Yoga for Chronic Pelvic Pain

crop faceless lady sitting in zen pose on yoga mat
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Kathryn Ahuja PT, DPT RYT200

Patients with chronic pelvic pain (CPP) often ask, “Is there anything else I can do?” They have often been living with pain for a long time and are eager to feel better as quickly as possible. The truth is that there is no fast lane to healing CPP. Healing should integrate the biomechanical, psychological, and social factors, which can all play a part in your symptoms. Yoga can be a very effective way to address each of these players and move you towards increased freedom and function.

Biomechanical factors: How can yoga help?

Previous blog posts,Pelvic Pain Awareness Month Part 1: What is Pelvic Pain  and Pelvic Pain Awareness Month: Part 2: Hope for Chronic Pelvic Pain  have discussed how the muscles of your pelvic floor can lead to CPP. If you have lived with pain in the pelvis, genitals, reproductive and urinary organs, coccyx, or pubic bones for a long time, the pain can alter the way you move in everyday life. People with CPP tend to be less active than their peers, have altered postures, (usually with a more posteriorly tilted pelvis (a tucked tail bone) and an increased thoracic kyphosis (hunch in upper spine), and they tend to adopt ways of sitting or standing that is protective of their painful spots (Zhang 2015). It makes sense! Pain in this area of the body makes us just want to curl up in a ball and stay there!

Being curled up like a cashew all day has a real influence on your pain. Our bodies are designed to move and when we stay in one place for a long time our joints get stiff, blood flow to and from our tissues is impaired, and the muscles that should help us stand tall become weak and tight. It can become difficult to actually differentiate the pain that is coming from your pelvic floor and the discomfort you may feel because of the adaptations you have made because of this pain.

Practicing yoga poses called asanas is an effective, safe way to get you moving again. Standing poses like warrior II (Virabhadrasana II) and crescent lunge (Anjaneyasana) simultaneously lengthen and strengthen the muscles of your legs and hips. When these muscles regain their function, it can help your pelvic floor muscles to back off any chronic holding patterns. Backward bends like cobra (Bhujangasana) or camel pose (Ustrasana) help restore the natural curves of your spine while lengthening any tension in the abdominal muscles. This may make it a little easier to keep your body in an upright posture throughout your day. Supine stretches like butterfly (Baddha Konasana) or happy baby (Ananda Balasana) can help ease tension in the muscles of the inner thighs (adductors) while you are supported by the floor. When these muscles relax, there can be a noticeable reduction in pain since trigger points in the adductors can refer to the genitals and pubic bone.

In a study performed in India, 30 women who attended a 1-hour yoga class five times weekly for eight weeks saw significant reduction in their pelvic pain ratings compared to the start of the intervention. These women also showed a significant reduction in pain scores compared to women who only took NSAIDS for pain relief over the same time. The researchers theorized that the intervention was effective not only due to the effects of the stretching and strengthening, but also because of the relaxation exercises which “modify neurological pain perception which could be the mechanism for pain reduction” (Saxena, 2017). This research suggests that yoga is doing something more than addressing the muscles. It may actually change the brains of those who practice.

Psychological factors: How can yoga help?

Ask any regular yogi and they will tell you that there is much more to the practice than just the asanas. It turns out, there is some really interesting science behind the feel good vibes you might experience after a yoga class.

Yoga is different from many other forms of exercise because there is an intentional focus on your breath. In Hindu philosophy, prana means not only breath, but “life force.” It is believed that one’s breath has tremendous power and in performing pranayama (breathing exercises) we can strengthen and harness that energy. Today, we understand that breathing does more for our bodies than move air in and out and we have even greater appreciation for this ancient philosophy.

You are probably familiar with the idea that slow, deep breathing can help to calm you down. The mechanism that drives this response is called the parasympathetic nervous system (PNS). Deep, slow breathing sends a message to your brain that you are not under a direct threat. The PNS then works to shift you out of “fight or flight” mode and into a calmer, more peaceful state. If you have CPP, your body might live in a constant state of fight or flight. Pranayama exercises have been shown to help quiet those signals and strengthen the signals from your PNS. With a consistent practice of slow, deep breathing you can actually shift your whole body towards a parasympathetic dominant state (Gerritsen, 2018).

Depression and anxiety are common comorbidities for people with CPP. Yoga can help to shift your mood which may also have an effect on your perceived pain. A randomized control trial evaluated the levels of a neurotransmitter called GABA in people with Major Depressive Disorder (MDD) and in a healthy control group. GABA is an inhibitory neurotransmitter that helps to regulate important cortical functions including mood. When compared to the control group, those with MDD had significantly lower levels of brain GABA. After completing a 12-week yoga program however, there was no difference in these levels between groups. Even more importantly depressive symptoms decreased significantly in the MDD group and anxiety levels improved for both groups (Streeter, 2018).

These stunning changes do not seem to be attributable to all forms of exercise. In comparison to people who walked for one hour, those who did yoga for the same amount of time had greater increases in GABA as well as improvements in mood scores (Streeter, 2010). While this study was small, it makes a great case for future research to determine if yoga may be a suitable alternative to medication for those with serious anxiety or depression.

Social factors: how can yoga help?

Persistent pain can have a profound effect on how you interact with the world. Symptoms of CPP are not visible to others and we tend to not talk about them with most friends and colleagues. Throbbing, aching, and stinging sensations can make you more irritable, less willing to put on certain clothing, or cause you to avoid aggravating activities. This can put a real strain on all your relationships. Emotional distress from fraying relationships can be difficult to manage when you are trying to heal and could even stress you to the point of making your symptoms worse.

If you are limited in your daily functions or feel that your quality of life suffers due to CPP symptoms, there is evidence to support using yoga to intervene. Women with pelvic pain had improved emotional well being and sexual function scores after a 6-week yoga course consisting of about 3 hours of yoga per week. At the end of the program, 75% of the participants indicated they felt the yoga program was something they could continue to do without guidance (Huang, 2017). It can be quite empowering to feel like you have control of your symptoms and are not reliant on a doctor or PT to “fix” you. Additionally, a yoga class can be a nice way to socialize while doing something positive for your body.

Yoga may not totally eliminate the pain you feel, but it may help you to manage your symptoms more elegantly. Breathing techniques can assist when symptoms strike at work. Mindfulness about your body can help you determine when it is appropriate to push yourself and when you need to rest. Mastering a tricky posture is very rewarding and may encourage you to open up to other novel challenges.

Ready to give it a try?

As with all new forms of exercise, if you are looking to try yoga for CPP you should seek out a class with a knowledgeable instructor who can offer modifications and cue your alignment appropriately. Start slow and never be afraid to ask your teacher a question if something does not feel right in your body. At first, the hardest part might just be learning to be still and breathe deeply: that’s ok, and it will get easier!

Please consider joining me for our virtual yoga class every Tuesday at 7pm. Click here

for more details.

References

Gerritsen RJS, Band GPH. Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity. Front Hum Neurosci. 2018;12:397. Published 2018 Oct 9. doi:10.3389/fnhum.2018.00397

Huang AJ, Rowen TS, Abercrombie P, et al. Development and Feasibility of a Group-Based Therapeutic Yoga Program for Women with Chronic Pelvic Pain. Pain Med. 2017;18(10):1864‐1872. doi:10.1093/pm/pnw306

Saxena R, Gupta M, Shankar N, Jain S, Saxena A. Effects of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int J Yoga 2017;10:9-15

Streeter C, Gerbag P, Nielsen G, Brown R, Jensen JE and Marisa Silveri. The Effects of Yoga on Thalamic Gamma-Aminobutyric Acid, Mood and Depression: Analysis of Two Randomized Controlled Trials. Neuropsychiatry Journ. 2018;8(6).

Streeter CC, Whitfield TH, Owen L, et al. Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled MRS study. J Altern Complement Med. 2010;16(11):1145‐1152. doi:10.1089/acm.2010.000

Zhang R, Chomistek AK, Dimitrakoff JD, et al. Physical activity and chronic prostatitis/chronic pelvic pain syndrome. Med Sci Sports Exerc. 2015;47(4):757‐764. doi:10.1249/MSS.0000000000000472

Pelvic Floor Physical Therapy for the Transgender and Gender Diverse Population

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By Molly Caughlan, PT, DPT (pronouns: she/her/hers)

Healthcare equality for the LGBTQ+ community is one area we as a society are significantly behind on and continues to require research, education, and training. For many, access to compassionate healthcare can be challenging, especially to those within the transgender/gender diverse population. According to a survey done by Lambda Legal, 52% of transgender respondents reported that they believed they would be completely denied medical services because of their gender status. They also found that 56% of lesbian, gay, or bisexual persons surveyed have experienced some type of discrimination in healthcare leaving many to avoid seeking treatment altogether.

As healthcare providers, we, at Beyond Basics Physical Therapy, understand the importance of cultural competence and strive to live up to the standards that the LGBTQ+ community deserves. Our goal is to ensure that every patient is provided with the highest quality of care, dignity, and respect. We strive to create a safe environment for patients and aim to deliver health care services with the specific needs of the patient in mind.

What Does a Physical Therapist Do?

At our core, physical therapists are MOVEMENT SPECIALISTS. We use a wide range of evaluative tools to assess how the systems of the body work together. We provide treatment to prevent, minimize, or eliminate impairments in order to optimize physical function. This includes restoration after injury, pain relief, maintenance of current function, and promotion of health.

Components of a Physical Therapy Evaluation

•        Self-report questionnaires

•        Posture and alignment in various positions

•        Breathing patterns

•        Range of motion and strength in relevant parts of the body

•        Functional movements – walking, getting in and out of chairs, in and out of bed and with any type of exercise 

•        Palpation of muscles in back, abdomen, pelvis, and lower extremity

(palpation is a fancy word for feeling parts of the body to assess for restrictions and tightness)

•        Goal setting – determine personal goals for coming to physical therapy

(How can we use the information from the evaluation to best help you meet your goals?)

What is Pelvic Floor Physical Therapy?

Pelvic Floor Physical Therapists receive special training to assess the pelvic floor muscles and abdominal organ mobility in conjunction with the other components of a standard physical therapy evaluation. This enables them to treat a variety of diagnoses including bowel, bladder, sexual problems, as well as prolapse, abdominal pain, back pain/pelvic pain, genital pain and more. We are experts in the areas associated with the pelvis, including vulvar and vaginal, penile and scrotal, and colorectal regions.

Pelvic Floor Muscle Anatomy

The pelvic floor is a sling of muscles that connect from the pubic bone to the tailbone and lives in the pelvis. They are responsible for providing the following 5 major functions:

  1. Stability: they work with the hip and core muscles to control movement in the pelvis
  2. Support: the “hammock” like muscle group holds and supports the abdominal organs (i.e. reproductive organs, bladder, bowel)
  3. Sphincteric: this function gives control to “open” (i.e. urinate or have a bowel movement) and stay “closed” (i.e. avoiding pee/poo accidents)
  4. Sexual: the muscles stretch to allow for receptive vaginal or anal intercourse; they also are what contract with orgasm
  5. Sump Pump: the muscle contract to move blood from the pelvis on its way to the heart

How can Pelvic Floor Physical Therapy help me?

If you have a pelvis, you may encounter issues with bowel, bladder, or sexual function. Although we specialize in pelvic floor treatment, it’s important to note that we treat the person as a whole and strive to understand the complexity of the many systems of the body work together.

There are also a number of common complications that accompany gender affirmation practices and surgeries that can be relieved through physical therapy. Since bottom surgeries drastically change the anatomy, there is an impact on the ability of the pelvic floor muscles to work properly. There are also many other post-operative considerations such as dilation (for neo-vaginoplasties), wound care/scar tissue management, and relearning toileting behavior with new anatomy. All of these considerations can be addressed and aided through pelvic floor physical therapy. Other procedures such as mastectomy or breast augmentation also create changes to the muscles of the chest as well as lymph vessels  and require the help of a physical therapist to ensure your body is able to function properly with that change. Practices such as binding or tucking come with their own set of complications, which can be minimized with a skilled physical therapist.  We understand how important these activities are and don’t want to make you stop, rather we want to help encourage good habits and help minimize any negative side-effects you may experience as a result.

Still unsure if we can help your specific needs after reading this article? At Beyond Basics, we offer free 15-minute phone consultations to ask us more specific questions. Give us a call to see how best we can help you today!


[1] https://www.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring_1.pd

Do I have Pelvic Congestion Syndrome?

 

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Eliza Etter PT, DPT, CLT

Do you ever notice at the end of the day your feet or ankles seem swollen? If you were on your feet for a long portion of the day, your feet, ankles, and legs may feel achy or heavy. This is not an uncommon experience and most of us have probably felt this at some point in our lives. But have you ever felt a similar sensation in your pelvis? If so, it could be related to something called Pelvic Congestion Syndrome.

What is Pelvic Congestion Syndrome?

Pelvic Congestion Syndrome (PCS) is essentially varicose veins in the pelvic region. There are several large veins coursing through the pelvis and around the pelvic organs. These veins can become “incompetent” meaning that they are no longer pumping blood back up towards the heart as effectively as they should. As a result, the blood begins to pool in these veins of the pelvis, termed “pelvic congestion.”

Symptoms of PCS often include chronic pelvic pain not associated with menstruation or a heaviness feeling in the pelvis which may frequently worsen with prolonged standing. PCS also has been found to have associations with painful periods, pain with sex, urinary urgency, and varicosities in the genitals or legs. A systematic study conducted in 2018 found that PCS was associated with pelvic pain in 30-40% of individuals with chronic pelvic pain diagnoses. The majority of the current literature describes PCS in women, with the prevalence increased in women compared to men, at least in part, due to hormonal changes and pregnancy.

What causes Pelvic Congestion Syndrome?

Similarly, to varicose veins of the legs, there are a number of factors that contribute to PCS.

These include:

· Dysfunction in the valves of the veins – These valves inside the veins are supposed to allow blood to travel only in the direction back to the heart, but can become weak and allow some of the blood to flow backwards.

· Anatomy differences in the veins themselves

· Pressure or kinking on the veins – One of the ways this can occur is from the position of the uterus.

· Structural and hormonal changes – These types of changes are often associated with pregnancy.

It is possible that pelvic varicosities may be present for a period of time without any pain or symptoms at all. Slower flow of blood return, inflammation, blood clots and insufficiency can be the result of pelvic varicosities that were possibly already present, but are just now starting to cause pain or symptoms.

How do I know if I have Pelvic Congestion Syndrome?

To be diagnosed with PCS requires medical imaging, such as pelvic venography, ultrasound, or MRI. However, based on your symptoms alone there are things that you can do that may give you some relief from your symptoms.

Tips to Help Relieve Symptoms of Pelvic Congestion Syndrome:

· Stay moving! Sitting or standing in one position for too long can increase the pooling of blood in the veins. When you move, the movement of your muscles assists the veins in pumping blood upward and towards the heart.

· Stay hydrated and eat a low-sodium diet. This can help with decreasing swelling and inflammation throughout your body which can overload your venous system.

· Elevate your pelvis. Just as you would elevate your feet if they were swollen, elevating your pelvis will use gravity as your friend to assist the veins with returning the blood from your pelvis back towards your heart.

· Pelvic floor exercises. Pumping the muscles in your calves can help decrease swelling in the feet and legs, and similarly contracting and relaxing the pelvic floor muscles can help pump the blood out of the pelvis. Not sure how to do this? Contact your pelvic health PT.

· Manual Lymphatic Drainage Massage. This is a particular type of skilled manual therapy that helps to stimulate the lymph vessels, which run along with and help the veins, that further assists and decreases the load on the veins, with moving the excess blood out of the pelvis and returning it towards the heart. Contact your Certified Lymphedema Therapist for this treatment.

For further information and non-invasive treatment options contact a Pelvic Health or Lymphedema therapist who has experience with Pelvic Congestion.

Brown et al. “Pelvic Congestion Syndrome: Systematic Review of Treatment Success.” Seminars in Interventional Radiology, 35.1 (2018): 35–40.

Jurga-Karwacka et al. “A forgotten disease: Pelvic congestion syndrome as a cause of chronic lower abdominal pain.” PLOS One, 14.4 (2019): e0213834.

Telehealth: Physical Therapy from Home

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Rachel Clausen PT, DPT

Pelvic pain doesn’t stop because of a pandemic. Beyond Basics Physical Therapy wants to make sure you have access to the care you need to stay healthy and feeling good in your body. If you are unable to leave your home because of coronavirus, we want you to know we are currently offering telehealth to new and existing patients who are in need of care.

So what is telehealth you may ask?

Telehealth is the use of telecommunication technologies to provide remote healthcare services. Both audio and video technologies are used to evaluate and treat patients who are unable to attend an in-person appointment, like a video chat or facetime. After extensive research, Beyond Basics has decided to use Doxy.me as our telehealth platform. This platform is easy to use, does not require downloads, and is HIPPA compliant, meaning the sessions are fully protected and encrypted. Telehealth is also now accepted by a wide range of insurance companies, including Medicare.

You may be thinking, what can a PT do without being able to touch me?

The answer is a lot! We can assess posture, mobility, movement strategies, coordination, prescribe and progress exercises, assess work from home set-ups, provide pain relief strategies, discuss behavioral modifications, work on breathing and system down-training, and the list goes on. Even if you feel that eventually you may need hands on treatment in clinic, telehealth can go a long way towards providing a sturdy foundation of strength, mobility, and good postural habits and strategies to allow hands on treatment to take hold more rapidly when you can come in.

As a PT I have found it especially helpful to be able to work with patients in their home environment. We are able to recreate positions in which you experience pain and work through modifications to decrease that pain. We can work on sitting posture and workstation ergonomics using the desk and chair you spend hours each day using. We can work on movement strategies in your environment, such as emptying the dishwasher or picking up a child in order to optimize core activation and decrease symptoms with functional activities. It is exciting to see patients continue to make progress towards reaching their goals despite being home without physical PT contact.

Are you interested in telehealth, but not sure you have the necessary equipment?

All you need for a telehealth session is a computer or phone, internet connection, and enough room to move around and lay down on the floor. Other helpful (but not necessary) items may include TheraBand, foam roller, balls, weights and yoga blocks. Don’t have any of these items? Don’t worry, PTs are great at being creative and using household items as props. Don’t have a foam roller? We can use a rolling pin or a bottle of wine to roll out tight muscles. Don’t have a yoga block? We can use books or pillows as props. Don’t have any weights? We can use soup cans or a bag of rice. Getting creative is part of the fun!

How does billing work?

Most likely, your current billing will not change, as many insurances are covering telehealth physical therapy sessions. However, for some plans, reimbursement rates may be different for telehealth services. All billing will be continued to be submitted by our staff. We are currently offering discounted rates and packages in order to serve our community at this time.

Please contact billing@beyondbasicspt.com for further billing information and clarification.

If you are interested in a telehealth PT session please contact our midtown office at (212) 354-2622 or downtown office at (212) 267-0240 to make an appointment or if you are uncertain if telehealth will work for you, we are offering a free 15 minute consult for a limited period of time. We are also continuing to offer in office appointments for those who would prefer them.

 

We look forward to helping you reach your goals and returning to the activities you love, symptom free!