Pelvic PT Part 1: It’s Not Just for Women

As a woman, I will never be a 100% expert on men’s health. 

As a woman who cares about the amazing men in her life, I wish there was more research and specialization on the topic.  Today I’d like to do more than wish; let’s open up the discussion.

Word Cloud made by author using http://www.wordclouds.com/

Women’s Health PT - Physical therapy in the United States is deeply rooted in the women-dominant field of nursing, starting in WWI when the “Reconstruction Aides”(1) rehabilitated wounded soldiers.  Nearly 100 years later, women still make up 70% of physical therapists. The current trend in PT is specialization in women’s health through CAPP Pelvic.  It is truly remarkable how far we’ve come, from post-baby stress incontinence being a hush-hush fact of life to curable with Kegels and other pelvic floor exercises.  Women’s health PTs also treat many other issues, such as lymphedema and upper extremity sensory and strength changes associated with mastectomy.  These specialists are changing the lives of women every day, but what can our profession offer the other half of the population?

The Other Half - While men hold the majority of administrative and ownership positions in the PT world they haven’t had nearly as much time in the clinic.  In fact, I know men who were denied the opportunity to apply to PT school in the 1960s, being encouraged to instead become clinic administrators.  Their shockingly low representation in the clinic, even at today’s rate of 30% (2), means men haven’t had as much opportunity to bring their specific needs to light.  “What kind of needs” you ask?

●     1in 10 children past the age of 5 wets the bed (nocturnal enuresis), and this is more common in boys than girls due to the delay in pelvic muscle maturation.  Pelvic floor strengthening can be performed through a variety of creative full-body activities such as dance and balancing on therapy balls.

●     Unlike most other cancers, testicular cancer is most prevalent among young men ages 15-34, the age when men are least likely to perform self-exams.  As health promoters, therapists can educate their communities about such self-awareness.

●     More than half of men in their sixties and up to 90% in their seventies and eighties (3) have lower urinary tract symptoms, including various forms of difficulty with urination.  These men can be helped through exercises targeting both the fast and slow-twitch muscles of the pelvic floor.  Kegels aren’t just for women - pubococcygeus exercises can help men improve urinary and fecal incontinence, erectile dysfunction, and premature ejaculation.

●     Diabetes is the primary etiology of erectile dysfunction.  In fact, men with diabetes are three times more likely (4) to experience ED, and their onset is approximately 10-15 years earlier than in men without diabetes. So why do commercials push to address ED with pumps and pills, when perhaps controlling and preventing diabetes would be more effective, and better for the person’s overall health?  Again, a therapist’s role as a health educator comes into play.

●     “A vasectomy’s a medical procedure,” one with hidden side effects.  The catchy Family Guy ditty (5) left out the possibility of Post-Vasectomy Pain Syndrome (6) (congestive epididymitis), which is at least 3 months of chronic or intermittent scrotal pain.  PVPS can affect approximately 15% of men after the procedure, but physical therapy can be part of the treatment plan to ease the pain while avoiding further invasive procedures.

●     Fertility is usually diminished in men after a spinal cord injury, but fulfilling sex doesn’t have to be.  With some creativity in adaptive movements and devices, physical therapists can help patients resume all activities of daily living.

●     Men can get osteoporosis, too.  In fact, 1 in 5 men over the age of 50 will have an osteoporosis-related fracture, which is greater than the risk of developing prostate cancer.  This number could be lowered with increased education for men about nutrition and continued weight-bearing and resistance exercises into the golden years.

While physical therapists are educated in the care of many specialized populations (pediatrics, pregnant women, geriatrics, and other groups), men’s health is not often an area of focus in PT school.  In fact, nearly all of the above health conditions were discovered during my own extracurricular research.  While writing this post (July 30, 2016), a quick Youtube search for “physical therapy men’s health” yielded 8,570 results, less than half of the results for “physical therapy women’s health” (19,500 results).  The same search on Google Scholar resulted in 529,000 results for women, which is over 6 times the 82,200 results for men.  Granted, women experience many major factors that put them at risk for intimate health issues, such as childbirth trauma and breast cancer, the most prevalent form of cancer. Still, one would expect more research than we currently have done into physical therapy for the many aforementioned men’s health concerns.  We’ve come a long way toward equality on both sides of the treatment table, but there is more room for improvement.

Awkwardness – Talking about your private business with strangers is uncomfortable.  I grew up in a conservative Bible Belt town, so believe me, I get it.  As health professionals, we cringe at the subject of intimate health for additional liability reasons.  With more female than male PTs in the field, male patients are less likely to be comfortable and open when discussing embarrassing intimate issues.  But physical therapists are trained to be musculoskeletal experts.  We have the skills to fix ANY dysfunctional muscle group in the entire body, including the ones no one wants to discuss.  We can still provide the necessary care while respecting the patient through appropriate speech, touch, and eye contact.  We all learned in school to explain every procedure and the reason behind it, provide appropriate draping, and check in periodically to make sure the patient is still comfortable during the procedures.  Keep the conversation open, and use your best judgement and creativity - after all, avoiding awkward situations is how the stethoscope was invented (7).

The Future of PT –  In the next 10 years, I envision not only women’s health PTs but also more specialists in men’s health, general pelvic health, and health issues faced by patients who are transgender.  With hard work and research, I see equality on the horizon for our profession to empower all people in the 21^st century.  Stay tuned for "Pelvic PT Part 2: Training the Pelvic Floor Musculature...Are Your Patients Missing Out?" from a male colleague’s perspective and "Part 3: Patients Who Don't Fit the Usual Boxes" about how sexual minorities fit into the physical therapy paradigm. 

If you're interested in learning more about this topic, the APTA Section on Women's Health offers a two hour online home study course entitled "Introduction to Male Pelvic Health Part 1: Urinary Incontinence."

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References

1.  Moffat M.  The History of Physical Therapy Practice in the United States.  Journal of Physical Therapy Education.  2003;7(3):15. https://www.questia.com/library/journal/1P3-571060931/the-history-of-physical-therapy-practice-in-the-united 
2. Physical Therapist Member Demographic Profile 2013.  American Physical Therapy Association.  March 2014.  http://www.apta.org/WorkforceData/ 
3. Urinary Incontinence In Men.  National Institute of Diabetes and Digestive and Kidney Diseases.  June 2007.  https://www.niddk.nih.gov/health-information/health-topics/urologic-disease/urinary-incontinence-in-men/Documents/uimen_508.pdf
4. Giles T, Giles S, Cowan D, Bailey R.  Other Systems. In:Giles S, ed. Scorebuilders PT Exam: The Complete Study Guide.  Scarborough, ME:  Scorebuilders; 2015: 357.
5. A more work-appropriate version of the Vasectomy Song,  adapted from “Sibling Rivalry.” Prod. Seth McFarlane, et al. Family Guy. Fox Broadcasting Company, 26 Mar. 2006. https://youtu.be/G5RJiU39v30?t=48s
6. Tan W, Levine L. An overview of the management of post-vasectomy pain syndrome. Asian Journal of Andrology. 2016;18(3):332-337. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4854072/ 
7. Roguin A. Rene Theophile Hyacinthe Laënnec (1781–1826): The Man Behind the Stethoscope. Clinical Medicine and Research. 2006;4(3):230-235. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570491/

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About The Author:  Lisa Henderson, PT, DPT earned her doctor of physical therapy degree from Angelo State University in 2016.  Her Professional Philosophy: “A physical therapist should address both the scientific and the human sides of medicine, employing the best evidence for a caring and individualized approach with each patient.”  

Special Thanks to my proofreaders:  Hannah Althof, B.Lit.; Jade Bradford, PT, DPT; Trevor Hansen, PT, DPT; Heidi Moyer, PT, DPT; Matthew Schmidt, PT, DPT, CSCS; Andrew Thomas, PT, DPT, CSCS; et al.

Again, I am not a man and therefore cannot represent the opinions of males, just as I am not affected by numerous other musculoskeletal conditions but desire to learn more and help those populations.

When Professional Relationships Become Toxic: It's Okay to Walk Away

Image from http://berto-meister.blogspot.com/2008/07/platos-allegory-of-cave.html

Despite the fact that there are a plethora of physical therapists, the field as a whole is still relatively small. Breaking into this tight-knit community can be quite intimidating for anyone from a new student to a seasoned professional who wants to become more involved. But what happens if you find yourself face-to-face with somebody who isn't a great influence on either you or on the perceptions of others concerning you? Physical Therapists are all humans, and to err is to human. Sometimes fame and ego can get in the way of our Core Values and these individuals can be led astray. Then, in the process of the pursuit of their goals, other people can get caught in the crossfire. So within the tight-knit community of the PT world, what do you do? Should you keep that contact so you don't lose other contacts? Do you give up, move to Alaska, and find a new career? There are some that will advocate to keep that person in your life because very often, you can benefit in some professional way from that person, but I'm actually here to present the opposite side to you.

Now... let us dissent.

Everyone in their life, at least once, has been at the mercy of another person's greed, jealousy, or pride. I know that I have experienced this from the receiving side several times before, and have also been on the other end of it as well. This situation can occur in several different forms. Maybe it is a co-worker who advocates for social media for one thing, but then acts in a manner completely contradictory when others aren't looking. Maybe a classmate is nice to your face, but spreads dirty rumors behind your back and attempts to get the rest of the class to turn against you. Maybe it is someone in your personal life who uses your personal accomplishments and efforts to advance their own agenda. Whether it's an outright bully or someone who you consider to be a friend, the experience can be seemingly out of control and is scary no matter the circumstances in which it occurs.

What I am about to say are the words that every person in a relationship like this needs to hear: It is okay to walk away. You do not have to subject yourself to that sort of treatment, and you do not have to allow that person continued access to your time and energy. If you have a friend or a colleague that is not a positive and healthy influence in your life, then you have more than enough reason to take control of the situation and remove yourself from that dynamic. This is perfectly healthy and can help decrease your stress in ways you never thought possible. Do not feel like seemingly important people can't make mistakes. Good people make bad choices and bad people can make good choices. To think otherwise is to commit an ad hominem logical flaw.

Philosophical ethics have many view points on this topic. I am a huge believer in Kantian as well as Platonian ethics, and I believe that theses paradigms are relevant to the scenarios I listed above.

In Plato's Allegory of the Cave, true reality and one's perception of reality are challenged as being two separate entities. In essence, the story is about cave dwellers who have no access to the sunlight (or the truth), and use shadows on the wall (which are being produced by fire, not light) of the cave as a means to interpret the truth. This is similar to using rumors and gossip to infer a person's true character instead of approach the actual person. Toxic people utilize shadows to manipulate the truth and, unless you openly seek out the light, you aren't likely to find it on your own. As a professional, is it important to know when you are being manipulated and to take change of what you consider to be truth and lies on many levels.

In Kantian ethics, one of the main philosophical beliefs for living an ethical life includes not using others as a means to an end. This means not using other people to get to where you want to be. Let's say, as an example, that a person treats you poorly and you truly have no other use for them other than their networking ability to fulfill your want of connection. In this scenario, you are no better than the individual I described above who rides your coat-tails. If you have no other use for a connection to a person other than their connection to other people, you are acting unethically. Therefore, this makes it ethical to distance yourself from said person.

This is not to say that you can't be professional about cutting ties. Smile. Be kind. Bow out quietly. Go through the appropriate channels for removing yourself from the situation, but don't bend over backwards to continue allowing that person control you. The more professional you are about the matter, the better you look to others. As you stay composed, other people tend to become more unraveled and observers certainly notice. While people may not have the full story (at least on your end), your actions and how to treat that other person will speak louder than any lie or rumor they spread about you.

One of my favourite quotes is listed to the right, and I have lived by it in the past few years. To be honest, I have no idea who the real author of this quote is, but I can say that they are truly an introspective and emotionally intelligent person. I have no doubt they have read the Allegory of the Cave.

One last thought I would like to leave with you is what you can do when you are an observer in a situation like this. If you are in a group and you see an instigator who is making claims against another person's character, recognize that your silence can be mistaken as approval. This can serve to be self-affirming for the trouble-maker and only encourage their bad behavior. If you have a friend who is on the receiving end of such a negative relationship, then console them and support them in this time. Stepping in will often result in the same treatment being directed at you. If the defensive tactics come from the person the actions are directed to, then the push-back of the poor treatment is much more powerful. And finally, if the person causing a fuss is your friend, then you owe it to them to point out their negative actions in order to make them not only a better person, but a better physical therapist. If you are a witness, get yourself out of that cave as quickly as you can!