Advocating for Patients Who Are Transgender

As a student physical therapist, I witnessed some incredible examples of competent and compassionate care. The only experience that did not live up to this standard was with a patient who was transgender. I observed this patient being treated exclusively with passive modalities, likely because the treating therapist was uncomfortable dealing with her (thankfully, my instructor advocated for this patient and took over her care). This experience stuck out in my mind for years to come. The APTA Code of Ethics1 implores us to treat all patients with dignity and respect, as well as to recognize our own personal biases. Why was it so hard for this otherwise compassionate therapist to do so with this one particular patient?

The July issue of PT in Motion featured an article entitled “Managing Patients Who are Transgender”. If you have not read it, I highly suggest that you read it here. This article2 provides information for creating a welcoming space for our patients in the LGBTQ community and addressing sensitive issues that may come up during the course of treatment. According to the article, our own Section on Women’s Health is compiling resources for practitioners regarding issues of gender and sexual orientation. This is extremely important, as these topics are barely covered in PT education, if at all. The article states that 70% of patients who are transgender report some form of discrimination within the healthcare system, and 28% report postponing medical care for fear of mistreatment. As Women’s Health physical therapists, we have a unique opportunity to end this cycle and to serve as advocates for all of our patients.

Curious about the experiences of patients who are transgender, I decided to ask a dear friend of mine to share his thoughts on dealing with the healthcare system. Aryn was born physically female, and announced his transition to the male gender several years ago. He states that he hasn’t experienced any outright abuse when dealing with healthcare professionals, but has had several instances where he felt neither heard nor respected. He has a primary care physician who has years of experience with the LGBTQ community. When dealing with other providers who do not have this level of expertise, however, he describes the experience as “hell.” In particular, he states that providers have seemed fixated on questions that feel irrelevant to his medical complaints, such as whether or not he has had gender reassignment surgery and why or why not (of course, there are times when this information may be important for the practitioner, but he feels that it has been overemphasized). He also describes medical professionals looking at him like he is “a freak or crazy, and I am neither of those things.”   As healthcare professionals, we need to consider what this would be like as a patient—to seek treatment for one ailment only to find your physician more (perhaps solely) interested in an unrelated aspect of your life. Would you feel like you were receiving the best possible care?

I asked Aryn if he had any advice for a new healthcare practitioner when working with patients who are transgender. He answered, “You are the doctor. It should not be my responsibility to educate you about the special needs of the transgender community. Educate yourself, and then educate your peers.” This resonated with me, as I realized that the Section on Women’s Health is one of the only voices in the PT community trying to do just that. We have a wonderful opportunity to be leaders in this area- we can educate ourselves and share resources with our peers, and we can commit ourselves to providing the highest quality, most culturally sensitive care to every single patient we see.

  1. Swisher LL, Hiller P, others. The revised APTA Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant: theory, purpose, process, and significance. Phys Ther. 2010;90(5):803-824.
  2. Hayhurst C. Managing Patients Who Are Transgender. http://www.apta.org/PTinMotion/2016/7/Feature/Transgender/. Accessed July 26, 2016.

About the Author:

Bio_pic Lisa Cheek, PT, DPT, is a 2016 graduate of Regis University.  She currently serves as the Assistant Director of Membership for the SOWH SSIG.  She is passionate about educating healthcare practitioners and the community about pelvic health PT.  She is currently employed at N2 Physical Therapy in Denver, CO, a specialty pelvic health and oncology clinic.

 

Evaluation of Percutaneous Tibial Nerve Stimulation for the Treatment of Refractory Painful Bladder Syndrome

By Yewande Apatira

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a condition that has garnered much interest over the years. Several treatment strategies for the management of PBS/IC have been researched into, including percutaneous tibial nerve stimulation (PTNS). Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment during which a needle electrode is inserted about one and a half to two inches proximal to the medial malleolus, and slightly less than an inch behind the tibia. Flexion of the great toe or fanning of the remaining toes confirms correct placement of the electrode. The intensity selected is the highest level tolerated by the patient, and sessions are performed for 30 minutes, one time a week for 10 to 12 weeks.

Several theories have been proposed for the positive effects of PTNS on PBS/IC and overactive bladder (OAB) syndrome. The tibial nerve, a branch of the sciatic nerve has fibers from nerve roots L4 to S3 and courses down the posterior lower leg, passing behind the medial malleolus en route the sole of the foot. The parasympathetic control of the bladder arises from sacral roots S2 to S4, and therefore, one theory is that stimulation of the tibial nerve leads to stimulation of S2 and S3 which in turn suppresses detrusor overactivity. Another theory discovered through animal studies is that PTNS decreased mast cell counts in the bladder of the female rats post-stimulation.

In a recent study by Ragab et al. 20 women aged between 31 and 53 years, with an average duration of PBS/IC symptoms of about five years and with poor response to other forms of treatments, were treated with PTNS for 30 minutes, one time a week for 12 weeks. At initial evaluation the majority of the patients (85%) complained of suprapubic pain, all patients reported frequency of micturition and nocturia, and glomerulations were seen in 95 percent of subjects. The outcome measures included the visual analog scale (VAS) for pain, O’Leary-Sant interstitial cystitis symptom index (ICSI), O’ Leary- Sant interstitial problem index (ICPI) and global response score (GRA). Measures were repeated after 6 and 12 weeks of treatment. Compared to baseline, no significant changes in all the outcome measures were recorded. However, the pain completely disappeared in one patient after 12 weeks.

The authors addressed only one aspect of PBS/IC, however PBS/IC has several drivers, including pelvic floor dysfunction and these drivers vary from person to person.  Therefore, reliance on only one form of treatment may not yield lasting or significant results for all patients. Furthermore, due to the chronicity of the PBS/IC among the subjects, chronic pain education and strategies may have been beneficial.

References

  • Gaziev G, Topazio L, Iacovelli V, et al. Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC Urol. 2013;13:61.
  • Preyer O, Umek W, Laml T, et al. Percutaneous tibial nerve stimulation versus tolterodine for overactive bladder in women: a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. Vol 191. Ireland: 2015 Elsevier Ireland Ltd; 2015:51-56.
  • Ragab MM, Tawfik AM, Abo El-enen M, et al. Evaluation of Percutaneous Tibial Nerve Stimulation for Treatment of Refractory Painful Bladder Syndrome. Vol 86. United States: 2015 Elsevier Inc; 2015:707-711.

Non-hip, Non-vertebral Fracture Sites: Don’t Forget About Me!

Why do hip and vertebral fractures get all the glory when it comes to fracture prevention related to osteoporosis in the current literature?  One study by Holloway et al. published in Osteoporosis International set out to change that trend.  The goal of the study was to introduce identified risk factors for non-hip non-vertebral fracture (NHNVF) sites, which commonly include the ribs, pelvis, humerus, forearm, wrist, upper and lower leg, and compare those risk factors to those for hip and vertebral fractures.  The authors suggest this is an important topic to look into because it has been found that NHNVF sites are actually responsible for a greater proportion of fractures when compared to hip or vertebral fractures.

Let’s get into how the data was collected before we dive into the results.  Control data was obtained from the Geelong Osteoporosis Study, which is a population based study that comes from southeastern Australia. Potential participants with fractures were obtained from the Geelong Osteoporosis Study Fracture Grid, and those who were 60 years of age and older and who sustained a fracture were then invited to participate in the study.  Final participants included 734 men and 1427 women.

How were those who had fractures different than controls in this study? The study found that women with NHNVF’s were heavier, while those with hip fractures were more likely to be older, have higher reports of past smoking, alcohol consumption and walking aid use, and reported lower mobility levels.  Women who had vertebral fractures had higher rates of dairy consumption.

Participants who had NHNVF’s were then compared to those who had hip fractures. Women who experienced a NHNVF had higher age-adjusted bone mineral density (BMD) levels at the femoral neck and spine, were heavier, had higher mobility rates, and reported more alcohol consumption.  In contrast, women who experienced hip fractures were on average older, had higher rates of past smoking and low dairy consumption, and reported using a walking aid more.   When women who experienced NHNVF’s were compared to those who had vertebral fractures, they found that those with NHNVF’s had higher age-adjusted BMD at the femoral neck, spine, ultradistal forearm, as well as total body.  Those with NHNVF’s were also heavier, younger, and reported more falls.

So what do these findings mean to us as physical therapists and physical therapy students?  This study has identified that the risk factors for different fracture sites are variable, and fracture prevention strategies should take this into consideration when developing prevention programs and identifying those individuals most at risk.

If you are interested in seeing how different clinical risk fractures (such as previous spontaneous fracture, parental hip fracture, history of smoking or alcohol use, RA, glucocorticoids, secondary osteoporosis, and BMD) can effect an individual’s risk for the development of fractures, check out the World Health Organization fracture risk assessment tool at http://www.shef.ac.uk/FRAX/.

Written by Kayley Mikolajczyk, a 3rd year PT student at the University of Minnesota and Assistant Director of Research for the Section on Women’s Health Student Special Interest Group.

References:

Holloway, Henry, Brennan-Olsen, Bucki-Smith, Nicholson, Korn, Sanders, Pasco, and Kotowicz. “Non-hip and Non-vertebral Fractures: The Neglected Fracture Sites.” Osteoporosis International 27.3 (2016): 905-13. Web.

 

Bladder Control: the topic that needs to be addressed more.

Most patients do not want to address this topic of incontinence, or loss of bladder control, unless it is directly asked. For many it is an embarrassing topic. Others believe it is something they just have to live with. That is far from true though. The sooner a patient seeks help for urinary incontinence the better. As physical therapists that spend quality time with patients, this is a topic we should address. It is often overlooked in primary care visits. Since we are musculoskeletal experts we should be providing optimal care and addressing musculoskeletal concerns. Incontinence can be due to muscle weakness that physical therapists, in particular pelvic floor or women’s health therapists can treat. It could also be due to bladder irritants. For a list of irritants go to: http://www.hopkinsmedicine.org/johns_hopkins_bayview/_docs/medical_services/gynecology_obstetrics/bladder_irritants.pdf

In 2009, a study was done looking at women from 25-80 years old in a managed care setting that had not been previously diagnosed with incontinence. The study conducted by Wallner et al found that out of the 875 women, 52% reported incontinence in the past year and 39% reported incontinence in the past week. This is alarmingly high considering incontinence has been linked to depression and nursing home admissions. This is an area that needs to be addressed more frequently in the health care field. So below are some ways to start.

Basic questions that all therapists should ask:

Do you experience any issues with bladder control? Making it to the bathroom on time or leaking when you cough? Or do you have to go frequently?

If yes, ask more:

How long has it been occurring?

Are you on any diuretics, HTN medications, depressants, or sleeping pills? (These can cause acute incontinence.)

How much do you drink per day?

How often do you need to go to the restroom during the day and at night?

Normal values therapists should know:

Average number of times you should urinate a day: 6-7 but it will vary depending on how much fluid you consume and if on diuretics. Anywhere from 4-10 times a day can be normal.

Average number of times one should have to urinate through the night: 0-1 time

Patients should consume eight 8 oz glasses of water per day or about 2 liters or ½ gallon.

If patients say they have to urinate frequently or cannot hold the urge, talk to them and see if they would be interested in seeing a PT that could address that issue!

What can be done to help with bladder control? Pelvic floor muscle re-education and training with biofeedback, pelvic floor strengthening, bladder diaries, avoiding bladder irritants, education on proper techniques to decrease intraabdominal pressure. Patients can look for physical therapists that have received additional training in this and have their Certification in Achievement of Pelvic Physical Therapy (CAPP). Click here to find a CAPP Certified Therapist: http://www.womenshealthapta.org/education/find-a-capp-certified-therapist/

 

Written by April Wenthe, SPT, a 3rd year at Maryville University in St. Louis, MO.

References:

Wallner LP, Porten S, Meenan RT, et al. Prevalence and severity of undiagnosed urinary incontinence in women. Am J Med. 2009: 122(11):1037-42. doi: 10.1016/j.amjmed.2009.05.016.

http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=a357f7d4-02f1-49cc-b03c-299c69d6dfc6

RC 11-16: The Quick & Dirty

Student Loan Debt” seems to be a buzzword these days and quite a hot topic. If you are a student like me, you love getting those emails showing your most “up-to-date current principal balance” and watching your balance skyrocket. But the Oregon Chapter has taken a step to combat (not eliminate) the increasing student debt issue, and has had some serious backing from chapters such as Georgia, Maryland, Mississippi, New Mexico, and Texas; as well as the Oncology and Pediatric Sections of the APTA; and this step is titled “RC 11”. So, as a student, what do you need to know about RC 11-16? Here is the quick and dirty of what it is composed of & what it could mean for you!

  1. The Why: You may be asking yourself WHY did Oregon put together this motion? Well, let me tell you!
    • RC 11-16 is attempting to understand the effect of student loan debt on the profession, the association, and ultimately society, and to take steps to ameliorate that effect.
    • RC 11 also encourages more research to be done about student loan debt burden.
      1. The last survey about student loan debt was completed in 2007, and as a result, there are no known tangible actions taken.
      2. No follow-up survey completed or even planned.
    • Finally, RC 11-16 is encouraging the need to understand the rising debt-to-income-ratio and how it impacts future decisions of those riddled with debt.

After all the information has been collected, RC 11 encourages the APTA to make recommendations for additional actions to mitigate threats facing our profession and associated related to student debt.

  1. The What: RC11 has broken down four main areas that the APTA can expand upon by examining strategies used by other professional associations and optimize them for the physical therapy profession. So what did RC11 use as the proposed examples of how to manage these four main areas?
    • Scholarship: The Foundation for Physical Therapy or another similar organization could establish an endowment funded by individuals and groups to support scholarships and loan forgiveness for well-qualified physical therapy students and new professionals. Although this is not within the current mission of the Foundation, RC 11 states that initial communication with the Foundation on this indicates it is willing to consider this.
    • Loan Refinancing: the APTA could partner with a lending organization to offer an attractive new member benefit to new professionals with student loan debt who maintain membership within our organization. This could allow more attractive interests rates.
    • Education: Provide financial literacy and money management skills to prospective and current PT students and new professionals to aid in decision making around student loan debt.
    • Advocacy: Our Student Assembly and other new professional and student-focused special interest groups could increase their power to impact state and national student debt legislation by intentionally aligning with an increased breadth of allies to significantly increase the number of individuals and voices working in ways that will benefit physical therapy.
  1. The How: How can this affect you? You may be a first year or still in your didactic curriculum and just wanting to pass your next Kinesiology Exam. But one day, very soon, you will be looking for a job! You may want to enroll in a post-professional residency program! You may want to start a life, as well as your career, and purchase a house! These loans will follow you, they will impact your future decisions. RC 11 questions if we, as students and new graduates, are seeking initial employment positions based on financial considerations rather than career enhancement and skills development? Following the money is not the answer; it just means that you will not be happy and potentially not provide the best care possible. If we can combat that first hand, we will provide better patient experiences out of the gate!
  1. What Can You Do? So, as a student, what can you do? Well, the fact that you are a STUDENT or a #FRESHPT works in your favor; people love to hear from the future of the profession! Students from the Wisconsin and Arizona Student Special Interest Groups (SSIGs) are starting to take action; they are taking the Advocacy subsection to heart! These two states are planning to get face time in each school and educate the students, call your representatives, voice your opinion on Social Media, and make some noise! These are all things that you can do! Does your state have a SSIG? Can you enlist the help of your Core Ambassador to work on calling representatives, going in to the classrooms within your state and educating your fellow students, or starting a social media movement?

RC 11-16 goes before the House of Delegates on June 6-8, 2016, so get out there and start talking about RC11 and make some noise!

 For more information on motions and the House of Delegates, or to contact a delegate, use the APTA website: http://www.apta.org/apta/directories/HODRosters.aspx?navID=10737423707

“The time for action is now. Each year that passes increases the number of individuals in our profession affected by student loan debt. The House of Delegates elevated our profession to the level of doctor to optimize our expertise and our utility to society. It is now time for us to make that plan sustainable by protecting the future of our profession.” 

 

About the Ajhoweuthor: Jen Howe is a 2nd year Physical Therapy Student at A.T. Still University in Arizona. She is currently the Director of Communications for the SoWH SSIG & works on the Arizona Student Special Interest Group’s Board as well. She is looking forward to starting her clinical rotations in August, and cannot wait to enjoy some time out in the sun or on her yoga mat in the one month she has off in July!

 

Student Perspective: 4 Take-Away Points From My First Introduction to Pelvic Floor Assessment Course

Take a moment and think about your current Physical Therapy or Physical Therapy Assistant curriculum. Most skeletons consist of Anatomy, Kinesiology, Therapeutic Exercise, Manual Techniques, and Evidence Based Practice; all of these topics are a small window as to what a PT student or fresh graduate is expected to know and carry on in to their practicing years. However, what I have come to learn is that my program is forward-thinking and different from those in my area, let alone across the country. I am one of the 62 students who attend a Arizona DPT program, who take a Gender Health Care class; a whole quarter of topics ranging from the childbearing year, pelvic floor anatomy, prostate health, incontinence, and so much more. Coming in to PT school, I honestly did not know that the pelvic floor was within the scope of the Physical Therapy practice guidelines; and now, we see it everywhere; Twitter & all over the 2016 CSM topics list!

Pelvic Floor health is a topic that I just want to know as much as I can. I am interested in the anatomy, the impairments, how PT is able to intervene, and the patient stories of their experiences. So, when my current Gender Health Care professor came to me with a great opportunity to take an “Introduction to Physical Therapy Assessment and Treatment of Pelvic Floor Dysfunction” course; I jumped at the chance. Off the bat, I was nervous to step outside of my comfort zone; but I wasn’t alone, there were 23 other students who were feeling pretty similarly to me. We spent all weekend learning how to assess the pelvic anatomy and structures, grade the strength and endurance of the pelvic floor muscles, and learn about the PT interventions for urinary and anal incontinence, pelvic organ prolapse, and pelvic pain. After the whirlwind of learning and working with other students who quickly became friends, there are four main take-aways that I pulled from this experience.

#1 Patient Comfort is THE most important aspect of any evaluation

Day 1, 55 minutes into class, it was time to bring up our first model, front and center. We all knew what we were getting into signing up for a course that focuses on internal examination, but the first was kind of a culture shock. Our lead instructor used this as a time to educate us on the importance of patient comfort. Walk your patient through what you are seeing, about to assess, and put them at ease that they are in control. We, as Physical Therapists, spend up to 45-60 minutes (maybe more) with our patients, we need to create a safe environment for open communication. Taking this course, I have a new found respect for how vulnerable a patient may feel on the table; nerves and anxiety cannot even begin to describe the mixed bag of emotions that I felt and I KNEW what to expect. Experiencing this first hand was an awkward experience at first, but an invaluable learning opportunity.

#2 Self Education brings more than just knowledge.

Self-education is not just showing up, listening to the speaker, and participating in the lab component. It is making new connections, being honest with yourself, putting yourself out of your comfort zone, reflecting in and on action, and applying these concepts outside of the course. Self-education can lead to a ton of self-growth if taken seriously. I made so many connections with 23 other amazing students from Arizona. These individuals are women who I may run into on my clinical rotations, after I graduate, or way down in to my future career. I am growing as a professional, building my networking, creating bridges, & keeping those doors open.

#3 The Pelvic Floor is Underrated

Pelvic anatomy differs between males and females, but one thing that we all have in common is a pelvic floor, which is a group of muscle bellies that help to complete our core canister. Working on our pelvic floor is not something most individuals think about on a daily basis, but with a pelvic floor that isn’t functioning at its’ best our organs would literally fall out of our bodies, we would have issues with urination and defecation, pregnancy would be next to impossible in a safe manner, and one would not be able to enjoy (or have) sex. These tasks are ones that most people take for granted, and so you can see that they are pretty important for daily functioning.

#4 Kegels are Hard

Kegels are hard. I cannot say that enough! It is not only hard to isolate the voluntary contract, but it is also hard to relax. So, it is no surprise to me that 70% of people are doing them wrong (including me)! Kegels are not appropriate for everyone, especially for someone, like myself, who should be down-training. As a Physical Therapist we can supply hands on feedback that can be crucial to the patient’s success! It is best to start slow and work from there. Work on activating the (correct) muscles and progress to increasing endurance and coordination; once these are mastered, the training of the pelvic floor knows no bounds and can be added into function activities and personal interests to the patient.

For anyone who is curious if their pelvic floor contractions correctly, you can see it! For a quick self-assessment, using a hand held mirror, you can see your perineum lift up and in when you contract and then lower when you relax!

I am so happy that I stepped out of my bubble and took a chance on this class. I encourage you all to do the same no matter what your interest are. Don’t stop trying to quench your thirst. Go out, continue to learn, and don’t stop; ever. Whether it is personal or for your future career, there are so many opportunities and others out there like you who are worth meeting & creating mutually enriching bonds to learn from/with as you pursue your passion.

 

About the Author: Jen Howe is a 2nd year Physical Therapy Student at A.T. Still University in Arizona. She is currently the Director of Communications for the SoWH SSIG & works on the Arizona Student Special Interest Group’s Board as well. She is looking forward to starting her clinical rotations in August, and cannot wait to enjoy some time out in the sun or on her yoga mat in the one month she has off in July!

jhowe