On the trip, I was invited to give a series of lectures to audiences of physicians, in both Beijing and Xi’an (pronounced Shee-an). As the first PT invited to assist GSEPS on its mission I was tremendously honored. While most of you are familiar with Beijing, China’s capital city, most are probably not familiar with the city of Xi’an. With a population of 8 million, it’s one of the most populated areas in inland China.
Somehow, somewhere, between Beijing and Xi’an, it was decided that I would evaluate a patient in Xi’an, and that this evaluation would be presented as a live feed to the attendees in the lecture hall. My reaction: What?!
To say that I was unprepared for this evaluation is an understatement. But thinking back on it now, all the preparation in the world would not have prepared me for what was to come. The patient, a woman in her 50s, was a field worker, who had suffered a fall on her tailbone some years prior. She presented with extreme tailbone pain, anal pain, and vulvar pain.
After meeting the patient, myself and about two dozen of my colleagues were led into a hospital operating room where we were instructed to don scrubs. As I stood in an O.R. wearing scrubs, it hit me that the Chinese had a pretty skewed understanding of what it was that I did. Plus, I was disturbed that a patient was to have her pelvic floor evaluated and treated in front of an audience! But, surprisingly, it seemed that the patient wasn’t fazed by it. I didn’t sense any modesty or hesitation from her at all. This is when the differences between our culture and the Chinese culture really began to sink in.
To make matters even stranger, the patient’s arms were tied down and her legs were tied to stirrups. When she asked to use the restroom, she was told “no” because it would hold up the proceedings. That’s when all semblance of diplomacy left me, and I insisted that the patient not only be untied, but allowed to use the restroom!
When she returned, I began to examine her. Right off the bat, I noticed that she presented with a severe case of lichen schlerosis, a skin disorder that affects the genitals causing blistering, redness and burning. In addition, her vulva and vagina appeared completely de-estrogenized meaning that low estrogen levels had resulted in redness, cracking, and dryness to the vulvar/vaginal area. The condition also can cause burning and pain. Either one of these conditions could cause a myofascial pelvic pain syndrome or be a source of pelvic pain in and of themselves. Together, they guarantee it. So before I had even gotten to examine the patient’s pelvic floor muscles, I had discovered two seriously under treated and pain-provoking issues.
It’s when I began the internal exam that I discovered a major cultural difference in doctor/patient relations in China. I was communicating with the patient with the help of Dr. Chung, who was acting as a translator. That’s when I learned that in China, voicing or showing that you are in pain in front of a doctor is considered a sign of disrespect. So even though I could tell which areas within her pelvic floor were painful to the touch, the patient would not let me know where her pain was or when it increased upon my palpation. I was incredibly disturbed by this because as anyone who has either had or administered pelvic pain PT knows, good communication between PT and patient is a must!
Despite the communication barrier, I uncovered trigger points in the patient’s obturator internus muscle, a good bit of pudendal nerve tenderness, and generalized pelvic floor tightness.
As you know if you’ve read our post about “good PT” external work is as important as internal work; however, I did not do any external work on this patient as it’s painful and is only beneficial when it’s done repeatedly over the long term. What I was able to do in the short time I had was to stretch out the patient’s pelvic floor muscles.
My treatment plan for this patient would include immediate treatment for her dermatological and hormonal issues. That alone would provide her with tremendous relief! From there I believe with weekly PT, she would likely have a good result. While the PT is of course not an option, sadly, I don’t believe the patient’s other issues will be treated either.
Here’s why: Chronic pain in general is under treated in China. And I realize how disingenuous it is to be up in arms about this because this is also very much the case in the U.S. Plus; our own medical system is rife with its own problems. But, unlike in the U.S., in China, especially in the least developed areas, the medical community is very much focused on survival versus the treatment of non-life threatening illnesses or pain.
Will China Pass U.S. in Treating Pelvic Pain?
I realize that up to this point, my report seems pretty dire. But, here’s the good news. GSEPS is a young organization, and already it has made some pretty major inroads on its mission in China. The goal of this trip was to increase awareness of pelvic pain diagnosis and treatment and to form relationships with the Chinese hospitals and medical schools. On all accounts: mission accomplished!
For my part, I gave three lectures in each of the cities we visited. My topics were “Physical Therapy Management of Myofascial Pelvic Pain,” “Physical Therapy Management of Pudendal Neuralgia,” and Interdisiciplinary Management of Chronic Pelvic Pain.” In Beijing, we presented this information to the OB/GYN department of the Peking Medical University Hospital and their entire medical school. In X’ian, we presented a joint conference with the Society for Laprascopic Surgery and the American Association for Gynecology and Laprascopic Surgery.
As you can imagine, included in my slide show was a no-holds barred look at pelvic pain physical therapy. The audience’s response was pretty priceless. From the gawking, it was clear that although they understood the concept of PT for pelvic pain, they were seeing a treatment method that they hadn’t even imagined existed.
I have to stress that there were many American doctors in the audience who shared this reaction. In fact, two general surgeons I spoke with from highly prestigious medical institutions in the U.S. readily admitted that they were completely unaware of pelvic pain.
What was so encouraging was that both the Chinese doctors and the American doctors were completely open to the information. In fact, I have been invited to speak at the Society for Laprascopic Surgeons’s conference in the U.S in 2013. I’m hoping the result will be fewer scheduled surgeries and more scheduled PT sessions!
In China, both the government and the physicians there seem committed to getting pelvic pain educational programs started. And one of the things I’ve learned about China is that the Chinese work fast. When they collectively decide to get something done, they get it done! One of the reasons for this is there’s much less red tape and bureaucracy there compared with the U.S.
The next phase of GSEPS’ mission is to get the PTs in China into the pelvic pain loop. To that end, Liz and I have invited the Chinese to attend our courses in the United States and GSEPS is expecting to sponsor hands-on seminars for PTs in China by 2014. From there it’s highly likely that the Chinese will begin taking steps to implement pelvic pain PT in PT schools there. Conversely, in the U.S., pelvic pain PT is NOT taught in PT school. And as far as I know, to date, there isn’t a major push in the works to change this.
Of course the big stuff got to me in China, like the absence of pelvic pain PTs and the communication hurdles between doctors/patients. But the small, seemingly mundane stuff also fascinated me!
For one thing, check this out: the Chinese go to the bathroom by squatting over what is basically a hole in the floor. While I personally found this very challenging—it was quite a feat of balance to not urinate on my heels! The truth is, this means of relieving oneself is actually much more conducive to a healthy pelvic floor than the way we Americans plop ourselves down on a toilet seat. That’s because squatting over a hole actually allows the pelvic floor to fully relax making for a more complete, streamlined, evacuation of both the bladder and the colon. So more squatting equals less straining! Full disclosure: as a pelvic pain PT, I am slightly obsessed with how people go to the bathroom. So you can imagine my giddiness over this particular discovery.
Curb your kids!
Speaking of going to the bathroom, another culture shock was the fact that toddlers and young children don’t seem to wear diapers in China. Great news for the landfills; not so great for the sidewalks. The children literally walk around with convenient slits in their pants so that when nature calls, they need only squat in answer–wherever! And in case you’re wondering, parents do not curb their kids!
All in all, this trip was an adventure of a lifetime. Not only was it fascinating on so many levels, it utterly reaffirmed my desire to work as hard as I can to spread awareness and education about pelvic pain PT.
Thank you for allowing me to share this amazing experience with you; now, I want to hear your questions/comments about my post!
Do you think it’s possible that China will overtake the U.S. when it comes to pelvic pain treatment?
What do you think about the current state of pelvic pain treatment here in the U.S. Have you noticed improvements?