In Your Pants with Dr. Susie G - Muscle tone pelvic pain in men

Starting point is 00:00:00 you're listening to the in your pants podcast i'm your host dr suzy gronski your penis friendly pelvic health physical therapist sex counselor and educator helping you get in the know down below Hi friends, Dr. Susie G here and welcome to another In Your Pants podcast. On today's show, we are going to be debunking the myths and misconceptions around quote, air quotes here, tight, overactive, non-relaxing, hypertonic pelvic floor muscles. So many names with no conclusive data to support either of them. And to help debunk these misconceptions that are running rampant on social media these days is researcher Rachel Worman.

Starting point is 00:01:22 Rachel and I dive into the depths of her research to determine whether greater tone or higher activity equals pain and is the same applicable with pain causing greater tone or higher activity. You don't want to miss this episode. So before we dive into the juicy parts of today's show, let me formally introduce Rachel Werman and her fantastic accolades here. So Rachel is a licensed physical therapist in the United States who has extensive dual training, clinical and teaching experience in both musculoskeletal and pelvic health physiotherapy.

Starting point is 00:02:14 She has worked as a musculoskeletal and pelvic health provider in the private outpatient setting and most recently held a senior physical therapy position as a pelvic health provider in the Women's Health and Neurology Clinics of a large medical group in Northern California. She has held part-time and adjunct faculty positions at both the California State University at Fresno and Sacramento as well as a clinical lecturer position at the University of California at davis school of medicine the division of pain medicine she received her bachelor's of science in biopsychology with an emphasis in visual neuroscience and a minor in exercise and health science from uc santa barbara in 2002 her master of physical therapy from csu fresno in 2007 and

Starting point is 00:03:00 doctorate in physical therapy from the joint program at uc san francisco and csu fresno in 2008. In 2019, she was awarded a full scholarship from the University of Queensland for a PhD candidacy as a result of her advisors, Paul Hodges and Ryan Stafford, being awarded a large NHMRC grant titled Efficacy of a Personalized Pelvic Floor Muscle Training Program on Urinary Incontinence After Radical Prostatectomy, a Randomized Clinical Trial with Embedded Physiological Studies, where she is working on the Embedded Physiological Studies. Her research focuses on the study of pelvic health outcomes measures and male pelvic health, and her thesis was confirmed in 2020 with the working title, Toward an Understanding of the Role of Pelvic

Starting point is 00:03:50 Floor Muscle Tone in the Examination of Male Pelvic Health Conditions, Investigation of concepts of greater tone and a preliminary framework for down training. So she is certainly someone to keep on your radar for all things clinical research for men's pelvic health. I hope you enjoy today's show. Rachel, thank you so much for being on the show today. Thanks for having me. Well, we're gonna we're gonna dive right in because this is a topic that is certainly very passionate, a passion of mine, certainly having to deal with the pelvic floor, but also this, your, your research in the male pelvic health realm is this such an amazing conversation to have with you and to go over your, your most recent systematic review that came out

Starting point is 00:04:43 about tone, pelvic floor tone and overactivity and et cetera. So there's a ton of hype on social media right we we no argument there about how you know your pelvic pelvic floor tightness overactivity hypertonic in air quotes non-relaxing in air quotes um cause all sorts of problems right like pain sexual dysfunction urinary issues bowel issues etc so based on your most your research and your most current systematic review what language should we really be using to describe the state or the health of pelvic floor muscles and why? Yeah, that's a really great question. And so this systematic review, which is regarding the evidence for increased tone

Starting point is 00:05:42 or overactivity of the pelvic floor muscles in pelvic health conditions, was designed to look at outcome measures and to look at study methods and then we also pieced in terminology and that's because we're not speaking the same language and it's problematic and it was one of the things that led me to design my thesis in the way that I did um so let's tackle hypertonic first um i think in clinical circles it's long been discussed that this is an inappropriate term you've probably heard that right uh-huh because the majority of pelvic health cases are not cases with central nervous neurologic problems such as a spinal cord injury which would be the most appropriate context for this term yet we continue to see and hear this

Starting point is 00:06:37 term all over social media as you mentioned and from self-proclaimed guru pellet pts who are um who are proclaiming that they are evidence-based and before our systematic review came out there was actually the international continent society um came out with a terminology report that also suggested that we not use the term hypertonicity um and so this systematic review actually found that hypertonicity is the most commonly used term in the clinical literature um but never was it used in the clinical literature in the context of neurologic pathology interesting um and so um i think that this is um it's a problem because it's actually inaccurate and again you know not just our systematic review but reports

Starting point is 00:07:37 prior to this have have stated that and we've discussed it for a long time so at this point anyone using this term in the absence of neurologic pathology is um currently not practicing evidence-based practice that's just full stop in the mid-2000s there was an effort led to reduce the use of this term with a substitute term, overactive. In fact, there was a textbook by Tali Rosenbaum and Anna Padua that was published in 2016 called the overactive pelvic floor. However, this is also an inaccurate term. So first, if we think about tone, it is made up of two muscle properties, the active tone, which is the nerve activity that causes the muscle to contract and passive property which is essentially all the other content of muscles that are active

Starting point is 00:08:30 so the connective tissue the water content etc that give us resistance when we push on muscle so overactive is a term that is best used when we have used a measure of the active component of tone and the only measure to do that is emg there's also been a trend for therapists i think to move away from using EMG. Problematic. So if EMG was not used as a measure, we cannot use a term that describes muscle activity. So if you've not used EMG, we can't say overactive. And we saw a lot, the term overactive frequently used when say something like digital palpation was the measure, not EMG, which is technically inaccurate. Terms like non-relaxing pelvic floor do not make sense when describing a muscle that requires at rest a certain amount of tone to maintain

Starting point is 00:09:31 continence. Makes sense, right? But if we say non-relaxing, well, we don't want these muscles to completely be turned off so unless we want to wear pampers all the time so um in some context though non-relaxing may be an appropriate term for instance if we're measuring function and usually this is found in the urologic and the colorectal literature so if the assessment we make is during bowel or bladder voiding in that case we want the muscle to turn off fully and relax fully to allow for passage of bowel or bladder content. So it might be appropriate to use it there. Now, from our systematic review, we now know that there is not very much normative data.

Starting point is 00:10:24 So terms recently proposed, and this was also by the ICS terminology document, such as increased tone are also inaccurate. So in the absence of normative data, we can't state that something is increased as we have no normal values to compare that against. We also cannot use that term on an initial evaluation because we don't have prior values for the previous test. Makes total sense. Right.

Starting point is 00:10:51 So the best term to use at this time is greater tone because it can describe the comparison of an individual to another individual. And that's based on our reference as a clinician. This person had greater tone than this person. I see. I see. And that's within, so as a clinician doing an assessment, that clinician is using their subjective experience with previous individuals, not just that particular individual, or is it just within that individual and assessing whether tone was greater or not with reassessment? It can be both. Okay. Yeah. And, and if we look at evidence where there is a healthy comparison, we can also use that term greater tone. And if we are using EMG, and in the absence of good and convincing normative data for EMG, we can say higher activity.

Starting point is 00:11:49 um so this activity was higher than that activity and higher is a better description than greater just because when we're looking at an EMG we're looking at lines going higher it's simple I like to keep things simple I mean the thing that's the thing that's really fascinating Susie about this is that um it was really complex um to arrive at that but now that we've now that we've arrived at at this new knowledge it's like oh duh this is so simple why didn't we think about this why haven't we been speaking this language all along but um anyway it totally makes sense and i think this this change in some cohesiveness with language and

Starting point is 00:12:40 actually having biologically plausible and also some data to back up what it is that we're actually examining, assessing, and treating. There's a lot of confusion there, right? Because depending on how I'm defining what I'm defining when I'm evaluating someone, then my treatment offerings are going to be based on my preliminary definitions and what I think those mean and what I think I'm actually doing? And is it actually, are we actually changing what we're changing or what we're assessing, right? There's just a lot of confusion. We're so excited to get to the next latest and greatest treatment. And so we've really bypassed the basics. I think sometimes, you know, we're taught the basics and then we think, oh, that's really basic. So I'm going to

Starting point is 00:13:33 move on to this other um advanced treatment concepts and we sort of we throw it we forget that right but it's always good to go back to the basics and um and really consider we know these things but we're we're skipping over it um unfortunately not thinking through our assessments and what it what it means and what our measures are actually telling us actually exactly exactly Now, this language, you know, as a clinician, I can understand this and this makes sense to me. But when I then, when we then go to explain this to the patient, right, because they're in pain or they have some sort of, you know, dysfunction, certainly, and they're wanting

Starting point is 00:14:17 to get help, how, what is your advice on like the language that we use with our patients and how might that influence their treatment outcomes, knowing what you know now? yeah um I think that's a really important conversation so I think in terms of language language with patients the best approach is honesty and education first of all um and I think that the certainty with which we speak or advertise and especially on social media sometimes is unwarranted and and misleading and we have to be careful um generalizations that are made on social media? Um, well we know better now. Um, and I think that we just went through this in other contexts. So, um, I, I think what, what I see in terms of the tone terminology is

Starting point is 00:15:12 hypertonicity causes pain. Right. And that's a very, that's a very common one. And as we just discuss hypertonicity is not factually accurate term and and those generalizations and that language is problematic because well we just went through this as I said in other contexts that treatment is between a patient and a provider and if we throw it out there as a you know one size fits all um then then it's problematic because what happens when we're we are so certain in the absence of evidence and a basis for that certainty and then we the the patient does not get better what do we do then we were so certain and the patient was certain and was almost guaranteed that they're going to get a certain result and it didn't happen um so i think

Starting point is 00:16:17 it can be a little bit damaging um and frustrating and it just repeats the cycle and a frustration for the providers for the patients some of my colleagues down here at the university of queensland um are working on the sociologic aspects of the biopsychosocial model so putting the social back into biopsychosocial and um the words matter and and they just put out a paper recently um talking about uncertainty in clinical practice and it's really fascinating but it turns out that patients seem to actually prefer and be okay with the fact that we're uncertain as long we put it out there in an honest way. So if we can humble ourselves to that uncertainty, I think we'll get further. Wise words. Wise words. Yes. Yes. So speaking of,

Starting point is 00:17:27 you mentioned this briefly in your discussion just now about, well, does greater tone or higher activity necessarily mean pain in all situations what are your thoughts we don't know and not necessarily so that simple answer right i love it i love how simple you are rachel this is great because my brain can only handle simple okay this is great so what i'm hearing is So someone might have experienced pain in their body or in their pelvis and have no signs of greater tone or higher activity, but still experience pain and vice versa may be also true as well. Right. Yes. So if we find tenderness on palpation, it doesn't necessarily mean higher activity. And this assumption is made all over the clinical literature.

Starting point is 00:18:29 and clinical practice um if there is pain it is assumed that there is tone um this comes up well what you'll see in in the clinical literature is um the measure that was performed um was pain on palpation and then the clinical output or interpretation is trigger point and trigger points by definition has greater tone as a background and so so there's an assumption made and it may not actually be the case one does not equal the other they may coexist but they also may exist independent of each other um so the best way to find out is to measure both so again we just keep it simple measure pain measure tone what's there just don't make an assumption palpate the muscle using the reasoning scale

Starting point is 00:19:36 to grade tone then use the numeric rating scale to measure the pain can you briefly oh sorry but rachel can you briefly uh walk us through the is it reason scale reason scale the reasoning scale yes um so the reasoning scale is the only palpation measure that measures resistance to passive stretch which is well so um let me just back up a little bit so when when we are measuring um stiffness from a physics standpoint it's a resistance to passive stretch by a tool that gives us a force output newtons per meter our finger does not give us that measure force we think so but it doesn't so we push into a muscle and then our brain interprets that based on our experience

Starting point is 00:20:40 so so what we're measuring is is actually not stiffness we call it that sometimes um it's it's tone based on our subjective interpretation so but the the reason scale is is um basically we push into the muscle and we measure our we give that interpretation of of that resistance to passive stretch. And we grade it on a scale of zero is normal, plus one, plus two, plus three is greater tone and minus one, minus two, minus three is lesser tone. So it's a seven point scale. And the reasoning literature also has a scale for the external anal sphincter muscle, which is a three point scale. Zero is normal, plus one is greater tone and minus one is less. The reliability of the seven point reasoning scale is somewhere in the range of

Starting point is 00:21:44 0.2 to 0.5. So it's moderate, has moderate reliability. There are a lot of different scales that are in the literature that are sort of invented by the researchers and they're not, they haven't been tested to be reliable the recent terminology paper by the international continent society has suggested that we just used increased tone normal and decreased tone and that's because of a paper that came out i think in 2019 by melissa davidson where they actually looked at the reasoning scale and found out on uh with a lot of different measures, um, that it may actually not be that accurate, but it is the most accurate thing that we have, unfortunately. Um, the nice thing about the reasoning scale is that we can superimpose it

Starting point is 00:22:44 onto the ICS scale, which is, um, I think it's necessary. Um, depending on the clinical setting that you're practicing, if you're working with insurance companies and you need to be able to show continued progress, then we, um, it's nice to have that extra three point scale, um, rather than, you know, just going from increased tone to normal. Cause that probably doesn't happen. Um, and I guess I could say also that, um, from the Melissa Davidson paper, what therapists are really good at is knowing when there's really, really high tone and really, really low tone. So the reason that ICS did that in part, I believe, is because we're not as good at distinguishing between that plus one, plus two, plus three. So we do have to

Starting point is 00:23:43 be careful. So I do say that with some caveat. No, that's super helpful because at least that give some guidance of having some sort of consistency with what we're assessing and the meaning behind what we're assessing. And also helpful to know that a lot of the scales that one might read in clinical research were created by the researchers in order to defend their research, essentially, or to make sense of their research, maybe. Maybe defend is a big word and I shouldn't use that word. Right. And I would say clinical researchers. And, and so sometimes what you'll see is that you've got a research team and you've got some pelvic health physical therapists that are sort of influencing that. And so. That makes sense. I mean, that makes sense.

Starting point is 00:24:41 Yeah, that makes sense. But, but I'm glad they're having this conversation about what to look for when we're actually reading papers, when we're, you know, looking at things on social media and reading and health literacy and how accurate that is and updating our language and updating our knowledge. Because I think it's freeing too, you know, because a lot of the people I work with too are sometimes, you know, they've been told a lot of things about their bodies that I think prevent them from full recovery because it's it's almost an unattainable goal of my pelvic floor muscles don't relax or my pelvic floor muscles are you know there's tone there's hyper tone in there there's too much you know it almost it can be very paralyzing i think yes yeah my opinion

Starting point is 00:25:32 so okay there's an interesting paper and i know we were speaking um before we started recording about the Yanni paper from 2022. And it's, it's very rare to see research for, for men's health, especially in this, in this way, the researchers compared men with chronic pelvic pain to a healthy control. It's a good start to those without pelvic pain. They did use the surface EMG internal electrode. Awesome. Also great. I thought it was very easy to, to kind of follow the research and things um but it but what what not shocked me really but what was surprising is that when i saw their data and you and they compared the controls with both conditions that they were they were testing the at rest condition and then the rest after contraction condition

Starting point is 00:26:26 the healthy controls EMG or muscle activity was higher than the the the pelvic pain group and and you know that's almost counterintuitive to everything that we're told right like again thinking that higher activity or greater tone equals more dysfunction or more pain or more symptoms etc and this was almost saying well that that there's a mismatch there so I would love to hear your thoughts about this paper. And yeah, I would love to hear your thoughts about this paper and their findings. I think that first of all, this paper is the first paper to provide convincing evidence because it uses a valid measure. The EMG, as you mentioned, has that healthy comparison, as you mentioned, and there's no application issues. So what we mean by that,

Starting point is 00:27:21 And this is how we judge papers in the systematic review, in our systematic review. No applications in the case of EMG means that we want to see that the data was normalized. And normalization of EMG data is really important if you are comparing between cases or between days. And they did all that, and it's great. In fact, the paper would have been in the systematic review if it was published a little bit earlier. I figured as much. I figured as much. Yeah. So it's really nice in that sense. I think one of my criticisms of the paper is that it only uses EMG, so there's not a combined measure there. And so we don't have an understanding. And I think to your question, well, they did find that the other nice thing about this paper is that, And we haven't seen this a lot in papers yet, is that they actually took the eligibility questionnaires and they actually delineated out the specific detail. So in other words, they were able to, um, look at the men who had more specifically

Starting point is 00:28:46 ejaculatory pain, for instance, um, compared to, I think it was testicular and maybe interrectal pain. Um, and per the NIH CPSI, I think was the tool they use. Um, so, so that's really nice. That's really important. That's something I'm really interested in, in seeing. Um, and so the men with the ejaculatory pain actually did have higher levels. Um, but, but the, I guess to answer your question, um, I, I've already sort of answered it in,

Starting point is 00:29:24 in that, um, if the tone, if the EMG activity is lower, um, but there's still pain there, what in the heck are the combined measures showing us so what is the passive stiffness looking like and we can't measure there's no measure for the passive property of tone it's sort of a relative concept that you would a judgment that you would make based on having tested two things active and passive and if there's not active there then but there is positive findings on the combined measures, then you can potentially make that judgment. And combined measures, just for clarification, is when you're using an active measure like a surface EMG that actually gives you an output of data and, for example, digital

Starting point is 00:30:21 palpation. Good question. So combined measure means that it can't differentiate between the active and passive properties. So when we do digital palpation and we, um, make a judgment that there's a greater tone, we don't know if it's coming from muscle activity or from connective tissue stiffness, for instance. Okay. Um, when we first started doing this review, we were going to judge out all the measures by, um, passive or active. And then we're kind of going, wait a second, that doesn't make sense. Well, we were going to call it mechanical. But that didn't really make sense because all these measures, all measures except for EMG are giving you an output that is a combination. That's why it's called combined.

Starting point is 00:31:11 I got you. Okay. Okay. Of active and passive components to muscle. Right. So that's why it's really important. And Millie Moran did this um, in one of her papers where she was using dynamometry, which is the combined measure. But what she did is she put EMG electrodes on the tip of the dynamometer, which is basically the dynamometer is kind of like chopsticks that they, um, place into the vaginal canal. We can't use this in men or we don't use this in men at this point. Um, but it, um, it pushes into the muscle. And so what they did with the EMG on the tip of the, of the, speculum the dynamometry speculum is they put this emg plate and then they can push into the muscle

Starting point is 00:31:55 wait for the muscle activity to die down and then do the passive measure so that's the closest that we have gotten to do actual passive measure wow wow yeah that sounds very complicated it does i mean just to get this data and i hope people appreciate the all the detail that goes into being a researcher uh when you do it well you know i mean there's so much thought there's so much detail there's so many questions there's no so many paths to go down um to really uh yeah to really have substantial um you know evidence or some sort of um conclusion you know to make from everything you've gathered so there's certainly a lot of problems solving and creativity and getting these measured these are some of the most difficult muscles to measure in the body they're

Starting point is 00:32:47 very problematic uh for a research standpoint so definitely definitely do you get a lot of folks who um i i i always wondered this that folks who volunteer for studies that have to do with pelvic floor is is is it easy to find folks to sign up for these studies well so um no um there there are a couple of factors um there you know we're we're testing male participants and i've had this discussion with a number of people i'm i'm doing this work in this research in australia so um there's it's a the i would say that the male participants it's little bit harder to break into um the men's health community here um it's just not it's not discussed well in the United States but it's really not discussed

Starting point is 00:33:53 a lot here either and so it has been a challenge um there was one of the studies that I did was done, um, in females, um, prior and there was plenty of willing participants. So, um, there are, there do seem to be some barriers. Um, I had this idea that, oh, well, once we get past the healthy controls, then, you know, there'll be plenty of patients to test. And I think that there are, but the willingness, and I thought that there would be some willingness there. Um, And because my experience in working with men over the years is that they're very keen to help the cause, because there is not a lot that we know about this population, unfortunately. And so, but it's been a challenge in men with pelvic pain as well. So we'll see.

Starting point is 00:34:53 yeah so for all those men listening and if this is your experience please connect with your researchers and help your your your fellow man you know um in that sense right so that's my that's my plug for the for the for the research push um yeah let us help you better right like let us um really do the research because it is it is a huge gap with male pelvic health and pelvic pain research for sure when compared to their counterparts. And also a huge gap in the transgender community and non-binary folk and gender expansive people. So yeah, lots of shoes to fill and so grateful for researchers like you and clinicians like you who take to, you know, step into this courageously with a lot of compassion and empathy for the people that

Starting point is 00:35:49 um, you're helping. So thank you. And thank you to your team. So, okay. So one last question here. Well, actually a couple, a couple, I have, I have two, if that's okay. The one going back to surface EMG, um, so numbers, numbers, and I, I'll be honest, I'll be the first one to say that I am one of those clinicians that have threw the baby out with the bath water when it came to the EMG, right? The biofeedback. No, no, no, that's crap, right? And I am actually, I'm considering bringing that back after having this conversation with you, after reading your research, after watching your webinars, because I think it has merit, but the narrative around the use of it has changed. And I think that was a really important

Starting point is 00:36:40 piece for me is, okay, this makes more clinical sense. And this definitely feels like it's biologically possible and based in science. Um, whereas the narrative before was very different. So I, there is a, how do we know you had mentioned your webinar that there's, there's, there's a number out there of two microvolts for muscle activity with an EMG. But then you had mentioned too, that there are other studies that say average or quote unquote normal is maybe could be six to nine uh millivolt so what are your thoughts on do we how do we hold do we hold lightly to those numbers can we be fairly confident in in two i don't know i don't know what to think about that i think we need overall more participants um to come up with that sort of

Starting point is 00:37:38 normative data um the white paper which was the original one that if you trace that back where that to i mean you you've heard this in coursework from the get-go i'm sure two two microwatts oh yeah um and um i so so that paper is not super convincing um and there's a couple of interesting findings in that paper. Um, one is that there's a couple of images and, uh, explanations of images that are mixed up, which just could be, um, just publication snafus. Um, the EMG image there's a image of the eung in there is actually um hand traced um so if you so it's just a little bit sketchy and it may be that because of how um you know from the date of that publication and how we did you know published images that that was why they did it but but what

Starting point is 00:38:52 you'll see on the image it's really fascinating is that so so emg is measured over time so there's a there's a spike in the emg that actually comes back in time oh that must be and so yeah it's just questionable um at any rate um and it could just again be a hand tracing to to make the image better and it just wasn't done well but um yeah and then the other study is more recent um probably a little bit more convincing but still you know relatively small population of subjects um and i didn't oh so this new paper showed also an average of two no so the newer paper is the one that showed closer to six okay okay yeah it's uh that's That information is in the, I think it's in the discussion section of the systematic review.

Starting point is 00:39:54 And I'm sorry, I don't remember the numbers off the top of my head or the author at the moment, but I think it's about six to nine was the resting data. I think you had mentioned that. Yeah. And then there's a number of authors that have used, I think it was one to two, um, microvolts in it. Um, yeah, I think it was microvolts, not millivolts. Um, microvolts in was the resting data for women. And then for men, it was two to three. And I might have the male and female reversed on that. Um, but that was based on clinical expertise. And so it's just

Starting point is 00:40:42 and judgment call. So we have to be careful there. Right. Right. I got you. Okay. Okay. So again, it sounds like to me, how I'm understanding this is it should always be applicable to the person or brought back to the person that you're working with just to connect that back with, is this biologically possible that, because we don't know prior to that person not having pain. I mean, we didn't measure that before. So I don't have that data, right? I don't have anything to really compare to and it kind of makes it challenging when there's such a wishy-washy inconclusive like well what is kind of normal or average that i can actually go over to make a conclusion that you know this number equals uh pathology or dysfunction or you know because

Starting point is 00:41:31 because we don't know that that's the case at all actually um sure and and to add to the complexity You know, the clinical EMG tools that we have do not provide us with the data that we need to do normalization. So comparing one patient from day to day, visit to visit, is problematic. um it is more um we can do a comparison from an early part in the same day to a later part so you know pre-treatment and post-treatment on the same day um and these are some things that i've had some discussion with some of the people working on the seed project which is the um isek group from the ISAC group, which is the International Society of Electro-Kinesiology. And I'm trying to put a bug in their ear to help out the pelvic floor clinicians,

Starting point is 00:42:42 because we are the ones that are really utilizing EMG the most, even though we've sort of gotten away from it. And I agree with you, you know, I use it a lot. I was a heavy utilizer of it up front, but time in the clinic I mean there are all these factors but like you said now now that I'm looking at it differently I think one of the criticisms is kind of centered around this is what you hear a lot in social media oh my gosh I just saw this patient who was at this clinician and all they did is put him on biofeedback and leave the room and have them watch this and try so so it's really

Starting point is 00:43:19 the complaints seem to be centered around the treatment aspect of it and we were and we're not just so we're thinking about it in terms of treatment but we're not really doing a good job considering what what it means from an assessment standpoint and a lot of times with EMG you know you you do the assessment and they're well they're hooked up so let's there's some findings there so let's maybe just kind of work on some things right and there's certainly times where we use a lot of EMG or pediatric cases where I think it's really important, our spinal cord injury patients, that's really important. But I've got kind of got away from it in other instances, except for just like every now and again, you're like something I need to, I'm not getting at the answer all these

Starting point is 00:44:05 other ways. So let's spend the time to do this. But I guess I just wonder, you know, if we're really considering the muscle properties in this way, would we arrive at a better conclusion earlier even though it's time consuming would we arrive at that conclusion earlier and get to the outcome that we want for the patient sooner and that's that's something that we need to to look at now right and so that that that sounds like knowing okay so so what's influencing a particular process right um or contributions to um this very protective uh you know a pain state pain sensitivity etc so this goes back to a question i had here about pelvic therapy being very heavily manual therapy focused and doing internal work and and so forth um does this

Starting point is 00:45:05 research that you, you know, in the research that you know and what you've learned so far, has that changed how you utilize manual therapy? Well, let me just kind of jump off your last question. I was just mentioning that EMG is really problematic, but actually all the measures that we have for tone are problematic. And the same people who are really critical of EMG in in our profession are the highest users of digital palpation and digital palpation is the least um reliable and it's certainly not valid measure that we have of tone um it's actually the it's it's the worst combined measure that we have it's very problematic. So, um, I think we need to really take a step back and, and really think about

Starting point is 00:46:10 what we're being critical of. Maybe it's like point the finger back to, um, look, I'm a, I am a manual therapy trained therapist. Um, I love manual therapy. Um, I, I think for the right case, it gets us places um I think there have been times so you're mentioning this concept of of manual therapy being sort of the trend and I I think there have been times where trends were the exercise focused and then we kind of went psych focused um where we've done essentially just talk therapy and no touch or exercise therapy and think the pendulum kind of always swings um Um, but, but I think, or at least that's how it gets kind of polarized in social media. And I think that if you really talk to clinicians, it's not really this, we only do talk therapy

Starting point is 00:47:03 or we only do manual therapy, but it just gets polarized that way. That's what I suspect. That's my hunch. Um, but you know, you notice this on courses and conference circuits as well. It's not just social media. I keep saying social media, um, but, um, but I think that what this systematic review has taught me is that we're not doing a good job of understanding and properly using outcome measures, which has the downstream effect of not getting to the right treatment efficiently and

Starting point is 00:47:33 potentially adds a longer time to that positive outcome, as I mentioned. So there is a tendency to over-utilize treatment trends of the hour and leave the others behind. And I think if we can really focus on doing a good assessment based on multiple measures across the spectrum so psychosocial questionnaires or psychosexual measures manual testing testing using other objective measures musculoskeletal pelvic hip pelvic SI joint whatever and then interpret that appropriately so this is a big problem is the interpretation of that will arrive at the best approach so manual therapy tends to be a lot of passive stretching type techniques and if you tested the active component and it was negative and your combined measure still showed stiffness

Starting point is 00:48:22 meaning the passive tone was greater then that is absolutely the right treatment manual therapy is 100 the right treatment um so and maybe that manual therapy for one person is is the right treatment and mindfulness meditation is the right treatment and another person needs biofeedback because they had higher activity and this other person tested positive on these psychosexual measures for instance um and or you know a combination of these treatments where the we would treat you know the predominant aspect of the presentation if everything was testing positive what's testing the most positive right so i think we need to be careful not to get into practice patterns or habits where we swing too far in any direction and stay there for every case

Starting point is 00:49:10 that's the problem. We need to consider the story of the person in front of us. We need to use the tools, the outcome measures, arm ourselves with a deep understanding of those. And unfortunately, this is not where our training system is at the moment. And I've just heard a lot of conversations about this, suggesting, as we talked about, that, you know, EMG is a waste of time, but are they? if it gives us the information we need to get to the treatment quicker. Well said. Well said. That's beautiful. Be flexible, individualized, science-based, and yeah, don't get stuck in the shiny loud noisemaker over here that all that like shiny stuff. Don't get too caught up with the shiny stuff. This stuff that looks

Starting point is 00:50:02 very enticing and exciting right go back to the simple keep it simple we you know biology is complex enough but the treatments i always say the treatments don't have to be they don't have to be um this is beautiful i i am so thankful for you uh being on the show today sharing your expertise your wisdom and your message of of helping clinicians really start to shift the way that they practice and the way that they and what they offer really to their to their patients and you're right we could be we could do a better job of being more efficient and if we use our outcome measures in the way that we not just to submit it for insurance or to do it because our institution is telling us to do and then never retest it again. And I'll never use it again. We just do

Starting point is 00:50:54 it once, you know, um, I fall in that trap too, but using appropriate measures, um, I, I, I think we would be, we would help people sooner, faster, and they wouldn't have to really rely on us for so long. Um, that's really the goal, honestly, that they don't need us anymore. So, um, you, One thing that you had mentioned really quickly is the psychosexual measures. Do you have any favorite ones that you like to use or that you use with your patients? I've not spent a lot of time investigating those. Those are more recent thoughts and conversations that I've had. There's a paper by Pandoa 2021.

Starting point is 00:51:42 There was a systematic review, or I think it's just a review report, part one and part two, and they highlight these measures. So they highlight the measures that I've talked about and then also have additionally added these psychosexual measures, and I've not spent much time in that space. But it is certainly something that I think we need to be considering because what do we do if this sort of construct that we've been living in for a long time of tone causes pain and pain causes tone breaks apart? and and then what what is the cause and and we need to start looking at these other concepts is it lifestyle factors is it perfusion it's one of my favorite topics is it sleep um sleep of course goes into the category of lifestyle medicine um looking at sleep right now which is really um i think going to be cool um and tone goes away when we sleep it should um and so if we're not sleeping what happens to our tone um so so we need to really and then of

Starting point is 00:53:07 course other musculoskeletal factors but um we hormonal factors we need to start looking at all of this more um and really quickly briefly perfusion you smiled and then you said i really love that could you explain that to to us yeah um well i i think we've all and i'm sure i would imagine you've talked about this on the podcast but you know we talk about um the penis being the barometer for the heart right ah yeah um and what we're talking about there is atherosclerotic plaques in the arteries going to the penis. Um, and that actually being an indicator of maybe something more, um, systemic, right. And, um, if you look at, um, populations of younger people, the first place that we start to see plaques form, um, is in the abdomen. And if you think

Starting point is 00:54:04 about the downstream effects that arteries start bigger and then they get smaller, smaller, smaller. And, um, and so I'm really interested in this idea of getting oxygen to, to tissue and how that relates to, uh, lifestyle medicine, um, diets, exercise, and, um, have some theories about, about that. But I, one of the first things I do a very extensive, um, diet, um, assessment. I think a lot of us do. Um, I do a lot of education there. Um, but I kind of base it around, um, concepts of, of perfusion and, uh, look, we know we have had this discussion for a lot of years about ischemia and how that relates to pelvic pain and pedendal rupture. Right. But we don't talk about it in the context of atherosclerosis in the pelvic region

Starting point is 00:55:06 as much and we need to go there sciatica that's one of the arteries that's downstream from where we know plaques form first um in youth so um low back pain everything right so we need to look at that oh my gosh oh so exciting i am so tickled this is wonderful i have to say i'm like i'm kicking out over here i love it thank you you're speaking my love language this is wonderful we again i i can't i'm speaking for myself i cannot wait to read more of the research that's that's going to be coming out and all that you are all doing with your team there and uh yeah such a pleasure having you on the show and thank you so much nice chatting with you suzy good luck yeah thank you and rachel if folks wanted to connect with you follow your work where would

Starting point is 00:55:59 be the best way to connect with you? I'm probably the most active on Instagram and my Instagram handle. Do you call it that? So terrible at social media. I think so. I don't. I'm also terrible. Pelvic.fit with three I's. Pelvic.fit.facts. And the goal of that Instagram account is to really sort of bridge research and clinicians, but patients are certainly welcome to join into the conversation. It's just really boring. I'm not a Canva person. So like, if you want Canva images, don't follow me. Don't come for the aesthetics. Is that what you're saying? Come for the facts, come for the knowledge, come for the truth, but don't come for the facts. i love it yeah that's that's awesome

Starting point is 00:56:56 a cute photo take shirts oh this is awesome great yes yes thank you um we will make sure to link your your your your research your instagram handle um and and certainly your your full bio and everything on the show notes in the show notes as well so yeah thanks yeah i'm also on twitter at um rachel underscore warren but that seems to be kind of where researchers hang out and i don't there as much so no that's awesome that's great yeah we do you know we have this show is a combination of of general public but also of the um clinicians and and health professionals so yeah no that's great anywhere that they can connect with you and your research

Starting point is 00:57:46 which I think is mind blowing. It's really awesome. And I'm really inspired, um, to really change some things in my own practice to, to keep up with what we're learning. I am, I'm really inspired. And to be honest, I'm going to be looking at, uh, some, uh, EMG machines for your opinion. Um, yeah, I'm going to be looking at that. I think it's great. And, and yeah, no, this has been very inspirational and I think you're right. I think we can do a better job being more efficient clinicians and yeah yeah for your phd that's right thank you rachel plug plug awesome awesome well thank you again and to all of our viewers and listeners out there i hope you enjoyed this show as always and loving wellness for your pelvis this is suzy gronski until next

Starting point is 00:58:34 time thanks for listening to today's episode be sure to visit my website drsuzyg.com for show notes and related resources on today's topic if you like what you're hearing head on over to YouTube and subscribe to my channel on my youtube channel you'll find content related to sex pelvic health and expert interviews for men if you got a question or a topic that you'd like me to answer on my channel be sure to type it in the comment box below

In Your Pants with Dr. Susie G - Muscle tone pelvic pain in men

There aren't comments yet for this episode. Click on any sentence in the transcript to leave a comment.