to stick with your home dilator schedule.” The patient nodded even more, and I raised my eyebrows in surprise— we had talked about the importance of empathizing with the patient’s emotions in classes, but this was the first I had seen it in action.

“Here’s my plan for the session,” Brianna continued as she listed off the types of interventions she wanted to do that day, and why. Finally, as the icing on the cake, she added “are there any things you would like to address with today’s session?”

I was awestruck.

It was new for me to watch a physical therapist outline the exercises they planned to do with the patient prior to the session, explain the clinical reasoning behind them, and encourage the patient to contribute.

It was a beautiful way to give the patient agency over their treatment and allow them to give true consent to the session, rather than being herded from one exercise to another with little explanation, as I had been trained to do so far.

As I watched Brianna treat several more patients that day, I realized that this type of care was not isolated to the first patient, and was applied to pelvic floor and orthopedic patients alike. Every session I noticed her repeating back the patient’s subjective, validating any strong emotions the patient might be feeling, outlining the planned treatment session, and asking for input. This was simply her standard of care for everyone who walked through her door, and I was impressed by the skill and care with which she executed it.

I think Brianna delivers such consistently exceptional patient care in part because of her training in pelvic floor physical therapy.

Due to the sensitive nature of that body region, pelvic floor physical therapy faces the practitioner with some of the most vulnerable, traumatized, ashamed, and fearful aspects of the patient’s life.

From what I have seen so far, the specialty has evolved to meet the needs of its patient population by leaning into gentleness, empathy, deliberateness, and a return of agency to the patient in a way that the wider world of physical therapy could benefit from. For example, one lecture from a pelvic floor elective class I took discussed consent and trauma-informed care more thoroughly than all the rest of the two years of my program combined.

Additionally, a Herman and Wallace pelvic floor class I attended last spring went in-depth into exam strategies to give the patient more agency and how to build comfort for saying “no.” The instructors counseled us to use these strategies with all of our patients, whether we are aware of a trauma history or not, because every pelvic floor patient benefits from this level of thoughtful care. I would take it one step further, and argue that every physical therapy patient in any setting or specialty benefits from this type of communication and care.

I think pelvic floor physical therapy should be included more in the core curriculum of physical therapy doctorate programs.

The philosophy behind pelvic floor care would improve student’s abilities to engage with difficult patient experiences, whether they practice pelvic floor therapy after graduation or not. Experience of trauma is not limited to the pelvic region, and any instance where someone’s body is touched against their will can create a traumatic experience.

We do not know if something seemingly harmless, such as a tactile cue to the low back, could cause a patient to feel out of control of the situation or bring back traumatic memories. I have often wondered this as I watch the way our profession tosses exercises at patients, thrusting weights and straps into their hands, bundling them onto a machine before explaining what the machine does, correcting and poking and instructing with little respect for the incredible trust it takes to allow yourself to be touched by a stranger. Could we take the time to be more thoughtful about the dynamic we create with patients? Would we see better health outcomes if we did?

I first became interested in pelvic floor physical therapy before applying to graduate school, when trying to connect myself with the community of queer physical therapists in my area. Not surprisingly, many of the LGBTQIA+ therapists I networked with were also pelvic floor specialists.

Because the genital region is the site of so much social, medical, and political trauma for those of us who are sexual and/or gender minorities, I think there is a desire to provide the type of safe, sensitive medical care to our community that we have struggled to find ourselves, to be one provider not adding to the horror stories our queer friends come home with every time they visit the doctor.

I believe that because of our insertion of ourselves into this specialty, the pelvic floor world has adapted to inclusivity in ways the rest of the physical therapy field is still struggling to catch up to. If you are treating a shoulder, you can culpably ignore the lived gender experience of your patient; however, if you are examining their pelvis, you cannot so easily bury your head in the sand. The difference has been stark in my experience as a student—within the general anatomy courses of my program, professors struggled and resisted using gender-neutral anatomical terms and persisted with language such as “male anatomy” and “biologically female,” despite widespread student protest.

From the first moment of my Herman and Wallace Level One Pelvic Floor course I took last spring, however, the instructors all consistently used gender neutral language such as “pregnant people” and “pelvis containing a penis” without fuss or fanfare. It was enough to make me want to weep with joy, to see how possible it was to have an inclusive and non-gendered medical education. The same experience was repeated later that year, when I took a pelvic floor elective as part of my second year coursework—even though my other coursework at that institution had no policy on inclusive language, the professors of this one elective course made a point of using gender neutral anatomical language throughout.

This is another huge gift that the pelvic floor community has to offer the wider field of physical therapy—an honest look at the impact our current medical language has on LGBTQIA+ patients, and how we can shift our teaching styles to do less harm. I think if pelvic floor physical therapy were more integrated into physical therapy core curriculum, we as a profession would become better healthcare providers to LGBTQIA+ patients across every physical therapy setting.

The nine weeks I worked with Brianna was an eye-opening experience.

She demonstrated a type of patient-centered care that I hope to emulate in my own career. I was reaffirmed in my reasons for being drawn to pelvic floor physical therapy, and gained a new appreciation for what pelvic floor physical therapy skills will add to my quality of care, across all settings and all patients I treat.

I was able to have vulnerable conversations about providing the best possible healthcare to members of my LGBTQIA+ community, and discuss queer-related patient care questions with her that professors at my program do not know how to address. I appreciate that doctorate programs are already intense educational experiences with little room to add to the curriculum, but in this case I think it is crucial for pelvic floor physical therapy to become a larger part of the core curriculum. It’s not just a matter of exposing students to a potential niche specialty, it’s about integrating a style of practice that will change the culture of our field of physical therapy to one that is more patient-centered, inclusive, empathetic, and intentional.

Get Movin’ (Part 2)

By Natalie Grant, PTA

The previous Get Movin’ blog post discussed why movement really is medicine and how national organizations and guidelines, informed by extensive research and scientific journals, have shown this to be true time and time again. The ideal minimum amount of movement (for adults), according to the US’ official physical activity guidelines, is 150 minutes of moderate-intensity aerobic physical activity every week and strength-specific training twice per week (called anaerobic activity). However, current research also supports that even just 5-10 minutes of movement has highly positive impacts on health outcomes as well.

Yet only 53% of American adults meet these guidelines for aerobic activity, and a mere ~23% meet the guidelines for both aerobic activity and strength training. These numbers alone are concerning, but the difference between them is just as distressing. More often than not, the objective benefits of strength training beyond just building strength is not common knowledge, so let this list persuade you of the importance of incorporating strength training into your fitness routine, and ultimately lifestyle.

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Improved bone density

As we age, our bone density decreases, which can lead to osteoporosis and an increased risk of fractures. But strength training has been shown to increase bone density, thus can help combat these risks.

Increased metabolism & improved body composition

Strength training increases muscle mass, which in turn can increase our metabolism and decrease body fat. This means your body will burn more calories at rest, ultimately helping you to maintain a healthy weight and reduce the risk of obesity-related health issues.

Improved balance and stability

Without training balance at all, studies show that strength training and resistance training improve balance and stability scores. This is particularly important for our older populations, who have a higher incidence of fall related injuries.

Reduced risk of chronic disease

Strength training can help reduce the risk of chronic diseases such as diabetes, heart disease, and even some forms of cancer. This is because anaerobic exercise improves insulin sensitivity, lowers blood pressure, and reduces inflammation in the body.

Improved mental health

Exercise, in general, has been shown to help reduce symptoms of depression and anxiety, and strength training specifically has been shown to increase self-esteem and confidence in daily life.

Improved sleep

Routine exercise, including resistance training, can improve the quality of sleep because it helps to regulate the body’s circadian rhythm. In turn, this can help improve not only the ability to fall asleep, but also the ability to stay asleep throughout the night.

Improved overall fitness

Gain flexibility without stretching? Improve your cardio without doing cardio? Yup! By training with resistance, research shows you can increase your flexibility, endurance, and cardiovascular health (!!).

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Strength training offers a wide range of benefits beyond just increasing strength. From improving bone density to reducing the risk of chronic disease, strength-specific exercise can have a significantly positive impact on one’s overall health and wellness. So while your goal at physical therapy may be to just heal from a sprained ankle, your team at Empower Physio knows this is only the beginning when it comes to living a truly healthy life. Joining the (hopefully growing!) 23% can get you there, and we’d love the help.

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References

American College of Sports Medicine. (2014). ACSM's guidelines for exercise testing and prescription (9th ed.). Philadelphia, PA: Wol

Baron, K. G., Reid, K. J., & Zee, P. C. (2013). Exercise to improve sleep in insomnia: exploration of the bidirectional effects. Journal of Clinical Sleep Medicine, 9(8), 819-824. doi: 10.5664/jcsm.2930

Church, T. S., Blair, S. N., Cocreham, S., Johannsen, N., Johnson, W., Kramer, K., ... Earnest, C. P. (2010). Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA, 304(20), 2253-2262. doi: 10.1001/jama.2010.1710

Gordon, B. R., McDowell, C. P., Hallgren, M., Meyer, J. D., Lyons, M., & Herring, M. P. (2018). Association of efficacy of resistance exercise training with depressive symptoms: meta-analysis and meta-regression analysis of randomized clinical trials. JAMA Psychiatry, 75(6), 566-576. doi: 10.1001/jamapsychiatry.2018.0572

Kafri, M., Myslinski, M. J., & Gade, V. K. (2019). Resistance training and balance in older adults: a systematic review. Journal of Geriatric Physical Therapy, 42(2), 92-100. doi: 10.1519/JPT.0000000000000131

Kerr, D., Morton, A., Dick, I., & Prince, R. (1996). Exercise effects on bone mass in postmenopausal women are site-specific and load-dependent. Journal of Bone and Mineral Research, 11(2), 218-225. doi: 10.1002/jbmr.5650110213

Kraschnewski, J. L., Sciamanna, C. N., Poger, J. M., Rovniak, L. S., Lehman, E. B., Cooper, A. B., & Ciccolo, J. T. (2016). Is strength training associated with mortality benefits? A 15-year cohort study of US older adults. Preventive Medicine, 87, 121-127. doi: 10.1016/j.ypmed.2016.02.038

Westcott, W. L. (2012). Resistance training is medicine: effects of strength training on health. Current Sports Medicine Reports, 11(4), 209-216. doi: 10.1249/JSR.0b013e31825dabb8

Swift, D. L., Lavie, C. J., Johannsen, N. M., Arena, R., & Earnest, C. P. (2014). Exercise training and the cardiovascular response to stress. Exercise and Sport Sciences Reviews, 42(2), 120-127. doi: 10.1249/JES.0000000000000008

Get Movin’ (Part 1)

By Natalie Grant, PTA

“Movement is medicine” is not just a fun, catchy phrase. This sentiment is backed by science. Our very own University of Washington’s School of Medicine published research just last month in the Journal of Physical Activity and Health reiterating how important movement is for patient health outcomes and national health spending. The authors found that “widespread medical efforts to prescribe more physical activity or more regularly check in on patients’ activity levels could significantly reduce the nation’s health care costs.” 

The study surveyed nearly 24,000 patients from early 2018 through the end of 2020. Those who were “sufficiently active” (only 37.4% of the participants) were far less likely than “insufficiently active” patients (28.5%) to be admitted to a hospital, visit their primary care provider, or go to the ER. It was also estimated that if the “insufficiently active” people were to meet the current national physical activity guidelines, then emergency room costs would decrease by more than $34,000 for every 1,000 patient-years (using the assumption that the average ER visit is more than $1,000). Moreover, the authors stated that the correlation between physical activity and healthcare visits was further amplified for older adult populations and those with comorbidities, or additional medical conditions. 

Wait, the US has physical activity guidelines? Yes. They are in their 2nd edition published in fall 2018 and are established by the US Department of Health and Human Services. Through extensive research and insights from health professionals, the minimum recommendation for adults to be “sufficiently active” is 150 minutes of moderate-intensity aerobic physical activity every week and strength-specific training twice per week.

The Center for Disease Control and Prevention (CDC) along with the American College of Sports Medicine (ACSM), aka the "gold standard" for evidence-based exercise recommendations since 1975, break it down even further. They explain moderate-intensity aerobics as “you’re working hard enough to raise your heart rate and break a sweat.” A good way to self-assess this level of intensity, they say, is “you’ll be able to talk, but not sing, the words to your favorite song.” 

And no need to do all 150 minutes at once! Research consistently demonstrates that dispersing activities across 3 or more days per week is beneficial for your health and reduces risk for injury. Mix it up by trying a brisk walk, riding your bike on a flat path, or taking a salsa class! 

As for strength-specific training, this generally means non-bodyweight exercise, though calisthenics like planks and push ups definitely count! At Empower Physio, we're big fans of lifting weights, but resistance bands and carrying heavy loads, like you might do with heavy housework, are great options as well. 

Only 53% of American adults meet these guidelines however. And a mere ~23% meet the guidelines for both aerobic activity and strength training. While there are many factors that affect how active a person is (socioeconomic status, physical education and ability level, accessibility, in/exclusiveness, job flexibility to name a few), not only can healthcare professionals help, they should. Dr. Cindy Lin was the lead author of UW’s research and is a clinical associate professor of sports and spine medicine. She is quoted in The Seattle Times saying, 

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“Our health care systems are very great at treating people once they have a condition, but what we’re finding is even if people do small amounts of physical activity at home, like breaking up prolonged sitting time or going for a walk after dinner, that all adds up.”

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She goes on to share that more and more current research finds that even just 5-10 minutes of movement has highly positive impacts on our health. Movement really IS medicine! So set a timer to use your stand-up desk, take a midday movement break, do calf raises while you brush your teeth, take the stairs instead of the elevator… The options are endless. And what better way to figure out a few “movement hacks” unique to YOUR life than to talk with your physical therapy team. 

Your goal at physical therapy may be to just heal from a sprained ankle, but your team at Empower Physio knows this is only the beginning when it comes to living a truly healthy life. We don’t treat body parts, we care for humans.

RPE vs. RIR, Part II: How do I use them?

By Natalie Grant, PTA

In the first blog about RPE and RIR, we learned what these acronyms stand for, how these tools came to be, and their intended use in various forms of exercise. But how do you use them…? Furthermore, what if you’re not familiar with your physical capacities? How does chronic pain or healing from an injury muddle your ability to tune-in? 

Rate of Perceived Exertion and Repetitions in Reserve help us not just train better, but also train smarter. Though they have their limits. RPE and RIR are attempts (excellent, well researched ones at that) at putting an objective measure to something that is ultimately subjective. These concepts rely heavily on one's ability to self-assess intensity and exertion – in general, let alone with accuracy. So here is some guidance to set you up for success. 

RPE and RIR are practically interchangeable, like peanut butter and almond butter. The image above has a great representation of how prescribing RPE 8 with RIR 2 is almost redundant. Some may prefer one over the other, and similarly some exercises lend themselves more towards one or the other. 

RPE is most useful for exercises with a high number of repetitions. Accessory exercises, like rows or hamstring curls, are great to use with RPE. Other exercises that lend themselves well to RPE are time-based activities, rather than repetition-based. This could be anything from biking to planks to a carry. 

RIR on the other hand is most appropriate for the “primary lifts,” aka the compound exercises performed right after the warm-up when you still have high energy reserves. The squat, deadlift, and bench press are quintessential primary lifts. And research supports this use of RIR. The Journal of Sports Sciences in 2012 studied bodybuilders performing squats and bench presses when they discovered that: 

...not only did participants report RPE ratings that fell short of maximal (less than 10) even when sets were taken to volitional failure (no further repetitions could be performed), but that the participants had a high degree of accuracy in estimating their number of repetitions remaining on a set. In addition, with each subsequent set the participants were able to more accurately gauge the number of repetitions remaining. 

TLDR; the closer a set was taken to failure in conjunction with accumulating fatigue from prior sets, the more accurate participants were able to estimate their RIR. Wow!

What numbers on the RPE/RIR scales should I aim for?

Our favorite answer… it depends! If you’re a regular gym-goer without injury, aim for working in the RPE 7-8.5 range or RIR 1-3. This is a high enough intensity to *actually* result in results! Yet not so high that you increase your risk of injury. The National Academy of Sports Medicine (NASM) states that training at RPE 10 or RIR 0, aka “training to failure,” here and there has its benefits, but “strength may be compromised due to over training” if someone frequently trains to failure.   

In addition, there are benefits to leaving a few reps in the tank! The Journal of Strength and Conditioning Research studied bench press performance and recovery against two RIR protocols: 4 sets at a relative high load taken to RIR 3, followed by a 5th set taken to failure; or 5 sets taken to failure each set. The researchers found that the reps in reserve protocol improved recovery in the participants, as well as improved both performance and exertion in subsequent sessions.

What if I’m NEW? 

Folks new to exercise tend to overrate intensity. Just about everything feels difficult in the beginning understandably! And being less familiar with signs of fatigue or how your body responds to a certain exercise, even well after the fact, makes it challenging to know “just how hard is hard?” We suggest sticking to RPE 5-6/RIR 4-5 to still get a good workout in while also acclimating yourself to this new endeavor. It takes time, so take time!

What if I’m ADVANCED? 

Advanced or experienced fitness folk tend to, you guessed it, underrate intensity. The study mentioned earlier from the Journal of Sports Sciences asked its subjects of bodybuilders to estimate how many more bench press and squat repetitions they believed they had left before failure. The authors found that all participants tended to underrate, by a significant amount, their RIR especially on the 1st set. This is a good reminder to check yourself before you wreck yourself, even for the pros ;) 

What if I have PAIN?

We agree with Barbell Rehab’s philosophy here… Whether you are currently dealing with pain or you are re-integrating an exercise that was once painful, start out in the RPE 3-4/RIR 6+ range. Make way for “small wins” and help your brain and nervous system pair positive stimulus with movement and exercise again! 

A unique twist comes into play when pain joins the game… RPE and RIR are based on exertion, not tolerance. So while your muscles may be able to lift 50 lbs without breaking a sweat (exertion), perhaps your pain levels disagree (tolerance). Thus, Barbell Rehab has introduced a new scale called Rate of Perceived Tolerance (RPT). 

Under RPT, folks are encouraged to be guided by their pain thresholds, rather than their exertional thresholds. When appropriate (there are always exceptions to the rule!), we at Empower Physio often use the “stoplight analogy” to convey RPT to our patients. 

Green (0-3/10 pain) = keep going.

Yellow (4-6/10 pain) = slow*.

Red (7+/10 pain) = stop**. 

*slow as in modify (intensity, rest time, load, duration, volume, etc) 

**stop as in stop that particular exercise/movement, not necessarily all exercise/movement

How Physical Therapy Can Help

Whether you have pain, are new to exercise, or are a seasoned gym-goer, physical therapy can help educate you on concepts like RPE/RIR (and RPT!) to stay safe, move well, and build a resilient body. The stoplight analogy above is one of MANY examples of how the Empower Physio team distills evidence-based research into actionable tools for your toolbox. Train well and train smart, my friends :)

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References

Hackett, Daniel A, et al. “A Novel Scale to Assess Resistance-Exercise Effort.” Journal of Sports Sciences, U.S. National Library of Medicine, 8 Aug. 2012, https://pubmed.ncbi.nlm.nih.gov/22873691/.

Hall, Brandon. “What Is an Accessory Exercise? Everything You Need to Know about These Training Staples.” Stack, 8 Feb. 2022, https://www.stack.com/a/what-is-an-accessory-exercise-everything-you-need-to-know-about-these-training-staples/.

Helms, Eric R., et al. “Application of the Repetitions in Reserve-Based Rating of Perceived Exertion Scale for Resistance Training.” Strength & Conditioning Journal, Aug. 2016, doi: 10.1519/SSC.0000000000000218. 

“How-to: Reps in Reserve Periodization.” Cutting Edge PC, 10 Dec. 2019, www.cuttingedgepc.com.au/reps-in-reserve/. 

Mahaffey, Kinsey. “Reps in Reserve (RIR): What You Need to Know.” NASM, 2 June 2022, blog.nasm.org/reps-in-reserve. 

Mahaffey, Kinsey. “The Rate of Perceived Exertion (RPE) Scale Explained.” NASM, 17 June 2022, blog.nasm.org/rate-of-perceived-exertion. 

Mangine, Gerald T, et al. “Effect of the Repetitions-in-Reserve Resistance Training Strategy on Bench Press Performance, Perceived Effort, and Recovery in Trained Men.” Journal of Strength and Conditioning Research, 1 Jan. 2022, https://journals.lww.com/nsca-jscr/Fulltext/2022/01000/Effect_of_the_Repetitions_In_Reserve_Resistance.1.aspx.

Mash, Dr. Michael. “Returning to the Gym after an Injury: 4 Common Programming Errors.” Barbell Rehab, 17 June 2020, https://barbellrehab.com/returning-to-gym-after-injury/.

Mash, Dr. Michael. “The Utilization of Rating of Perceived Tolerance (RPT) as a Guide for Training with Pain.” Barbell Rehab, 26 July 2021, barbellrehab.com/rating-of-perceived-tolerance/. 

“Perceived Exertion (Borg Rating of Perceived Exertion Scale).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 June 2022, www.cdc.gov/physicalactivity/basics/measuring/exertion.htm. 

Popadic, Elena. “RPE vs RIR: What Are the Differences? How to Use Them?” PowerliftingTechnique.com, 12 May 2022, powerliftingtechnique.com/rpe-vs-rir/. 

Ryg, Jeff. “Using Repetitions in Reserve to Improve Your Strength Training Workouts.” Mend, 19 Jan. 2022, https://www.mendcolorado.com/physical-therapy-blog/2022/1/19/using-repetitions-in-reserve-to-improve-your-strength-training-workouts. 

RPE vs. RIR, Part I: What are they?

By Natalie Grant, PTA

Perhaps you’ve overheard trainers in the gym ask their clients “how many more reps do you think you could’ve done?” after a set, or maybe your physical therapy team has asked you “how challenging was that for you to complete?” These questions are more intentional than they may seem and are highly effective for training progressive overload. They come from two concepts called Rate of Perceived Exertion (RPE) and Repetitions in Reserve (RIR), and are used to gauge how easy or difficult an exercise is for an individual. 

Rate of Perceived Exertion (RPE)

Swedish researcher Gunnar Borg developed the RPE scale, now known as the Borg RPE scale, in the 1960s to help a person quantify how intense a given exercise was for them, or in other words put a number to their “perceived exertion.” It ranges from RPE of 6 to 20… Strange numbers, no? That’s because the scale was mostly applied to aerobic exercise and thus is based on heart rate: 60 beats per minute (bpm), which is considered the lowest “normal” resting heart rate, all the way to 200 bpm, which represents a very high level of activity. 

The Borg RPE scale has since evolved to be more applicable to any movement method, anaerobic or aerobic. This RPE scale ranges from 1 to 10; 1 being no effort (like what you experience lying on your couch watching TV), and 10 being all out maximum effort (like “being chased by a bear” or “lifting a car off the ground to save a child” are some fun examples I’ve heard). Though the Borg RPE scale is still used occasionally, the updated RPE scale is most common and considers not just heart rate, but also muscular fatigue, how hard a person is breathing, increases in perspiration, etc. For instance, RPE 7 can roughly be attributed to 70% of a person’s maximum heart rate and/or 70% of a person’s maximum effort or muscular abilities. 

Repetitions in Reserve (RIR)

Renowned coach and powerlifter Mike Tuchscherer modified the RPE scale in his first book The Reactive Training Manual to have more objective usefulness for lifting athletes. The method behind RIR is to estimate how many more repetitions of an exercise you could have done before technical failure, or “an inability to perform the lift with good form” according to the National Academy of Sports Medicine (NASM). 

One meta-analysis published in the Strength and Conditioning Journal quoted a study performed in 2012 out of the University of Sydney with some incredible outcomes regarding RIR and RPE. This research found that “participants had a high degree of accuracy in estimating their number of repetitions remaining on a set,” especially when compared to RPE. Furthermore, “with each subsequent set, the participants were able to more accurately gauge the number of repetitions remaining,” aka more fatigue meant more accurate RIR estimations (Helms et al., 2016)! And the more accurately someone can gauge their repetitions “left in the tank” so to speak, the safer they can train. 

Limitations & How Physical Therapy Can Help

A limitation shared by both RPE and RIR is the ability to self-assess intensity and exertion – in general, let alone with accuracy. These tools have attempted to put a number to something that is ultimately subjective, and what if you’re not familiar with your own physical capacities? How does chronic pain or healing from an injury muddle your ability to tune-in? Physical therapy can help educate you on tools like RPE/RIR to stay safe, move well, and build a resilient body! Next month, the writers at Empower Physiotherapy will share what implementing RPE/RIR into your activities can actually look like and when to use one versus the other! 

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References

Helms, Eric R., et al. “Application of the Repetitions in Reserve-Based Rating of Perceived Exertion Scale for Resistance Training.” Strength & Conditioning Journal, Aug. 2016, doi: 10.1519/SSC.0000000000000218. 

“How-to: Reps in Reserve Periodization.” Cutting Edge PC, 10 Dec. 2019, www.cuttingedgepc.com.au/reps-in-reserve/. 

Mahaffey, Kinsey. “Reps in Reserve (RIR): What You Need to Know.” NASM, 2 June 2022, blog.nasm.org/reps-in-reserve. 

Mahaffey, Kinsey. “The Rate of Perceived Exertion (RPE) Scale Explained.” NASM, 17 June 2022, blog.nasm.org/rate-of-perceived-exertion. 

Mash, Dr. Michael. “The Utilization of Rating of Perceived Tolerance (RPT) as a Guide for Training with Pain.” Barbell Rehab, 26 July 2021, barbellrehab.com/rating-of-perceived-tolerance/. 

“Perceived Exertion (Borg Rating of Perceived Exertion Scale).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 June 2022, www.cdc.gov/physicalactivity/basics/measuring/exertion.htm. 

Popadic, Elena. “RPE vs RIR: What Are the Differences? How to Use Them?” PowerliftingTechnique.com, 12 May 2022, powerliftingtechnique.com/rpe-vs-rir/. 

Tikkanen, Jami. “Reps in Reserve (RIR).” The Training Plan Help Center, 2022, intercom.help/thetrainingplan/en/articles/2920138-reps-in-reserve-rir#:~:text=What%20does%20RIR%20(Reps%20In,in%20reference%20to%20technical%20failure. 

RIR Image From Fit-Philosophy (https://www.fit-philosophy.com/)

Unsolved Mysteries: finding & reviving atlantis

By Natalie Grant, PTA

In the second blog in the Unsolved Mysteries Series, we learned that the nature of dance itself can create rather “choppy waters” for the pelvic floor, our Atlantis deep within all of us, yet undetected and mysterious to many (check out the first blog in the series for a little more context). The diverse physicality required of an artistic athlete alone can create the “perfect storm” to have dysfunction here – not to mention the myriad of mental, cultural, and emotional influences ever present in dance. We’ve also discovered through this series that if a dancer is experiencing symptoms possibly pointing towards pelvic floor dysfunction, hypertonicity is the common culprit... 

*A quick recap on hypertonicity*

A hypertonic pelvic floor is a strange combination of being “tight yet weak.” Range of motion is limited by hypertonic states in that a muscle at rest has excess tone and essentially exists in a constant semi-contracted state. With a loss in range of motion comes a loss in power, or force production. If we think of a rubberband that is too tight, too rigid, and cannot get stretched enough, we understand it cannot be slingshot across the room. In other words, the rubberband here cannot build enough potential energy (stored energy) to then produce kinetic energy (energy of motion). It is tight yes, but it is also weak in that it cannot produce force. Same goes for the pelvic floor! To have the strength to resist gravity, endure petite allegro, or control leakages, it needs a healthy elastic relationship. 

How might hypertonicity show up in the body? Here are some of the common symptoms to be on the lookout for: 

• Incontinence (bladder or bowel leakage, even gas!) 

  • This can be due to urgency, “stress” like coughing jumping (allegro!) or laughing; functional (are you not allowed to take restroom breaks until class is over but you’ve been needing to go since tendus at barre?), or some combination of these. 

• Urgency or frequency   

• Pelvic or tailbone pain 

  • Can feel deep inside and/or can be difficult to localize or describe 

• Persistent hip or back pain 

  • The pelvic floor can refer to surrounding areas, as well as share structures with surrounding areas (remember obturator internus? That muscle in the hip and part of the pelvic wall?)  

• Pain with intercourse 

  • Or problems like difficulty achieving orgasm 

• Pain during gynecological exams 

• Difficulty using a tampon or period cup for folks with a vulva 

• Constipation (fecal, urinary, or again even gas!) 

  • Or just difficulty to start emptying 

Do any of the above resonate with you? What about several? It is common to live with multiple symptoms at once. While there are many reasons for this, one of the most prevalent is that these issues can feel awkward, embarrassing, or even shameful to discuss; and thus people don’t. 

BUT! Pelvic floor dysfunction is extremely common. Research published in the International Urogynecology Journal studied elite AFAB (assigned female at birth) athletes in eight different sports, including ballet. They found that 43% of ballet dancers experienced urinary leakage! With that number, you’d think this would be much more of a hot topic in the dance community… 

So, what can you do for yourself if you…

1) believe you might have a hypertonic pelvic floor? And/or 2) you’re hoping to prevent dysfunction knowing just how much dancers are prone to dysfunction here? Essentially, anything that helps you relax, lengthen, and reduce stress:  

• Spend time in positions that encourage pelvic floor relaxation & elongation  

  • Happy baby pose, deep yoga squat, child’s pose 

• Deep intentional breathing

  • This requires relaxing your abdomen and allowing movement into your belly and entire rib cage 

  • Pair this with the positions above! 

• Relax your abdomen 

  • Worth repeating, it gets its own bullet point ;) 

• Meditation, mindfulness, and/or stress management 

  • Truly anything to help you calm your nervous system and quiet the mind – research has shown that mindfulness or meditation has a positive effect on urinary urgency and pain. 

• Incorporate neutral/parallel positions into your daily life 

  • If your dance style’s primary residence lives in turnout, try spending time in non-rotated positions outside of the dance studio. This means walking in parallel, using stairs in parallel, cross-training in parallel (yoga or weight training for example), standing in parallel, etc. 

  • Go even further, literally, by performing internal rotation exercises to truly balance yourself out. 

If your symptoms change or worsen, if you feel like “finding Atlantis” is just not happening for you, or if you want professional insight, reach out to a pelvic health PT team! Dr. Brianna Durand, PT, DPT and Natalie Grant, PTA of Empower Physiotherapy are both pelvic health certified PT professionals. You can also check out this video here from our YouTube Channel to learn a little bit about what a pelvic floor PT session with us might look like. 

For the sake of long careers and happy humans, ensure that your pelvic floor is as resilient as you are in all that you do! 

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Are you a dancer or dance professional with a pelvic floor? 
*cough* yes, everybody and every body has one ;)

Are you a PT Professional, pelvic health speciality or not, treating artistic athletes?  

Just curious?

GREAT! 

Keep an eye out for future blogs, share with your  friends and colleagues, and give us a visit! Book an appointment here. 

---

References

Adelstein, S.A., Lee, U.J. The Role of Mindfulness in Urinary Urgency Symptoms. Curr Bladder Dysfunct Rep 11, 38–44 (2016). https://doi.org/10.1007/s11884-016-0348-5 

Thyssen, H., Clevin, L., Olesen, S. et al. Urinary Incontinence in Elite Female Athletes and Dancers . Int Urogynecol J 13, 15–17 (2002). https://doi.org/10.1007/s001920200003 

Unsolved Mysteries: dance as a precursor to pelvic floor dysfunction

By Natalie Grant, PTA

In the first blog in the Unsolved Mysteries Series, I talked about the initial strokes I made on my voyage towards discovering my “Atlantis” – the undetected, mysterious pelvic floor residing deep within me. Why didn't I know about this "lost city" for so long? Perhaps being a dancer didn’t exactly clear the waters for me… 

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Every industry places demands on bodies that are unique to that industry. A software coder moving from desk to couch to kitchen island in their home will experience different physical stressors than that of a nurse clocking 20,000+ steps per shift or a hairstylist’s hands moving through speedy, finite movements over and over again. Some bodies walk away unscathed as if 9.5 hours of staring at a screen didn’t just happen – maybe they’re just lucky. Or maybe it was a longer journey – perhaps this person hadn’t been so lucky in years past and then found themselves learning about ergonomics and seeking out “anti-desk” exercises. Dance is no different. 

There’s a reason why dancers are also called artistic athletes – the nature of dance itself is intensely demanding on the body. The diverse physicality of dance alone can create the “perfect storm” for pelvic floor dysfunction, not to mention the myriad of mental, cultural, and emotional influences. So while some “boats” navigate these stormy waters without a scratch, others traveling the same waters may need some TLC… What makes dance so turbulent for the pelvic floor?  

Though also true for many dance styles, one of the most iconic features of ballet technique is that it places dancers in a constant posterior pelvic tilt and external rotation of the hip, aka a tucked pelvis (sort of like a scared dog with its tail between its legs) in a turned out position. Over time, the muscles responsible for this positioning can get shortened, which in turn can create this strange combination of tight yet weak muscles. One of those muscles is the obturator internus – and it’s also a muscle of the pelvic floor! And since the pelvic floor reflexively coordinates and communicates within itself, one tight/weak muscle here can lead to others following suit OR cause others to compensate. 

Another muscle reflexively connected to the pelvic floor is the diaphragm, the primary muscle for breathing. It contracts with inhalation to expand the belly and ribcage, ultimately resulting in space for the lungs to take in oxygen. But when techniques, like jazz for instance, reinforce time and time again the idea of staying “lifted off the pelvis” with a ribcage that is suspended out of gravity in order to achieve the longest damn waist there ever was, it is very hard for the diaphragm to behave as it should… and I don’t blame it! Dancers’ bodies are asked by the pressures of society and peers, generations before them, and false markers of success to meet unattainable, unsustainable ideals of perfection, physique being just one of them. Rather than allowing natural movement and relaxation in the abdomen and diaphragm (therefore in the pelvic floor too), the practice of “flattened bellies” and thin, or dare I say “cinched,” waists becomes second nature. And though these “ideals” are being challenged, uprooted, and full-on abandoned (woo!), they are still woven into the fabric of dance. 

Words like “Squeeze together!” “Pull up!” “Hold in!” or, as we just heard, “Stay lifted off the pelvis!” are threads in the fabric. Sure, perhaps for a specific area in a singular moment in class, they are said with good intentions. Language is passed down from generations before, and even with conscious effort to rebel against “ideals”, it seeps through. These words; along with more than I could fathomably list from my own experience, let alone know from others’ unique experiences; begin to flood dancers’ minds and bodies without specificity and without an off switch. In addition, dancers characteristically do as they’re told, no questions asked, often at the sacrifice of their bodies. This obedient culture is rewarded, highly regarded, and an Achilles heel for dancers. And so, it is not surprising that we see verbiage go from instruction to concepts to a way of life. 

A common outcome of the turned out and tucked positioning is a hypertonic (super tight yet often weak, unwilling and/or unable to relax) pelvic floor. A common outcome of a rigid, stuck, held diaphragm is a similarly rigid, stuck, held (*cough* hypertonic) pelvic floor. A common outcome of words like “Squeeze together!” and “Pull up!” reinforced by every inch of the studio dynamic, you can probably guess how the pelvic floor is going to behave (hint: starts with hyper). 

A hypertonic pelvic floor is that strange combination of being tight yet weak. Range of motion is limited by hypertonic states in that a muscle at rest has excess tone and essentially exists in a constant semi-contracted state. With a loss in range of motion comes a loss in power, or force production. If we think of a rubberband that is too tight, too rigid, and cannot get stretched enough, we understand it cannot be slingshot across the room. In other words, the rubberband here cannot build enough potential energy (stored energy) to then produce kinetic energy (energy of motion). It is tight yes, but it is also weak in that it cannot produce force. Same goes for the pelvic floor! To have the strength to resist gravity, endure petite allegro, control urinary or fecal leakages, it needs a healthy elastic relationship. 

I’m not here to bastardize any technique, language, or set of ideals. I understand why they’ve come into existence, for better or for worse – but what should stay and what should go is a loaded question for another blog perhaps ;) I’m also not here to say “you WILL have pelvic floor dysfunction if you are a dancer!!” Instead, I’m here with you simply to say dance, for obvious and nuanced reasons, can predispose dancers to a dysfunctional pelvic floor, more often than not from hypertonicity. And for the sake of long careers and happy humans, dance professionals and their physical therapy teams must understand the waters in which they swim in order to receive the best, most effective care.

Stay tuned for Empower Physio’s next month’s blog in which we continue to contextualize and break down the dance industry’s unique need for informed pelvic care, and how to help!

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Are you a dancer or dance professional with a pelvic floor? 
*cough* yes, everybody and every body has one ;)

 Are you a PT Professional, pelvic health speciality or not, treating artistic athletes? 

 Just curious?

GREAT! 

Keep an eye out for future blogs, share with your friends and colleagues, and give us a visit! Book an appointment here.

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 Check out the first blog in the Unsolved Mysteries Series talking about the importance of dance professionals understanding their pelvic floors. 

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*I am unable to speak to social dance styles (salsas, swing, waltz, etc) nor world dance (bharatanatyam, Irish dance, traditional folk dances, African styles, etc). This blog is referencing westernized dance styles and techniques. 

Unsolved Mysteries: dancers & the pelvic floor

By Natalie Grant, PTA

Dancers are uniquely attuned to their bodies. Their proprioception is off the charts, their calibrations for balance is a sight to behold, and their athletic range is unmatched. They meet the demands of power, subtlety, and depth from their fingers to their toes. More often than not, dancers can describe to their healthcare providers what is or isn’t happening in the finite corners of their bodies. As a dancer myself, I am proud of these attributes when I walk into my physical therapy appointments. I can tell you how my left elbow feels and experiences space, time, and its own structure at any given moment. I understand my elbow’s role in port de bra just as much as its role in rond de jambe. I love having this awareness and curiosity about every inch of my body… or so I thought. 

Surrounding my pelvis there is exploration a’plenty – I can fold, react, stretch, twist. My pelvis itself is an engine, a source of power and pivot. The inner workings of my pelvis? I thought nothing of it. If someone had asked me, I probably would’ve likened it to the knee – a space among big bones full of ligaments, cartilage, connective “stuff” helping to suspend my many organs. Something somewhere deep, undetected by radar, lost and perhaps meaningless to my knowledge... Atlantis? Beyond primal human functions, not much happens “down there.” Any conscious happenings, from dancing to controlling the urge to pee on a road trip, had to come from friendly neighbors: inner thighs, glutes, and abdominals. It wasn’t until my Physical Therapist Assistant degree did I learn that I have a whole set of muscles INSIDE my pelvis that can tighten, relax, and react just like any other muscle in my body… a world undiscovered by even those prideful of body awareness. Atlantis! 

If my college anatomy course didn’t tell me this, should my parents have? Do they even know? Is this something my dance instructors should have eluded to while teaching the whole-body experience of grand plié versus sous sus? These were some of the tangents my brain ran down as I learned about the pelvic floor’s many roles, its dynamic relationships and implications within the body, and the myriad of opportunities for dysfunction. THEN my brain began to tumble through all the ways dancers; through training, the culture and subcultures, the language used, the “ideals” of perfection, burnout, and body image; are perhaps not set up for success in this area… hmm! 

But what are the implications? Did it matter to the dancer in me that I didn’t understand this part of my body? Do educators and PT professionals need to understand that the nature of dance itself makes artistic athletes ripe for dysfunction? YES. I believe there are real implications. I believe, for the sake of long careers and happy humans, that dance professionals should be much more aware of pelvic health, function, and contributions. And, I believe, the best physical therapy teams understand both their patients AND the worlds in which they operate in order to deliver the best, most effective care. In the coming months, Empower Physiotherapy is going to help its readers contextualize and break down the dance world’s unique need for informed pelvic care, and how to help!

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Are you a dancer or dance professional with a pelvic floor? 
*cough* yes, everybody and every body has one ;) 

Are you a PT Professional, pelvic health speciality or not, treating artistic athletes? 

 Just curious?

GREAT! 

Keep an eye out for future blogs, share with your friends and colleagues, and give us a visit! Book an appointment here. 

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What every queer person should know about their pelvic floor

Any queer or trans person who has sought medical treatment is probably quite aware that there are a lot of harmful misconceptions and myths about healthcare pertaining to them. One of the least discussed is the pelvic floor. Pelvic floor health has long been assumed to be relevant only to cis women, and specifically to pregnant cis women.  While pelvic floor health has been gaining greater attention in the medical community and society at large, the conversations have been primarily centered around pregnancy-related care and (assumed) cis women’s experiences. In fact, during one of my recent guest lectures, a student asked me about urinary incontinence and made the assumption that this condition only affects people with vulvas. We all have a pelvis and therefore a pelvic floor – regardless of our genitals or genders.  And because we all have a pelvic floor, we all can be susceptible to dysfunction or injury of the pelvic floor just like any other body part. 

Don’t get me wrong, pregnancy-focused health care and women-focused health care are both important, historically marginalized, and should be talked about.  However, by centering the conversation on pregnancy in cis women, the health of other patients is neglected. So let’s talk about anatomy, function, and symptoms of when something’s wrong because let’s face it, almost everyone wants to be able to pee, poop, and have sex without pain. 

So, what exactly is the pelvic floor, and moreover, what does it do? Let’s start with some basic anatomy:

• The pelvic floor has 16 different pelvic floor muscles (PFM) separated into 3 layers.

  • Layer one is the most superficial and can even be felt externally. This layer is responsible for closing the anal sphincter as well as clitoral and penile erections!

  • The second layer’s main purpose is to close the urethral sphincter (to prevent leakage of pee). 

  • The deepest layer includes one of the more well-known groups of muscles called the Levator Ani. This muscle group is crucial for strength, support, and preventing prolapse.

• We also have the pudendal nerve, connective tissue called fascia, and even a few ligaments! The pudendal nerve allows us to feel external sensation in the genital region and sends nerve signals to the pelvic floor muscles causing them to contract.

Interestingly, pelvic floor anatomy is almost completely the same regardless of genitals. 

Netter F. Anorectal musculature. Memorang Website. Accessed 29 Sept, 2020

Superficial view and deep view. Anatomy Note Website. Updated 2019. Accessed 29 Sept, 2020

You’ve probably heard of a Kegel, which is a contraction of the PFM and is vital for controlling the urge to pee among many other things, but have you heard of a reverse kegel? A reverse Kegel is an elongation of the pelvic floor and necessary for PFM relaxation to pass a bowel movement. These are only a few examples of the many functions of the pelvic floor. Let’s break it down a bit more using a mnemonic called “The 5 S’s”:

1. Sphincteric

   • One of the most well-known functions of the PFM is the use of our urinary and anal sphincters.

   • This is important for the prevention of incontinence.

2. Sexual

   • Did you know that an orgasm is, in part, a rhythmic sustained contraction of the pelvic floor?

   • Strong, powerful orgasms can be facilitated by a strong, coordinated pelvic floor.

   • Conditions such as erectile dysfunction, premature ejaculation, changes in orgasm strength, and pain with sex (penetrative or not) can be indicative of dysfunction. 

3. Support

   • Have you heard of Pelvic Organ Prolapse (POP)?

   • This is a condition where some internal structures such as the bladder, uterus, and rectum start move downward in the vaginal or anal canals. While society most affiliates this to folx in the postpartum stage, POP can happen to anyone- not just those who have had vaginal deliveries. While your organs are not going to just fall out of your body and onto the floor, your fascia prevents that, it is still beneficial for many reasons to keep them in the correct position inside your body. 

4. Stability

   • Are your 6 pack muscles the ones you think of when someone mentions “the core”? Maybe you also know that part of your core are the muscles in your back?

   • Both of these are true, but in the deepest layer of your core lies 4 key muscle groups, one of which is the pelvic floor!

   • That’s right, your PFM actually helps to support your spine and maintain good intra abdominal pressure, so sometimes the only obvious symptom of pelvic floor dysfunction is nagging back or hip pain that just hasn’t gone away. 

5. Sump Pump 

   • Last, we have the “sump pump” which is just another way to describe the muscle pump action of the PFM.

   • All of our muscles help to pump fluid back up towards the heart via our blood and lymph vessels and the pelvic floor is no exception.

   • When this function is not working properly we might see swelling in the lower body for no apparent reason, however this is more common in folx who have had significant trauma to the pelvis such as a forceps or vacuum-related vaginal delivery. 

Now that you’re a little more familiar with the pelvic floor and its many functions, let’s take a look at some more trans-specific symptoms:

• Pelvic pain & pain with sex after various gender affirming “bottom” surgeries like vaginoplasty, vulvoplasty, phalloplasty, and metoidioplasty 

• Urinary incontinence or increase in urinary frequency/urgency after surgery due to change in the length of the urethra

• Post-op constipation due to scar tissue in the pelvic floor muscles that were cut during surgery

• Pudendal nerve pain which can range from numbness or burning to a sharp, stabbing pain in the buttocks, genitals, or perineal region (space between vagina and rectum or scrotum & rectum)

These symptoms are not exclusive to those who have undergone surgery, however. There is some evidence that hormonal changes during HRT can influence the pelvic floor. Other behavioral factors like holding your pee for a long time if you don’t feel safe using the restroom can also contribute to some of these symptoms. 

Many people experience pelvic floor symptoms that disrupt their lives without knowing that they can be treated! If you are experiencing any pain, unexpected or uncontrolled urination, or any other symptoms mentioned above, please consider reaching out to a local pelvic floor specialist for an individualized assessment.

When can I start exercising after top flattening surgery?

By Katie McGee, PT, DPT (they/them) & Brianna Durand, PT, DPT (she/her)

Exercise is an important key to success after any large surgery. Exercise can speed up the healing process, rebuild strength, and prevent complications like blood clots. After top flattening surgery, however, it is incredibly important to choose the right exercises at the right time to avoid complications such as excessive scarring or opening of incisions. Read on for advice to get back to working out. Remember, your surgeon and medical team know what is best for your unique situation. Always follow their advice as much as possible.

Walking:

Walking for exercise is typically started two days after surgery. Think leisurely stroll excessive arm swinging might bother the incision(s). A good goal for the first couple weeks after surgery would be 1,000 steps per day. Steps can be tracked on a smartphone or with a fitness wrist band. Many surgeons will give the go-ahead for longer walks around 15 to 21 days after the operation. After about a month, most people undergoing top flattening surgery no longer have restrictions on walking. While there might be guidelines around returning to walking, don’t worry about it being dangerous. Walking is one of the best ways to add healthy movement to your life. 

Running & Cycling:

Most people can resume running and cycling 21 days after top flattening surgery. It is best to ease back into any cardiovascular exercise. For example, if your daily run was 3 miles prior to surgery, you might want to start with a 1.5-mile jog while also incorporating rest breaks. With cycling, it might be best to start with a 20-minute ride and build up before, say, rejoining a Peloton class or biking 25 miles straight.   

Weightlifting:

Often, the biggest challenge to weightlifting after top flattening surgery is keeping elbows from going above shoulders for 6 months (although some surgeons may allow movement overhead as soon as 4 weeks after surgery). The concern is that overhead movement early in the healing process will stress the scars, leading to more visible or excessive scarring. This guideline may be especially important for people with a history of severe scarring, which is also known as keloid or hypertrophic scarring. Generally, only 5 pounds can be lifted at a time during the first three weeks. Afterwards, the lifting limit goes up 20 pounds at a time, although some surgeons may remove weight limits by 6 weeks. Bodybuilders and other strength athletes can begin more strenuous workouts around three months after surgery.  

Note: If more visible scarring is less of a concern than working out hard  - or perhaps you are thinking about tattooing your scars later anyway - it could be worth having a discussion with your surgeon about a modified plan for return to lifting. Even if a scar is more noticeable, it can still be healed and move well. 

Yoga & Stretching:

As with weightlifting, return to yoga is limited by no elbows over shoulders for the first 6 months, if directed by your surgeon. This rule applies to any position, not just when standing. This means that common movements, such as child’s pose and downward dog, might require modifications. Before dropping into a plank or arm balance, consider how much lifting you are currently permitted to do in your stage of healing. Be aware that some surgeons will place additional limits on arm and other joint movements. It can be stressful and overwhelming to think about all the movements that are off-limits or modified following surgery, but it can be helpful to use this time to focus on activities you can do such as breathwork and leg stretching. 

Swimming:

Walking in a pool may be resumed when scars are closed, as soon as three weeks after surgery. When walking in the pool, it will still be a good idea to wear your recommended bandages. However, swimming for exercise may need to be delayed until 6 months after surgery to allow optional healing. By 6 months out from surgery, it is unlikely that bandages will be needed for the duration of exercise. 

Note: Sun exposure can cause changes in scar color for some people (either extra light or extra dark).  If the color of your scars is important to you, be sure to wear sunblock when exercising outside to protect scars for at least the first 6 months. 

Exercise can be a powerful tool in bouncing back after surgery, giving you more energy, strength, and comfort in your body. Don’t hesitate to reach out to your medical team or a knowledgeable physical therapist for help with exercise after surgery. You deserve to feel comfortable and confident when moving in your body!

How can I optimize my scar healing after top flattening surgery?

By Katie McGee, PT, DPT (they/them) & Brianna Durand, PT, DPT (she/her)

Top flattening scars require special care over time for the best healing possible. If you are considering top flattening surgery, or recently had top flattening surgery, read on to learn how you can optimize your scar recovery.

Use the proper bandaging:

Bandages achieve two goals to promote healing of a surgical incision. The first goal bandages achieve is reducing swelling. When swelling is reduced, the edges of an incision can come closer together. Accordingly, the collagen involved in closing the incision is able to form better aligned cross bridges. Better aligned cross bridges mean that a scar is more flat and strong. Light activity, such as walking and torso rotation without arm movement can also help reduce swelling in the chest and thereby promote better incision healing. 

The second goal bandages achieve is protecting the new incisions. Bandages do this by keeping out dirt and other material. They also prevent tension from pulling the incision wider and affecting the collagen cross bridges. It is most important to limit tension across the incision during the first two weeks of healing. Interestingly, after two weeks, scars need a light amount of tension to direct the alignment of the collagen cross bridges. This is one reason scar massage is generally started a few weeks after surgery instead of immediately after surgery.

You may have bandages that stay on from surgery all the way through the first month after surgery, or your medical team may decide to change your bandages sooner. You might be instructed to use a silicone bandage, such as Meptiac. Silicone bandages can make scars feel more pliable and further minimize their appearance. Some people find that silicone use leads to flatter and less visible scars. A provider may recommend a silicone ointment instead of a bandage.

Note: Silicone bandages and ointments can be expensive! Sometimes people will attempt to use a less costly silicone product not designed for scars, such as silicone lubricant. Substitutions for medical silicone products may not create the right level of moisture and protection from oxygen. Talk to your healthcare team if you need a different product to fit your budget before trying out an alternative.

Manage chest swelling:

A special vest from your medical team can help reduce swelling as you heal, again reducing tension across the incisions. Typically, a vest is worn for around two weeks after surgery although sometimes longer. Your medical team may opt for compression bandages, such as an Ace wrap, or nothing at all. Note: This compression vest is not the same as a binder that might have been used prior to surgery.

Your medical may also suggest a low sodium diet to decrease the risk of swelling on your chest. It might help to practice low sodium eating and/or cooking prior to surgery so that you are prepared when you come home.

Follow movement & lifting guidelines:

The goal of mindfully limiting arm movement is to reduce tension across the scars. You might be instructed to avoid lifting your elbows above your shoulders for four weeks, but possibly longer. In addition, some surgeons may recommend that you avoid sleeping on your belly for the first few weeks to further avoid healing complications.

Protect scars from the sun:

Sun exposure can cause scars to become either very light or very dark. Your medical team might encourage you to wear silicone tape over your scars when topless outside for about the first three months after surgery. (Alternatively, some providers recommend silicone gel with sunblock applied over the top, or a combined silicone-sunblock product.) For at least the first six months and possibly even the first year, sunblock is highly important for scar protection. Try to use a sunblock with a SPF of 35 or higher. Some providers recommend a combination of silicone gel and sunblock.

Try scar massage:

Scar massage helps scars move better over the chest wall so that they do not feel stuck or cause a sensation of pulling. Some surgeons will recommend this while others may not. It is important to follow the guidance of your medical team when deciding whether to begin scar massage. Not all scars need scar massage. If scar massage is recommended, it is typically begun after scars have fully closed. Sometimes scar massage may be helpful even years after surgery. A physical therapist or massage therapist trained in scar management can help you with scar massage if you need further guidance.

Steps for scar massage: 

1. Find the right pressure for scar massage.

   • Look at your dominant hand. 

   • See the pads at the fingertips on the index and middle fingers. 

   • Place these pads over the skin on the back of your non-dominant hand. 

   • Use the pads of the dominant hand to slide around the skin on the back of your non-dominant hand. Do this without the nail beds of your dominant hand changing color. Your nail bed changing color is an indication of too much pressure.

   • Just the amount of pressure your need to slide the skin around is about how much pressure you will need on your scars. 

2. Gently move the scar(s)

   • Place the pads of the index and middle fingers on one end of your scar. 

   • Using the pressure described in Step 1, try lightly sliding the scar. It’s okay if the scar only moves a tiny amount

   • AVOID PAIN. Pain can be a sign that too much pressure is being applied, however, it is normal to feel a light tugging or burning sensation. 

   • Spend about 5 to 10 seconds massaging over each 1 inch of scar. You can typically expect to spend 5 to 15 total minutes per day on scar massage.  

3. Be regular with your scar massage. 

   • Continue scar massage daily or most days of the week until your scars slide easily. 

   • Scars are often more mobile by a month of treatment.  

Note: It is also possible to perform scar massage with tools that might more commonly be associated with facials, such as rollers and gua sha tools (gua sha uses tools to scrape the skin and promote circulation.) Be aware that the pressure for using these tools on scars yourself is very light - less than a pound of pressure. Traditional use of gua sha tools risks damaging chest tissue, unless performed by a traditional practitioner of these methods.

Manage substance use:

Tobacco products, alcohol, and recreational drugs can impair scar healing. If you need help reaching the right amount of substance use for you, there are a number of resources: 

• Smoking cessation: https://smokefree.gov/

• SAMHSA National Substance Abuse Helpline: 1-800-662-HELP (4357)

Speak up if something doesn’t seem right: Is your scar suddenly looking raised? Has the scar started growing beyond the original incision line? Is your scar limiting your movement? These are all reasons to reach out to your medical team. There are multiple medical interventions available for scar improvement that are not described in this blog (i.e. MicroPen, BroadBand Light Therapy, and Kenalog steroid injections). Know that you have options, and it is always your right to advocate for yourself when receiving medical care. 

What exercises should I do to get ready for top flattening surgery?

By Katie McGee, PT, DPT (they/them) & Brianna Durand, PT, DPT (she/her)

It’s likely that you’ve been waiting for top flattening surgery for some time now and you may want to do everything you can to ensure the best possible outcome. Exercise – at the level and amount that feels right for your body – is one path to a smoother recovery after surgery. Read on to learn about some simple exercises you can do to better prepare.

Deep breathing

During the first few days after top flattening surgery, taking a deep breath can feel difficult and even scary for some people. Fortunately, you can improve your ease of breathing following surgery by practicing ahead of time. Training yourself to breathe deeply before surgery has also been shown to reduce the risk of lung issues such as an infection or blood clot after an operation1,2. Pick the amount of breathing exercise that feels manageable to you. You could start with 10 deep breaths per day or try 15 minutes of deep breathing along with a guided meditation. Looking for an app to help you with breathing? You could check out Insight Timer (free) or Headspace (both are available in the App Store or Google Play).

Shoulder stretching

Your top flattening surgeon may recommend that you avoid lifting your arms over your head after surgery, for weeks or possibly even months. You can imagine how your shoulders might start to feel pretty stiff. Stretching your shoulders ahead of time can lessen some of this tightness. What shoulder stretches are a good idea to try? I usually recommend that people start with shoulder rolls and arm circles, each repeated 10 times per day (see below for video demonstrations.)

Here are some other options:

1. Stand close to a wall and slowly walk your fingers up as high as you can go.  Repeat 10 times per side.  

2. Sweep your arms up and down as if you are making a snow angel. Repeat 10 times.

Occasionally, big arm movements can bring on feelings of chest dysphoria. If this is the case, please do not feel obligated to continue. Your body’s ability to heal from top flattening surgery does not hinge on whether you do arm stretching prior. It is fine to stop stretching and try other activities that honor your body. Note: If you have shoulder pain or issues prior to surgery, be sure to let your medical team know. They may have unique guidelines for you to follow in order to balance the health of your shoulders with your healing from surgery.

Cardiovascular exercise

Cardiovascular exercise refers to movement that makes your heart pump harder than usual. It’s also known as aerobic exercise. Examples include propelling in a manual wheelchair, walking, jogging, swimming, using an arm bike, and stepping in place. Multiple studies regarding recovery from a variety of different surgeries suggest that cardiovascular exercise prior to surgery can improve outcomes. One of the exciting parts of cardiovascular exercise is that the health benefits start at just one minute of activity3! When choosing cardiovascular exercise to get ready for surgery, I recommend picking whatever activity feels most comfortable for your body, and aiming for 10 to 30 minutes of that activity most days of the week. Looking for help getting started with cardiovascular exercise? You can reach out to your medical team or a physical therapist for guidance. Another excellent resource is Nonnormative Body Club (also on Facebook) which has a diverse collection of exercise resources for transgender and non-binary people of all exercise levels. 

Upper Body Weightlifting

Weightlifting before top flattening surgery is a common topic that comes up in online forums. Some people believe that a more muscular chest will allow a surgeon to better line up scars. Other people couldn’t care less how their scars line up with their chest muscles. If you have specific goals about the way your top flattening scars look, it is best to ask your surgeon what they recommend. If a more muscular chest is a goal, one might consider bench press, pushups, and dumbbell chest fly. Additionally, certain nutrition changes, such as adequate protein intake for muscle development, may be needed and are best discussed with a registered dietitian. It can take a month or longer to notice changes in the bulk of chest musculature, called “hypertrophy”, so plan accordingly before surgery. Be assured that upper body weightlifting is not required to have a successful outcome for top flattening surgery. 

Surgery happening quicker than expected?

Sometimes people get scheduled for top flattening surgery months out, only to have the surgeon offer an immediate operation date due to a cancellation. In a situation like this, don’t worry if you hadn’t been exercising diligently ahead of time. Exercise after surgery can still promote recovery. Check out the next article in this series, coming soon: When Can I Start Exercising After Top Flattening Surgery?

Sample daily exercise programs to prepare for top flattening surgery: 

Basic 

• Deep breathing

  • 10 deep breaths (video demonstration above)

• Shoulder stretching

  • 10 shoulder rolls

  • 10 shoulder circles 

  • 10 arm snow angels 

  • 10 seated or hands and knees cat/cow

• Cardiovascular

  • 20 minutes of chosen activity

  • Can be broken into smaller sections, such as four 5-minute walks 

• Upper body weightlifting

  • 30 wall push ups 

Advanced 

• Deep breathing

  • 5 minutes of deep breathing against resistance band crossed around the chest

• Arm stretching

  • 5-minute upper body yoga flow 

• Cardiovascular exercise

  • 30 minutes of preferred cardiovascular exercise

• Upper body weightlifting 

  • 10 reps, 3 sets bench press

  • 10 reps, 3 sets pushup

  • 10 reps, 3 sets dumbbell chest fly 

---

Citations 

1. Ge X, Wang W, Hou L, Yang K, Fa X. Inspiratory muscle training is associated with decreased postoperative pulmonary complications: Evidence from randomized trials. J Thorac Cardiovasc Surg. 2018;156(3):1290-1300.e5.

2. Levett DZH, Grocott MPW. Cardiopulmonary exercise testing, prehabilitation, and enhanced recovery after surgery(Eras). Can J Anaesth. 2015;62(2):131-142.

3. Gillen JB, Martin BJ, MacInnis MJ, Skelly LE, Tarnopolsky MA, Gibala MJ. Twelve weeks of sprint interval training improves indices of cardiometabolic health similar to traditional endurance training despite a five-fold lower exercise volume and time commitment. PLOS ONE. 2016;11(4):e0154075.

Providing compassionate & competent care to LGBTQ+ patients

Over the last five years there has been a groundswell in the recognition that healthcare for those in the LGBTQ+ community has been, at best, incredibly lacking & the world of physical therapy is no exception. Fortunately, this growing awareness is being followed by tangible efforts to improve the quality of care provided to this population as evidenced by the formation of PT Proud, a Catalyst Group in the APTA, & a growing body of research to address the unique needs of LGBTQ+ patients. Hermann & Wallace is even offering it’s first ever 3 day course solely focused on treating patients who are gender diverse!

However, it is not uncommon for people to feel overwhelmed by all of the changing terminology & fear of accidentally offending someone. Thus, despite good intentions, many providers find themselves avoiding education & discussion of this topic altogether. The problem with this is that every clinician will inevitably encounter someone who is LGBTQ+ & merely “treating everyone the same'' may inadvertently end up causing harm. This is especially pertinent to pelvic health practitioners as we work on highly personal & vulnerable areas of the body. There are countless reasons why it is worthwhile endeavor to & your knowledge on this topic which is discussed more thoroughly in a blogpost I wrote a few years ago (here), but this post will focus more on practical takeaways that you can implement in your practice.

As mentioned earlier, the terminology can be intimidating; let's break them below into two categories: gender and sexual minorities:

Sex - biological characteristics of chromosomes & anatomy (ie. male, female, intersex)
Gender - societal & cultural categorization based on one’s sex (ie. man, woman, non-binary)
Cisgender - one who identifies with the gender assigned to them at birth
Intersex- someone born with aspects of both male & female anatomy (i.e. externa vulva & internal testes)
Transgender - one whose gender does not match the sex they were born with (may be abbreviated trans; this includes people who are non-binary)
AFAB- assigned female at birth
AMAB- assigned male at birth
Transwoman/MTF - assigned male at birth & identifies female
Transman/FTM - assigned female at birth & identifies male
Non-binary- one who identifies as neither male nor female; may use gender neutral pronouns (they/them)
Top surgery - breast removal (typically FTM) or augmentation (typically MTF)*
Bottom surgery - reassigning one’s genitalia to the anatomy they identify with
Gender identity - the gender that someone associates with internally
Gender expression - the external gender that someone conveys through appearance & behavior
*Non-binary folks may also undergo various gender affirmation surgeries & /or take hormones.


Sexual orientation - the gender(s) that one is attracted to. (Transgender is not a sexual orientation.)
Lesbian- a woman attracted to other women
Gay- a man attracted to other men
Bisexual- a person attracted to both men & women
Pansexual- someone attracted to people regardless of their gender identity
Asexual- a person who is not sexually attracted to others; may still experience romantic attraction
Queer- an umbrella term that applies to all LGBTQ+ people; used as a sexual orientation when other labels are not accurate; may be perceived as a derogatory slur, especially among older individuals

There can be many combinations of the terms above. Someone could identify internally as male, but live outwardly as a woman for a variety of reasons including safety, cost of transition, etc. Also, gender & sexual orientation do not always pair up in a heteronormative fashion. A person could be cisgender & bisexual (a woman AFAB attracted to both men & women) or transgender & lesbian (a transwoman AMAB attracted to women). Furthermore, not all people who are transgender have surgery or undergo hormone therapy, but this does not change their gender identity. Some helpful visuals to understand these ideas are the Gender Unicorn (here) & the Genderbread Person (here).

Now that you have some context to work with, what else can you do to put patients at ease?
-Consider having a rainbow flag in the waiting room to let patients know they are in a safe space.
-Wear a small pin indicating that you are an ally.
-Have inclusive intake forms with a blank space to enter gender rather than a checkbox for male or female.
-If applicable, know where gender neutral bathrooms are located & inform patients.

Ultimately, the best method to providing compassionate & competent care is to minimize your assumptions. There are many things you can do in your day-to-day interactions with patients to convey that you are trying to open up your world view. For example, if you find yourself assuming someone’s gender identity based on their name or appearance, I’d challenge you to practice using the gender neutral they/them pronoun until you learn how they identify. If you are unsure, it is okay to privately ask them! This is far less triggering than misgendering someone. Another common microaggression is assuming a patient’s partner’s gender based on heteronormative values. Try using the terms “spouse” or “partner” when talking to a patient about their loved one(s). It may seem banal to you, but your LGBTQ+ patients will notice.

Disclaimer: I can only represent the part of the community that I identify with. The views expressed are my informed opinions & may not be generalizable to all LGBTQ+ persons. I am thankful to be given a platform to address a topic that is so rarely discussed, but if I have made any errors or misrepresentations, please correct me!

The Pelvic What?

“Platform ready!”

You take a deep breath, clasp your belt, and walk out. This is your first powerlifting competition and you’re kicking ass so far. It’s your final deadlift attempt and you know you got this. You step on the platform, set your feet, and wrap your hands around the bar. The crowd of spectators are screaming at you to lift it up and just as it clears the floor you feel a strange, new sensation. Thinking maybe it’s just your nervous bladder, you keep pulling on the bar and get 3 white lights! Later when you look at the video of your attempt, you see that there is something leaking in between your legs.

This is a common example of Stress Urinary Incontinence (SUI), or the leakage of urine during times of increased stress on the bladder and pelvic floor.

We all know moms who cross their legs whenever they cough, laugh, or sneeze, but this can happen even in folks who have never been pregnant or had children. If you’re a powerlifter, you might be familiar with this happening in the deadlift, but it can occur anytime there is increased intra-abdominal pressure. In Crossfit this is most commonly seen during double unders, box jumps, or running. Ultimate players might experience this when coming down from a jump, laying out, or during incidental contact with other players.

Contrary to some of the information circulating in the strength world, peeing while lifting is not a marker of intensity, but a neuromusculoskeletal dysfunction that can be prevented and treated! Conversely, SUI does not mean you are a weak person, but ignoring these symptoms can likely lead to further problems and injuries down the line.

Why does this happen?

SUI can result from a decreased strength or endurance of your pelvic floor muscles (PFM) as well as impaired motor control and coordination. You have 8 primary pelvic floor muscles and just like anywhere else in the body they can get injured, become weak or tight, and need to be trained.

In the U.S. more than 25 million people suffer from urinary incontinence. Although it is not exclusively a “female problem”, women are twice as likely as men to experience SUI. This increased prevalence is associated with things like hormones, pregnancy, and menopause. For men, one of the largest contributors to incontinence is prostatectomy due to prostate cancer.

While this is a fairly common problem that affects people across the lifespan, most keep their struggles to themselves. Due to society’s branding of anything related to the pelvis as taboo, there is often embarrassment, shame, and isolation felt by those experiencing pelvic floor dysfunction. When they do confide, many are told by family members or friends that it’s just a normal part of life. Not to mention seeing advertisements for panty liners, bladder supports, or adult diapers can reinforce the idea that you’re doomed to struggle with this forever.

The PFM have 5 primary functions that, due to their location, have a tremendous impact on your quality of life.

• Sexual function: dysfunctions here can result in painful sex, difficulty achieving orgasm, erectile dysfunction, premature ejaculation

• Support: maintaining proper positioning of the organs and preventing prolapse

• Sphincteric control: urinary, fecal, and gas continence

• Stabilizing the lumbosacral spine: these muscles are actually part of the core and prevent back/hip/abdominal pain

• “Sump pump”: helping to move blood and lymphatic fluid in the lower body back up towards the heart

So, I should just do some Kegels right?

Ahh, the Kegel. If you Google anything related to the PFM, there will be countless links discussing this exercise. A Kegel is merely a contraction of your PFM, sometimes described as engaging the muscles you would use to stop the flow of urine (please don’t actually try to do this while peeing or you could wind up with a UTI). Contrary to popular belief, people of all gender identities have pelvic floors and should be able to do a Kegel. However, this exercise is not a blanket treatment applicable to everyone. Kegels are a fantastic exercise for someone with a weak and over-lengthened pelvic floor. But just like every other muscle in the body, PFM can be weak and tight. Sometimes doing the opposite of a kegel, a pushing down and out to lengthen the muscle or a "reverse Kegel" is more appropriate. Different issues require different interventions and a one-size fits all approach could exacerbate the problem for some.

For those who could benefit from Kegels, isometrics are just the beginning. One research article suggests that working up to a minimum of 50-60 sustained Kegels per day is enough to help 88% of patients improve their incontinence. While that may be sufficient for some, it likely is not aggressive enough for many others. Ultimately, progressing PFM exercises will be needed and variations can be achieved by simply using Kegels concurrently with other movement.

What about non-cishet folks?

I was fortunate enough to be introduced to pelvic floor PT early on during my 1st semester of graduate school. The topic immediately interested me, but most of the discussion revolved around learning about the effects of pregnancy on the body. During some independent research, I became fascinated by the hormonal/biological differences between men and women that influence their risks for various ailments. For example, ACL injuries are 2 - 10 times more common in female athletes than male athletes playing the same sports. Additionally, there is an established association between knee laxity and hormonal changes during a menstrual cycle as well as a relationship between testosterone and improved athletic performance.

Prior to this lecture, I never considered the idea of something like our sex hormones having such a great impact on our musculoskeletal health. I became curious about how the exposure to both testosterone and estrogen would affect people who are transgender. This extended into a broader interest in the topic of trans health care, including the biological and psychosocial components of providing high quality treatment.

There are many instances in which someone’s identity as transgender could impact the pathology a PT addresses with their intervention. For example, some people who are FTM practice binding their breasts, which can lead to compressed ribs, collapsed lungs, and back pain. If a patient who is FTM undergoes removal of both breasts, PT could be indicated to improve scar mobility, prevent keloids, and maintain upper extremity range of motion during healing. A survey from the Williams Institute at UCLA claims that “54% percent of respondents reported having some sort of physical problem from trying to avoid using public bathrooms, all of whom reported that they ‘held it,’” including dehydration, UTI’s, and kidney infections. Any pathology of the genitourinary system can have a negative impact on the pelvic floor resulting in secondary injuries.

Other ways that pelvic floor PTs can help TGNC individuals include dilation and maintenance of the vagina after bottom surgery to improve comfort with sexual function or manual therapy and re-education improve function of the neo-penis.

Summary

Pelvic floor health is not just for pregnant women anymore and it is possible to do any and all of the activities you love pee-free. If you are experiencing symptoms of pelvic floor dysfunction, it would benefit you to see a PT who specializes in this area. Queer folks in particular may avoid discussing this region of their body with medical providers and are at increased risk for pelvic floor issues due to having more barriers to care. Having an individualized assessment and plan of care can help address your specific deficits in order to meet your goals. While SUI may be a common problem and is absolutely nothing to be ashamed about, it is definitely not normal, and not something you just have to deal with on your own.

Disclaimer: I can only represent the part of the community that I identify with. The views expressed are my opinions and may not be generalizable to all LGBTQ persons. I am thankful to be given a platform to address a topic that is so rarely discussed, but if I have made any errors or misrepresentation, please forgive me.

“Let me try my insurance first”

The air is crisp outside and the sun is shining down on you. As you walk down Alki Beach, you can hear birds chirping and people laughing, generally enjoying life. Out of nowhere emerges a huge branch causing you to trip and fall.

Looking down, your ankle is already starting to swell up and throb; you’ve done this before. Once you’ve gotten home safely with a compression wrap, some anti-inflammatory meds, and ice, you start to look for a physical therapist. Luckily for you, Washington State has direct access so you don’t need a referral from your physician. After a cursory review of Yelp and Google, you’ve settled on one close to work so you can go on your lunch break. When calling to schedule your initial evaluation a friendly voice picks up on the other end of the line, proceeding to answer all your questions except for some specific ones regarding your insurance which they’ll go over in person when you arrive to the clinic.

Hopefully you only wait a week or so before you can get in and the receptionist is kind while going over your new patient paperwork. Maybe you’ve already met your deductible and you only have a $10-$50 copay per visit. Or maybe you haven’t and you’ll have to pay out of pocket at first. The information available regarding how much each visit will cost is so nebulous, because honestly even the receptionist or the clinician working with you doesn’t even know. Healthcare in the United States revolves around reimbursement. Clinicians are required to charge abstract ‘codes’ for the types of services they provide which are billed out to insurance that goes through this black box of previously negotiated contracts and discounts, all with the hope that the amount returned to the clinic will cover the cost of overhead and ideally turn some sort of profit.

All of the rules and regulations involved in an insurance-based payment model is at the very least confusing and unfortunately potentially damaging. If you have been to any PT practice, and with an estimated (Statistic about how many people will need physical therapy at least once in their lifetime), you probably have, you’ve seen the impacts of this. Healthcare workers are required to see an improbable number of patients, 15-18 being the standard in an 8-hour work day. The burnout is felt not only by clinicians but by those they are meant to serve.

Have you ever been to a PT clinic and seen the staff running from one patient to the next or possibly even juggling two or three patients at a time? Have you been handed off to an unlicensed technician after 20-30 minutes with your PT? Or, if you are lucky enough to have one-on-one care from the therapist for the entirety of the session, were they always typing away on their computer while attempting to multi-task during the treatment? This is not a criticism of the altruistic clinicians who are merely trying to care for their patients. This is a criticism of the insurance-based payment model. It truly serves no one.

Healthcare workers get burnt out mentally and physically having to keep up with grueling patient volume and go unpaid for their time spent documenting through their lunch or hours after the clinic closes. And patients get the short end of the stick because the quality of their care goes down and it takes longer for them to get back to the activities they enjoy.

How can we change this?

A simple change in perspective could offer incredible opportunities for growth and development. Physical therapy is an incredible profession that enables practitioners to improve someone’s quality of life in immeasurable ways. PTs can utilize their unique knowledge and hands-on manual skillset to educate, exercise, and empower their patients to lead healthier lives. Anyone who has had a successful episode of care with a physical therapist can tell you how profound this impact was on their function and happiness. Sadly, insurance companies devalue our services with no objective rhyme or reason and, to be honest, society isn’t aware of the influence we can have due to our lack of educating the general public. Are you willing to pay $100 for a massage? How about $60 for a mani-pedi with detailed designs your toes? People will happily pay cash for these services because one thing is clear to them: the value. Across the country more folks are shifting to a cash-based payment model and finding that even those with insurance are willing to entertain this idea because they recognize the value of quality care. If you are a provider tired of working in the revolving door model of patient care, or if you are a patient fed up with not getting better, consider a cash-based practice because as with most things in life, you get what you pay for.

What is Concierge PT?

A new type of home health PT is emerging and it is being referred to as concierge PT. Many of the same services are available including exercise prescription, manual therapy, and neuromuscular reeducation. The difference now is that this care may be provided using a cash based model and can be unique to a certain population.The majority of people who are familiar with physical therapy typically envision an outpatient orthopedic clinic, but in reality physical therapists can and do work in a variety of settings. Some examples include acute care hospitals, inpatient rehabilitation, skilled nursing facilities, school systems, traveling with sports teams, and home health. The population who has heard of home health PT before might imagine the treatment of patients with recent joint replacements or folks with neurological/memory issues that impair their ability to leave their residence in order to obtain care. All of this is true, and usually involves the use of insurance for the clinician’s services to be provided.

A new type of home health PT is emerging and it is being referred to as concierge PT. Many of the same services are available including exercise prescription, manual therapy, and neuromuscular reeducation. The difference is that this care may be provided using a cash based model and can be unique to a certain population. Dr. Krystyna “TK” Mosher is the owner of TKO Physical Therapy in Boston, MA where she caters her concierge services to combat athletes and fighters. There is even a company named Concierge Physical Therapists that provides care all across the country for myriad diagnoses including pelvic floor dysfunction!

While prenatal and postpartum care is becoming more talked about and prioritized, many new mothers have difficulty finding childcare or coordinating their schedules for the trek out to a brick and mortar clinic. How much easier would it be for patients if the care was brought to their doorstep?

We have taken a page out of the manual followed by massage therapists, estheticians, event planners, and countless other industries that have emphasized the worth of the one thing many of us value above all else: our time. All of us lead full, busy lives and it can feel impossible to fit in all the things that we need or want to do. Combine this with the concern for one’s physical health and well being and it becomes crystal clear why concierge PT is becoming so popular.

The truth is that we are all merely trying to live our best lives and physical therapy can propel you towards your goals. Remember, you can’t pour from an empty cup. Take care of yourself first.

Where you think it is, it ain’t

Have you ever been watching a movie and one of the characters is suddenly unable to breathe, their chest feels tight, and they are clutching their left arm? What instantly comes to your mind? Likely, a myocardial infarction, otherwise known as a heart attack. Why does a heart attack cause left arm pain? This is due to a phenomenon called referred pain.

There are two primary explanations for referred pain: 1) the nerve cells of organs follow similar pathways as certain musculoskeletal body regions and can be misinterpreted by the brain and 2) during development in the womb these areas originate out of the same embryonic tissue.

Referral patterns can also arise from non-visceral tissue (aka non-organs). For example, I have included some pictures of facet joint referral, where a joint in your spine can result in symptoms at a distant site. Many of us have been treated by a rehab professional who discerns that our knee pain is actually due to weakness in the hips or the cramping on the bottom of our feet is due to fascial restrictions in our low back. There are countless examples of how pain that may be felt so strongly in one area is not due to a pathological cause at that location.

But, what if I told you that you have no pain receptors? It’s true. We instead have something called nociception, which is the possibility of danger. With my patients I like to use an example of a rolled ankle (see stick figure drawings below). Previously, the medical community believed that tissues, such as ligaments, muscles, and tendons, in our ankle would send a message up to our brain “Ow! We are in pain!”. Within the last decade, the latest researchers in pain neuroscience have discovered the process works something more like this:

Nociceptors in the tissues in your ankle tell you brain “Hey, man. We might be in danger here. We’ve rolled the ankle”

Your brain then does some gnarly stuff where it processes this information and ponders “Has this happened before? Have I seen this happen to others? What do I know about rolled ankles?”

After combining your past experiences with similar injuries and considering the context you are currently in (your physical environment, emotional/hormonal environment, stress level, etc) your brain will decide whether or not it is worth it to put out a pain signal

With most acute injuries, your brain will trigger a cascade of events that result in a pain response because your tissue is likely damaged and you need to protect it. But here is the interesting thing: tissues heal. Even if you do nothing to them, within 3-6 months they heal. Shy of a spinal cord injury, severe vision/hearing loss, or nerve cell death due to something like a stroke- and even in these cases, the jury isn’t out about whether all hope is totally lost- your tissues heal! Bodies are incredibly, amazingly, fantastically resilient. Humans are marvelous and complex, though, and pain can stick around for non-physiological reasons.

Have you ever heard of Pavlov’s dog? Every psychology course talks about this experiment in something called classical conditioning where the experimenter (Pavlov) gives his dog food every time he rings a bell. After a while, the dog will salivate, because it is expecting food, when the bell is rung. Even if food is not present. Let me repeat: this dog, and humans, can learn to expect one response (pain) in the event of a previously unassociated stimulus (movement). If you still have pain in your low back every time you bend over and it’s been going on for more than 6 months, you likely have learned to pair movement and pain. I am not saying that the pain is in your head. It is very real and very valid. But the pain is in your brain. This is not psychological, it’s neurological. If you don’t believe me, watch this incredible video by leading pain science researcher Lorimer Moseley, or this awesome 5 minute video put out by Australia about chronic pain.

There is nothing that you have done wrong, and there is absolutely nothing messed up with you if you are experiencing chronic pain. Pain is your body’s alarm system and it is just trying to protect you. But I want you to know that you aren’t destined to live with it forever. Compelling studies have demonstrated that the more you understand pain, the less you experience it. After all, everything you do, see, feel, and experience is a mere neurological impulse. Think about it: by thinking of food you can make your stomach growl due to physical hunger and by thinking of something that makes you sad, your eyes can start to water. Your thoughts and beliefs undoubtedly have impact on your physical self. We can use this to your advantage!

So, what can be done about it? We need to recondition your brain to find movement to be a rewarding, pleasurable experience instead of a painful one. Starting with gentle aerobic activity and movements that tease, but don’t stress, the nervous system, you can begin to truly heal. Interested in learning more? Seek the guidance of a knowledgeable and compassionate physical therapist near you.