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