On Creating Agency as a Patient

Agency is defined as, “the capacity of individuals to act independently and to make their own free choices.” What does this mean for healthcare? How does the healthcare consumer maintain and create agency while also navigating the complexities of medicine?

A few weeks ago, I traveled to Washington DC to teach a group of 40+ physical therapists and occupational therapists about working with people who are dealing with various types of pelvic pain. Over this 3-day course, we covered topics related to diagnosis, medical management, manual therapies, movement interventions, and much more. On the third day of the course, I gave a lecture on “trauma-informed care.” What is trauma-informed care? Trauma-informed care means the “adoption of principles and practices that promote a culture of safety, empowerment and healing.” While we do focus on how widespread trauma is, the varying ways people experience trauma, and strategies to develop sensitivity, respect and consideration for the needs of our patients, we also strongly emphasize the importance of treating all patients in this way.  One of the key pieces in doing this is helping a person develop a strong sense of agency– the ability to make their own educated decisions and partner alongside their healthcare professionals, instead of being the recipient of directed care.

The idea of agency can seem fairly basic. Shouldn’t every patient feel like they can make their own decisions? Shouldn’t they feel like their healthcare providers are all members of the same team? But, that is often not the case. When a person loses this agency, they can end up in situations where things start happening to them, instead of with them, and this can create difficult and sometimes traumatic experiences. This could be a mother who feels pressured to have a birth intervention she was really not comfortable with having. This could be a person being scolded for not being “compliant” with their recommended home exercise program (as opposed to their clinician understanding what happened and partnering with them to fit exercise in their lives). Or, it could be feeling pressured to continue a painful examination that they otherwise would choose to stop.

There are many reasons why losing one’s agency is detrimental. Remember, the pelvic floor muscles respond to threat. So when a person is in a situation where they feel threat (whether that is due to stress, a difficult situation, or other circumstance), the pelvic floor  will activate. When someone is dealing with something like pelvic pain, sexual pain, and other diagnoses, this can lead to a problem becoming worse. So, how can you maintain your agency as a patient?

  1. Ask Questions. All the Questions. “The only stupid questions are the ones that are not asked.” If you aren’t understanding what is being recommended to you, ask more questions for clarification. Your healthcare provider should always be happy to answer any questions you may have to help you make the best decisions for your care. This also applies to times when you are in the middle of a treatment/procedure/etc. Ask away.  Try saying:
    • “Would you mind explaining my options again?”
    • “Can you clarify what the benefits and risks would be to…”
    • “Are there any risks in not moving forward with that treatment?”
    • “What are the reasons you think I need to…”
    • “I’m sure you have a busy day, but it would really help me if you could answer a few questions.”
  2. Don’t be afraid to slow things down. If your treatment session or medical appointment is going a direction you are uncomfortable with, or if something is happening that you don’t feel like you understand, feel free to take a break. Try saying:
    • “I need some time to think about that.”
    • “I would like to take a few minutes to consider my options.”
    • “I would prefer not to move forward with that today.”
    • “Can you explain _______ to me again?”
    • “I’m not sure I understand all of my options.”
    • “I’d like to go home and think about all of this. I’ll let you know what I think at our next visit.”
  3. Bring a friend. If you know that you tend to get overwhelmed at your appointments and have difficulty expressing your needs or how you feel, consider bringing a friend/partner/spouse who will have your back! Tell them in advance what you want their role to be and how they can help you! This could be stepping in to ask for some time to consider options, asking a provider to slow down and repeat their explanation, or simply being a person to be present with you during a difficult appointment.

I hope these tips have been helpful in helping you develop strategies to create agency as a patient. If you are a healthcare provider, I urge you to reflect on your own practices. Do your words and actions support your patients in maintaining autonomy? support agency? Do you unintentionally pressure patients into participating in treatments or exams that they may not feel comfortable with? Do you shame patients when they don’t follow your recommendations? None of us are perfect. I truly believe that most health care providers have the best of intentions. But, we can all do better. Reflect on our own words, habits, body language, and be better partners for our patients!

What other strategies have you found to help you improve your agency as a patient?

~ Jessica

 

 

Podcast Interview: Real Talk with the Pelvic Docs

Happy Monday Everyone!

I am 2 weeks in to my new practice, and absolutely loving it! I was fortunate this past week to be a guest on the podcast series, Real Talk with the Pelvic Docs. Jenny LaCross has been a friend for a few years (we connected when she was in her residency program), and she’s doing amazing things for the pelvic health community! It was such a pleasure to talk with her about my experiences with pregnancy, childbirth and my own postpartum recovery. You’ll also hear more about my journey to private practice and my hopes and dreams for the future! I hope you enjoy this podcast as much as I enjoyed recording it!

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Click here to listen to my guest interview on Real Talk with the Pelvic Docs!

Attention Health Care Providers! Come learn about Vulvar Dermatology from Dr. Andrew Goldstein!

I am super excited! I am hosting Dr. Andrew Goldstein at my NEW CLINIC for a one-day intensive course on Vulvar Dermatology on Saturday, November 2nd!!! This course is open to PTs, MDs, PAs, and NPs, and should be absolutely epic!!

Dr. Goldstein is known internationally as a leader in the treatment of vulvar pain disorders, and is very well-published on the topic. It should be an incredible day of learning, and I can’t wait to show you all my new space!!

I hope you will join me for this important class! Pelvic PTs and other HCPs- let’s always keep learning!

Register for the class!!

~ Jessica

Early Recovery After Caesarean Birth

6 weeks ago, we welcomed our second daughter into the world. Mary Lynn was 6 lbs 10 oz of squishy, adorable, babyness. And she came into the world via a Caesarean birth. And it was amazing. And hard. But good.

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In the recovery room right after Mary’s birth!

C-sections come with challenges, just like vaginal births do, and for me, these challenges included a significant blood loss that led to me fainting on the second day, a super low blood pressure due to a response to the epidural that contributed to the fainting but also meant going off of my epidural pain meds really early, and nerve pain that lasted for about a month after Mary was born. (We’ll y’all more about that another time.)

Since I am living the early postpartum life, I thought it would be fun to do a series of posts on my own rehabilitation journey (since, in many ways, each of my births has been a mini-case study for myself!).

So, let’s talk Cesarean rehab in the first 6 weeks!

Moving well after major abdominal surgery

I love when people imply that birthing via Cesarean section is somehow “the easy way out” compared to birthing via the vagina. Hello people, this is major abdominal surgery! All mommas get birthing badges– let’s support each other in our journeys, right?!

Initially after a Cesarean, movement alone can be challenging. Standing up from a chair. Rolling over in bed. Lying down in bed. But the good news is that with some easy tips, this movement can become much easier. First, as you are moving, bending, standing, etc. remember to “blow before you go.” This easy to remember phrase comes from my friend and colleague, Julie Wiebe. This means, begin to exhale before you initiate a movement. Breathing like this with movement helps to control pressures within the abdomen and pelvis, so it can significantly help you in your movement after having your baby- both in terms of ease but also in protecting your pelvis and abdomen.

When standing up from a chair, remember, nose over toes. Scoot to the edge of the chair first. As you go to stand, lean forward first. This puts your body weight over your legs and helps take the burden away from your core.

When you lie down or get up from lying down, channel your inner log. So, when you lie down, first sit on the edge of the bed. Slowly lift your legs onto the bed, then lower the rest of the body down, using your arms for support. If you need to roll over, bend your knees, then roll your body as a unit- like a log. Reverse these steps for getting up out of bed.

Abdominal Binders and Compression Underwear? It depends. It may be worth considering  using an abdominal binder for the first few weeks after your birth, progressing to wearing compression underwear or shorts(ie Spanx, SRS recovery shorts, Core shorts). These types of garments provide support to the abdomen and can be incredibly helpful for moving and walking around after your surgery. The flip side with compressing the abdomen is that it can impact how well you can move your ribcage and can influence pressure mechanics within the pelvis. So, if you are already struggling with pelvic organ prolapse or urinary leakage, or if you pushed for a period of time before having a Caesarean birth, it may be worth talking with a pelvic floor PT prior to utilizing this during your recovery. Generally, the compression underwear/shorts provide more support to the pelvic floor and abdomen, so they may be a little better with pressure modulation than the binder. For me personally, the binder and compression undies were amazing! They took away my nerve pain, and helped me move much better. I chose to wear these sporadically during the day (a bit on, a bit off), and practiced breathing well with my diaphragm during the times the binder was off.

Handling your incision

Initially, your main focus here is keeping your incision clean, and monitoring it to make sure it is healing well with no signs of infection. Around 6 weeks, if you are cleared by your physician, you can begin to gently mobilize the tissue around the scar and aim to desensitize the scar. I usually start above and below the scar, before working on the scar itself. You can perform gentle massage to the tissue above and below the scar and gently stretch the skin in all directions above and below the scar. You can also gently desensitize the scar by touching it with your fingers or a wet cloth, and gently rubbing across the scar in all directions. We can mobilize this scar tissue further, but we are going to talk about this in a future post as this post is focusing on the early period of healing.

At this time, you can also begin applying silicone gel or silicone strips to help soften your scar and prevent hypertrophic or keloid scars. Silicone is considered a gold-standard treatment for the prevention or treatment of hypertrophic scars. While most of the research regarding silicone is of poor quality with significant bias, evidence does tend to suggest a positive benefit. My first Caesarean did lead to a hypertrophic scar, so I began applying silicone gel to my scar once cleared by my OB to do so, around 4 weeks after Mary’s birth. I’ll report back on the difference between this new scar and the old one (See, mini case study!).

**I also have to note here that my colleague, Kathe Wallace, has a fantastic book that details some recommendations for scar tissue management after Caesarean. Kathe also offers a free abdominal scar massage guide at her website, which is a fantastic resource!

Exercise in the Early Postpartum Period

If I could give you one piece of advice on this early postpartum period, it would be to relax. Give yourself a break. Allow yourself to recover and heal. I find that so many people want to jump into too much, way too soon, and unfortunately, this can be more harmful than it is helpful. Remember, you just did something incredible. You just had major surgery. You deserve to rest. 

When we think about exercise during this initial period of healing, we are going to start very gently. Here are a few things you can get started on:

  • Walking: I’m not talking about going and walking several miles. During the first few weeks, it’s best to really rest, and give your body time to heal. Getting up, walking around the house as you feel comfortable can be very beneficial.  As you continue to heal, during the next few weeks, you can increase your walking. So, this may include some outings and short periods of walking between 2-4 weeks. Between 4-6 weeks, you can generally consider a leisurely walk in your neighborhood or a longer outing. The key here is to listen to your body. Rest when you need to, but gradually move to increase your endurance. After you see your OB for a postpartum visit around 4-6 weeks, and you are cleaned to do so, you can continue to gradually increase your walking as you are feeling comfortable.  Are you antsy to jump back into running? Zumba? Bootcamp? Pilates? Don’t. We’ll get there. But let’s rest right now.
  • Breathing: You all know I am fairly obsessed with the diaphragm. 4 years after this post was written, I still think it’s one of the coolest muscles in the body. The diaphragm works in coordination with the pelvic floor muscles, deep abdominal muscles and deep low back muscles to provide support to the abdominal organs, modulate pressure in the thorax and pelvis, and provide dynamic stability to our spine and pelvis. Slow breathing, aiming to expand your ribcage and relax your abdomen as you inhale, then slowly exhaling your air can be incredibly beneficial to re-establishing these normal functional relationships.
  • Gentle Pelvic Floor Muscle Activation & Relaxation: First, my biggest recommendation would be to SEE A PELVIC PT before and during your pregnancy so you really know your current function and can have an individualized plan to get the most out of your muscles and your body. I encourage people to discuss their delivery with their OB, and ask about beginning gentle pelvic floor and abdominal exercises. The timeline for starting this will depend on the specifics of your delivery, and we want to be smart when activating muscles that have been cut. When your provider is on-board with you starting, I like to pair gentle pelvic floor and abdominal wall activation with breathing. This looks like this:
    • Inhale, expanding your ribcage, relaxing your abdomen and your pelvic floor muscles.
    • Exhale and gently draw in your pelvic floor muscles, allowing your lower abdominal muscles to also gently draw in. Aim for a “moderate” effort to allow activation of the muscles but not overactivate them.
    • Then, relax your muscles again as you inhale, repeating this cycle.
    • Aim to do this for a minute or two, twice each day.

Stay tuned as we continue this journey over the next few weeks and months! What have been your challenges after childbirth? For my fellow health care professionals, what else do you like people to know immediately after a caesarean birth?

Have a great week!

Jessica

5 Ways Pelvic PTs Can Help with IBS

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This month is IBS Awareness Month!

Irritable Bowel Syndrome (IBS) can be an incredibly life-impacting condition, affecting around 10-20% of the population (80% of those individuals being female!). The exact cause of IBS is unknown, but it is thought to likely be multifactorial.

IBS is characterized by abdominal pain paired with constipation and/or diarrhea. When many people hear about IBS, they may not automatically think that working with a physical therapist could be useful; however, there is so much that physical therapists can do to help improve symptoms related to IBS. Here are a few!

1.) Assist the client in developing optimal bowel habits.

We’ve discussed in detail several times how our habits can be extremely connected to our bowel function. This is also very true for individuals dealing with IBS–whether struggling with constipation, diarrhea or both! Training bowel habits includes developing a consistent bowel routine, optimizing dietary habits, and even toilet positioning/defecation strategies. These factors basically aim to help make sure your habits are working for you instead of against you. Sometimes these components require a more multidisciplinary team. This can include working with your GI physician, pelvic PT, as well as a dietician, functional medicine provider, and other specialties.

2.) Global downtraining and stress management.

Did you know you have an extensive neural network throughout your GI system? This network has been termed “the second brain” due to its ability to function even when cut off from the rest of the system. It’s also often called “the emotional brain of the body,” which makes sense when we think about how often we feel our emotions in our gut (i.e. “butterflies in your stomach” or “my gut reaction”) All is this means that our GI function can often be influenced by our stress, emotional regulation, and general psychological well being.

Qin et al. (2014) stated, “More and more clinical and experimental evidence showed that IBS is a combination of irritable bowel and irritable brain.”  They went on to add that psychological stress can impact intestinal mobility, motility, secretions and permeability. They concluded that, “IBS is a stress-sensitive disorder, therefore, the treatment of IBS should focus on managing stress and stress-induced responses.”

Pelvic PTs utilize strategies promoting downtraining and neuromuscular relaxation to help calm the nervous system and promote a more parasympathetic dominant state.  This can be done through movement, relaxation strategies, mindfulness/meditation, and many other techniques. Want to get started on mindfulness now? Check out this prior post on Mindfulness, Meditation and Pain.

3.) Specific exercises aimed at promoting better movement.

This may not seem connected at first, but the reality is that when people aren’t feeling well or when someone is struggling with constipation/diarrhea, people tend to move less. This can often impact bowel function as regular exercise tends to stimulate more regular bowel movements. This 2019 review of 14 studies involving exercise interventions aimed at improving IBS symptoms found that exercise does seem to have a role in helping bowel function (Note: many of these studies were not so great, and found to have a high risk of bias, so more studies are definitely needed!)

Schuman et al. (2016) performed a review of 6 randomized-controlled trials looking at the role of yoga in helping people with IBS. I’ll be honest, I absolutely love yoga and find the pairing of breathing, mindfulness and movement to be so beneficial to myself and my patients. So, I was not surprised to see this review showing that the groups participating in yoga had decreased bowel symptoms, IBS severity and anxiety.

Additionally, it is common for someone with chronic constipation and/or diarrhea to have restrictions in the movement of their hips and spine. Restoring this movement through specific exercise can facilitate better function of the muscles around the pelvis, including those involved directly in bowel function.

4.) Treat the myofascial components of the problem.

We have discussed the viscerosomatic and somatovisceral reflexes in the past. Basically, when a person has an organ problem (in this case, IBS), we often will find that the myofascial tissues around the organ can become restricted and sensitive. This can be interconnected where myofascial dysfunction can worsen a visceral problem and a visceral problem worsens myofascial dysfunction. Thus, addressing both sides of the problem can often be very optimal. From a musculoskeletal standpoint, this means identifying structures around the abdomen and pelvis which may be sensitive or not moving as optimally. This can often include the abdominal wall, hip muscles, thigh muscles, buttocks muscles and the muscles around the low and mid back.

5.) Treat underlying or co-existing pelvic floor problems.

Prott et al. (2010) found that there were relationships between pelvic floor symptoms and anorectal function in individuals with IBS. Dysfunction of the muscles of the pelvic floor can present as weakness, which can lead to either difficulty holding back stool or poor support around the rectum. It can also include overactivity and poor relaxation of the pelvic floor muscles. This can contribute to pain, but also can influence how well the muscles can open for defecation , or hold back when they need to. Additionally, people can experience difficulties with coordination of the pelvic floor– basically, when the muscles do not contract or relax when they should. Dyssynergic defecation occurs when the pelvic floor muscles contract instead of relax when a person has a bowel movement. This can be a significant problem for those struggling with constipation. I wrote a whole article on that, and you can find it here. Sphinctor dyssynergia can occur in individuals with IBS as well as other types of constipation, and can be treated with pelvic PT (lots of treatment options, including SEMG biofeedback which has been found to be helpful for people with and without IBS).

IBS can be so impacting to a person’s life, and you don’t have to suffer alone! I encourage you to build your multidisciplinary team and start getting the help you need to get the most out of life!

What strategies have you found most helpful in dealing with IBS? As always, I’d love to hear from you!

~Jessica

Video Interview with Dr. Ken Sinervo: Internationally- Recognized Endometriosis Expert

Happy Endometriosis Awareness Month!

Did you know that Endometriosis affects more people that inflammatory bowel disease?

Did you know that 10-15% of women (and some men too!!) suffer with endometriosis?

Did you know that they often see 7+ physicians before being diagnosed with the condition?

Endometriosis is so common, and often can be a very life-impacting condition. As a pelvic PT, I often treat individuals with endometriosis, helping them with the musculoskeletal and neuromuscular sequelae of the condition. I have also helped many patients navigate the healthcare system to ultimately receive the appropriate care they so desperately have needed.

In honor of Endometriosis Awareness Month, I asked Dr. Ken Sinervo, the medical director for the Center for Endometriosis Care in Atlanta, GA to spend some time with me discussing this important diagnosis. Dr. Sinervo is an expert in treating endometriosis, and I can’t tell you how lucky I am that his office is about 20 minutes from mine! He is also a kind and humble person and a compassionate physician, and I was so excited to interview him for this post!

In the video below, we discuss: 

  • What is endometriosis and where does it occur?
  • What are the current theories on the causes of endo?
  • How can it be treated?
  • Excision vs. Ablation surgery
  • How to find an Endo expert
  • For pelvic PTs: How do you identify patients who may have endo?
  • And, as an extra bonus, cherry on top, Dr. Sinervo describes the research he is involving in trying to identify potential markers to actually test for endometriosis!!

I hope you enjoy the video as much as I enjoyed interviewing him! I apologize in advance if our video cuts out a little bit, but I don’t think it impacts the incredible content (Our weather in Atlanta was a little struggly, so I think my internet had some difficulties!).

 

Interview with “The Vagina Whisperer” on Pregnancy & Postpartum Health, Advocacy, Being a Mom, and Everything in Between!

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About 2.5 years ago, I had the incredible opportunity to join Herman & Wallace Pelvic Rehabilitation Institute as a Faculty instructor for the Pelvic Health Series. This was an absolute dream come true for me, as I completely love teaching and had always dreamed of teaching continuing education in pelvic health. (Seriously… as a new grad, I remember asking an instructor at a course what advice they had for someday becoming an instructor. Funny story is that I now co-teach with that very instructor!).  Teaching in pelvic health has been such a incredible blessing for me– not only do I get to travel across the country and help other clinicians learn to treat my most favorite population of patients, but I also get the opportunity to co-teach with inspiring and incredible experts in pelvic physical therapy.

This past September, I had the opportunity to teach with Sara Reardon, PT, DPT, WCS, BCB-PMD, who is not only an incredible clinician, but is also hilarious, down-to-earth, and passionate about women’s health. One night at dinner, Sara, Darla Cathcart, and I had a long conversation about pregnancy, childbirth, the postpartum period, and becoming moms. At one point, I think all of us had tears in our eyes, as we shared our own journeys, challenges we/our family/our patients have had, and our hopes for making everything better. After that chat, I just knew I needed to interview Sara here so all of you have the opportunity to learn from her and feel her passion! I hope you enjoy this interview! Please feel free to leave any questions or comments below!

If you would like to see Sara’s work, check her out at www.thevagwhisperer.com. Here, you will find information about seeing Sara in-person, her online therapy options, mentoring options, and her instagram/blog presence!

Happy New Year!

Jessica

If you want to see all of our expert videos in one place, be sure to check out my youtube channel! This video as well as the others can be found here!