Anatomy of a Blog Post: From Abstract Creativity to the Internet

I have been hosting this blog for nearly half a year now, and I have had a few questions about my creative processes, so I figured I would write a post on how to create a post. I resisted the urge to call it "Post-ception" as I didn't want any copyright issues popping up, but corny title aside, I am writing about how I write. I have had a formula that I discovered early on in high school and has carried me through graduate school and beyond. Thankfully for me, it works for both creative and formal writing pieces, so I am sticking to it! Here goes:

1. It all starts with a single sentence or phrase. It might not be the title, it might not be the thesis, and it might not even be the most poignant part of my post, but it serves as a spark for the flame of creativity. I type it out first, bold it, and keep coming back to it throughout my writing. It keeps me grounded and on-topic. 
2. I don't write chronologically. To prove my point, this is actually the bullet point that I wrote last. I move throughout the the text, editing as I go and rearranging as I see fit. Usually the paragraph that I write in the last half of my time spent is the first paragraph of my post, which makes sense to me because by then I know the tone of the entire post and can write a more appropriate introduction to set the stage for the drama I create. 
3. I often write several posts at once. Right now I have 3 windows open for 3 different topics. As I come up with ideas, I realize that an idea I am developing in one post is better off as it's own idea. While this may seem a little scattered, it lets my mind move fluidly and unhindered, allowing the creative juices to spill from my mind and onto the page. 
4. I listen to music that inspires me and take frequent dance/singing breaks. I have participated in both of these arts and I feel that by letting my mind do what it wants like an ADHD child, I am able to articulate my thoughts more crisply. The soundtrack of Hamilton has been my main inspiration as of late. Sia's new album is another I like to jam to as I type.
5. I don't always finish in one sitting, but most of the time I do. The times that I do walk away from it and stew are the times when I don't get beyond more than a paragraph. I learned to abandon topics that aren't coming easily to the paper (or word doc) early before I invest a lot of precious time into them. If it isn't flowing from my finger tips, the topic either isn't ready or it isn't made to be. And I am okay with that fact. I don't sit down to write until I have at least a few hours to dedicate to the task. I have been known to sit for hours until 20 page term papers are done. I also wrote my literature review, as well as my thesis for DPT school, in one sitting. This time is of course interspersed with random dance/jam breaks. 
6. I let ideas sit in my brain for weeks on occasion before setting aside time for the activity of writing it out. I really capitalize on the concept of subconscious processing to allow more ideas to form. The longer I wait, the faster I am able to write. 
7. I dress for the occasion. If I am writing a professionally invigorating post, I wear business casual. Seeing as this is more of a creative post, I am currently wearing my mermaid yoga pants, a brand new haircut, a punk band shirt, and a single sock. It's odd, but it's working for me currently. 
8. I edit very minimally. I look at spelling and grammar, clarify confusing statements, and delete duplicate thoughts. I really only make the adjustments my editor requests, as I know that my process helps with a lot of the other issues authors run into.

Creative people are often seen as inherently quirky, and I suppose the way that I approach writing a blog is much the same way. Seeing as Van Gogh chopped off his ear and Darwin married his cousin, I think I am in a pretty good place. If you are looking to understand more habits of creative people, the Huffington Post write a neat article explaining several things that highly creative people do different. It might help explain a lot about your abstract relatives or even give you a few ideas on how to foster your own creative spark! 

Legacy: It's Not What We Do, but What We Leave Behind

As I turn 26, I am noticing that a lot of people at my age are in a turning point of their life. People are getting married, having children, and starting career paths. Coming from the Millennial Generation, we are often seen as the "me" generation... and for good reason; what with the advent of social media, it is hard to not to be lambasted with images of "look where I vacations" and "look what I am eating" and "look at my accomplishment." People measure success in different ways, however I believe that true success is measured not by what we are doing, but what we leave behind from those efforts. Events such as marriages, having children, or creating a DPT program happen to more than one person, and it is what you do to make this experiences special that create true success.

One example of this is holding titles/offices. Any one can hold a title, but it is what you do with that power that matters. For instance (at the chance of being political here), the title of President. Anyone can be president, but it is what you do with that title that you are measured for your success. History is a documentation of what was left behind, and greatness is determined by those historical artifacts. Think of a president of the United States. Right now. Any president. My guess is that you chose Washington, Jefferson, Lincoln, JKF, FDR, or maybe even Obama. It is also my assumption that the names Filmore, van Buren, and Harrison probably didn't cross your mind. That is because, unlike the former, these individuals didn't leave much of a lasting impact. Now that is not to say that they weren't good at their job, but relative to other POTUSes, these guys weren't exactly political icons. Another difference between these two groups are that the POTUSes that were in power during the greatest times of adversity had the opportunity to engage with and react to the challenges presented to them, thus leaving a memorable legacy.

With the ever-changing landscape of health care reforms, we as physical therapists have the same opportunity to leave a lasting impression on our fellow health care workers. We are presented with unprecedented challenges right now to which we can either respond with strength and passion, or we can wait 20 years to wave an "I Participated" pennant. If we allow ourselves to be defined as what we are doing, such as simply attending PT school, or completing a PT residency, or treating patients, we are only filling half of the puzzle. We must see our actions from the perspectives of future minds who will look at us and see what we left behind. What did we do to create a lasting impact on the field? Simply existing and showing up isn't enough. Anyone can hold an office or say they are "super involved," but unless you have the evidence to back up your claims, people are going to call you on your null hypothesis. We must thirst for change and strive for lasting impacts.

In short, don't make people just look, make them focus. Saying that you held an office is not nearly as impressive as the programs you implemented or the practices you affected. You may have a laundry list of a resume, but that will eventually mean nothing. Resume-building is important, but once you reach a certain level of superiority, people start to look at what you are doing instead of the fact that you have that status. History will forget you if you do only enough to look impressive on paper. To quote the play Hamilton, history has it's eyes on you... so now that it is looking, what are you going to do to make it focus in on you?

The Genesis of Genius: When McMillan Lectures all Make Sense at Once (Book Review Part 1)

On my flight home from the GSA Annual Scientific Meeting in New Orleans, I picked up a book in the airport, having exhausted my stash of scientific journals that I brought along with me. The title of the book is The Geography of Genius: Lessons from the World's Most Creative Places by Eric Weiner. Weiner is a journalist who is on a mission to determine why "genius flourishes in certain places at specific times" in an effort to essentially find an algorithm for intelligence uprisings. Throughout the book (I am only half way through it at this point), he travels the world to speak with experts, temporaries, and prodigies of the most genius minds in history. His travels take him to Athens to explore the ancient and most profound philosophers, Edinburgh to immerse in the medical and other scientific advancements of Scotland, Hangzhou to bask in the glory days of the Song Dynasty, and many other adventures. He takes an in-depth look not only at the personal lives of individuals who we as a culture now deem as "genius," but also at the political, environmental, and sociocultural dynamics taking place at the time of the uprising of these great minds.

I found this book most interesting because of how I felt it related to the field of physical therapy. While a physical therapist hasn't been deemed an official genius to the greater community of the world (to my knowledge anyway), we have many individuals within our microscopic infrastructure and related-community who would qualify for the title based on their life's works in either the clinics, the research lab, or often times, both. 

Two Mary McMillan Lectures were called to mind thus far in my indulgence reading. The first of which was Alan Jette's 2012 lecture entitled Face Into the Storm. In this lecture, Alan makes several interesting and inspiring points in relation to managing the many challenges that physical therapy was about to face at the time. However, the most pertinent lesson that I internalized from attending the lecture was that the field as a whole must face into the incoming storm and not run away, but rise up to meet the challenges head on.  This pedagogy, according to Weiner's discoveries thus far, is a cesspool for breeding an influx of genius within the field. Many ideas are birthed in the face of adversity. Just as the need for good hand hygiene was the window of opportunity between post autopsy and pre-delivery events in the medical field, limited insurance reimbursement and rapid health care cuts led the way for the inspiration of many community based programs as well as health and wellness initiative for the physical therapy field. 

The second lecture that presented a parallel to my readings was Lynn Synder-Mackler's 2015 lecture entitled Not Eureka. In this 46th lecture, Lynn describes how the greatest moments of discovery are not necessarily known immediately and are not often a big event initially. In act, the greatest discoveries and moments of genius tend to occur with a quite moment followed by  a solemn "well, that's funny." A subtle change or shift in the winds can result in needing to adjust your trajectory to a solution, often leading you down the novel and rarely-traveled path of ingenuity. Many scientific discoveries are not considered major until years of discussion, attempts to discredit them, and other new theories begin to support this existing paradigm (think spherical earth theory). 

The two most important ideals established in this work of literature are the following: 

1. Genius is a Process. That is right, with a capital P. It often doesn't happen all at once and the efforts of the individual are often not rewarded until years after the death of the individual (which might be why we have no certified PT geniuses as we are still a relatively infantile field). Also, a major part of the process of genius is a collective cultural response to the works of said individual stating the status of "genius", as society as a whole often has to see the worth and relevance to the ideas. 
2. Genius is often a unique response to a unique challenge which is necessary to continue to drive forward progress, survival, and stability for the human race. The reason I say human race is that we don't often describe animals as geniuses, and the ones we do are somehow able to successfully mimic human qualities anyway (such as Suda the painting elephant or KoKo the gorilla) therefore, genius seems to be an explicitly human or human-esque title. 

I highly recommend this book. It is witty, information, and has enough fun side tangents to keep this piece of non-fiction from being too dry and boring. It is also a good reminder that when the going gets tough, the tough better get going to the library because genius is only a train of thought away. 

Beyond APTA Involvement: Is there worth in membership to groups outside our clique?

I recently got home from a whirl wind trip to the Gerontological Society of America's (GSA) 2016 Annual Scientific Meeting in New Orleans, Louisiana. While I was only present in the city for a measly 36 hours due to the constrictions of having starting a new job (PTO what???), it was still an unprecedented, highly inspiration 36 hours which has led to the culmination of several new blog post ideas as well as many new networking relationships and activities to keep me busy throughout at least the first half of 2017. Each conference has a theme, and this year the theme was "New Lens on Aging." The thought behind this theme, which was carefully and most appropriately selected by our outgoing chair, Nancy Morrow-Howell, was to take a new look at how we view the science behind aging. However, I feel that this theme had a subtext to it that wasn't expected by myself, or perhaps any of the conference goers.

I feel that as healthcare, academic, and research professionals, we all wear our unique set of lenses when it comes to how we view aging. My physical therapy-shaded glasses will be different than the filter provided in the lens of that of an MD, public health official, or even that of the patient/client we are all simultaneously assisting. In order to be successful in our endeavors to aid and assist those who are aging, each lens is a small part of the greater image that is aging, and without the entire team, we fail in even the best intentions for this diverse population.

I have been a member of GSA for 3 years now. I initially joined as a way to gain access to their extensive database of interdisciplinary research as I was embarking on my primary thesis at the time for my Doctor of Physical Therapy degree. What I discovered in this organization was beyond just a data blitz. It was also mentor-ship, friendship, and collaboration with individuals from around the world which has shaped me into the young researcher and clinician that I am today in the field of human aging. Surprisingly though, most of these individuals who has inspired me within the realm of GSA were not physical therapists. I have found that through my involvement with other groups, I have connected to people who are also involved in APTA who I might not have met otherwise through the APTA alone.

Interdisciplinary collaboration: this recent buzz word is a new trend in medicine and medical management of our patients. The paradigm has shifted to include opinions from all sorts of professionals within the health care system including even spiritual care staff. Within GSA world, this interdisciplinary conversation takes place among clinicians and academics, grad students and field experts, social workers and doctors, and on and on and on. These relationships foster the growth for improving translation of knowledge from the lab to the patient experience.

As for the main stem of my thesis in this post, the answer is "it depends" on whether or not membership in groups outside of the APTA is worthwhile. I feel that it depends on the group. Someone else who isn't as driven by this pedagogy might not find the same value.

Nevertheless, I implore you to look into at least one professional association outside of the APTA in order to broaden your scope of practice and gain new insight into the world you love (be it geriatrics, neuro, sports, ortho. or whatever else). You might even have some fun and meet some neat people along the way.

47th Mary McMillan Lecture: Inspiring Lasting Change or A Social Media Blip?

At the APTA NEXT 2016 conference, Dr. Carole B. Lewis, PT, DPT, PhD, GCS, GTC, MSG, FAPTA gave the 47th Mary McMillan Lecture titled "Our Future Selves: Unprecedented Opportunities" in Nashville, TN. I was not in attendance, but once the event was over, I was bombarded on social media about the importance of care for our aging population. My initial reaction was joy. "Finally," I thought, "People are getting what I have been talking about for the past 3 years!" But that elation was quickly turned into cynicism. The people advocating for change the most were people whom I had grown to know as having a general distaste for the geriatric population; some of whom had downright ageist viewpoints and had complained about having to work with a geriatric patient instead of a young, recovering athlete in the clinic. Suddenly, I felt catapulted into the Twilight Zone and waited for what seemed like ages for the Tower of Terror to suddenly jerk downwards until everyone's feet were back on solid ground and minds were returned to their rightful place.

You may ask yourself, what is wrong with a renewed focus on geriatrics? How could a sudden interest in one of the most difficult populations to obtain appropriate care for be a bad thing? After all, there is strength in numbers right? Yes and no. I am thrilled that this topic was brought to the forefront of our minds. Its important and relevant to all issues related to healthcare. My issue is not with the message which was flawlessly presented, but with the reaction of the PT masses to the topic (or to any major announcement really). There are two types of change agents: those that garner short term results and those that garner long term results. Most of the positive results are incurred short term in a reaction like this, which is not not the solution that we so dearly need right now.

Now, let us dissent....

I'm not saying you can't be interested in or can't explore other realms of PT. For example, I'm not the biggest fan of pediatrics, but if a worthwhile petition to improve service provision to the population comes my way, of course I will sign it. Will I go out of my way to make sure I hunt down every other PT I know to sign it? Mostly likely not. And that is okay. If we all reacted this way to everything, then nothing would be special and no one would be specialized, which is an absolute necessity in our field. 

This is similar to the high school student who is aiming for Ivy League schools and signs up for as many extra-curriculars as possible. They don't really like what they are doing, but they see it as a way to get to the next step of what they want to do. The goals in the PT world can be anything from an executive position in the APTA to the glory of all those likes, re-tweets, and social media attention. What ever the underlying motive, if its not an altruistic one, then that individual is sure to crash and burn eventually.

Growing up, my parents had a saying: "If it isn't fun anymore, then don't do it." While this is an over-simplified mantra, and there are a lot of things that aren't fun but should still be done (dentists appointments, paying taxes, etc), there is a lot of merit to it and it has lead me to the successful and happy person I am today. I tried pee-wee basketball, hated it, and never went back. When dance became too stressful (Dance Moms is real, y'all!), I switched studios and eventually stopped to focus on school. When Academic Decathlon turned out to be just as ridiculous as it sounds, I left. When I had to quit a job because of an insufferable co-worker,  I found another position that I was even more thrilled to participate in. These may sound like a lot of instances in which I quit, but I don't see it that way. For a short period of time, all these things gave me joy and pride. But then, as circumstances changed, so did my happiness. It was then time to pick up a new hobby or adventure to make sure that I was taking care of myself.


This is why when I see someone tackling issues that I know they actually don't care about, and they are just getting caught up in the hype of "should do" instead of "want to do." I pity that individual. I am a huge proponent of "If I don't want to, then I won't." I can't be made to do anything I don't want or need to do. If it isn't necessary to my survival and/or job, and it's not interesting, then I won't participate in it. Pressure from peers, or even my own mother, can't even change my mind. I feel like this ends up making my convictions stronger in the end because all my actions are backed with the passion to fuel them to success.

I also witnessed a similar instance occur after the previous Mary McMillan lecture. Students whom I had known for years were suddenly interested in research and calling themselves "clinician scientists" when just the previous day they were complaining about how having to complete a research project to graduate from their program was a colossal waste of time. (For reference, our program only required one project and several students in the program - myself included - were able to complete several successfully in that time, so I have no patience for the "waste of time" complaint.) It was equally as amusing as it was annoying watching people get all riled up with the rest of social media and the conference goers only to see them slowly drift back into their old habits.


Now I can relate to the whole research thing. When I found out my senior year of undergrad that I would have to conduct a research study to fulfill my honors capstone requirement, I was pissed. I hated research. It was boring and monotonous and I wasn't interested. However, after creating my own study, carrying it out, and presenting the results at a research symposium, I was hooked and hungry for more. While I consider myself dedicated to the scientific method, this relationship has only been official for the last 4-5 years. I am no means an expert, but in that time I have conducted several other studies and have demonstrated that I am dedicated to this lifestyle.

Look, no one is doubting the fact that research seems cold and heartless. Research doesn't care about your feelings or woes. It simply exists as a venue for information discovery and dissemination. The scientific method is a well-oiled machine with no room for your bullshit. At the end of the day, the results are the results and your job is to figure out how best to present and connect them to the existing paradigms we currently operate under. It's an entire beast in its own right and it is not to be messed with. I don't think that people really understood that when they all jumped on the bandwagon in the summer of 2015.

Now to be perfectly clear, this poor sustainability of action resulting from the lecture topics is not the fault of any of the lecturers, the conference committee, or the APTA as an institution. Their purpose is to showcase their passion and message to the crowd at the conference, in hopes of inspiring lasting change and social engagement. My qualm is with the people who take the message, run with it, get tired, and put it down to rest in some ditch in the middle of nowhere.

While NEXT and CSM are great for information dissemination and networking, gone are the days of deep discussion and face-to-face contact in the advent of social media. Using social media to convey a message about something as important as the renewed focus on geriatric care or clinical research results in these vitally critical topics being handled as superficially as the relationships garnered on social media platforms. Sure we get the instant gratification of a topic trending on Twitter, but do we actually see lasting policy change to benefit clinicians and their patients? Not commonly. The facade of "I care about everything" is then shattered and debunked as humanly impossible. Moreover, the dreams of individuals who actually care about these things are often left deferred and no real change is garnered to ensure to future of physical therapy.

In the advent of social media, people get all jazzed up for a few days/weeks/months and then nothing comes of it or people forget about it as the next big thing comes around. Case in point: the ALS ice bucket challenge. People got super into campaigning for raising money for the foundation and then they forgot about it. This was evident through the number of posts I see currently with the link to the research that was actually conducted with the money raised paired with "I forgot about this" statements.

If you are going to make a lasting change, great! But if you pledge, push, and advocate for it, then make sure you follow through. One of my biggest pet peeves is to see someone get excited about something that I am excited about, only to see them back off and change their mind a week later after the conference hype has settled down. The best way to make a lasting change is to align it with interests you already have established. For instance, as a sports PT, you can still advocate for geriatric physical therapy, but that lasting change will come if you actually carry that attitude over to your clinical practice. Examples of this include volunteering as a medical professional for the Senior Olympics or holding a movement/health screen for seniors interested in starting a sports recreation program. When you extend your advocacy efforts too far beyond your prevailing interests, you often don't have enough support or resources to continue to foster growth in that area.

In conclusion, your time is valuable. Don't waste it on an endeavor because you feel like someone is expecting you to or it is what your peers are doing. The only conviction that matters is your own. I don't care if everyone else thinks that something is the best idea ever; if you are not convinced, then its time to figure out why so you can direct your attention to something that reaps lasting benefits for not only yourself, but also your patients.

All memes were created by Heidi Moyer using Meme Generator. 

Pelvic PT Part 3: Patients Who Don't Fit the Usual Boxes

Introduction

During my first semester of physical therapy school, my class was fortunate enough to have a guest lecture from one of eleven Board Certified Women’s Health Specialists in the state of Texas. It was during this lecture that I was first introduced to the practice of pelvic floor physical therapy (PT). Learning about the effects of pregnancy on the body and the hormonal and biological differences between men and women that influence their risks for various ailments fascinated me. For example, ACL injuries are 2 - 10 times more common in female athletes than male athletes playing the same sports¹. Additionally, there is an established relationship between knee laxity and hormonal changes during a menstrual cycle² in addition to a link between testosterone and improved athletic performance³. 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 service.

Before exploring the topic further, it is important to have a basic understanding of the terminology associated with this demographic.

Sex - biological characteristics of chromosomes and anatomy (ie. male, female, intersex, etc.)

Gender - societal and cultural categorization based on one’s sex (ie. boy, girl, etc.)

Cisgender - describes one who identifies with the gender assigned to them at birth

Image courtesy of advancedreportingtimes.wordpress.com

From Transgender - describes one whose gender does not match the sex they were born with (may be abbreviated trans)

Transwoman/MTF - born male and identifies female

Transman/FTM - born female and identifies male

Top surgery - breast removal (FTM) or augmentation (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 shows the world through appearance and behavior

Sexual orientation - the gender(s) that one is attracted to. (Transgender is not a sexual orientation.)

Gender 101. Trangsender Health Information Program, Provinicial Health Services Authority Web site. http://transhealth.phsa.ca/trans-101/gender-identity. Accessed Aug 13, 2016.

There can be many combinations of the terms above. Someone could feel male, but live outwardly as a woman. Also, gender and sexual orientation do not always add up in a heteronormative fashion. A person could be cisgender and bisexual (an XX female attracted to both men and women) or transgender and lesbian (an XY MTF woman attracted to women) or any other combination. Furthermore, not all people who are transgender have surgery or undergo hormone therapy, but this does not change their gender identity.

Why does it matter?

For many health care providers, there is high emphasis placed on maintaining respect and tolerance for all patients, regardless of their beliefs or lifestyles. However, for some unique populations, providing high quality care must extend beyond tolerance and into awareness. The July 2016 issue of the APTA’s PT in Motion magazine displayed “Managing patients who are transgender” on the cover. There were some fantastic examples of why it is important to be aware and knowledgeable about patients who are trans. One physical therapist, Daniela Mead, states, “If someone who identifies as a woman comes in reporting hip pain and I don't know that she is biologically male, I'm not going to screen for something like prostate cancer … because that's not going to be on my radar.”⁴ Dr. Kimberlee Sullivan, a PT and clinic-owner in Austin, TX, explained that physical therapists will see patients who are post-op MTF sex reassignment surgery to address pain and scar tissue. PTs work with this population with vaginal dilators to prevent stenosis so that they are able to have successful intercourse. “Since pelvic PTs have more creative liberty in regards to discussing sexuality and function; they are in unique positions to have a profound impact,” says Dr. Uchenna Ossai, a Board Certified Women’s Health Physical Therapist at Houston Methodist. 

There are many other instances in which someone’s status 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 pain⁵. 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 “Fifty-four 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 infections⁶. In regards to being efficient primary care clinicians and screening for non-musculoskeletal causes of symptoms, it is important to consider a sexually transmitted infection in the case of groin or low back pain. In one study, the prevalence of both syphilis and HIV were more than twice as common in the transgender group compared to the cisgender group⁷.

During the subjective interview with a patient, physical therapists screen for cognitive and emotional conditions that may interfere with PT or warrant a referral to another professional. For this reason, PT’s should be made aware that mental health disorders, often secondary to ‘minority stress’ are higher in the LGBTQ community. According to the National Alliance on Mental Illness, suicidal ideation is experienced in 38-65% of transgender individuals⁸. There are other psychological components specific to this demographic, such as gender dysphoria, which is diagnosed when one displays “a marked difference between the individual's expressed/experienced gender and the gender others would assign him or her,” often to the point of causing significant distress and social/functional impairments⁹.

The transgender population also carries with them some distinct barriers to health care access, including PT. Currently, only 18 states have laws to protect a person who is trans from being fired solely on the basis of their gender identity¹⁰. Considering how many people obtain health insurance through their employer, a patient may harbor anxiety and fear of losing access if they are terminated. Furthermore, there is no nation-wide legislation in place requiring health insurers to cover transition-related to health care¹¹. If a patient is paying for most of these services out of pocket, they may not want to spend additional time and energy on PT because it is perceived as less necessary.

What can we do?

As a second year PT student, I have noticed that there is absolutely no mention of this demographic in my curriculum. Considering that the research on this (incredibly diverse) group of people is scarce, that is somewhat understandable. But the best method to increase awareness for our patients who are trans is starting early education! Even just one lecture by a specialist to expose students to the idea and provide them with more resources would be excellent. Creating more resources for practicing clinicians by way of continuing education courses and seminars would also help spread information. Something that could be done locally within your own clinic could be allowing in-services on trans healthcare to be given by interning students or employees. Since the resources may be limited and it may not seem like a pressing topic because the population is small, it could be as simple as creating a work environment where these discussions are welcome.

There are so many other efforts that PT clinics can employ to put patients at ease. The article in PT in Motion mentioned having a rainbow flag in the waiting room to let patients know they are in a safe space. “While I was shadowing at a clinic in Seattle, some of the PT’s wore a small pin to indicate peace and acceptance of other cultures. Another idea could be intake forms with more than one gender choice to include transgender and genderqueer. You as an individual employee may not be able to accommodate patients by providing gender neutral bathrooms, but if they already exist at your facility it wouldn’t hurt to know where they are located and offer it to patients. This may make them feel more comfortable and convey respect, helping to build rapport.

If you are a clinician, or future clinician, who would like to make a conscious effort to practice this awareness but don’t know where to begin, have no fear! There are so 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 have a patient who you know or suspect is transgender/non-binary you can start with pronouns. If they came into the clinic with someone, you can wait for their friend/family member to address them as a certain pronoun. I use ‘they/them’ since it is gender neutral until I have a better idea of how someone identifies. If you are unsure, it is okay to privately ask them! This is far less triggering than misgendering someone. “I believe in a professional medical setting, they should always ask how their patient identified. When my primary care physician's nurse found out I was on testosterone, she immediately asked me what my preferred name was. It was a great feeling,” states Elliott T., a transman from Ohio. “My doctor on the other hand offhandedly asked me why I was on testosterone. Even though he's had transgender patients before, it was very obvious that he was not educated or trained on how to approach the subject.”

Dissenting Opinion

As with any controversial topic, there are opposing viewpoints. Some health care professionals believe that the field has become too politically correct (PC). From this perspective, it is thought that being PC is sugar-coating problems and inhibiting a clinician from addressing the impairments at hand. For example, Dr. Dominic Carone claims that “...we should not abandon the use of scientific terminology because someone does not like the stigma attached to it. The problem that emerges when we start to substitute euphemistic phrases for scientific terminology is that we start to de-emphasize the seriousness of the problems.”¹² In his article, he is primarily talking about using the words ‘unhealthy weight’ rather than ‘obese’, but he also gives many other examples including cancer, anorexia, and diabetes. Similarly, a clinician may choose not to pay extra attention to the unique aspects of all patients because it is too time consuming and detracts from time that could be spent treating. One could also argue that using person first language like ‘person with a disability’ rather than ‘disabled person’ makes no fundamental difference or is negating an important part of someone’s identity.¹³

Summary

Ultimately, being mindful of different life perspectives only serves to benefit you and those you treat. If all of the other suggestions seem too far-fetched or difficult, I challenge you to do something simpler. Even if you disagree with other sexual orientation and gender non-conforming lifestyles, you can practice awareness by not making assumptions about your patients. Although the apparent shock at discovering someone’s differences may not be malintended, it can come across as embarrassing to the other person. This can hurt the therapist-patient relationship and hinder outcomes. As PT’s we strive to care for others and help restore or improve function to promote optimal health and quality of life. This includes all patients, regardless of their gender identity or sexual preference. If there is something you could start doing to be an even better therapist, why not give it a try?

Disclaimer: I can only correctly 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.

Please visit Part 1: It's Not Just for Women and Part 2: Training the Pelvic Floor Musculature...Are Your Patients Missing Out? of this series for more information on pelvic floor health in general and how to implement techniques to train this unique muscle group without your patient populations. 

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Sources

1. Timothy E. Hewett P. Why women have an increased risk of ACL injury. AAOS Now. 2012(Nov).

2. SHULTZ S, KIRK S, JOHNSON M, SANDER T, PERRIN D. Relationship between sex hormones and anterior knee laxity across the menstrual cycle. Med Sci Sports Exerc. 2004;July 36(7).

3. Wood R, Stanton S. Testosterone and sport: Current perspectives. Horm Behav. 2012;January 61(1):147-155.

4. Hayhurst C. Managing patients who are transgender. PT in Motion. 2016;July.

5. Health consequences of chest binding. Transgender Cosmetic Surgical Procedures Web site. http://www.ftmtopsurgery.ca/blog/ftm-faq/health-consequences-chest-binding/. Published 18 December 2014. Updated 2014. Accessed Aug 13, 2016.

6. Herman J. Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender People’s lives. The Williams Institute: UCLA School of Law.

7. Toibaro J, Ebensrtejin J, Parlante A, et al. Sexually transmitted infections among transgender individuals and other sexual identities. Medicina (B Aires). 2009;69(3):327-330.

8. Lgbtq. NAMI: National Alliance on Mental Illness Web site. http://www.nami.org/Find-Support/LGBTQ. Accessed Aug 16, 2016.

9. Gender dysphoria. In: Diagnostic and statistical manual of mental disorders. 5th ed. American Psychiatric Association; 2013. http://www.dsm5.org/documents/gender%20dysphoria%20fact%20sheet.pdf. Accessed Aug 17, 2016.

10. Transgender FAQ. Human Rights Campaign Web site. http://www.hrc.org/resources/transgender-faq. Accessed Aug 17, 2016.

11. Transgender health care. Healthcare.gov Web site. https://www.healthcare.gov/transgender-health-care/. Accessed Aug 18, 2016.

12. Carone D. How political correctness interferes with healthcare. KevinMD Web site. http://www.kevinmd.com/blog/2011/12/political-correctness-interferes-healthcare.html. Updated 2011. Accessed Aug 18, 2016.

13. Ladau E. Why person-first language Doesn’t always put the person first. Think Inclusive Web site. http://www.thinkinclusive.us/why-person-first-language-doesnt-always-put-the-person-first/. Updated 2015. Accessed Aug 18, 2016. 

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About the Author: Brianna Durand is a 2nd year Doctor of Physical Therapy student at Texas Woman's University in Houston. As a military brat, she has a love of travel, but her heart is nestled in Seattle. She enjoys weight lifting, yoga, cycling, and heartfelt discussions about changing the world. 

Pelvic PT Part 2: Training the Pelvic Floor Musculature...Are Your Patients Missing Out?

August 19, 2016 by Matthew Schmidt, PT, DPT, CSCS

What you’re getting yourself into:

2100 words; 9-15 minutes reading time

Key Points:

1.      The pelvic floor muscles are like nearly every other muscle in the body: they are split between fast and slow twitch fibers. The levator ani muscles, however, are proposed to be nearly 80% slow twitch.

2.      Fast twitch fibers are typically trained with high weight and low reps, whereas slow twitch fibers are typically trained with high reps and low weights, based on the idea that you need to train differently based upon predominance of fiber types.  Difference in training style has not been conclusively shown to affect muscle fibers in such a way; evidence is very mixed, though opinions on the matter are quite impassioned.

3.      Regardless, the general recommendation is to keep training muscles with a variety of rep ranges; in other words, follow the rules of periodization and specificity.

4.      Don’t be afraid to challenge your patients; Kegel isometrics are really only the beginning. Training this muscle requires the same amount of consideration as training any other muscle group. Rules of periodization should be followed. Variation for Kegels can be achieved by simply using Kegels concurrently with virtually any other movement.

Part 1:  Pelvic Floor Health, its not just for pregnant women anymore!

Shirts showing “pride” for leakage ²

Pelvic floor musculature (PFM) is one of the most overlooked muscle groups during a physical therapy evaluation. As healthcare professionals, we pride ourselves on being able to talk about intimate topics such as urinary incontinence with our lumbar patients or the ability to obtain an erection for a patient with a recent spinal cord injury. But it is this critic’s opinion that this simply does not go far enough. Sure, some attention has been brought to the Exercise Induced Urinary Leakage epidemic (EIUL as CrossFit names it, or Stress Urinary Incontinence as the rest of the world calls it), or the idea that the majority of strength athletes “leak” during a lift; some even wear this as a badge of pride ¹.

 As has been said before in this well written piece on Pelvic Guru³,this is not a normal occurrence and it should be addressed. That all sounds well and good, but somehow I doubt that when Mattie Rogers sets a new American Record Olympic Lifting Total, or when Marisa Inda squats the equivalent of a house filled with lead, they’re thinking “Alright, knees out, stay aggressive, keep the torso upright, and squeeze the heck out of that Kegel!” No, that’s pretty doubtful.

Mattie Rogers⁴

You might be thinking to yourself, “but Matt, I don’t see athletes, why do I need to care about Kegels??” Because believe it or not, your 79 year-old Parkinson’s patient named Jim, who is seeing you for back pain and is a glaring fall risk has weak PVM. Unfortunately, Jim stopped drinking more than 16 ounces of water a day because he is afraid of falling, and since he has weak PFM, drinking water will require him to get up many times, so what better way to decrease the chances of not falling than by not drinking water so he doesn’t have to get up?

Then what is the therapist’s role in training the PFM? It starts with education. I am by no means an expert in the matter, but I can provide a quick rundown of some key points that will hopefully be of benefit to the average therapist that is interested in a brief introduction to the clinical application.

Part 2: Muscles are Muscles

The pelvic floor muscles are like nearly every other muscle in the body, they are split between fast and slow twitch fibers. The levator ani muscles, however, are proposed to be nearly 80% slow twitch⁵.

Let’s determine what we know (or should know) about fast and slow twitch muscles fibers? Fast twitch (Type II) muscle fibers are quick to fatigue and are responsible for quick contractions and typically are capable of stronger muscles contractions, whereas slow twitch (Type I) fibers are slow to fatigue and are therefore capable of sustaining contractions for a longer period of time, though they are usually not capable of as strong of a contraction as Type II fibers. The reason that I bring up fiber type in relation to PFM is NOT so that you can choose to do isometric holds for only one specific length of time or at specific intensity because you think that your patient has problems with holding a contraction for a long time but not for short bursts (like during a lift), or vice versa. The following key point explains why.

Fast twitch fibers are typically trained with high weight and low reps, whereas slow twitch fibers are typically trained with high reps and low weights, based on the idea that you need to train differently based upon predominance of fiber types.  Difference in training style has not been conclusively shown to affect muscle fibers in such a way. Evidence is very mixed, though opinions on the matter are quite impassioned.

This key point comes straight from Greg Nuckols of Strengtheory. I highly recommend reading his article Training Based On Muscle Fiber Type: Are You Missing Out?⁶, which in large part inspired me during the writing of this post. Online searches for PFM materials and personal clinic experience have shown that there seem to be two major ways that PFM exercises are taught: long holds for Type I muscle fibers and “quick flicks” for Type II fibers. Regardless of what you learned in school, or what you read in some fitness magazine, research is very mixed (and passionately so) about how to train a specific muscle fiber type more effectively.

This is seen in one of the best examples taken from the Strengtheory article as seen below:

 

Type 1 and Type 2 fiber growth after training with 30-50% of 1rm vs. 75-90% of 1rm. As you can see, the growth of both fiber types was darn near identical for both loading zones⁷

While performing PFM training in the above ways is certainly a great start, is far from where training should stop.

Part 3: Variety is the Spice of Life

Regardless, the general recommendation is to keep training muscles with a variety of rep ranges; in other words, follow the rules of periodization and specificity.

Example of a periodization model⁹

The fact remains, like nearly every other muscle in the body, the PFM is split in relation to fiber type, so a variety of methods need to be used to provide a truly effective program for your patient. Gone are the days when telling your patient to “Do a Kegel, hold and relax it for 5 seconds, relax for 5, and repeat that 10 times” is the end all be all for PFM training. I’d like to inspire you to do more. One research article suggests that working up to a minimum of 50-60 sustained Kegels per day is enough to help 88% of the patients in their study to improve their issues with incontinence⁸. That may be enough for some, but it likely is not aggressive enough for many others.

But how can you apply this to Kegels? There’s only so many ways to vary a Kegel, right? Not necessarily.

Keep in mind, though, that a football team does not simply train at full capacity all year. There is periodization. During the off-season they build strength maximally and as they near the start of the season, strength work is decreased, skill work is increased, and the total volume of work declines slowly.

Part 4: Use it or Lose it.

Don’t be afraid to challenge your patients; Kegel isometrics are really only the beginning. Training this muscle requires the same amount of consideration as training any other muscle group. Rules of periodization should be followed. Variation for Kegels can be achieved by simply using Kegels concurrently with virtually any other movement.

Quinn Henoch, PT, DPT of Darkside Strength and Juggernaut Training Systems, often stresses the importance of progressing and incorporating core work and breathing through neuromuscular retraining by an athlete and using active, sport specific warm-ups to retrain posture. As we think about retraining a movement, let us envision a pyramid. At the bottom of the pyramid is the simple act of breathing and maintaining a neutral posture; if trained properly, proper breathing/posture/bracing should eventually be a reflexive act. At the top of the pyramid is skill work. Skill work can take many different forms. It might be the ability of a high school quarterback to maintain a neutral spine pre-snap and it might just as likely be the act of standing over the sink doing the dishes but maintaining that same neutral spine. The objective for each person should be the same: to maintain the proper position to decrease their risk of injury and stay in the most efficient position possible. Without the necessary work on the base of the pyramid, skill work at the top level will nearly always crumble as result. This idea transfers to the world of PFM very easily. Without a strong base ability with simple isometric Kegel holds or pulsing Kegels, maintaining a Kegel during a 200 kg front squat attempt is not going to be natural and reflexive.

Therefore, I have provided a simple chart, one column for a higher level athlete and one column for a patient that requires less complex activities. You may be surprised by the similarities. This is only meant to be a jumping off point.

	Higher Level	Lower Level
Static Stability	Maximal contraction isometric, progressing to multiple pulses for time
	Long isometric holds
	90-90 breathing getting the ribs down and bringing in an ab and glute isometric
Dynamic Stability	In hooklying, bring in the abs, Kegel, and glutes, then relax one of the aforementioned, hold the other two. Alternate which is released and which are held.
	Bring in all three, alternate arm movement. Then alternate leg movements, ie marching.
	Dead bug with holding all three isometrics, or pulsing Kegel.
	Psoas marching in the same fashion as above.
Specific muscle strengthening needed to aid in success with high level demands	Perform a sit to stand, from elevated position down to low position, holding the Kegel for one stand then relaxing on the sit, then vice versa	Half kneeling chop, either pulsing a Kegel or with a low grade sustained hold.
	Hip hinge	Reverse chop in a lunge
	Good morning	Overhead pressing with rear foot elevated while in a lunge
	KB DL from elevated box	Push Press
Highest Level Activity Needed	Being able to wash the dishes in the sink with pain not exceeding 1/10	Power Clean and Jerk

As you can see, it isn’t until the more skill specific areas that the programs start to diverge, and even then the exercise selections are pretty similar. These two programs had specific patients in mind, but in reviewing the selected exercises, it should be clear that each exercise builds on the last and slightly progresses to the end goal in mind.

Tomes of novels have been written on the subject of periodization, so I could do little to add to this topic. I will provide this one bit of advice, however: if nothing else, have a general idea of how your total volume of PFM work is being affected as you progress towards the patient’s end goal. Volume should build quickly at the beginning of PFM training with all the isometrics they can start doing. But as they near their goal, don’t forget that the PFM can fatigue, so taper off the simple stationary isometrics and utilize Kegels mostly during skill specific work.

One final area I would like to briefly touch on is this, I hope that readers will take away this realization if nothing else: incorporating Kegels into a patient’s exercise protocol really is pretty simple; it should require relatively little on your end as a therapist in terms of changing your plan of care for a patient. The biggest time commitment will be the 15 minutes you spend explaining the importance of PFM and how to perform the isometrics on the first session. After that, most of the coaching is complete, you simply have to cue them, “Abs, Kegels, Glutes, now… (fill in the blank with whatever exercise you are teaching).” Don’t just settle for good enough. Strive to be better. Your thoroughness could be life changing for a surprising number of your patients.

I would like to briefly thank Jennifer Hughes, PT, DPT of Atlanta Falcons Physical Therapy for originally inspiring me to utilize more PFM techniques on my clinical rotation and Quinn Henoch, PT, DPT for his contributions on Darkside Strength and Juggernaut which have motivated me to apply postural restoration techniques combined with pelvic floor strengthening principles with patients of such a wide variety.

For Part 1 of this series entitled "Pelvic PT Part 1: It's Not Just for Women," click here. Stay tuned for "Pelvic PT Part 3: Patients Who Don't Fit the Usual Boxes" about how sexual minorities fit into the physical therapy paradigm. 

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References

1. CrossFit. Do you pee during workouts? [Video]. YouTube. https://www.youtube.com/watch?v=UKzq1upNIgU. Published June 16, 2013.
2. Screenshot. In: PelvicGuru. Dear CrossFit and “CrossFit Gynecologist,” I’m Appalled. There’s Help For ‘Peeing’ During Workouts! [blog].
3. Sher T. Dear CrossFit and “CrossFit Gynecologist,” I’m Appalled. There’s Help For ‘Peeing’ During Workouts! PelvicGuru. https://pelvicguru.com/2013/06/22/dear-crossfit-and-crossfit-gynecologist-im-appalled-theres-help-for-peeing-during-workouts/. Published June 22, 2013.
4. Rogers M. In: mattiecakesssss. Instagram [application]. 2015.
5. Newman DK. Kegel exercise. Seek Wellness. http://www.seekwellness.com/incontinence/pelvic_floor_muscle_rehab.htm. Updated March 2013.
6. Nuckols G. Training Based On Muscle Fiber Type: Are You Missing Out? Strengtheory. http://strengtheory.com/muscle-fiber-type/. Published June 15, 2016.
7. Morton R, Oikawa S, Wavell C, et al. Neither load nor systemic hormones determine resistance training-mediated hypertrophy or strength gains in resistance-trained young men. J Appl Physiol. 2016:30. doi: 10.1152/japplphysiol.00154.2016.
8. Miller J, Aston-Miller J, DeLancey J. The Knack: Use of precisely-timed pelvic muscle contraction can reduce leakage in SUI. Neurol Urodyn. 1996;15:302-393.
9. Winer L. A simple guide to periodization for strength training. Breaking Muscle. http://breakingmuscle.com/strength-conditioning/a-simple-guide-to-periodization-for-strength-training. Publication date unknown. 

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About Dr. Matthew Schmidt, PT, DPT, CSCS

Matthew Schmidt is a physical therapist in Bedford, Texas at Riata Therapy Specialists. He splits his days working with outpatient neurological patients (MS, Parkinson’s, post-concussion, vertigo, etc.) and outpatient orthopedic patients. He enjoys participating as an amateur natural bodybuilder and applying what he has learned in the gym through personal experience to his varied client’s interests.

 “Non nobis solum nati sumus. Not for us alone are we born.” -Cicero