Navigating Life with Chronic Pain: Part 1

cactus

Fiona McMahon, PT, DPT

Why Should Everyone Care About Chronic Pain

Chronic pain is the in vogue topic of the day. It is a subject that has pushed its way into American’s awareness for very good reason. According to the American Academy of Pain Medicine, chronic pain currently affects more than 1.5 billion people worldwide, affecting work, sleep, and quality of life. Most importantly chronic pain has become dangerous as the opioid crisis has come to a head. Out of the 28,000 people who died of accidental drug overdose, nearly 12,000 died from painkillers, three times as many in 1999, according to the American Academy of Pain Medicine.

What Is Chronic Pain

Chronic pain is classically defined as pain that persists more than 3 months, but it is so much more than that. When pain becomes chronic, it is actually processed in the brain differently than acute pain. This is one of the reasons chronic pain has proven to be so difficult to treat using traditional means.

Pain serves a vital function and is something we need to survive. Pain alerts us to danger like a hot stove or broken bone and compels you to take action. This “take action now” pain is acute pain. Chronic pain lingers and can be totally independent of what is actually going on in the tissue. In fact, the tissue may have healed completely and still pain persists. There are a lot of thoughts as to why pain becomes chronic. It can seem like there is nothing left to treat, and all we can do is blunt it with analgesics and painkillers. But there is more to do. All pain, whether it is acute or chronic is processed by pain receptors, the spinal cord, and finally the brain. By addressing pain at the level of the nervous systems, we can change the way stimuli are perceived in the brain, and hopefully reduce pain.

The book, Explain Pain, by David Butler and Lorimer Moseley does a really superb job explaining this concept. In the book, they explain chronic pain is the body’s response to prolonged exposure to noxious stimuli. (In non medical person terms: basically if you have pain for a long time, the body becomes much more sensitive to things that may or may not be painful or damaging). In states of chronic pain, your body can actually lower the threshold for something to become considered painful in the brain. Meaning, that simple stimuli like tight fitting clothing, or sitting can feel very painful. Your body is doing this, because it is on guard for anything that might hurt it. Chronic pain is your body’s way of looking out for you, but has gone way too far.

This blog is not long enough to dig into all of the varied nuances of how and why chronic pain occurs, but if your interest is peaked, I would highly recommend taking a look at Explain Pain or The Explain Pain Protectometer in order to dig down into the deep and fascinating science behind chronic pain.

False Leads and Dead Ends In Pain

Opiods, Addiction, and Efficacy

The nature of chronic pain has proven to be elusive for patients and healthcare practitioners alike. In the 1990’s, in an effort to finally address chronic pain, opiods became much more widely used. At the time, drugs like Oxycontin were marketed as a safe way to treat chronic pain. The manufacturer of Oxycotin, Purdue Pharmaceuticals, instructed their drug representatives to tell doctors that the rate of addiction for long term Oxycotin users was 1%, according to pharma who help fund these studies. Although one study did indeed find these numbers many other found addiction rates in excess of 40%.

Probably one of the most unfortunate aspects of the push by pharma to prescribe opioids more freely, is despite marketing to the contrary, there have been more and more studies supporting the theory that opioids may in fact be ineffective for the treatment of chronic pain. Studies of worker’s compensation patients being treated for chronic pain indicate that patients on higher opioid dose, return to work more slowly than those on lower doses. Additionally, patients with back pain, who are being treated with long term opiod therapy report greater disability than those who are not on opioids.

Opiods have their place, especially in the treatment of cancer, procedural, and end of life pain, however it is becoming more and more clear that opiods are not the miracle drug we once thought they were in the treatment of long term chronic pain. The increased risks of addiction, accidental overdose, falls and fractures, depression, and severe constipation (which can indeed worsen the pain for which the opiod was prescribed in the first place), make it clear that as a medical community, we need to find a safer and more effective way to reduce chronic pain symptoms.

First steps

If you can find a cause, but at the same time don’t get hung up on it.

This is easier said than done. Often times, by the time patients reach us here at Beyond Basics Physical Therapy, they have folders that are stuffed to the brim with expensive diagnostic tests that read “unremarkable”. This can be incredibly frustrating for someone suffering with very real pain. My first word of advice is, If something doesn’t feel right with your body, don’t stop looking for help, until you find someone who can truly help you. There are many pain conditions like, chronic prostatitis and endometriosis. Which are poorly understood by many providers, that require treatment and or consultation by a specialist. This isn’t to say that the clinicians that are unfamiliar with chronic pain conditions aren’t fabulous providers, but these chronic pain conditions often require a clinician who spends his or her career treating and managing these type of pain syndromes. Basically, don’t allow yourself to be written off by any clinician who tries to tell you your pain isn’t real. It is, but most importantly there are things to be done. At Beyond Basics, we have extensive training on chronic pain conditions, additionally we have multiple connections with physicians, nurse practitioners, and other clinicians who treat chronic pain, that we will often refer too if we feel additional intervention beyond physical therapy is necessary.

I am warning you, before you read this paragraph, I am about to say something that on its face will seem mind numbingly contradictory. Bear with me please, and read the entire passage. If you do get a diagnosis, do not expect an immediate cure of pain. Chronic pain has gone past the point of solely being about tissue damage. A chronic undiagnosed infection, muscle spasm, or injury should be treated to remove the fire or proximate cause of the pain. Just because the pain is gone, does not mean the nervous system will immediately calm down. In chronic pain, treating the proximate cause enables the nervous system to begin to down regulate (or less threat sensitive) with further treatment, but does not always guarantee immediate cure.

This brings me to the problem with imaging. Imaging is a great tool and advances in the ubiquity and affordability of imaging techniques like ultrasound and magnetic resonance imaging (MRI), are allowing more and more people glimpses inside their body. If you have ever looked at an MRI of yourself the feeling is profound. I have been fortunate enough to see both my brain and right hip in mind blowing detail on MRI. It’s amazing, but sometimes knowing where every tear, herniation, and bit of swelling is not only unhelpful, but downright dangerous to some patients.

I am not being hyperbolic simply to drive a point home. Early and unindicated MRI in cases of low back pain has been shown to result in increased time spent on disability and increased cost of care ranging between $8,000-13,000 according to the article by Webster, cited in the sources. The fact is with imaging as powerful as MRI, we get to see almost EVERYTHING and because MRIs are getting slightly cheaper and more common, we are identifying structural changes like disc herniation in people, who might not have had a reason to suspect that there was something wrong in their spine in the first place. Sometimes knowing there is a structural abnormality in your body can cause pain and hypervigilance, when prior to knowing, you may not have had the same quality or as much pain in the first place.. Reports indicate that disc herniation and narrowing of the spinal cord can be seen in up to 57% of people who have no symptoms at all. It’s not a far leap to imagine someone with pain hanging all of their problems on a slipped disc if the MRI shows it. What’s worse, is MRI results are alluring and can often lead practitioners down the wrong path of treatment, because it is an easy answer.

In physical therapy school, my professors drilled into us, with almost religious fervor, treat what you find. A fabulous Physician’s Assistant of mine also told me 90% of what you need to know is in a patient’s history of their present illness. It is so true. You can tell a lot about the origin of the pain by asking questions like, how long has it been around, what makes it worse, what makes it better, and what does it feel like. Imaging can sometimes be a bit of a red herring, rushing well intentioned clinicians towards what they think is a cure, while skipping some crucial information through gathering steps that would aid in a more accurate diagnosis.

MRI’s aren’t all bad. They can be life saving and life improving when they are used appropriately. There are many clinical practice guidelines that guide providers on when it may be beneficial to order MRI or other imaging, however, research has certainly borne out that early imaging is actually counter productive in the treatment of chronic pain.

 

If you find a cause, great. If you don’t, or still feel bad don’t despair

We place so much of our hopes on diagnosis. It seems logical that if there is a cause, there must be a cure. Unfortunately, it is not alway so simple. We went over in the opening paragraphs about how chronic pain is more than what’s going on in a specific body part, it also involves the brain. Sometimes simply curing the tissues is not enough. Sometimes we never know what the cause is. This can be so frustrating for patients. As a pelvic pain specialist, I treat a lot of patients with pelvic floor pain and spasm, who have not yet figured out what specific incident brought the pain on. Rarely, in these cases, is there the “oh, crap” moment, when you realize you have injured yourself. Sometimes the development of chronic pain is like having a water glass. We are all born with water glasses of different sizes. We pour a little water in for something like poor posture, genetics, injury, diet, stress, etc., and when our water glass has overflowed, we develop chronic pain. There is no one definitive cause in cases of the overflowing water glass. Many factors have contributed, and many factors must be addressed in order to treat it properly. That’s why the holistic, mind-body approach is really where it’s at, when we treat chronic pain.

Now that you have a grasp on pain science and how chronic pain can behave differently from acute pain, you can begin to approach treating and dealing with it in a different way. In part two of this blog we will discuss different treatments for chronic pain, including yoga, acupuncture, meditation, of course, physical therapy, and many more. Please stay tuned.

Sources:

AAPM Facts and Figures on Pain. The American Academy of Pain Medicine. http://www.painmed.org/patientcenter/facts_on_pain.aspx. [Accessed June 25, 2017]

Butler, David S, and G L. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print.

Zee A. The Promotion and Marketing of Oxycotin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009;99(2):221-227

Singh P, Chaturvedi A. Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review. Indian J Palliat Care. 2015. 21(1): 105-15

Von Korff M. Long-term use of opiods for complex chronic pain. Best Pract Clin Rheumatol. 2013 Oct 27(5):663-72

Webster B, Bauer A, Choi Y, et al. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work Related Low Back Pain. Spine. 2013. 38(22) 1939-46

Pilates with Kierstin! Kneeling Side Twist

Kierstin Elliot

Exercise: Kneeling Side Twist

Set Up: Kneel on the reformer facing either right or left side of the room with a strap held in both hands. Hands should be directly in front of the sternum, and arms rounded as if holding a big beach ball. Shoulders relaxed, lats slightly engaged, lower abs lifting up and glutes engaged for stability.

Execution: Inhale to prep. Exhale to twist from waist towards foot bar while maintaining fixed upper body posture. Inhale to return back to starting position. Imagine wringing out your waist.

Focus: Obliques and TA, spinal rotation, and pelvic stability. Be sure to keep the pelvis still while twisting from your waist. Your range of motion should only be about a quarter of a pie. Initiate movement with the ribcage, not the arms.

Importance: Core strengthening, spinal mobility, pelvic stability, and overall coordination.

Modifications: If dealing with bad knees, perform the exercise while sitting on the long box. This can also be done standing on the floor with a theraband attached to a doorknob, or standing with free weights.

 

Do You Speak Pelvic Floor? Guide to Anatomy Part 1: Female Genital Anatomy

woman wearing white high top shoes
Photo by Dương Nhân on Pexels.com

Fiona McMahon PT, DPT Pronouns (She, Her, Hers)

Do you speak pelvic floor? I do. There is so much going on in the pelvic floor, that unless you are thinking about it every day, it can be difficult to find the right words to describe exactly what you are feeling where. Today we are going to focus on individuals with female anatomy.

Your Genitals: Your 3 V’s

vulva.jpg

When we refer to female reproductive organs many times we say vagina to describe the whole kit and caboodle down there. The truth is the vagina is just part of it. There’s much more going on.

Vagina: The vagina is the passageway from the uterus to the external world. It can expand to accommodate a penis, toy, or allow for the passage of a baby. It can do this shape-shifting because it has folds called rugae, which can stretch out like an accordion to allow the vagina to stretch as needed. Neat, huh? We call the opening the introitus, but we may also interchange it with simply, “vaginal opening”. Either is fine. The introitus can be an area of pain with penetration, so in Pelvic Floorland, we use that term a lot.

Vulva: The vulva is usually what people are referring to when they say vagina. The vulva encompasses all the external genitalia. Including the labia majora and minora (the lips), clitoris, vagina, and urethra.

Vestibule: The vestibule is the area in between the labia minora (small lips) and vagina. This is another special area, that can become painful with certain conditions

Other Vulvar Components

Urethra: This is the exit of the urinary system and is where pee comes out. Between the anus, vagina, and urethra there are three holes “down” there.

 

clitorisClitoris: This part is pretty cool. The clitoris provides sexual sensation. Did you know it averages four inches in length! Externally we can only see a small bit of it. We call that part the glans. Covering the glans, is the clitoral hood, which helps to protect it. Most of the structure of the clitoris is not viewable from the outside. Branching off the glans and traveling underneath the labia are the bulbs of the clitoris and the cura. These elements are erectile and fill with blood during arousal.

Labia Majora: The labia majora are the outer pair of lips when looking at the female vulva. They protect the delicate tissue of the vulva.

Labia Minora: The labia minora are the smaller set of lips and are contained within the labia majora. The labia minora can come in all different shapes and sizes and still be completely normal. Some women have long labia minora which extend past the labia majora, while others may have shorter labia minora which stay tucked within the labia majora. Variation is normal between women.

Having the words to describe where the pain it can be useful to both your pelvic floor physical therapist as well as your doctor. Stay tuned for future additions of “Do you speak pelvic floor?” where we will discuss male genital anatomy as well as the muscles of the pelvic floor itself.

Pelvic floor physical therapists are specialists in this area and have been added in the last decade, to urological and gynecological guidelines as the first line of treatment for various pelvic and sexual pain and weakness disorders.

ACOG Guidelines on Pelvic Pain:

https://www.acog.org/Patients/FAQs/Chronic-Pelvic-Pain?IsMobileSet=false

AUA Guidelines for Pelvic Pain

https://www.auanet.org/guidelines/interstitial-cystitis/bladder-pain-syndrome-(2011-amended-2014)

Pelvic floor Mythbusters: Is Sitting the New Smoking?!

adult-brick-wall-bricks-450276

Fiona McMahon PT, DPT

Nowadays everywhere we turn we keep hearing the warnings about sitting. I’ve heard it on the radio, from fitness instructors, from colleagues. But is it?! Are we sitting our way closer and closer to the grave and disability? Should I fear my own chair?! Or is it like so many purported dangers of the past, caffeine, egg yolks, fat, carbs, and the like, an overblown threat? Let’s venture into the science and the common sense about sitting in our next installment of Pelvic Floor Mythbusters!

Is sitting the new smoking? When I ponder this question, there are so many other mini questions wrapped up in it. I want to break them down for us so we have a running chance at trying to answer the big overarching question: “is sitting really catapulting us faster towards our graves?”. Here are the questions contained within the larger question in my eyes.

  1. Is sitting just as bad as standing?
  2. Are we really sitting more as a society than our ancient ancestors did?
  3. If we have sedentary jobs, what can we do to counteract the ills of remaining sitting for too long?

… let’s dig in.

Is sitting just as bad as standing?

By now most of us know that a sedentary lifestyle can lead to a whole host of maladies including cardiovascular disease, obesity, amongst other conditions. In a study by Edwardson et al, office workers were cited to be the most sedentary out of all workers, spending 75-80% of their time sitting. Clearly being a sedentary person will increase your risk of serious health conditions and sitting certainly qualifies as being sedentary, but does a standing desk reverse all of the bad effects of sitting, or does it still qualify as being sedentary?

The truth is, the time spent standing at a desk versus sitting at your desk is not burning a ton more calories so one could infer that it won’t help much with improving the maladies I listed earlier. Sitting burns about 80 calories an hour, while standing burns 88. The difference is negligible. A standing desk will not get you out of going to the gym to get that 150 minutes of exercise recommended a week by the CDC.

Some studies have found that a standing desk can help in musculoskeletal complaints, especially neck and shoulder issues, which is certainly a boon for many and a reason to consider a standing desk. The studies did not find that standing desks increased baseline activities levels as measured by daily steps.

Are we really sitting more as a society than our ancient ancestors?

In a brilliant piece, (and inspiration for this blog post) on National Public Radio (NPR), by Michaeleen Doucleff about sitting, an anthropologist was interviewed about whether or not excessive sitting is a new epidemic. Anthropologist, David Raichlen studies modern hunter-gatherers call the Hadza. Using heart-rate monitors, he found out that their daily sitting times were actually pretty comparable to that of modern day Americans. The big difference between Americans and the Hadza is that the Hadza get approximately 75 minutes of exercise a day, where many of us Americans are not getting the 150 minutes weekly recommended by the CDC. He also surveyed back pain and found that the Hadza experience less back pain than Americans do with age. We will get into why in a bit. If you want to listen to this piece, click here it’s really worth the listen. If we can extrapolate and say that the Hadza lived their lives like our ancient ancestors, we can say sitting is not the new epidemic that has wrought so many chronic diseases upon us. It may be that we are more sedentary.

If we have sedentary jobs, what can we do to counteract the ills of remaining sitting for too long?

By this point in the blog, I think we have come down on the verdict that it is not necessarily the sitting that’s doing the harm it’s the inactivity. That being said, if sitting is painful, then the way you are sitting is doing harm to your body and action should be taken to make sitting more comfortable.

If you prefer to sit, or your workplace does not allow standing desks, there are a few things you can do to make sitting more comfortable. The most common “mistake” I see in sitting, is sitting with a rounded spine. In the NPR piece movement coach Jenn Sherer described the shape of a person sitting with a rounded spine as resembling the letter “C” or looking like a cashew. That prolonged posture can be super nasty on your spinal discs and cause back pain and disability over time. To undo the C shape, you should sit more forward on to your pelvis to reduce the C shape, rather than trying to straighten your back by starting at the top of your spine. In the radio piece. I cited earlier, Jenn Sherer recommended visualizing yourself like a dog. You want to sit so you would be able to wag your tail. I really like this visual. It helps me to remember the proper way to sit. Again I would recommend listening to the full piece cited above to get the most out of the story.

What if sitting hurts?

Many of our patients here at Beyond Basics Physical Therapy, find sitting to be painful even if they are in “the proper posture”. Pain with sitting can be caused by many different things including poor hip and back mechanics, muscle tightness in the back and pelvic floor, or poor work set up. If your job requires you to sit and it is painful, feel free reach out to us to learn how you can make your sitting situation more comfortable and to relieve any musculoskeletal dysfunction contributing to your pain.

Verdict

This myth is busted! Sitting in itself will not hasten your demise, however; being sedentary certainly may. The real problem that we face as office workers, or workers, in general, is that our jobs often require us to be sedentary and often times we are not counteracting that outside of work. In order to make sure we are living our most healthy and happy lives, we should be participating in some type of exercise at least 150 minutes a week. This can be a challenge and it doesn’t all have to be done at once you can do it in small doses. If pain or dysfunction is holding you back from exercising, feel free to contact us.

fiona2018

Fiona treats at our midtown location

 

B Ee J, Parry S, Ir de Oliveira. Does a classroom standing desk intervention modify standing and sitting behavior and musculoskeletal symptoms during school time and physical activity during waking time? Internation Journal of Enviromental Research and Public Health; 2018; 2

 

Doucleff, M. To fix that pain in your back, you might have to change the way you sit/ Morning Edition. August 14, 2018

 

Edwardson C, Yates T, Biddle S, et al. Effectiveness of the stand more AT (SmArt) work intervention: cluster randomised controlled trial. BMJ.2018;363

 

Sperlich B, De Clerck I, Zinner C, et al. Prolonged sitting interrupted by 6-min of high-intensity exercise: circulatory, metabolic, hormonal, thermal, cognitive, and perceptual responses. Frontiers in Physiology. 2018; (9)

 

 

The truth behind standing desks
POSTED SEPTEMBER 23, 2016, 9:30 AM , UPDATED SEPTEMBER 27, 2016, 7:47 PM
Robert H. Shmerling, MDRobert H. Shmerling, MD
Faculty Editor, Harvard Health Publishing

Demystifying Persistant Genital Arousal Disorder (PGAD)

PGAD photo

Fiona McMahon PT, DPT

Hello, everyone. Today I want to discuss a condition called Persistent Genital Arousal Disorder (PGAD). PGAD is an often sensationalized, painful, and disruptive condition that causes unwanted genital arousal, which doesn’t typically get better with orgasm and if it does, orgasm only brings relief for a short period of time. The key feature of this disorder is the genital arousal is unwanted and can cause deep psychological distress.

Typically when I write blogs, I will spend the lion’s share of my time sifting through scholarly articles, health articles targeted at the general public, and maybe I will read one or two essays or editorials written by people with that particular condition. The process of writing this blog went a bit differently.

I was researching a condition that had only been first classified in 2001. There really was a small pool of articles from which to pull. I also had to sift through a lot of garbage. There were titles like “ Woman has 100 orgasms a day”, click bait, on click bait, on click bait. I thought of my patients and women and men, who are just starting their journey, not knowing where to start. Frankly, I was sad. I can’t think of a more eloquent way to say it: the web can be a real garbage pit sometimes. I can imagine how hopeless it might feel scouring the Internet for answers.

The good news is, I did not end my research sad. I ended up finding some great articles, but most importantly I listened to a fabulous Pelvic Messenger podcast with our very own Stephanie Stamas PT, DPT with guest Dr. Irwin Goldstein, MD, on PGAD. I ended my research feeling empowered, and it is my hope through this blog and additional resources I have provided, that you will too. If you have found your way here because you have or think you may have PGAD, please, do yourself a massive favor and give this podcast a listen. I will be breaking down some of its points in this blog, but what the podcast does so well, is give hope.

Let’s go ahead and read on, and learn more about PGAD and how to manage it.

What Causes this Condition?

PGAD can affect people with both male and female anatomy. As Dr. Goldstein explains in the pelvic messenger podcast, It is more common in individuals with female anatomy, secondary to the fact the people with female anatomy have a shorter refractory period after orgasm. The term refractory period refers to the interval of time that is required between an individual’s first orgasm and when they are able to become sexually aroused again. People with male anatomy tend to have longer refractory periods, allowing them some relief between bouts of arousal.

There are many factors that are thought to contribute to PGAD. It used to be considered more of a psychological disorder. Over the past 17 years, researchers have found that the development of PGAD can be influenced by stress, but there usually is some sort of anatomical or physiological factor contributing to the development of this condition.

The Role of the Brain

Like we discussed before, stress is a contributor and trigger to PGAD symptoms. Additionally, one of the criteria in diagnosing PGAD is that the genital arousal causes distress. Examining stress triggers and managing the stress of the disorder itself is paramount to effectively managing PGAD, especially if it is taking time to determine what physiological intervention will help treat the symptoms.

There also is some discussion that the sensations that trigger PGAD are processed differently in the brain. Disruptions in the vulvar, penile, or scrotal tissue, nerve compressions, pelvic congestion, etc may be processed in the “action” areas of the brain and may be interpreted as or cause arousal, when in fact, there is a physical condition irritating that delicate tissue that must be addressed.

Studies have also found a connection with PGAD suffers and individuals with restless leg syndrome. In a 2008 study, PGAD and restless leg syndrome were found to be correlated. Restless leg syndrome bears some similarities to PGAD in that sufferers often feel they need to take action, like moving their legs, adjusting their position, and in individuals with PGAD, obtain orgasm for momentary relief. These findings amongst others support the theory that the brains of individuals with PGAD may interpret sensory signals differently than those without the condition.

Medication, Pearls, Back Problems, and Cysts

Now that we have talked about a potential explanation for persistent genital arousal as it relates to the brain, let’s talk about some of the physiologic contributors. The first factor found to be correlated with PGAD has to do with what we put in our mouths. There had been some evidence to support that increased soy intake may affect the development of PGAD. Also, certain medications and withdrawal from them may also contribute to PGAD. Trazadone has been found to contribute to priapism (persistent and painful erection of the penis) in individuals with male anatomy and may also contribute to PGAD in individuals with female anatomy. There also has been a correlation with sudden withdrawal from selective serotonin reuptake inhibitors, (SSRI’s), a form of antidepressant, and the development of PGAD. We always have to remember the old adage that is familiar to anyone who has been taught to consume scientific literature that, “Correlation does not equal causation”. It’s really important to remember that phrase with PGAD, because there are many correctable physiological conditions that also contribute to PGAD.

Keratin pearls, sounds lovely, right? Not so much, and these bad boys are a big factor in the development of PGAD and other pelvic pain syndromes. Keratin pearls develop when the normal products of the vulvar tissue collect and harden under the clitoral hood. As you can imagine, having a keratin pearl is super irritating to this extremely sensitive tissue, not unlike having a piece of sand caught in your eye. This constant stimulation can certainly contribute to PGAD symptoms. Keratin pearls can be removed by an experienced doctor and bring relief for PGAD.

In pelvic floor physical therapy land we think a lot about the pudendal nerve. The pudendal nerve transmits sensory information from our genitals to our brain and gives our pelvic floor muscles instruction from the brain. The pudendal nerve comes off the sacral nerve roots, S2, S3, and S4, (remember this for later). This nerve can become compressed from tight muscles and fascia and can cause PGAD symptoms.

Physical therapists and other clinicians also think about the various “dynias”. Dynia is the Greek word for pain. In relation to PGAD we often think of clitorodynia, vulvodyina, and vestibulodynia referring to pain in the clitoris, vulva, and vestibule respectively. These “dynias” can be caused by irritated nerves, hormonal conditions and overactive pelvic floor muscles and should be addressed in order to help treat PGAD. Additionally, other pelvic syndromes like pelvic congestion can contribute to PGAD.

Do you remember the nerve roots for the pudendal nerve? It’s okay if you don’t. They are the sacral nerve roots S2, S3, S4. Your sacrum is part of your spine and problems in your back like a slipped disc, irritable facet joint, stenosis can all be culprits in irritating these very important nerve roots.

There are these things called Tarlov’s Cysts which recently have been found to be huge in the development of PGAD. Tarlov’s cysts are little sacs filled with cerebrospinal fluid and they can irritate those important nerve roots, S2, S3, and S4. In 2012, it was found that the rate of Tarlov’s cysts is exceptionally high in individuals with PGAD. Management of these cysts can help with this disorder.

Treatment Options and Finding the Correct Practitioner to Connect you to Those Options

So there is a lot of stuff to sort through when trying to figure out where your PGAD is coming from. It requires a skilled clinician to separate the signal from the noise. At Beyond Basics Physical Therapy, we are especially poised to help you get started on the correct treatment path.

Unlike many other clinicians, we are comfortable assessing things like the mobility of the clitoral hood, the mobility of the structures surrounding the pudendal nerve and other pelvic nerves, as well as being able to treat issues involving the back and tailbone. We also have strong and robust connections to physicians who are pioneers in the treatment of PGAD and can help facilitate access to complementary medical treatment.

The most important part of treating PGAD is finding the cause or the driver. Once the driver or drivers are found, you can begin the process of treating them and reducing PGAD symptoms. Dynias, clitoral adhesions, pelvic floor congestion, back issues and irritation to a pelvic nerve can be treated by physical therapy or a combination of physical therapy and medical intervention. Tarlov’s cysts may require surgery to correct. Additionally, medication to reduce the symptoms, mental health therapy and relaxation techniques can be helpful.

PGAD used to be such a mystery and in some respects, it still is; however, we are in a very exciting time, where knowledge about PGAD is growing as well as our ability to diagnose and treat this disorder. The internet is a very scary place to research PGAD and it can be hard to find almost anything hopeful or positive, but there is hope. Give the Pelvic Messenger Podcast a listen and make an appointment to see us here at BBPT today.

Charitable Giving Options to Support Research and Treatment

Like many pelvic pain conditions, PGAD is under-researched. Research is an essential weapon to help us fight PGAD and improve individual’s lives. Please consider donating to the following organizations to fund the development of diagnosis and treatment protocols for PGAD and other pelvic conditions. Also, consider having your company or a friend’s company match your donation.

Donate to support pelvic pain research here:

International Pelvic Pain Society: IPPS https://wjweis.association-service.org/securesite/ipps/donations.aspx

International Society for the Study of Women’s Sexual Health ISSWSH; http://www.isswsh.org/about/endowment-fund

Sources

Aswath M. Pandit L, Kashyap K. et al. Persistent Genital Arousal Disorder. Indian J Pyschol Med. 2016; 38(4)

Jewell T, Legg T. What is persistent genital arousal disorder (PGAD?). Healthline. 2017 [Accessed: November 13, 2017]

Komisaruk B, Lee H. Prevalence of Sacral Spinal (Tarlov) Cysts in Persistent Genital Arousal Disorder. J Sex Med. 2012 Aug;9(8):2047-56.

Stamas, Stephanie. “ Dr. Irwin Goldstein: Treating Persistent Genital Arousal Disorder (PGAD).” Audio Blog Post. Pelvic Messenger Podcast. Blog Talk Radio. March 2017

Waldinger M, Schweitzer D. Persistent Genital Arousal Disorder in 18 Dutch Women: Part II- A Syndrome Clustered with Restless Legs and Overactive Bladder. J Sex Med. 2008

Hope with Pelvic Pain: A Patient’s Story

The writer of this blog and patient and wishes to remain anonymous.

flower
I am a 65-year-old married professional male who resides in NYC. About a year ago, I woke up with pelvic pain and I assumed it was a urinary infection. Immediately I went to my urologist, who gave me a urine test which showed a slightly elevated white blood cell count and was given antibiotics for two weeks. Despite this treatment, the pain continued and I went for another test, which was negative.  I was told I had an inflamed prostate and to avoid spices and caffeine. This pain was so severe and constant that it affected all my daily life activities. Even painkillers, which I took for a short duration, could not relieve the pain.
Having performed my own internet research, for the better or worse, I came across several blogs on how pain sufferers had these similar symptoms that remained unresolved for years. The majority of these blogs focused on the perineal nerve, which I thought could be my issue. Therefore, I then went to a neurologist who claimed this was not the problem and then had other nerve blocks without any relief. Neither the urologist, neurologist, or general practitioners could offer any explanation.
Then, going back to the internet I found the keyword “pelvic pain”, which unlocked this pain mystery with services offered by only a handful of providers. The explanation was that rather than having headaches or backaches from stress, I was tightening my pelvic floor muscles thus creating pain.
After reviewing the few physical therapy sites I decided to try Beyond Basics for a discussion, evaluation, and treatment. I was able to schedule an appointment right away without needing a prescription from a physician. At my first session, I explained that I lacked the hope that this problem would ever be resolved, but that I would be committed to their program.
Now after almost two months of weekly sessions, my Physical Therapist has led me on a road to holistic recovery guided by exercises, massage, education, and emotional support.  I understand that the scale of pain relief will be a roller coaster, but now for the first time, I can relax when there are dips in pain.
I want to conclude my first blog by saying that my Beyond Basics PT has given me “hope” by defining the problem and offering a solution with life lessons on how to deal with this issue that is unknown to so many people.
It has been a few weeks in which I have no pain, feel fully recovered and I am back to appreciating life.

Anonymous

 

If you have questions about orthopedic, pelvic, or sports physical therapy, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

 

 

Pilates with Kierstin! Slingshot Lunges on the Reformer

Just in time for your New Year’s Resolutions, here’s another awesome exercise from Kierstin Elliot, Pilates Teacher at Beyond Basics Physical Therapy!

Goal: Strengthen the glutes and balance 

Exercise: Slingshot Lunges on the Reformer

Set Up: Standing on the floor with right foot near foot bar and left foot against the shoulder rest. Keep left knee straight and tilt upper body forward creating one long diagonal line from head to back toes. Use one blue spring as resistance. Belly button and chin are tucked in with neck lengthened and shoulders rounded back.

Execution: Inhale to send pelvis back into lunge bending the front knee 90 degrees while reaching arms forward and keeping the pelvis level and squared off to the front. Keep shoulders away from ears. Exhale to straighten the front knee, lower arms to sides, and return to your starting position.

Focus: Be sure to keep proper alignment throughout the spine. Lumbar spine should be elongated and supported throughout the entire exercise. Maintain core connection by dropping bottom ribs towards the top of your hips bones. Hips should also be level and squared off to the front- make sure there’s no pelvic rotation during lunges.

Importance: One of the best exercises for strengthening your glutes! This exercise also enhances your ability to stabilize the pelvis and lower back while connecting to the core for improved balance.

Modifications: Limit the range of motion in standard position, or drop back knee to the carriage. Dropping the back knee may draw more focus to the quad, making the exercise feel more like a stretch, however, the focus should still be held on standing glute. For an added challenge, grab a set of 3 pound free weights for your arms for added core control.