Navigating Life with Chronic Pain: Part 1

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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

A Holiday Gift for You! BBPT is Offering Free Consults for People Living in the Greater NYC Area!

Group Serious 2

Any persistent pain or chronic back or pelvic pain can be tough. It is tough to have and often times it can be extremely isolating. Many of our patients have to go through a number of clinicians before they even get a diagnosis of pelvic floor dysfunction. If you are reading this blog, you probably have some questions about pelvic floor dysfunction and if physical therapy is right for you.

We are here to help. If you are living in the Greater New York Area and have some questions about orthopedic, sports or pelvic floor dysfunction and if physical therapy is right for you, I encourage you to call our office. For a limited period of time, we are offering free 15-minute phone consults with our licensed physical therapists to patients in the greater New York Area. For those of you living outside this area, a fee may apply to the consult but can be applied towards payment for a PT visit if you chose to visit us. Don’t miss this opportunity to learn more about your pelvic floor and what PT can do for you.

The Physical Therapists at Beyond Basics also treat orthopedic (sport and joint injuries), pediatric pelvic floor dysfunction and orthopedic injury, and much more. Give us a call to discuss how PT can help with any one of these issues!

All the best,

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

PH101: Ladies Only Session

By: Fiona McMahon, DPT
Hey Ladies!!! In the next installment of our Pelvic Health 101 course, we are hosting a women’s only session to allow for a safe and non-threatening place to discuss many issues that can affect the health of your pelvic floor. This class one of Stephanie Stamas’s (the founder of PH101’s ) favorites and is definitely not to be missed. Hear more about it in her video below! Join us at 7pm on October 25th, 2018. Please register at pelvichealth101.eventbrite.com

 

 

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Fall 2018

Breast Cancer Awareness Month

awareness cancer design pink
Photo by Miguel Á. Padriñán on Pexels.com

Fiona McMahon, DPT

Have you noticed an increase in the amount of pink on just about everything the last couple of days? The increase of pink everything is because October is Breast Cancer Awareness Month.  Breast Cancer is an extremely common cancer. According to the Nation Breast Cancer Foundation, 1 in 8 women will be diagnosed with breast cancer in their lifetime. Men can also get breast cancer, however, it is much rarer for men to develop breast cancer. Luckily with early detection and treatment of early stage and localized cancer, the 5-year relative survival rate is 100%. That being said, early detection is crucial and it is important to catch breast cancer early to ensure the best possible outcome. Let’s take some time to review the signs of breast cancer and recommended screening protocols.

Signs and Symptoms of Breast Cancer

  • Change of Sensation/ texture of the Breast or Nipples
    • Lumps, change in texture in the breast, nipple, or underarm area
  • Change in appearance of Breast or Nipple
    • Swelling
    • Shrinkage
    • Dimpling
    • Change of nipple orientation
  • Discharge from nipple

Detection

Recommended Screening:

Mammogram

  • Recommended every 1-2 years for women who are 40 years old or older.
  • May be recommended for women who are under 40, but have increased risk of breast cancer.

 

Genetic Testing

For some types of breast cancer, there is a very specific link to a person’s genes and her or his risk of developing breast cancer. BRCA1 and BRCA2 are genes that are responsible for the production of certain tumor-suppressing proteins. In some populations, there are mutations in these genes that disable their tumor-fighting properties. These gene mutations are relatively rare and currently, screening is recommended just for individuals with increased risk of harboring these mutations. According to the National Cancer Institute, individuals who are at higher risk and should consider genetic testing are:

  • Individuals who have a male relative who has developed breast cancer
  • History of BRCA related cancers within family history
  • People of Ashkenazi (Eastern European) Jewish ancestry
  • Breast Cancer diagnosed before age 50 in family
  • Multiple cases of breast cancer in family

Individuals that test positive for BRCA mutations may consider increased screening, prophylactic surgery or chemoprevention.

Mastectomy and Physical Therapy

Mastectomy, removal of the breast is currently the most common treatment for breast cancer. Some women chose to have their breasts reconstructed after their mastectomy and others do not. It is obviously a very personal choice.  Like any surgery, mastectomies require close postoperative care to ensure maximal function and recovery.

You may have read the last sentence, and thought, “What is the function of the breast, besides breastfeeding and for sexual pleasure?” The breast lies in an important intersection in the body. The armpit (axilla) contains bundles of nerves, blood vessels, and lymph vessels that course through it, serving the arm down to the fingers. After a mastectomy, their course can be interrupted by scar tissue, radiation damage (if your treatment included radiation), causing painful conditions such as nerve entrapments, frozen shoulder, and lymphedema, ( a backup of lymph fluid, if left unchecked can cause permanent damage and deformation of the arm).

victoria2016Victoria LaManna, DPT, CLT, is our lymphedema expert. If you have had a mastectomy and are unsure about lymphedema care, she is an excellent resource. She will be able to instruct you in self- care and lymphedema prevention measures. Physical therapy can also help to release scar tissue in the breast and upper arm area, regain strength in the arm, and ultimately improve your function. Visit us, and read up on Victoria’s bio here, as well ask on our website at:  www.beyondbasicspt.com/lymphedema

Sources:

http://www.nationalbreastcancer.org/. Accessed: September 24, 2016

National Cancer Institute. BRCA1 and BRCA2: Cancer Risk and Genetic Testing. https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet#q1. Accessed September 25,2016

http://www.beyondbasicspt.com/lymphedema

PH101: Does my Diet Really Matter?

Fiona McMahon, DPT

 

 

Gluten free, soy free, low FODMAP… It’s amazing how many diets there are out there that really can provide people with symptom relief. If you are suffering with chronic pain you may be confused on where to start, or what is right for you. You also may have tried out a bunch of different ways of eating, not seen results, and got really frustrated. If this sounds like you, I highly encourage you to come to our next pelvic health seminar on October 4th  at 7pm “Does my diet really matter”.

jessica-drummond-headshot-197x300This seminar will be hosted by a special guest speaker, nutritionist Jessica Drummond, MPT,CCN,CHC. Jessica Drummond is a former pelvic floor physical therapist who now specializes in nutrition for those suffering with pelvic floor dysfunction. This seminar has been a huge hit and is a great starting point for those considering adding nutrition as part of their healing journey.

Register at pelvichealth101.eventbrite.com today.

 

 

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Fall 2018

 

The Special Care Needs of the LGBTQ+ Community

Happy Pride Month!!!!

We are reposting an old post broadly discussing the LGBTQ+ community, with special focus on transgender individuals. Please keep checking back as we continue to discuss specific issues relating to the care of the LGBTQ+ community.  

Amy Stein PT, DPT and Fiona McMahon PT, DPT

rainbow flag

Who are LGBTQ+ individuals?

At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc.  They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.  

Never Assume. Listen, Ask.

We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community.  First rule of thumb:  with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.

 As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us.  Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.  

We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in trans care. Hormones, either testosterone, estrogen, lupron, puberty blocking, testosterone suppressing can be used in many patients, but are also used specifically to aid in transition in transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options.  There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration.  Endometriosis can be worsened with testosterone hormones.  Hormones can be administered via injection, pellets, patches, creams, gels, and pill form.  It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc.  Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals.  Progression of hormones can be monitored for each patient and according to patients wants and needs.  

For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs.  Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that  can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.

 

How is care for the LGBTQ+ community funded and regulated?

Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.

How can physical therapy help?

At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction.  We also specialize in orthopedics and functional manual therapy.  We treat the LGBTQ+ community and we welcome any questions at desk@beyondbasicspt.com or call 212-354-2622. We are happy to help and look forward to hearing from you!
Resources: Center of excellence for transgender health.

WPATH center for care Endocrine Society

  • speaks on hormone therapy (however some information may be out of date).

 Adolescent Health Center

Continuing our Education: Vestibulodynia, Vulvar Pain, and Beyond

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Fiona McMahon PT, DPT

In a blog a few posts back, we covered some of our new skills we developed with our friends, Kelli Wilson PT, DPT, FAAOMPT, and Sara Sauder PT, DPT in addressing issues of the male pelvic floor. In this post, we will cover the new techniques and latest information we learned in issues concerning pelvic floor dysfunction in individuals of the female anatomy.

As experienced and expert physical therapists, we are all extremely comfortable with treating disorders of the pelvic floor, but the thing is, there is so much new information coming out, that even if your latest training was two years ago, chances are, there is a lot of new information out there to discover, which can really help your patients.

One of the most interesting things we learned about was in regards to hormonally mediated vestibulodynia and vulvar atrophy. Although many of us know how to spot these conditions, learning about the specific mechanism that causes them in cases of long term birth control use was fascinating. Long term birth control use can actually suppress the production of estradiol and testosterone from the ovaries and cause the liver to increase levels of sex binding hormone globulin, which takes even more of these hormones out of circulation. When this happens, the vulvar tissue can shrink, become thin, and friable (tear easily). This can cause burning and pain. It is important for PT’s to be able to screen for this condition so we may refer our patients to MDs who can get them on a different method of birth control or prescribe them topical treatments as needed.

We also learned more about conditions such as interstitial cystitis, lichens planus and sclerosis, pelvic congestion, vaginal adhesions, as well as other current medical treatments that are now available for our patients who are in pain.

All in all, it was a great course and we look forward to bringing our new knowledge to our patients to help them be more successful in our physical therapy treatments.

For most of last year, myself, Sara, and Amy worked together to contribute a chapter to the International Society for the Study of Women’s Sexual Health latest textbook on female pelvic pain which will be available soon on Amazon, and is an essential tool for practitioners treating pelvic and sexual pain from both a medical, mental health and physical therapy perspective. Check out the following excerpts from our chapter detailing treatment of pelvic pain here:

On who is an appropriate candidate for physical therapy:

“Ideal candidates for pelvic floor physical therapy referral are patients with pelvic floor musculoskeletal dysfunction or those who have been treated by clinicians for pelvic pathology but have not experienced symptom resolution. Clinicians can identify appropriate patients by palpating the vulva, performing a digital examination of thevaginal and rectal muscles, and performing a moist cotton swab test on the vestibule. If the patient reports reproduction of any of her sexual or pelvic pain symptoms with this examination, she is likely affected by pelvic floor dysfunction”

On what pelvic floor physical therapy is:

“Physical therapy intervention for the dysfunctional pelvic floor incorporates a comprehensive approach addressing specific tissue characteristics, strength, alignment, and neuromuscular control. Manual therapy is a hands‐on approach to correct tissue restrictions, improve alignment, and enhance blood flow. Different manual techniques may be used to achieve different objectives.”

Check out the full text: Musculoskeletal Management of Pelvic and Sexual Pain Disorders available here.

 

Sources

Pukall C, Goldstein A, Bergeron S, et al. Vulvodynia: definition, prevalence, impact, and pathophysiological factors. J Sex Med. 2016; 13(3): 291-304

Burrows L. Basha M. Goldstein A., et al. The effects of hormonal contraceptives on female sexuality: a review. J Sex Med. 2012;9 (9) 2213-23