Show Notes
Rewards for quality, consequences for a lack of. It’s not a big ask, is it?! Yet to my eye we have neither and it risks stagnating the MSK industry. In any healthy environment the incentives are well balanced. An excess of rewards, especially for those undeserving when it comes to effort and ability, creates a cringeworthy, self-important and sycophantic atmosphere [1]. The technical literature in this direction names it ‘Distributive Injustice’. As a deeply untechnical person I’m going with ‘too many carrots’. Disproportionate consequences decrease healthy risk taking, innovation and creativity whilst inadvertently promoting deception at best and bullying at worst [2]. The modern lingo refers to ‘Psychological Safety’ and its absence. Again, I am reaching for the accessible term ‘too many sticks’. The Missing Town Square The reason I’ve immediately gone to describe an excess of both is because I think by temperament, we clinicians tend towards carrots and have a healthy concern for sticks. We witness the upside of positively praising a patient’s participation in their rehab and recognise the difficulty recovering a relationship when a patient feels dismissed or threatened. But we are in the behaviour change business. We need to balance incentives and recognise that good rapport gives you scope to discuss both the positive outcomes of treatment AND the negative consequences of functional disability. But we’re nice [3]. It’s a care thing. It’s a therapist thing. It’s the selection pressures that make certain people work in pain and injury rather than civil engineering and finance. But I think that this disposition leaves us ill-equipped when it comes to the necessary work we need to do to improve industry standards, practices and policies. It feels uncomfortable for some to even witness someone asking “Why do you do it like that?” or “Might there be a better way of doing this?”; especially if said challenge is across a perceived authority line! This discomfort made the professional debates on podcasts such as Physio Matters, and public social media such as Twitter, a surprising and rare phenomenon. We listened and watched because some of the friction sparked positive engines of change. We listened and watched because some of the friction sparked destructive wildfires of shame. Between 2013 and 2023, Twitter was the MSK town square and while Facebook, Instagram and LinkedIn had their artisanal monthly craft markets, Twitter was always open and had stalls for all arguments. A crucial difference between Twitter and the other platforms was that you couldn’t delete other people’s replies when they were inconvenient. Now I don’t want to romanticise this time and I’ll absolutely be coming back to the ample issues of it, but when I look out over the current MSK landscape, I am very concerned that we are missing a town square. Very rarely is the answer to an imperfect forum to instead not have any at all. We’ve regressed into siloed, closed shops where special interests, style specific and professionally exclusive clinical discussions are left under-scrutinised and under-exposed. We lack sticks, have forgotten how to make them and I fear that our next generation have developed the stick allergy of the 1990s and 2000s. Bring back the square, not the stocks Public MSK debate back then was a bit aggro. The injustices in how patients were being mismanaged and how authorities and institutions were gatekeeping knowledge were so obvious and blatant that tensions ran high much of the time. It disrupted stale and lazy thinking but also disrupted a polite agreeableness that was seen as the ‘professionalism’ of the time. To my taste, it was often overstated how hostile the atmosphere was and the vast majority of the time, people shared opinions and literature in defence of their styles of practice. But any opposition to the norms of the time felt uncomfortable in the same way that democracy is uncomfortable. That said, the fact that Twitter and iT
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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