March is Endometriosis Awareness Month

abstract-art-background-1020317Amy Stein BCB-PMD, IF (Pronouns: She, Her, Hers)

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

 

We’ve written a lot of blogs over endometriosis (endo) over the years. It is a common diagnosis at Beyond Basics Physical Therapy, and frankly, out in the world. The current estimate is 1 in 10 people with female anatomy have endometriosis, and the average time for a proper diagnosis is 11 years. This number may be subject to change as currently laparoscopic surgery is the gold standard for diagnosis. We write extensively about what endometriosis is, and how it is thought to develop in this blog, But the cliff notes version is that endometriosis is the deposition of endometrial-like cells outside of the uterus. There actually was some degree of controversy about what the deposits actually are. It was originally thought that the deposits were endometrium (the lining of the uterus), but now the endo community is moving away from that thought. The deposits can cause a whole host of symptoms, or none at all. Symptoms severity is not related to the number/amount of endometrial deposits someone has.  We still don’t know why some people with large amounts of endometrial implants and or adhesions can experience little to no symptoms, while others who have a relatively small amount of endometrial deposits may experience debilitating pain.

For most people who know anything about endometriosis, they know it is associated with painful periods. Although this is true, if we look at painful periods, we may be missing a lot of other endometriosis-related symptoms.  Endo can affect the urinary system, resulting in urinary pain, hesitancy, frequency, urgency, and incomplete emptying. It can cause painful defecation and constipation, and it can affect your sex life causing pain with penetration and or orgasm. Endo can present itself in so many diverse ways and two people with endo may present completely differently.

For individuals with symptoms from endo, there is a lot that can be done to help minimize pain. But the same approach is not always effective for everyone. It is really important to look at your own goals when deciding on what to focus on so you can express them to your care team.

There is no magic pill or treatment that works on every endo patient. Oral medicines, surgery, physical therapy, nutrition, and lifestyle changes can all help with symptoms of endo. Often times treating endo requires some combination of all of these things and the frustrating part is what may have worked for someone else may not necessarily work for you. We will take a little look, (by no means exhaustive) at each one of these interventions with the intention of piquing your interest and hopefully facilitating a discussion about these options with your healthcare provider.

Endometriosis is thought to be an estrogen-driven condition. Some people with endo may find relief from medications that affect hormone levels. Oral contraceptive pills (OCPs)  are an example of medication used to affect hormone levels. There are other options beyond OCPs that work to alter hormone levels. For some people with endo, this approach can be helpful for symptom management, although hormone altering medication won’t cure endo.  You do have to consider the side effects of all the medication options however because some of the side effects can be worse than the medication’s positive effects.

Excision surgery is both treatment and the gold standard for diagnosis and treatment of endometriosis. Surgery works by cutting out the endometrial deposits. Performing biopsies on these deposits allows the practitioner to know if the deposit is Endo.  Ablation surgery has been shown to only clear part of the endometrial implants and is not nearly as comprehensive as excision surgery. As a result, repeat surgery is commonly required with ablation, and in many cases, multiple repeat surgeries.

So we’ve just explained to you that endo is an estrogen-dependent condition that causes deposits in the abdominal cavity. Logically it makes sense that getting rid of these deposits via surgery or slowing their growth with medication could help treat endo and the pain associated with it. But what does physical therapy have to do with the treatment of endometriosis? The answers range from simple to complex, with the complex delving into some pretty heady neuroscience. Why don’t we start with the simple first, and get more complex as we go.  

 

The deposits created in the abdominal cavity by endo can cause the tissues of the abdomen to get stuck and not slide and glide freely, we call those stuck areas, tissue restrictions or adhesions. The scars created by endo removal surgery cause adhesions. Sounds pretty bleak, but it’s not as bad as it sounds. Physical therapists have been treating scars for eons (actually since the start of the civil war, but we digress). Whether or not you have had surgery, chances are you will benefit from some myofascial release, which can help reduce endo and surgery related adhesions. Although most physical therapists know their way around scar massage, it is important to go to one who has been specially trained in pelvic floor conditions and ideally has been trained in visceral mobilization. This training will allow your PT to address adhesions of the viscera (your organs) as well as allow them to work on adhesions in the pelvic bowl by performing intravaginal and intrarectal release.

Here’s where it gets heady, bare with me. Let’s start with defining my subheading. Trigger points are taut bands of muscle that are extremely irritable. Trigger points can be described as “latent”, meaning they are painful when touched, or they may be an active myofascial trigger point, which is constantly angry and can refer pain elsewhere in the body. Trigger points in the abdominal-pelvic region can radiate to some funny places far away from where they actually are. Someone may feel the referred pain from a trigger point in their belly or back, near their bladder, or in their “ovary”, as well as other places.  Physical therapy can help relieve these trigger points by performing myofascial release as well as using techniques like biofeedback to help you learn how to relax your pelvic floor and prevent trigger points from reoccurring.

People who have been in pain for a long time may experience a phenomenon called central sensitization. What that means is the body, in an effort to protect you, starts perceiving things that wouldn’t necessarily be painful as painful. No one actively does this, and it is not in your head. It actually happens in the spinal cord and brain. This is what I mean by endo lowering pain thresholds. Physical therapy can be instrumental in improving pain thresholds through a process of desensitization.

What we just discussed are some of the most common things physical therapists address in patients with endometriosis. But let us not forget that everyone with endo experiences it differently. Pelvic floor physical therapists may address issues with urination, sex, and bowel movements directly as well as other issues like weakness, joint pain, and instability. It really is specific to the individual with endo.

Many people find relief in making adjustments to their lifestyle and diet. There have been numerous studies on the benefits of yoga on endo pain, as well as making changes in diet such as avoiding gluten, dairy, sugar, caffeine or committing to an IC and anti-inflammatory diet. In my experience, different things will work better for different people, but we have seen these changes be extremely helpful for some people. We write more about these changes in this blog.

We hope this blog was helpful to you. Having endo can really suck (we can’t think of a better word for it). If you think you may have endo, talk to a gyno who specializes in the treatment of endometriosis, because there is something you can do about your symptoms. Endo is a disease which requires much more research and awareness. Please take time this March to wear some yellow and do your part to spread endo awareness to physicians and other healthcare providers, to high schools and to your community.  

endo
This is the cover from Dr. Amy Stein and Iris Obruch’s latest book on endometriosis, available soon

 

Alimi Y, Iwanga J, Loukas M, et al. The clinical anatomy of endometriosis: A review. Cureus. 2108

 

Aredo J, Heyrana K, Karp B, et al. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Semin Reprod Med. 2017; 35(1):88-97

 

Mayo Clinic. “Endometriosis”.

. Accessed on February 19, 2019  

 

Mehedintu C, Plotogea MN, Ionescu S. Endometriosis is still a challenge. Journal of Medicine and Life. 2014. 7(3); 349-57

PH101: Running to the Bathroom Again?!

Fiona McMahon PT, DPT

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via Pexels

Bladder problems can be vexing, it may hurt for you to pee even though every test for infection you’ve taken has come back negative. You may find yourself incontinent after surgery or childbirth, or for no reason at all. You may find yourself waking up countless times to go, or needing to memorize every bathrooms’ location in the city because you go too often.

The bladder and the pelvic floor are intimately related and often times problems with the pelvic floor can cause real trouble with the bladder. Pelvic floor dysfunction can cause you to suffer from bladder frequency, urgency, incomplete emptying, slow stream, stream that stops and starts, bladder or urethral pain, or leaking.  By the way, it’s not just a female issue. Men and children can also have these symptoms. Learn from one of our experts, Sarah Paplanus, about how exactly the pelvic floor is related to bladder function and dysfunction, what you can do about it, and about common medical conditions affecting the bladder. Join us for this great seminar on March 26th at 7pm . Register here: pelvichealth101.eventbrite.com

And for those who can’t wait to learn about the bladder, check out our blog on bladder health here!

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Spring 2019

Navigating Life with Chronic Pain: Part II

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Fiona McMahon, PT, DPT

Welcome back to our discussion on chronic pain. In our last blog we discussed why one might experience chronic pain and some common missteps and pitfalls that have occurred in our understanding of chronic pain. If you haven’t yet read part one of this blog, I highly recommend checking it out first so you can get the most out of this post. Click here to read it now.

For chronic pain, we have drugs, surgery, mental health therapy, physical therapy, and what is called complementary alternative medicine (CAM), which includes modalities like yoga, acupuncture, and mindfulness meditation. We discussed earlier how some opioids may actually be harmful in treating chronic pain. Unnecessary surgery can also have risks of actually increasing pain post-surgically, because it can change the brain’s sensitivity to pain. Because, for most musculoskeletal conditions, a course of conservative treatment is recommended for a period of time before turning to surgery, we will focus on non-surgical, and non-medical approaches to chronic pain.

Before we dive into specific treatments, let’s talk about what puts a person at risk for chronic pain. We can divide these risks into modifiable and non-modifiable risks. Nonmodifiable risks are situations or characteristics about ourselves that we can not change. They include socioeconomic status, where you live or have lived, cultural background and genetic factors. Unfortunately, we can’t change these things, but things like alcohol intake, nutrition, and obesity are all things we can change and have been generally understood as modifiable risk factors for chronic pain. Now that we have that in mind, let’s explore different approaches for the management of chronic pain.

 

Mindfulness Practice as Pain Management

Have you tried mindfulness practice? I ask this question a lot. When I ask it, I am careful to frame it in a way that does not give the patient the impression that I think their pain is all in their head, but rather, I try and present it as part of an adjunct to the current physical therapy treatment they are receiving from myself or any of the other PT’s at Beyond Basics Physical Therapy, and any other medical intervention they may be receiving.

Mindfulness and mindfulness meditation are somewhat based on eastern meditation practices.  Not all mindfulness programs are the same, but the basic premise is to allow the participant to observe their thoughts, feelings, sensations, and attitudes without judgment. Giving them the opportunity to reframe their thoughts in a positive manner.

It may sound like a small change, but research is really starting to bear out that changing your frame of mind about pain can have some very real results. In a meta-analysis done by Hilton and colleagues, mindfulness programs were found to have statistically significant positive results on pain, depression, and quality of life.

There are a lot of ways you can incorporate mindfulness into your day to day life. Apps for your phone are really helpful. I recommend both Calm and Headspace. I personally like Calm a bit better, but both are excellent. Headspace is a good starter because it breaks up meditation into more digestible nuggets, which can be a good way to start your meditation practice. Calm, as the name implies, is more soothing.  There are also guided classes you can attend in your area if that’s more up to your speed.

Be patient with mindfulness, I definitely suggest giving it the old college try. Stick with it for a week or two. If it isn’t for you, that’s perfectly okay. It’s not a moral failing, or a psychological one it’s definitely a case of different strokes for different folks.

Psychological Intervention

In a study performed by Macrae and colleagues, it was found that patients who engaged in catastrophizing type behaviors experience post-surgical pain at a significantly higher rate. Catastrophizing is envisioning a situation to be far worse than it actually is. A good example for this blog would be a patient with low back pain, jumping to the conclusion that her back pain will prevent her from being able to work and she would end up on the street, secondary to her lack of ability to secure an income. Although this is a possibility, it really isn’t a realistic one and it fails to entertain the possibility of the back pain remaining stable or getting better.

Mindfulness meditation can help with catastrophizing behaviors, but sometimes you need a little extra help. Psychological interventions, like talk therapy and cognitive behavioral therapy, can help you get a handle on these thoughts and address your current loss of function, secondary to pain in a more productive manner. Cognitive behavioral therapy as well as other forms of therapy have shown improvement in pain symptoms and quality of life in adults and has shown even more robust effects in children.

Acupuncture

Acupuncture is an ancient form of eastern medicine that is gaining a stronger and stronger foothold in the States. It has been shown to be effective in managing a number of conditions, and chronic pain is no different. Reviews of acupuncture in scientific literature have found that acupuncture can improve pain and function. The same review found that electroacupuncture had even more robust results for pain and stiffness.

Yoga

Yoga is super hip right now. In fact, it now has its own international day on June 21st of each year. It does for good reason. A consistent and solid yoga program has been shown to improve conditions such as low back pain, myofascial pain syndrome, fibromyalgia syndrome, osteo- and rheumatoid arthritis. It can be a great option to continue to add consistent exercise and pain management into your life.

Physical Therapy and Exercise

Exercise is good for you, even if you have chronic pain. The old way of thinking was to put someone on days of bedrest when they have chronic pain. No more. Evidence has shown gentle movement progressing into more functional training can really help with chronic pain. In fact, the National Institute for Healthcare Excellence’s (NICE) osteoarthritis guideline is  “exercise should be a core treatment… irrespective of age, comorbidity, pain severity and disability. Exercise should include local muscle strengthening [and] general aerobic fitness”(NICE 2014) . Geneen and colleagues found in their review and meta-analysis of the current literature that just receiving the advice to exercise alone is not sufficient to produce improvements in pain scales. That’s where the professionals like physical therapists come in, PTs have the knowledge and expertise to prescribe exercise that is not only safe and functional but hopefully kind of fun. PTs also can diagnose and treat issues such as tissues with reduced mobility and poor alignment to ensure you get the most out of your exercise.

Data show that a prescribed and monitored exercise program by a physical therapist can have good effects on pain symptoms and can help facilitate the production of your body’s own natural painkillers.  Additionally, exercise can help individuals lose weight, which can reduce the pressure on one ’s joints and further improve pain.

Aside from exercise and hands-on work, we can use modalities like Kinesio tape at physical therapy. Kinesiotape has been shown to improve not only pain but decrease trigger points, improve range of motion and improve disability rates in individuals suffering from myofascial pain syndrome.

Conclusion

Chronic pain is complex. Rarely is there a silver bullet that will cure it. Treatment requires a multidisciplinary approach, which has been shown to be more effective than traditional treatment alone. Start small, where you feel comfortable when adding something new into your treatment approach. You will find what works best for you. A good place to start is here at Beyond Basics. Our staff not only has the expertise to treat you from a physical therapy perspective, but they also have the ability to guide you towards other traditional and complementary treatments/practitioners that can help you reach your goal. Your treatment for chronic pain does not have to be and should not be passive, please call and make an appointment today to start your journey.  

 

Sources:

 

Achilefu A, Joshi K, Meier M. et al. Yoga and other meditative movement therapies to reduce chronic pain. J Okla State Med Assoc. 2017;110(1):14-16

 

Andersen T, Vægter H. A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls. Clin Pract Epidemiol Ment Health. 2016;12: 49-58

 

Ay S, Konak H, Evick D, et al. The effectiveness of kinesio taping on pain and disability in cervical myofascial pain syndrome. Rev Bras Reumatol. 2017; 57(2) 93-9

 

Eccleston C, Crombez G. Advancing psychological therapies for chronic pain [version 1]; referees: 2 approved]. F1000 Faculty Rev. 2017

 

Geneen L, Moore R, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews ( Review).  Cochrane Database Syst Rev 2017; 4

 

Hilton, L, Hempe; S, Ewing B. Mindfulness Meditation for Chronic Pain: Systematic review and meta-analysis. Ann Behav Med. 2017. 51:199-213

 

Kamper S, Apeldoorn A, Chiarotto A, et Al. Multidisciplinary biopsychosocial rehabilitation for chronic pain ( review). Cochrane Database Syst Rev. 2014; 9.

 

Macrae W. Chronic post-surgical pain: 10 years on. Br J Anaesth 2008;101: 77-86

 

Mayer F, Scharhag-Rosenberger F, Carlsohn A. The intensity and effects of strength training in the elderly.  Dtsch Arztebl Int 2011; 108(21):359-64

 

Neira S, Marques A, Pérez I. Effectiveness of aquatic therapy vs land based therapy for balance and pain in women with fibromyalgia: a study protocol for a randomized trial. BMC Musculoskelet Disord. 2017; 18(22)

 

Perry R, Leach V, Davies P, et al. An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools. Sytematic Reviews. 2017. 6(97)

 

Saxena R, Gupta M, Shankar N, et al. Effect of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int J Yoga. 2017. 10(1): 9-15

 

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

 

     

 

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On March 19, 2019 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. In our first class, we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health as well as the function of your bowel, bladder, and sexual muscles and organs. We will also be covering how things such as alignment, posture, muscle tone, and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes:

Pelvic Health 101 Spring 2019

 

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 million 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

Yeast the Inflammation Beast

 

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Fiona McMahon DPT, PT

You are what you eat. Trash in equals trash out. You can’t exercise yourself away from an unhealthy diet. These adages are often on my mind as I make my food choices because of the myriad health professionals who have taken time to come to our practice to tell us how we can improve our own and our patients’ health by taking more time to look at what we are consuming in our diet. Lately, many of these clinicians have been focusing on candida overgrowth and diet, which can contribute to pain and inflammation conditions.

What we eat can directly affect the bacterial and fungal makeup of the gut, AKA the gut microbiome. The gut requires a certain level of good bacteria to help us digest what we eat. Over time a poor gut microbiome can affect how efficiently the gut works. The function of the gut goes beyond just digesting food but also is vitally important for the production of neurotransmitters, which help to spread messages within the brain and throughout the whole body.  The microbiome also plays an important role in our hormones and immune system. When the microbiome of the gut is not balanced, it is called dysbiosis.

One of the most common culprits in gut microbiota dysbiosis is candida, (Yeast!). Candida is a naturally occurring inhabitant of the body and when it’s at appropriate levels, it doesn’t tend to be noticed, but anyone who has experienced a yeast infection knows that if this little guy is allowed to go unchecked, it can do a lot to make you miserable. Besides plaguing women with itching, burning vulvas, a yeast overgrowth may cause many other ailments.

Science has pointed to the role candida can play in contributing to chronic and inflammatory conditions. In one study by Kumamoto in 2011, candida overgrowth was associated with delayed healing of inflammatory lesions and was associated with pro-inflammatory cytokines (chemicals) and increased incidence of inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

Yeast overgrowth can also affect the bladder along with over colonization of Saccharomyces (another form of fungus). In fact, yeast and Saccharomyces were found to be higher in women during a flare of interstitial cystitis than when their symptoms were low.

Yeast is not the only organism that can get out of balance and affect our bodies in harmful ways. There are many other players that can get out of balance. Some signs of an altered gut microbiome is a history of allergies, eczema, or repeated fungal infection.

 

What to do?

It all seems pretty dire, right. How do you control who is colonizing your gut, when you barely have enough time to make it to the gym after work? There are a few simple steps you can start with.

Avoid antibiotics, unless your doctor thinks you need them.

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The medical community has become a lot more aware of the dangers of over-prescribing antibiotics from their perspective, but it is important to keep in mind that a powerful antibiotic can wipe out good bacteria and bad bacteria in one fell swoop. If the good guys in your gut are reduced, the bad bacteria have a better chance of taking over. Take antibiotics only when recommended. Keep in mind antibiotics will not help treat viruses like the flu, they can only treat bacterial infections.

Modify your diet

close-up-cooking-cuisine-629093.jpgIncrease your consumption of good fats (omega 3’s) to help reduce inflammation.

Food high in omega 3’s includes flax and hemp seed/oils, fish (the fishier the fish, usually means more omega 3’s, for example, herring is higher in omega 3 than a milder fish like snapper). Also, reduce your consumption of processed foods which can increase inflammation levels and eliminate simple sugars and fried foods. If this is only minimally successful, try a gluten and dairy free diet.  

If simple changes are not helping consider seeing a professional

Find a naturopath, functional or integrated MD, or nutritionist who can investigate more fully whether or not you have SIBO (Small intestinal bacterial overgrowth), candida overgrowth, or other gut microbiome disorder. Or perhaps you are lacking certain ingredients, vitamins or mineral.  These professionals can tailor a diet and medication regimen to help return your gut microbiome to tip-top shape.

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Fiona McMahon is currently seeing patients at our Midtown Location

 

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)

 

 

Sources:

Kamamoto C. Inflammation and gastrointestinal candida colonization. Cur Opin Microbiol. 2011;14(40): 386-391

Be a Bladder Whiz! Healthy Bladder Tips for All!

Fiona McMahon PT, DPT and Amy Stein PT, DPT

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So we busted some myths in our last Pelvic Floor Myth Buster Blog, where we discussed whether or not holding your pee causes urinary tract infections. If you haven’t gotten a chance, check it out here. People living with bladder conditions, like pain, hesitancy, frequency, post void dribbling, and incontinence know that an unruly bladder can be really disruptive. In this blog, we are going to take some time to discuss some practical tips and tips you can employ right now to tame an unruly bladder. Many of these tips come from Amy’s book, Heal Pelvic Pain, available here.

So what are we working with?

Male or female, we all have the same basic structure of the bladder, with a few exceptions. Here’s what everyone has in their lower urinary tract.

Detrusor Muscle: Forms the body of the bladder and is responsible for squeezing the bladder to empty its contents. It spends most of its time relaxed in order to allow for bladder filling.
Trigone Muscle: Forms the neck of the bladder, and is a powerful sensory organ. When the trigone stretches in response to the filling of the bladder, it sends a message to the brain that it’s time to pee.
Internal Urethral Sphincter: Smooth muscle (involuntary) which seals off the exit of the bladder and allows for continence.
External Urethral Sphincter: Striated or voluntary muscles which also seals the exit of the bladder.
Urethra: This is the tube that leads out of the bladder and is the pathway for urine into the outside world.

Sex differences:
Many men have a prostate. The prostate is a sex organ and is responsible for keeping the semen at the right pH to fertilize a waiting egg. It wraps around the urethra and lives just under the bladder. It also provides a mechanical buttress or support for the bladder, lessening the load on the pelvic floor. Because of its proximity to the urethra, problems with the prostate can cause problems with the bladder. An enlarged prostate, which can be a part of aging, cancer, or infection, will restrict the flow of urine out of the urethra, resulting in a weak stream, painful, burning urination, and difficulty urinating (however, the same thing happens with tight pelvic floor muscles with or without prostate involvement, which makes bladder issues super confusing).

Another important difference between guys and gals are the respective length of their urethras. Male urethras are a lot longer than female urethras. This is one of the reasons women are more prone to bladder infections. In a female, bacteria have a lot easier time making the trek to the bladder because of the shorter urethra.

So how do I help my bladder?

Posture

If you are having problems fully emptying your bladder or you have post void leakage (dribbling following going to the bathroom) consider your toileting posture. People with bladder issues should sit on the toilet (even dudes), to allow the pelvic floor muscles to relax and allow the bladder to fully empty.

Stretch!

Here’s a great stretch from Amy Stein’s book, Heal Pelvic Pain available here in hard copy and digital download.

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Here’s how to do the stretch

1. Lie on a firm surface-on a mat on the floor or on a hard mattress. Bring your knees up to your chest and then let them relax and rotate out to the side so that they flare outward. Use your hands to hold your knees in this position.

2. Stretch as you deep-breathe for six to eight breaths. Do not bounce, and do not push hard. Just gradually and progressively fill and empty your lungs.

3. Hold the stretch for 30 to 60 seconds. Do three repetitions, two to four times a day. 

Bladder Training

If you have bladder frequency or leakage with urge now is the time to try and train your bladder to hold more urine. Keep in mind you should start treatment to address pain with physical therapy and in certain cases, with medication, to allow you to be successful with bladder training. I always tell my patients to start their bladder retraining at home, where a bathroom is available to take the stress out of possible leaks or not being able to find a bathroom. Start by simply waiting to go to the bathroom 5-10 minutes past your first urge to urinate. Use behavioral strategies, such as deep breathing and pelvic floor drops, mindfulness, gentle stretches, distraction, and others. If you don’t have to go after 5-10 minutes, Great! If you do, go to the bathroom. As waiting 10 minutes becomes easy, stretch your time to 20 minutes and so on until you are able to go 2-3 hours in between urination.

 

Diet

This can make such a huge difference. My boss and Beyond Basic’s founder, Amy Stein, writes in her book Heal Pelvic Pain, that we should really try to get eight 8-ounce glasses of water a day, and try to finish them at least two hours before bed, to reduce your chance of needing to go at night. We call this symptom, nocturia.

As far as things we chew on, many foods can irritate the bladder, but not all foods bother everyone in the same way. It’s all about experimenting to find your triggers. Some common foods include food high in sugar, spices, acid (like tomatoes and citrus), tannins (like in wine). John’s Hopkins has a really good list, which you can access here. This list is totally overwhelming at first blush, but remember my bladder irritant may not be yours. Typically you will know shortly after eating the offender, on the same day. So the best thing to do is to try the suspected bladder irritants one at a time to see if you can identify a triggering food or drink.

Manage Constipation

The bladder does not have a lot of space, where it lives. In front of it lies the pubic bone, behind it lies a vagina for some of us, the rectum, and then the sacrum bone. The bones sandwich the bladder like bookends. Although these bones have some movement, which we treat, it’s not enough to allow for much more space for the bladder if your rectum is full of poo from being constipated. With an overfilled rectum, the bladder gets squashed against the pubic bone. With a squashed bladder, you may not empty it as well, feel urgency, or even experience bladder leakage. Therefore, avoid constipation at all costs! We advise our patients to drink more water and eat more soluble and insoluble fibers.

 

Physical Therapy Can Help Cure!

Physical therapy is considered a mainstay and the number one treatment for musculoskeletal causes of bladder disorders and bladder and urethral pain. Expert pelvic floor physical therapists (PFPTs) are clinicians who can find the cause of your bladder issues and provide you with a customized plan that will provide you with the best results possible. PFPTs can work to relax spasmed muscles, treat constipation contributing to bladder issues, improve your toilet posture, reduce tightness and shortening of tissues around the bladder, abdominal and thigh region that can contribute to bladder dysfunction, as well as strengthen weak muscles. If you are experiencing bladder issues, please come to see us. There is so much we can do to help!

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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)