Show Notes
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Observing clinicians across the landscape of musculoskeletal care, I see the relentless effort poured into every consultation. Everyone is doing their best in the healthcare system, be that public or private, but as we know, the workload and complexity have increased. The total number of people living with an MSK disorder globally sits at approximately 1.68 billion representing a 95% increase in total cases since 1990 [1] and are on a trajectory to expand by more than half by 2050 [2]. While physiotherapists have significantly increased their scope of practice over the last 40 years, in particular into areas of practice that were historically occupied by medicine, how are we managing this continuing and increasingly challenging future? Recent research suggests that physiotherapists in the UK are struggling with burnout [3–6], work related stress [7] impacting on wellbeing resulting in moral distress and injury [8,9]. It appears that the profession is stretched holding the professional duties, roles, responsibilities and obligations in one hand and trying to adapt to growing and multiple patient, societal and system related influences in the other. This can make clinicians feel trapped, stagnant, and stuck in a healthcare system that itself is struggling to adapt. In a way, we feel like we are on a treadmill, walking, running, even sprinting, but never getting anywhere. Dave Nicholls captured our current predicament beautifully in his 2024 IFOMPT presentation in Basel, titled ‘The post-professional futures for the physical therapies’ [10]. He articulated the profound global and specific challenges facing our profession, pointing to three forces that are actively accelerating them: late-stage capitalism, the unbundling of expertise, and digital disruption. Dave asked penetrating questions about what comes next, concluding that we must uncover what truly lies beneath the surface of physical therapy. Only by doing so can we open up opportunities to adapt to this rapidly unravelling landscape. Before we attempt to answer this question let’s briefly take a history of the present of MSK physiotherapy.
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It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com