Five Bullet Friday: Women’s Health – January 3, 2020

Happy Friday!

Today’s Five Bullet Friday:

1. The Effects of Intermittent Fasting on Health, Aging and Disease – NEW Article in NEJM

2. Explaining Pain to Your Patients – A Physio’s Favourite Resource

3. Urinary and Gynaecological Dysfunctions Common with EDS and Associated Hypermobility Disorders

4. Global Consensus Guidelines on Use of Testosterone in Women (2019)

5. PATIENT HANDOUT: 5 Toileting Mistakes that Could Contribute to Pelvic Floor Dysfunction

Five Bullet Friday: Women’s Health is meant to be a quick, easy to skim resource for you and other health and medical professionals to keep you up to date with all things related to women’s health. My goal for these emails will be to bring to you pertinent and helpful resources for patients (such as short videos or handouts), new research and guidelines, clinical pearls, or anything else interesting related to women’s health! If you’d like to be added to my email list to receive my Five Bullet Friday: Women’s Health, or if you would like suggest particular topics you are eager to hear about, please send an email to cassie@tayloredtraining.ca.

Thank-you, and happy reading!

 

1. The Effects of Intermittent Fasting on Health, Aging and Disease – NEW Article NEJM

In this excellent review article in the New England Journal of Medicine, authors Cabo and Mattson discuss intermittent fasting and its many benefits for humans. They discuss previous nutrition animal studies that assumed that benefits came from calorie restriction, at the time not recognizing that the animals typically consumed their entire daily food allotment within a few hours after its provision, thus meaning they had a daily fasting period of up to 20 hours, during which ketogenesis occurs.

For humans, preclinical studies and clinical trials have shown that intermittent fasting has broad-spectrum benefits for many health conditions, such as obesity, diabetes mellitus, cardiovascular disease, cancers, and neurologic disorders. Positive outcomes from intermittent fasting extend past those of simply restricting calories and the beneficial effects involve metabolic switching and cellular stress resistance.

In this review article, it is recommended that physicians can advise patients to gradually reduce the time window during which they consume food each day with the goal of fasting for 16 to 18 hours a day. They can alternatively recommend another intermittent fasting protocol as outlined in the review.

Reference: De Cabo, R. & Mattson, M. New Engl J Med. 2019; 381: 2541-51. DOI: 10.1056/NEJMra1905136

 

2. Explaining Pain to Your Patients: a Physio’s Favourite Resource

One of my favourite resources to share with patients regarding why they experience pain and what to do about it comes from pain specialists in Australia. Check out the following video “Understanding Pain and What to Do About it in Less Than Five Minutes”

Check out this great resource, here!

 

3. Urinary and Gynaecological Dysfunctions Common with EDS and Associated Hypermobility Disorders

Ehlers-Danlos syndromes (EDS) and associated hypermobility spectrum disorders (HSD) are a group of connective tissue disorders associated with significant morbidity. A recent review suggests that in this population a higher index of suspicion for urorgenital problems is warranted in this population, with urinary, gynaecological and obstetrical complications reported as common.

This information is helpful to encourage early referrals to appropriate disciplines in this population, including pelvic health physiotherapists.

Reference: Gilliam, E, Hoffman, JD, Yeh, G. Urogenital and pelvic complications in the Ehlers‐Danlos syndromes and associated hypermobility spectrum disorders: A scoping review. Clin Genet. 2019; 1– 11. https://doi.org/10.1111/cge.13624

 

4. Global Consensus Guidelines on Use of Testosterone in Women (2019)

A Task Force of representatives of leading societies, whose international memberships include clinicians assessing and managing sex steroid therapy for women, was established in order to create a global consensus position statement on the use of testosterone in women. This Guideline was published in December 2019, it addresses available evidence and states:

  • No cut-off blood level can be used for any measured circulating androgen to differentials women with and without sexual dysfunction
  • There are insufficient data to make any recommendations regarding the use of testosterone in premenopausal women for treatment of sexual function or any other outcome
  • The only evidence-based indication for testosterone therapy for women is the treatment of HSDD, with available data supporting a moderate therapeutic effect, in postmenopausal women
  • There are insufficient data to support the use of testosterone for the treatment of any other symptom or clinical condition, or for disease prevention
Reference: Davis, Susan & Baber, Rodney & Panay, Nicholas & Bitzer, Johannes & Perez, Sonia & Islam, Rakibul & Kaunitz, Andrew & Kingsberg, Sheryl & Lambrinoudaki, Irene & Liu, James & Parish, Sharon & Pinkerton, Joann & Rymer, Janice & Simon, James & Vignozzi, Linda & Wierman, Margaret. (2019). Global Consensus Position Statement on the Use of Testosterone Therapy for Women. The Journal of Clinical Endocrinology & Metabolism. 104. 10.1210/jc.2019-01603.

 

5. Patient Handout: 5 Toileting Mistakes that Could Contribute to Pelvic Floor Dysfunction

Toileting habits are something we don’t often talk about but that can absolutely encourage or exacerbate pelvic floor dysfunctions. See attached to this email a great resource for patient’s talking about common toileting mistakes and what they can do to correct them!

Are you always Kegel-ing during exercise? Find out two reasons that may not be the best idea

As a Pelvic Health Physiotherapist I have the privilege of working with and helping so many awesome women, many of whom are struggling with incontinence during activities such as running, weightlifting, or sports.

When I first meet these women, I’ve found that so many employ various strategies in order to reduce their leaking during exercise. Some empty their bladder frequently between sets, some squeeze their legs together, and others try to hold a Kegel while they perform each exercise. Though each of these strategies are not ideal, today I want to speak specifically about the strategy of holding a Kegel during an exercise. Let’s take the squat for example: many women I have met will try to perform and hold a Kegel for the entire duration of their squat in order to reduce the amount of leaking they are experiencing.

Is this an effective strategy?

Squats are an awesome exercise but can be a little less fun if you have to think about your pelvic floor the entire time you do them!

Honestly – the answer is no.

Sure… it may do something. It may help some depending on your level of incontinence, pelvic floor strength, and body awareness. Or it may more help by easing your mind, because you feel you are doing something to help. But the truth is this is almost always an ineffective strategy to both treat and manage your exercise incontinence.

Why?

Because it fails to train two very critical aspects of how our pelvic floor should work during activity: descent and relaxation, and unconscious competence.

1. Descent and Relaxation

Our pelvic floors are meant to both contract and relax. For the most part when these muscles contract they ascend upwards and when they relax they descend downwards. Going through relaxation and contraction throughout the day, or throughout an activity, is very important for how effectively and efficiently our muscles can work, especially when extra stress or load is applied to them.

In order to think about this ascent (contraction) and descent (relaxation) of our muscles, I want you to think about catching a baseball for a minute.

When you go to catch a baseball, you don’t just stop your hand abruptly when you catch the ball, nor do you punch your hand forward in to the ball (aka ascend/contract). No, instead you actually absorb some of the pressure, or cushion some of the force by allowing your hand to move backwards with the ball (aka descent/relax). This allows a much smoother catch, doesn’t lead to pain or discomfort, but most importantly makes catching the ball EASIER! It means we actually exert less effort AND have more success.

Now, let’s go back to the example of incontinence during squatting. If you employ the strategy of performing and holding your pelvic floor throughout the entire squat then you are contracting the muscles the entire time… but remember, we need to allow descent of those muscles to cushion the pressure created during the exercise! So, if you aren’t allowing for this your muscles cannot actually work optimally. And though this may perhaps help to some degree in the immediate moment, it will not allow your muscles to work as effectively and efficiently as they should. What this usually translates to is a ceiling effect where maybe this strategy works “a little”, but will never entirely correct the incontinence.

2. Unconscious Competence

This topic – unconscious competence – is something that is very, very important to me. As a pelvic health physiotherapist I am constantly meeting incredible women who almost never stop thinking about their pelvic floor because they are always trying to manage their symptoms. They do Kegels during exercise, try to manage their abdominal pressure in any way possible, are nervous of doing certain exercises, and are basically always thinking about their pelvic floor.

One of my goals for each and every client I work with is getting to the point where you don’t have to THINK about your pelvic floor AT ALL!!! Constantly thinking about what your pelvic floor is doing during activity or exercise is EXHAUSTING! Not only that, truthfully it is not healthy and can drive pretty much anyone to feel anxious, nervous, scared, or even a bit obsessive.

Now, I’m not saying there isn’t a place to think about your pelvic floor during exercise – there absolutely is, especially in the beginning when you are learning about your pelvic floor, what it does, and how it should work. But, this is not a long term solution! This thinking is more short term and is geared to help you learn about your body!

Depending on your symptoms, pelvic floor coordination and body awareness, we will often go back to the basics at the beginning of your pelvic floor rehabilitation and ask you to consciously think about and control your pelvic floor. This is known as conscious competence, simply meaning that when you consciously think about it, you can contract and relax your pelvic floor as desired. However after conscious competence is achieved we must, must, must transition to training unconscious competence!!

This is a critical piece of rehabilitation that I often see skipped: training your pelvic floor to work when and how it should when you are NOT thinking about it!! Holding a Kegel during an exercise, like the squat, does not help you train those muscles to be unconsciously competent.

What to do Instead

I wish I had a cookie-cutter answer for this, but the truth is you need to work with a pelvic health and fitness professional who can guide you, will as we can guide you, give you exercises and techniques to make sure you don’t have to always think about your pelvic floor and can instead start enjoying activities and exercises again!

Once we assess your pelvic floor coordination and general movement we will be well equipped at walking you through the steps to go from conscious incompetence –> conscious competence –> unconscious competence!

Should you exercise during pregnancy? Yes!

Pregnancy is an incredibly exciting time of life, but it can also be a time where you feel unsure about all of the things you should and should not do. A lot of women who have always been active wonder if they can continue to train the way they have previously, while others who have been more sedentary feel they cannot start anything new as their changing body isn’t yet used to it.

It’s time to clear some things up for you!!

Unless you have a high-risk pregnancy exercise is not only a good idea, it is actually so incredibly important for both your health and the health of your baby!!

Due to all of the misconceptions out there on exercising during and after pregnancy, an Expert Committee from the IOC was formed to specifically look at exercise and pregnancy in both recreational and elite athletes. Their recommendations are as follows:

In absences of maternal or fetal contraindications, exercise prescription in pregnancy includes the same principles and elements used for the non-pregnant population.

BUT it is important or remember and work with someone who understands the changes associated with pregnancy, which the IOC committee list as “significant anatomical, hormonal, metabolic, cardiovascular and pulmonary changes/adaptions.”

What does this mean?

That pregnant women should continue to incorporate exercise (or start to exercise)! In fact, the article continues on to state that there is very strong evidence that strength training both in general and of the pelvic floor muscles during this time can both prevent and treat urinary incontinence during pregnancy and after birth. It is also associated with a shorter first stage of labour.

Are there any signs you should slow down?

The IOC Committee explains that women without contraindications should exercise regularly during pregnancy while being regularly assessed. They indicate the following signs to indicate it may be time to stop exercising:

  • Vaginal bleeding
  • Regular painful contractions
  • Amniotic fluid leakage
  • Dyspnoea (shortness of breath) prior to exertion
  • Dizziness/syncope (fainting)
  • Headache
  • Chest pain
  • Muscle weakness
  • Calf pain or swelling

What about Post-Partum?

The birth of your child is a wonderful moment, but it also can very much impact Mom’s musculoskeletal system, with delivery being likened to an acute sports injury. Therefore, deciding when and how to return to exercise can sometimes be more complex and multifactorial. This is why it is important to seek the help of a pelvic health physiotherapist who can guide you based on your needs and your rehabilitation goals.

The IOC committee encourage exercise in the post-partum period should start gradually with a pelvic floor muscle first focus.

Key Take-Aways:

– Exercise before, during and after pregnancy is so important for both the health of you but also for your baby

– In the absence of high-risk pregnancies, exercise is safe and beneficial as long as the anatomical and physiological changes that mom undergoes are considered

– Monitor your body during exercise and be followed/assessed regularly by a skilled coach or practitioner who is experienced in working with pre and post-natal clients.

– Begin exercise post-partum slowly and under the guidance of a professional who can help you take a pelvic floor first approach to strength training

Find this awesome research article, here.

And to find out more about exercise during pregnancy, follow the amazing @coach_vanessagiguere on instagram (she is the one above in the photo, rocking the prowler while in her third trimester!)

Remember, it’s OK to Walk Before You Run.

Today I just wanted to remind you that its okay – in fact not just okay, but necessary – to walk before you run. To slow things down and master the basics before trying to get to the advanced stuff. To recognize that just because you aren’t achieving your end goal at this moment in time, it doesn’t mean you won’t get there. And most importantly to appreciate that its your habits over time that make the biggest impact on your results.

I once had a goal of doing a pull-up. So, in an effort to achieve my goal I would jump on the pull-up bar and try with all my might to do a pull-up. My legs kicked everywhere, my neck got all tense, and I pretty much just shrugged my shoulders instead of using any sort of useful strategy to lift my body upwards. Oh, and then I would always have to let go of the bar because I didn’t actually have the grip, back or core strength to hold on to it for long.

I was trying to run before I walked.

I was trying to perform my end goal before developing the strength and movement patterns needed to successfully execute this goal. And in my effort I ended up just creating a number of compensations that were harder to break later when I focused instead on learning the fundamentals.

Fast forward to today: I still can’t do a pull-up, but I can hang on the bar with all the right muscles engaged and hold myself there in a solid position. If I have a coach around, with their assistance I can pull-up without those wonky strategies I once used – no flailing legs, sore neck or shoulder shrugs. And I know that this puts me at a much better trajectory towards the end goal of a pull-up than if I had just kept trying to “do a pull-up”.

I think we are all guilty of this sometimes. Of wanting to reach our end goal so badly that we skip steps along the way. But most always the process of learning the skill is so important and doing so properly under the guidance of a coach will help you achieve your goal at a much faster rate AND avoid a lot of frustration along the way.

What This Means in Relation to Our Pelvic Health

When it comes to our pelvic health I find a lot of times women start running before they walk. And to be clear, I don’t mean literal running and walking. I mean trying to do advanced versions of their pelvic floor exercises or advanced exercises (with little to no coaching) that they may not yet be ready for.

The progression of what we work on will differ, of course, depending on the individual, the presence of any pelvic floor dysfunction and the activities they are doing. But to give you a few examples of the most common cases of running before walking I see are as follows:

  • Practicing Pelvic Floor Muscle Contractions (PFMC aka Kegels) when you are not ready to do so (either due to incorrect technique or oversight pelvic floor muscles
  • Holding the contractions longer than you are capable of, leading to compensations
  • Doing other exercises with poor form (holding breath, increasing intra abdominal pressure unnecessarily)
  • Doing exercises your pelvic floor is not yet able to tolerate

Sometimes doing these things can lead to further dysfunction (aka worsening symptoms, which no one wants!), or simply putting forth a substantial effort with little to no results from all the hard work. Either way, it can be incredibly frustrating to work towards something without seeing the results you want.

When this happens, we just need to re-adjust and focus on finding out what it is we need to be doing to see continued progress! And I am here to help you do just that

How Do You Know What is Too Much?

Quite simply, you will know by working with a Pelvic Health Physiotherapist who will assess your body (including your pelvic floor) and determine what is best for you.

You see, during an assessment we look at the whole body (posture, alignment, movement, range of motion, coordination, strength, tissue health) including a detailed assessment of the pelvic floor. When speaking of the pelvic floor we assess your ability to voluntarily contract and relax those muscles (in other words, can you do a Kegel properly? Can you relax those same Kegel muscles?), the strength and endurance of the muscles, the coordination of your pelvic floor (does it contract and relax when it is supposed to? Is the timing right?), and how supportive it is to the organs above/is there a prolapse present.

Based on this assessment we will guide you and coach you on how to train the muscles of your pelvic floor to work on any one or combination of the following: strength, endurance, power, and/or coordination. We will coach you on how to move and exercise effectively to both improve your overall fitness and health, but also to both protect and improve your pelvic health.

When your body starts making compensations, or symptoms start occurring (incontinence, pain) we know that we have to adjust what we are doing. Common compensations related to the pelvic floor include holding your breath (which can sometimes lead to more pressure on the pelvic floor) and recruiting other, bigger, muscles or strategies, such as using the abdominal muscles, glute muscles, squeezing your thighs together and tensing your upper body.

What this Blog is NOT Telling You

I want to be clear: I am here to work with to ensure you experience success when it comes to your pelvic floor muscle training and training in general. I will help guide and coach you on how to progress your pelvic floor muscle training, chat with you about all the lifestyle and behavioural strategies we can use, and work with strength coaches to ensure you are incorporating physical fitness.

When I say you have to walk before you run, what I am NOT telling you is this:

  • You can only walk for fitness
  • Running is bad for you
  • You can’t workout and train
  • You can’t do most exercises
  • You are not doing as well as you should be or you are not good enough
  • Something is “wrong” with you
  • You won’t get better
  • You are alone in this

No. All of these are NOT true.

You can workout. You might be able to run. You can do most exercises, though some may just need to be modified slightly.

You see, it isn’t so much about what exercise you do, but how you do it. And luckily I work with some amazing strength coaches who are highly educated and skilled so they can ensure you can have a great workout doing things you love that will not only not negatively affect your pelvic floor, but that will help!

You are good enough. Nothing is wrong with you. You will get better. You are not alone.

So many people think that whatever they are dealing with – be it incontinence, pelvic pain, prolapse, weakness – is just going to be their new normal. That they just have to get “used to it”. This is absolutely not the case! Regardless of what symptoms or things you are experiencing know this: it is common, but there is SO much we can do and you will see change. Because you are not alone in this. So many other women experience these same symptoms, and they, along with us are here with you. We will guide and coach you and ensure that you can be your best you.

Remember: it’s not only okay, but it is also necessary to walk before you run. Allow yourself to go through the process instead of rushing to the finish line. I promise, it will be worth it in the end.

What to Look for in a Pelvic Health Physiotherapist

Your pelvic health is such a huge part of your overall well-being and quality of life, and I’m so happy to see that this critically important aspect of our health is starting to get some more attention in mainstream media and news as of late.

Women have long since suffered from pelvic floor dysfunctions including pelvic pain, incontinence, pelvic organ prolapse, or pain with sex, usually believing that these symptoms are simply their new ‘normal’.

One thing that us pelvic health physiotherapists have known for years, and what we have worked tireless to educate the world on, however, is that though these symptoms are incredibly common, they are NOT normal. This means though many women experience these things, there is so much that we can do about it to make you feel and move better and to help you rid yourself of these symptoms and feel amazing!

Though North America isn’t quite as advanced as many places in Europe such as France and the Netherlands that include pelvic health physiotherapy as mandatory after women have a baby, our medical professionals and patients alike are learning more and more the importance of having your pelvic floor assessed and treated if any of the above symptoms occur, or after giving birth to a baby.

And though I’m incredibly happy to know that this change is starting and to hear that more and more women are taking charge of their own health by seeking out help with a physiotherapist, I must caution one thing:

Please beware of who you entrust your health to.

Do not pick just anyone, just any practitioner who tells you they treat pelvic floor dysfunctions.

Find someone who you can trust, someone who is highly educated and who treats you as a whole person.

As amazing as it is to me that we are talking more and more about pelvic health in popular media, we must be careful as it is also becoming “trendy” to talk about, which means even those people who are not truly educated and skilled in assessing and treating the pelvic floor are jumping on the pelvic health bandwagon in an effort to not be left behind.

This is why I want you to arm you with some important knowledge before you pick the physiotherapist that you will work with to better your health.

  1. Your physiotherapist should perform an internal examination

I am quite shocked at the number of physiotherapists who claim to treat common pelvic floor dysfunctions who are not trained in, nor perform, an internal examination.

Though I do applaud and think it important that all physiotherapists take continuing education on pelvic health and learn some basic external clues and assessments for dysfunction, it is not appropriate to entrust these same therapists to assess and treat your pelvic floor dysfunctions.

Assessing the pelvic floor without doing an internal exam is like an orthopedic surgeon or physiotherapist assessing the shoulder without ever touching it, or a physician assessing your abdominal pain without lifting up your shirt.

This would (rightly) be thought of as ludicrous and completely unacceptable, yet for some reason has been thought of as ok in the world of pelvic health.

You see, the pelvic floor muscles are on the inside of our body. They surround the opening of the urethra, vagina and rectum and the only way they can truly be assessed is via an internal assessment where a physiotherapist uses a gloved finger in the vagina or rectal canal. In fact, research study after research study has shown that the gold standard recommended first line of defense against most pelvic floor dysfunctions is pelvic floor physiotherapist using internal assessment and treatment techniques.

Though it is important to look at external factors, muscles, and movements during assessment and treatment (as it would be with any injury and to not look at the body in isolation), not addressing the pelvic floor muscles themselves is missing a big part of the picture.

In order to fully test muscle symmetry, strength, length, and tone, there must be an internal exam. In order to look at the presence of trigger points, the irritability of the peripheral nerves, to see if the connective tissue is involved, there must be an internal exam. In order to assess sensitivity, blood flow, myofascial restrictions, and the positions of the coccyx and organ positions, there must be an internal exam.

And in order to properly teach and coach you on what to do – whether it be how to properly contract those muscles to strengthen them or learn to effectively relax those muscles to decrease tone – an internal exam is truly the game changer and the gold standard.

So, when it comes to working with a professional when it comes to your pelvic health, please ask the questions and make sure they are trained and educated in how to properly assess and treat the pelvic floor internally as well as externally and accept nothing less.

  1. Your physiotherapist should also have a strong orthopedic background

Your body, including your pelvic floor, does not work in isolation. Instead it works together as a system, a unit, to create movement. This is why it is important that your pelvic health physiotherapist has a strong background and knowledge in orthopedics as well. That they understand proper movement and exercise. Good alignment, movement, and overall body strength is a huge part of pelvic health as well and should not be overlooked.

Common areas that may be involved in pelvic floor dysfunctions include your spine, SI joint, hips, core, and even your feet! Having a physiotherapist who can effectively assess and treat these areas of your body and how your body moves as a whole is so important in order to best treat you as a whole.

In addition, your physiotherapist should be able to teach you and modify exercises so that you can continue (or start!) to incorporate full body strengthening and fitness into your life as this is such a crucial part to both our overall and specific pelvic health. They should also have a referral network of trusted and skilled strength and conditioning coaches whom they work closely with in order to help you get your best results.

  1. Your physiotherapist should discuss with you behavioural and lifestyle changes that are crucial to your pelvic health

There is so much amazing research out there that shows the huge benefit of pelvic floor muscle training done with a physiotherapist for a number of pelvic floor dysfunctions. However, there is also a ton of amazing research out there that shows the huge benefits of behavioural and lifestyle changes on pelvic floor dysfunctions as well.

This is why it is crucial that your physiotherapist not talk ONLY about the exercises you should do, but also about important strategies and modifications you can make throughout your day to day activities that can make huge and positive changes for your health. These should include, but are not limited to, nutrition and physical activity, bathroom behaviours, managing constipation, and managing fluid intake.

These tips and tricks may oftentimes seem simple, but they are not always common sense and oftentimes need to be discussed to understand their importance. I remember when I was first delving in to my pelvic health education I was shocked at how obviously important these were but something that I had never once previously considered.

  1. Your Physiotherapist is current on new research, evidence, and is using the best methods to help you get results

It is so important that your physiotherapist does not using a cookie-cutter approach to treatment. This means that what works for one person may not work for another, and your therapist needs to be prepared and be able to work with a multitude of different conditions with a variety of different treatment methods to ensure best outcomes.

It is also important that they stay current with research and best practices in the world of pelvic and orthopedic physiotherapy to offer you the best treatment possible.

For example, you may have heard of some therapists using what is called biofeedback while others do not. What’s that all about?

Essentially, biofeedback (in the pelvic health world) uses sensors both internally and externally that measure muscle activity which then give a visual representation of what the muscle are doing on a laptop screen. This gives you the ability to know, in real time, what muscles are doing what by seeing the activity on screen. You will be able to see if your pelvic floor is contracting or relaxing, or if other muscles such as your abdominals or glutes are taking over and compensating. The key with this tool is that you get this feedback in real time and can make immediate adjustments to better learn.

And according to a Cochrane Review (a highly authoritative and reliable research resource) looking at incontinence it was determined that women who received biofeedback in addition to pelvic floor muscle training were significantly more likely to report that their urinary incontinence was cured or improved compared to those who received pelvic floor muscle training alone.

Though there may be times when biofeedback is not necessary, there are also many times when it is highly beneficial, leading to significantly improved outcomes for pelvic floor dysfunctions.

It is therefore important that your therapist is trained and set up to use this important tool in their practice in order to help alleviate and cure your symptoms effectively and efficiently!

In Conclusion:

These are just a few important things to consider when choosing the right health practitioner to work with and I could go on and on adding about 10 other things, but I don’t want to bore you with yet another long read by me, so I will leave you with these, most important points.

Know that it is OK to ask your practitioner questions. Ask them about these things, about their education, about their experience, about how long they have been doing this, about who their colleagues and mentors have been. You have to advocate for your own health and it is OK to want only the best for yourself.