Pelvic Pain Awareness Month Part 1: What is Pelvic Pain

Beyond Basics remains open and is offering both in person and telehealth appointments. Call 212-354-2622 for our midtown office and 212-267-0240 for our downtown office to learn more

Mayis PelvicPainAwarenessmonth

Fiona McMahon PT, DPT

I don’t need to write it out. You’ve already heard it. But I will write it anyway. These are uncertain times. This May, much like March and April, is shaping up to be a May that is very different than ones we’ve ever experienced before. That said, life still marches on. May is Pelvic Pain Awareness month and it seems appropriate to take some time to recognize those who are dealing with pelvic pain as well as spread awareness to what it is and how we can make it better… even in these uncertain times.

What is Pelvic Pain?

Pelvic pain can sound really simple, it’s pain in your pelvis, but let’s explore what that really means. The pelvis is a bowl shaped set of bones, the innominate (literally meaning no name), the sacrum, and the ischium, that connect your abdomen to your legs. Within this bowl lives your reproductive organs, your bladder, and rectum. Surrounding these bones and organs you have this nifty stuff called fascia. Fascia is the organ of shape and helps to both give structures within our body form as well as help them to slide and glide past each other. Like I said, nifty. Also within the pelvis we have muscles, nerves, and blood vessels! It gets really busy down there!

Because there is so much going on in the pelvis, pelvic pain can feel a lot of different ways depending on what structures are involved and even individual differences in how the body feels pain. Pelvic pain can have the feel of a dull ache, which you can feel in your pelvic bones, genitals, and or abdomen. It could also feel sharp and “stabby”, hot and burning, itching,and/or like a bunch of pressure. It can come and go or be a constant sensation. It can be what we call provoked, meaning certain triggers elicit it, or it could come and go seemingly without any obvious cause.

Pelvic pain can come in a lot of different varieties and it can affect everyone, regardless of gender or age. Many people who hear that I am a pelvic floor physical therapist, assume that I only treat postpartum women. The truth is postpartum women are not the only ones who can experience pelvic pain.

People with male anatomy can experience pelvic pain. They may feel burning with urination or climax, pain in the tip of the penis, in the testicles, or in their rectum. Sometimes this pain limits the ability of its sufferer to sit, wear tight clothing, or have pain free sexual experiences Often these symptoms get confused as a bladder, prostate or yeast infection. Although infections can certainly cause these symptoms, many times tight and spasmed muscles within the pelvis can be the culprit. We will discuss this further in part two of this blog.

People with female genitalia can experience many of the same symptoms listed above with obvious anatomical differences. Instead of the tip of the penis, a person with female anatomy may feel pain in their clitoris, or labia. They also may have pain with sexual penetration or arousal. Patients may also experience burning urination similar to the sensation of having a bladder infection. For people who menstruate, the cramps may be so debilitating that they are unable to work or go to school through the pain. All of these different presentations fall into the category of pelvic pain.

Children can also experience pelvic pain. Oftentimes this is caused because of prolonged constipation, but it can also be caused by muscle tightness, and gynecological conditions like endometriosis or lichens planus/ sclerosis.

People with pelvic pain, regardless of age or gender may also experience pain with voiding, either urine or feces, abdominal bloating, and or difficulty sitting.

What Causes Pelvic Pain?

So now that you know what pelvic pain is, what causes it? Many, many, many different things can cause pelvic pain. As we spoke about earlier in the blog, infections can cause pelvic pain. That is why it is important to get yourself in to see a doctor if you are experiencing this type of pain. She will be able to rule out or rule in infections or other medical causes for your pain. Often the problem causing your pain may be musculoskeletal. People with this cause of pelvic pain may not feel relief with traditional medical intervention. The muscles of your pelvis include the muscles of your abdominal wall, your bottom, and the muscles that live between your pubic bone in front and your tail bone in the back, also known as your pelvic floor. These muscles may be in spasm causing the types of pain I described earlier, (yes even the burning urination pain). It may also be that a muscle group in the pelvis itself or supporting the pelvis may be too weak to do its job properly. When this is the case, it is important to get yourself in to see a pelvic floor physical therapist, who can figure out exactly why your muscles are causing your pain.

Although pelvic pain can seem really bleak, there is a lot that can be done to treat it. It’s all about finding the right qualified professional to treat it. At Beyond Basics Physical Therapy we are the experts in pelvic pain and we treat patients from all over the world. We not only treat musculoskeletal causes of pelvic pain, but also work to connect our patients with other professionals who can help to holistically treat pelvic pain. If you have pelvic pain, please remember that there is hope for you.

Alright readers, that’s the basics on what pelvic pain is and what it looks like in different people. Next week we will go Beyond the Basics (see what I did there?) and discuss how to treat pelvic pain, especially pelvic pain caused by muscle dysfunction, in the clinic and even at home.

For more reading on pelvic floor dysfunction please check out these blogs as well as Amy’s books books on pelvic pain

Treatment

How to Deal with Pelvic Floor Pain From Home

What is Pelvic Floor Physical Therapy

What is Myofascial Release and Why do We Always Talk About it So Much?!

For People with Female Anatomy

Endo Awareness Month: How Endo can Affect your Tummy

Endo Awareness Month: Understanding Endo

Endo Awareness Month ( Part 2 of 4) : How Endo can Affect your Bladder

When it Feels Impossible to Have Sex

For people with male anatomy

All About Testicles

What’s Neater Than Your Peter? Burning Urination

Prostatitis What it is and What to do About it

Bladder Health

Pelvic Floor MythBusters! Don’t eat lemon to avoid bladder pain, true or false?

How to Improve Bladder Health

Books By Dr. Amy Stein PT DPT

Heal Pelvic Pain : available here

Beating Endo: available here

The International Pelvic Pain Society (IPPS) is a multidisciplinary group working to promote awareness and education of pelvic pain, if you care to donate, click here

Running During a Pandemic

 

Fiona McMahon PT, DPT

running picture

Hello all!

We in NYC are closing in on completing our very first six weeks and counting, of social distancing. It has been tough. Many of us have had to drastically uproot our lives and routine to help keep our communities as safe as possible. For many of us, our daily escape of a yoga class in a studio or a lifting session at the gym is on pause. As a result, we are turning en masse to running, many for the very first time. As with any time you add a new exercise, one must proceed with caution as your body begins to adjust to the new exercise, throw in a global pandemic, and things get a lot more complicated. To guide you through this transition, we have compiled practical tips to start your running journey.

Socially Distant (and Responsible) Running

You want to protect yourself while running, but if you are feeling laissez faire about your own health, (maybe you’re young and healthy), you must remember that as a runner, you are a much larger threat to other people than they are to you. Anytime you are working out, you are exhaling more breath in volume, than someone walking at a moderate pace. That increase in breath volume, and thus respiratory droplets makes you far more likely to pass anything on if you are carrying a covid infection. You must do what is in your power to avoid getting others sick. No exercise is worth harming others.

In NYC, you are required to wear a face mask if you cannot avoid being within 6 feet of another person. For most running areas in NYC, it is nearly impossible to maintain 6 feet, so opt for a moisture wicking gaiter, to prevent any chapping of your lips. Keep in mind that running with a face mask can be more difficult, so go easy on yourself. You are running to get your ya-ya’s out, not to break a world record, so take plenty of walk breaks if you need them.

For those of you who do not live in a densely populated area, continue to try and maintain 6 feet. Take back roads, rather than main drags and run on off hours to avoid large crowds. Run against the flow of vehicular traffic so you can easily determine if it is safe to dart into the road safely (maintaining 6 feet) to overtake a fellow runner or walker. When it is not possible to avoid coming within 6 feet of someone else on your path, be prepared to stop altogether, or dart up onto someone’s lawn or driveway.

How to Start

If you aren’t a seasoned runner a run/walk program can be a really nice place to start. Starting by alternating walking 2 minutes and running for 30 seconds for 20 minutes is a good way to dip your running toes into the water. Also there are scads of really lovely couch to 5k programs out there to build you up from a novice jogger to a confident runner.

Volume of Training

With all this time on our hands, it can be really easy to up your weekly mileage. Your agenda is practically clear, why not bust out a 16 miler everyday? In general, bumping up your mileage by more than 10% a week is a fast-track way to invite injury. So if you are typically running 20 miles a week, bumping up to 22 miles a week is fine, but more than that can invite injury.

 

Stretch and Strengthen

Most runners will happily trade 10 minutes of stretching for an extra mile on the road. Don’t do it. Stretching after a run, when your muscles are still nice and warm can help prevent injury and keep you up and running. Stretching through your quads, hamstrings, inner thighs, and calves are all great places to start.

To run well, our bodies require lots of strength to stabilize our joints and provide us the power to gain speed. Core strength is essential as well as learning to perform core strength exercises properly. Did you know that your pelvic floor is part of the core too? Amy Stein, founder of Beyond Basics Physical Therapy, writes about it here.  Even on lock down, virtually meeting with your physical therapist will help you to review stretches and stability exercises specific to your body.

Beyond Basics is still open and taking patients, as well as providing virtual appointments. If you require treatment at this time, please call 212-354-2622

How to Deal with Pelvic Floor Pain From Home

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Dear reader, 

As I sit down to write this, New York City is on PAUSE, many other cities around the world are on various forms of lock-down. As a planet, we are working to slow the spread of COVID-19, the condition caused by the novel coronavirus. Those of you who are working from and staying at home, your efforts are noble and life saving. We thank you. For those of you in pain, we see you and feel for how tough it can be to feel like you have to wait to get help. Hopefully in a short period of time this virus will have passed . Follow these simple tricks to get started on tackling your pelvic pain. 

 

Check In With Your Seat

Work from home setups can leave a lot to be desired. Designed for portability, but not ergonomics, our laptop computers can leave us curled up like little cashews or “c’s”. This position tucks our pelvis underneath us and can cause us to put extra pressure and compression through our pelvic floors, not to mention putting extra pressure on our spinal discs. Even if you only have a laptop, you can remedy this c position by imagining you are a puppy dog with a tail. You want to sit so you could wag your tail like a happy puppy. Now for some people this may actually feel a little worse, if it does, this is not the trick for you. Don’t worry I have more. 

If you can, use a portable mouse and keyboard to discourage your cashew sitting tendencies. Arrange your setup so your eye line falls just about in the middle of the monitor by elevating it on some books.  You should be able to access your keyboard with your elbows bent at 90 degrees.

Now it’s time to think about what you are sitting on. I recognize that those of us living in teeny tiny NYC apartments may not have a lot of options to think about. But keep in mind that pelvic floor pain can be counterintuitive and an overstuffed couch, may not be the best thing if your pelvic floor is overworking to stabilize your body while you are sitting. Likewise, your kitchen chair may be too firm. Play around, how does the couch cushion feel on the chair? Is a firmer seat better or worse? You may have to trial and error your way into a solution.

Move

This one is so important. Depending on where you are geographically, you may be allowed different degrees of movement. If you are currently allowed to leave your home for exercise, go for a walk. Besides breaking up the day, walking can decrease the pressure from all the sitting you have been doing, as well as increase blood flow to the pelvic floor. While the requirements for social distancing remain, ensure that you maintain a distance of 6 feet (about 2 meters) between yourself and other people and wear a homemade mask.

If you cannot walk outside, and even if you can, get up periodically throughout the day. Stretch out, do some gentle air squats if they feel good. Look for some free restorative virtual yoga classes. Movement is medicine. 

Just be Happy… Like a Happy Baby

I love this pose so much that I could write a love song to it. Honestly. It works to stretch not only your pelvic floor, but your entire posterior chain  (back of the body). 

The most traditional way to do it, is to lie on your back, bend at your hips and knees, so that your feet are in the air, and grab the outside of your feet. As you stretch bring your knees towards your armpits. Hold this pose for 10 deep, beautiful breaths.

Feel free to modify this pose. Grab on the back of your calves or behind your knees if you have tight hammies. Put a pillow between your abdomen and thighs to prevent any pinching in your hip. It’s honestly all good.

Breathe

Another super important tool in your toolbox. Deep slow breathing can calm your nervous system, which can help to decrease pelvic floor spasm and guarding. In fact, in a study by Van der Velde, it was found that stressful stimuli do cause an increase in pelvic floor tightening. Try 10 deep slow breaths throughout the day and note how you feel from both a pain and stress perspective.

We are OPEN and also offering Telehealth

For those of you who are ready to get started NOW. You can. We are currently offering office evaluations and treatments, and telehealth services. Both Corey Hazama PT, DPT and Amy Stein PT, DPT are doing in person visits and telehealth visits are available with Sarah Paplanus PT, DPT.  For more information contact Beyond Basics Physical Therapy at 212- 354-2622 or check out our website: http://www.beyondbasicspt.com

 

Van der Velde J, Laan E, Everaerd W. Vaginismus, a component of a general defensive reaction. An investigation of pelvic floor muscle activity during exposure to emotion- inducing film excerpts in women with and without vaginismus. Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12 (5) 328-31

 

Pelvic Health 101 is back!

Pelvis Drawing

***In light of current events, and in an effort to keep our community as healthy as possible, we have moved our Pelvic Health 101 (PH 101) seminars from in person to online.  Although we regret not being able to meet everyone in person, we are excited for the opportunity to broadcast information about pelvic floor disorders and how to treat them fair and wide. Please keep an eye on our social media as well as the blog to find out how you can learn more about the pelvic floor.****

Warmly,

The Team at Beyond Basics

 

On March 19th, at 7pm we will be kicking off our spring semester of pelvic health education class, we call Pelvic Health 101 (PH101). 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 and function of your bowel, bladder, and sexual functioning. 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.

 

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

Here is our line up of this and future classes

ph101 sp 20

 

 

Endo Awareness Month: Understanding Endo

Amy Stein and Fiona McMahon

Beating Endo Cover

March Is Endometriosis Awareness Month. Treating endometriosis and improving the lives of people with endometriosis, has long been a passion of Dr. Amy Stein, founder of Beyond Basics Physical Therapy, so much so, that she teamed up with Dr. Iris Orbuch and wrote a book about it! This month we are reviewing some of the major talking points in their book, Beating Endo. Available here.  For more on endometriosis, check out our past blogs as well as Beating Endo.

Endometriosis is a condition that affects people born with female anatomy. It occurs when a tissue similar to that of lining of the uterus (known as the endometrium) grows outside of the uterus. Seems like a pretty simple definition, but it can cause a whole host of symptoms.

When something that doesn’t “belong” in the body is detected by the body, inflammation will occur. It is this inflammation that is believed to cause the myriad symptoms someone with endometriosis may experience. These symptoms can include

  • Irritable bowel syndrome (IBS)
  • Painful bladder syndrome
  • Pelvic floor dysfunction

One of the confusing things is, you don’t have to have all of these symptoms to have endo and the severity can range. This is Fiona writing, and I’m sure Amy would agree, no two endo patients are alike, and your pain is valid even if your symptoms do not necessarily look like someone else’s’ who is suffering with endo. It is this variability in presentation along with poor awareness within the medical field and public, leading to an average of 7 to 12 years to get a diagnosis.

Endometriosis can only be diagnosed by analyzing the suspected endometrial lesions removed during an excision surgery. There is no other test to confirm it, which can make diagnosis obviously, very difficult.

There is another condition that is called Adenomyosis. Similar to endo, adeno occurs when cells similar to the lining of the uterus occur within the muscular wall of the uterus. Most people with adeno have endo, but it is not always true that most people with endo have adeno. Adeno can show up as heavy periods, low back pain, and pelvic pressure.

Endometriosis is a chronic illness that affects millions of people. There is still a lot to figure out about endo and because of that fact there are many truths, half-truths, and myths floating around out there about endo. Check out some of the myths Amy and Iris busted together in Beating Endo.

Common Endo Myths

The abdominal and pelvic floor muscles are rarely affected by endometriosis.

False: Constipation, frequent urination or retention, pain with vaginal penetration from endometriosis causes tightening of the abdominal and pelvic floor muscles; So too does assuming the fetal position which is our go to pose when we are in pain. Both contribute to tight abdominal and pelvic floor muscles which causes pain.

The pelvic floor and abdominal muscles do not cause bladder, bowel, sexual dysfunction or abdominal-pelvic pain in patients with endometriosis.

False: Tight pelvic floor muscles caused by years of straining or reflexive tightening due to pain, often cause a severe amount of pain which results in further tightening and shortening of the pelvic floor muscles. Good news is that pelvic floor physical therapy benefits most people who have been experiencing abdomino-pelvic or sexual pain and/or are straining due to ongoing bladder and bowel symptoms.

Hysterectomy is a cure for endometriosis.

False: Hysterectomy is neither a treatment nor a cure. By definition endometriosis consists of cells similar to those in the lining of the uterus but found outside the uterus. Only surgical ‘excision’ removes endometriosis cells.

Medical menopause is a cure for endometriosis.

False: Just because your medicines give you hot flashes doesn’t mean your endometriosis is going away. The best treatment approach is to meet with an endo specialist to discuss options, and in most cases PT management. As well surgical excision has much better results than ablation of Endometriosis.

There is no correlation between quantity of endometriosis and severity of disease.

Truth: Even if you have a minimal amount of endometriosis, you can be in debilitating pain with lots of symptoms and in most cases dietary changes, physical therapy and mindfulness practices can help manage a lot of your symptoms.

Teenagers are too young to have endometriosis.

False: Teenagers can have endometriosis and their endometriosis can cause debilitating symptoms.

Pregnancy is a cure for endometriosis.

False: Just plain no. Pregnancy does not cure endometriosis.

Ablation surgery is the same as excision surgery.

False: Not even close. Excision surgery is the proper treatment for endometriosis. Ablation surgery, burns the surface of the endometriosis lesion but leaves the bulk of endometrial implants behind.

Surprising Endo Facts:

Fact: Physical therapy (pelvic PT) can help many suffering from the many pains and symptoms of Endo, including back, abdominal and pelvic pain, bladder, bowel and sexual function.

Fact: The majority of patients with Endometriosis require pelvic floor physical therapy. Pelvic floor PT can be instrumental in the healing process and can help abdominal-pelvic pain, bladder and bowel urgency, frequency, retention, incomplete emptying, and any sexual pain related to the musculoskeletal system.

Truth: Painful bowel movements, constipation, diarrhea and bloating are symptoms of endometriosis as well as symptoms of pelvic floor dysfunction .

Truth: Painful sex is a symptom of endometriosis as well as a symptom of pelvic floor dysfunction.

Truth: 40 to 50% of women with unexplained infertility is caused by Endometriosis.

Truth: Teens with endometriosis often have acyclic pain, that is, pain at other times of the month rather than only during their period, in addition to cyclic pain.

Truth: Back pain is a symptom of endometriosis.

Truth: If your ultrasound is normal you can still have endometriosis.

Truth: roughly 10% of women have endometriosis. That’s close to 200 million women worldwide. Endometriosis is much more than just bad period pain. 1 in 4 women have pelvic floor dysfunction.

Truth: Endometriosis commonly affects the musculoskeletal system, and in many cases can be a primary contributor to one’s pain and symptoms.

 

Orbuch I, Stein A. Beating Endo. New York. Harper Collins. 2019

Prostatitis What it is and What to do About it

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Fiona McMahon DPT

Introduction

Prostatitis is a common diagnosis we see at Beyond Basics Physical Therapy. If I have a new evaluation on my schedule, who is male and between the ages of 18-40, we can place a pretty good bet that they are coming to see me for issues pertaining to non-bacterial prostatitis. It is estimated that 35-50% of men are reported to have prostatitis symptoms  in their lifetime (Rees). Prostatitis can be classified into different types based on their causes and response to treatment. Prostatitis is a vexing condition for many patients. In cases of non-bacterial prostatitis, which makes up 95% of all prostatitis, it’s often very difficult to determine what brought it on, and often times our patients have been bouncing from practitioner to practitioner trying to find answers and effective treatment. Let’s dive into the causes, symptoms, and treatment in order to help shed light on this condition.

 

Prostatitis Symptoms,

Although there are different types of prostatitis, the symptoms of prostatitis are mostly the same between types. That isn’t to suggest that every man with prostatitis experiences the same symptoms, quite on the contrary. Men with prostatitis may experience almost all of the symptoms listed below or they may only notice one or two. This melange of symptom possibilities can add to the confusion of having prostatitis and getting down to an effective cure.

 

Symptoms:

  • The sensation of having a golf ball stuck in the rectum
  • Hesitant urinary stream (having trouble getting the urine to start flowing)
  • Post void dribble (spotting of urine on underwear following voiding)
  • Pain that radiates into the abdomen (this is one of the differences from symptoms of benign prostatic hyperplasia)
  • Erectile dysfunction and decreased libido
  • Painful ejaculation
  • Painful or burning urination
  • Genital pain: penile, testicular, groin and perineal pain

 

Types of prostatitis:

Here’s where it gets a little more complicated. There isn’t one type of prostatitis. There are four. Each type of prostatitis is a little different in terms of etiology (how it developed) and how it’s treated.

Type 1: Acute bacterial prostatitis

This type of prostatitis is caused by an infection by a microbe. It is relatively rare. In addition to the symptoms above, a person with this type of prostatitis will feel the symptoms of an ongoing infection, including pain in the body, fever, and chills. This type of prostatitis generally response well to antibiotic treatment.

Type 2: Chronic bacterial prostatitis

Chronic bacterial prostatitis can occur after multiple infection or when there is an ongoing low grade infection. The symptoms, particularly those of infection are dampened in this form of prostatitis than those of type 1. Type 2 is often more tricky to treat and may require multiple courses of antibiotics

Type 3: Chronic Prostatitis/ Chronic pelvic pain syndrome (the most common making up 90-95% of all prostatitis and WHAT WE TREAT!)

This type of prostatitis occurs with no evident infectious cause and makes up the majority of cases. This is the classification that is one of the more frustrating for patients to deal with because the causal agent is much harder to ascertain; however the majority have musculoskeletal dysfunction, which we now know can be treated effectively through expert pelvic floor physical therapy.  Type III prostatitis can be further categorized based on the presence or absence of white blood cells in the urine or prostatic fluid, inflammatory and noninflammatory respectively.

Type 4: Asymptomatic inflammatory prostatitis

As the name implies, this type of prostatitis is usually not noticed unless semen or urine analysis is being performed to diagnose another condition. Typically this type is left untreated.

 

Causes

Here’s one of the universal questions that patients with prostatitis have: “why do I have this?”  Sometimes patients may find themselves blaming their prostatitis on something they have done in the past, like masturbating or poor hygiene habits as children. The fact is, prostatitis can occur for a multitude of reasons, and it’s usually something one has no control over like a fall on the bottom or an infection. It’s unfortunately something that happens, and as noted in the introduction of this blog, it is quite common. Here are some possible causes:

 

  • In chronic nonbacterial prostatitis/ chronic pelvic pain syndrome 90-95% of cases- no definitive cause ( or very difficult to ascertain); however pelvic floor dysfunction is a prevalent contributor.  
  • Bacterial infection, which can have good results with antibiotics
  • Chronic bacterial prostatitis, recurrent infection
  • Inflammation to the pelvic area
  • Central and peripheral sensitization- meaning a past injury in the area caused your pelvic nerves to perceive non painful stimuli as painful
  • Trigger points (irritable points of muscle) in the pelvic floor and abdomen

 

Treatment

Treatment is evolving in prostatitis. Increasing evidence supports a multimodal approach to treating prostatitis and its symptoms, meaning that not only is medical intervention used, but psychological, nutritional, and physical therapy.

From a medical perspective the first line of treatment for prostatitis is the “3 A’s”, antibiotics (especially the quinolone class), anti-inflammatories, and alpha blockers. Antibiotics obviously clear up any infection that might be causing your symptoms, anti-inflammatories to bring down the pain and discomfort, and alpha blockers to improve urine flow. Sometimes this is just what the doctor ordered (literally), especially in individuals with type 1 prostatitis and they are on their way with no further treatment needed. Since the vast majority of people with chronic prostatitis fall outside of the type one category and into more difficult to treat types, their recovery may require a more involved intervention to effectively treat their symptoms and the 3 A’s may not be the answer, or the complete answer for these patients.

 

Physical Therapy: Anderson and his colleagues described the relationship between the presence of myofascial trigger points and symptomatic prostatitis. They also showed that physical therapy intervention, including manual release of these trigger points was effective in reducing symptoms of prostatitis. The benefit of physical therapy was shown again to be more effective than placebo in a 2011 paper by Nickel. In addition to treating the trigger points themselves, PT’s work to determine what lead up to the formation of the trigger points in the first place, whether that be poor habitual posture, poor strength, or tight muscles in other parts of the body. They also teach patients how to avoid clenching their pelvic floor to prevent exacerbating symptoms.  This type of therapeutic approach was found to be effective in reducing pain in 72% of participants in a study conducted by Anderson and colleagues in 2005. The therapists at Beyond Basics Physical Therapy work to go beyond simple treatment of the trigger points themselves.  We develop plans and treatments to prevent their recurrence in the future.   Some other effective physical therapy techniques that we use include but are not limited to, joint mobilization to assist proper structural alignment, therapeutic exercise, postural and neuromuscular re-education and a detailed and individualized home exercise program.

 

Dietary Modifications:

Avoiding irritants to the bladder and gastrointestinal system is another simple and effective place to start. In some men, avoiding spicy foods, alcohol and caffeine can work wonders in making symptoms more manageable.   

 

Phytotherapy:

Preliminary data shows that there is evidence to support the use of saw palmetto, quercetin and bee pollen extract in reducing the pain of prostatitis. If supplementation interests you, consult with your general practitioner or urologist.

 

Stress Reduction

As clinicians who have seen a lot of cases of prostatitis, high stress is a contributor that we see with the vast majority of our patients. Studies have shown that high levels of stress are correlated with higher pain and disability scores in individuals with prostatitis. Stress can also perpetuate unhealthy holding or clenching in the pelvic floor, which causes or contributes to trigger points discussed earlier in this section. Stress reduction is a key component to expediting your recovery and is something we recommend to nearly all of our patients.

 

Final Thoughts

  • Prostatitis is a common and aggravating condition to be living with, and the fact is, every case of prostatitis is different. You may fall into the category were a course of antibiotics does the trick or you may fall into the category where you require physical therapy alongside medical intervention which can be much more slow going. Regardless of where you fall, be patient, there usually is a lot that can be done to help the more complex cases of prostatitis clear up. If you are suffering with this condition, make an appointment with an expert pelvic floor physical therapist today. There is so much we can do.

 

Sources

Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8

Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60

Chronic nonbacterial prostatitis (chronic pelvic pain syndrome). Harvard Health Publications. Harvard Medical School. 2007. http://www.health.harvard.edu/newsletter_article/chronic-nonbacterial-prostatitis-chronic-pelvic-pain-syndrome. Accessed December 11, 2016

Duclos A, Lee C, Shoskes D. Current treatment options in the management of chronic prostatitis. Ther Clin Risk Manag. 2007; 3(4):507-12

 

Rees J, Abrahams M, Doble A et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015; 116(4):509-25

 

Nickel J. Prostatitis. Can Urol Assoc J. 2011; 5(5): 306-15

What is Pelvic Floor Physical Therapy

marigold-2117436_960_720By Amy Stein, DPT and Fiona McMahon, DPT

As physical therapists who specialize in abdomino-pelvic pain disorders, one of the toughest parts of the job is meeting men and women who have suffered with pelvic pain for years, only to be told by their doctors/healthcare providers that there is no help for them. It is not uncommon to meet a patient who has suffered for 5- 10 years without help before finding us. Musculoskeletal causes of abdomino-pelvic pain are treatable conditions and often times we can start to improve a patient’s symptoms within just a few visits. Please read on to see how we can help you with your pain.

What do pelvic floor physical therapists actually do? Why do they do what they do? What can you expect from your first physical therapy visit?

Physical therapists (PTs) are experts in movement and function, which sounds like a pretty broad topic to be an expert in, and it is. After physical therapists graduate PT school (now-a-days at the doctoral level), they find their niche and specialize. You can find PTs working with high-level athletes, children, infants, people who are recovering from injuries, people with neurological conditions, and many other types of clients.

Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but don’t have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to inquire about the experience and level of training your potential physical therapist has had in this specialty.

What is the pelvic floor and what is pelvic floor dysfunction?

Who needs pelvic floor PT? The pelvis performs many important functions of the body. The muscles, nerves, connective tissues and skeletal structures of the pelvic floor help to keep us continent, aid in sexual performance and function, and assist in core stability.

When some or all of these structures of the pelvic floor are not functioning properly, they can cause a multitude of different symptoms. People who are suffering from bowel, bladder, and or sexual problems, as well as those who are suffering from pain in the pelvis, upper legs, abdomen or buttocks most likely have pelvic floor impairments contributing to their pain.

Issues with the pelvic floor can arise from a multitude of reasons. Infections, previous surgeries, childbirth, postural and lifting problems, and trips and falls can all bring on pelvic floor dysfunction. Pelvic floor pain can persist well after the cause of it has been removed. So it is entirely possible to feel the effects of an old infection, surgery or injury, days to years after it occurred. Anyone who has had long standing abdomino-pelvic pain, or pain that they can’t seem to get rid of after seeking the help of medical doctors or other healthcare providers is a good candidate for a pelvic floor physical therapy evaluation and possible curative treatment.

What is Pelvic Floor Physical therapy?

Physical therapy is a practice of healing that restores function and reduces pain through the use of techniques to improve bony alignment, reduce trigger points, and improve muscle coordination and strength. Pelvic floor physical therapy is a branch of physical therapy and is built upon these same principles.

What sets pelvic floor physical therapists apart is their in depth understanding of the muscles and surrounding structures of the pelvic floor, beyond what was taught in physical therapy graduate school. What that means for a patient who is seeking the help of a pelvic floor physical therapist, is that his or her pelvic floor issues will be examined and treated comprehensively with both internal and external treatment, they will be provided  with lifestyle modifications to help remove any triggers, and receive specific exercises and treatment to help prevent the reoccurrence of pain once he or she has been successfully treated.

What exactly do Pelvic Floor Physical Therapists Do?

The elephant in the room with pelvic floor physical therapy is the internal exam/ treatment. It can seem a little daunting, especially if you have pelvic floor pain, but pelvic floor therapists are trained to be as thorough as possible while minimizing discomfort.

During the internal exam, your physical therapist will place a gloved finger into your vagina or rectum to assess the tone, strength, and irritability of your pelvic floor muscles and tissues. Internal exams and internal treatment are invaluable tools that are taught to pelvic floor physical therapists. It can tell us if there are trigger points (painful spots, with a referral pattern or local); muscle/tissue shortening; nerve irritation and/or bony malalignment that could be causing your pain directly or inhibiting the full function of your pelvic floor muscles. We can also determine if your pelvic floor has good coordination during the exam. A pelvic floor without good coordination, may not open and close appropriately for activities such as going to the bathroom, supporting our pelvis and trunk, sexual activity, and keeping us continent.

It is essential that we, as pelvic floor physical therapists, also include other assessments when we are examining our patients for the very first time. We employ the tried and true physical therapy exam practices to determine if there is an underlying condition elsewhere in your body, such as a strength deficit or alignment issue that could be affecting your pelvic floor. It’s wild to think of it, but something as seemingly unrelated as a flat foot or a hip injury can be enough to set off pelvic and abdominal pain!

Some pelvic floor physical therapists may have the opportunity of getting a lot of time to speak one-on-one with a patient to determine possible causes of his or her symptoms, educate the patient and to guide them to other practitioners who may optimize their physical therapy results if necessary. We truly can find out so much by just listening to what our patients have to say. A fall, or infection can be significant as well as a patient’s feelings and knowledge about their current condition.

Once we determine the cause of our patient’s pelvic floor dysfunction, we design a plan tailored to the patient’s needs. At Beyond Basics, we have a diverse crew of physical therapists who bring their own training and background into each treatment. What is really beautiful about that, is that all teach and help each other grow as practitioners. It will be difficult to go over every single type of treatment in one blog post, but we will review some of the main staples of pelvic floor rehab.

Manual Techniques

As physical therapists, are our hands are amazing gifts and phenomenal diagnostic tools that we can use to assess restrictions, tender points, swelling, muscle guarding, atrophy, nerve irritation and skeletal malalignment. We also use our hands to treat out these problems, provide feedback to the muscles, and facilitate the activation of certain muscle groups. There have been a great number of manual techniques that have evolved over the course of physical therapy’s history. Let’s go over a few.

Myofascial Release

Myofascial release was developed by John Barnes to evaluate and treat the myo-fascia throughout the body. The myofascial system is the connective tissue that coats our muscles, nerves, blood vessels, and bones, and runs throughout our bodies. Any tightness or dysfunction in the myofascial system can affect the aforementioned structures and result in pain and or movement dysfunction. By treating the fascia directly, therapists can improve their patient’s range of motion, reduce pain, and improve a patient’s structure and movement patterns.

Myofascial release is a more gentle technique that can be useful in cases where a patient is already experiencing a great deal of pain. The therapist will hold gentle pressure at the barrier of the tissue (the point where resistance is felt) for a short period of time, usually less than 2 minutes until the therapist feels the tissue release on its own. The therapist does not force the barrier.

Scar Tissue Manipulation

Scars are almost always a fact of life. From surgeries, to accidents, to conditions like endometriosis, or certain STI’s, almost everybody has one. What doesn’t have to be a fact of life are the muscle, nerve and skin restrictions and overactivity that they can cause. By releasing scar tissue in physical therapy, it has been shown that the surrounding restrictions also decrease their resistance and adherence to the deeper tissues and surrounding organs.

Myofascial Trigger Point Release

Discussed extensively in Travel and Simon’s two volume series, trigger points are taut (firm) points in the muscle that have a consistent referral pattern (they transmit pain to the another part of the body). Trigger points are not only important because they cause pain, they also can affect how the muscle works. This is one of the main reasons our therapists at Beyond Basics are fastidious about ensuring all trigger points are released in the abdomen, back, legs and pelvic floor before transitioning to any core stabiltiy or strengthening exercises that can re activate a trigger point.

People with trigger points in their pelvic floor and surrounding areas can experience pain in the rectum, anus, coccyx, sacrum, abdomen, groin and back and can cause bladder, bowel, and sexual dysfunction. When physical therapists find a trigger point they work to eliminate it and lengthen it through a myriad of techniques. Recent literature has found that trigger point release alone can achieve an 83% reduction in symptoms.

Connective Tissue Manipulation

Skin rolling, ie. rolling of the skin over another layer helps to improve the movement of those two layers and reduce the tension and pulling between them. It feels like a scratch or ‘nails’, and in cases where a patient has more restrictions, the sensation may be more amplified.

One of the great benefits to skin rolling is it increases the circulation in the area to which it was applied. Often times, areas that are tight or restricted are receiving reduced blood flow and oxygen. By bringing blood flow to the area, toxins can be cleared and the healing contents of the blood are brought to the injured area. Skin rolling can also restore the mobility of surrounding joints and nerves, which can help to restore normal function. By allowing the skin to move more freely, pelvic congestion, heaviness and aching can be effectively treated.

Neural, Visceral, and Joint Mobilization

Nerves, organs, and joints can lose their natural mobility over time and cause a whole host of symptoms from pain, to loss of range of motion, and poor functioning of the bodily symptoms. Skilled and specialized therapists can use a variety of active techniques (patient assisted) and passive techniques to free up restrictions in these tissues and organs and improve overall function.

Neural mobilization as the name implies, involves the restoration of neural structures back to their normal mobility: to glide and slide. Neural structures that cannot move properly can cause pain that can radiate down an extremity or into the trunk and can give the sensation of burning, zinging, and stabbing. Some orthopedic therapists practice this type of mobilization; common examples include the sciatic nerve in the leg and the ulnar nerve in the arm. Pelvic floor PTs focus on these nerves when they cause issues, but they also pay attention to nerves that innervate the perineum and genital region (bicycle seat area), such as the pudendal, iliohypogastric, obturator, ilioinguinal, genitofemoral and the femoral cutaneous nerves. By allowing these nerves to move freely, symptoms such as vulvovaginal, penile, rectal, clitoral and testicular pain, itching and burning can be greatly improved.

Visceral mobilization restores movement to the viscera or organs. As elucidated earlier in our blog, the viscera can affect a host of things even including how well the abdominal muscles reunite following pregnancy or any abdominal surgery. Visceral mobilization aids in relieving constipation/IBS symptoms, bladder symptoms, digestive issues like reflux, as well as sexual pain. Visceral mobilization can facilitate blood supply to aid in their function, allow organs to do their job by ensuring they have the mobility to move in the way they are required to perform their function, and to allow them to reside in the correct place in their body cavity. Evidence is beginning to emerge to demonstrate how visceral mobilization can even aid in fertility problems.

Joint mobilization is a common and favorite tool of most orthopedic physical therapists. We love it so much because it can have so many different benefits depending on the type of technique used. Maitland describes types of joint mobilization on a scale between 1 and 5. Grade 1 and 2 mobilizations are applied to a joint to help to lessen pain and spasm. These types of mobilizations are typically used when a patient is in a lot of pain and to help break the pain cycle. On a non-painful joint, grade 3, 4, and 5 (grade 5 requires post graduate training) mobilizations can be used to help restore full range of motion. By restoring full range of motion within a restricted joint, it is possible to lessen the burden on that and surrounding joints, thereby alleviating pain and improving function.

Neuro-education of the Pelvic Floor and Surrounding Structures

The muscles of the pelvic floor must work together and in coordination to perform specific tasks. The pelvic floor has to contract, elongate and relax in very precise ways to perform basic functions like urination, defecation, support the pelvis and organs, and sexual function and pleasure. If your pelvic floor muscles and/or nerves fail to do what they are supposed to do at the right time, problems like painful sex, erectile dysfunction, constipation, and incontinence can occur.

Biofeedback is a modality that allows you to learn how to better control your muscles for optimal function. Biofeedback shows you what your muscles are doing in-real time. It is helpful to teach patients to lengthen and relax the pelvic floor for issues like general pelvic pain, painful sexual activity and constipation or to contract the pelvic floor in order to prevent leakage with activities like coughing, laughing, lifting, running or moving heavy objects. However, biofeedback does not demonstrate shortened muscles and tissues; therefore, in certain cases the biofeedback may seem to be within normal limits but yet the patient has 10/10 pain. In these incidences, manual palpation is more appropriate to identify restricted and shortened tissues and muscles, and myofascial trigger points.

HEP: Home Exercise Program

 

Home exercise programs are essential for each patient. In the case of weakness, a patient will require more pelvic floor, core and functional strengthening and stability exercises. For overactive and pain conditions, the HEP typically consists of relaxation techniques, self-massages (both external and internal), gentle stretching, cardiovascular fitness as tolerated, and eventually pain-free core stability exercises. Both require postural and behavioral modifications and self-care strategies. For more information and detail, check out the book: Heal Pelvic Pain, by Amy Stein or her DVD: Healing Pelvic and Abdominal Pain here.

Conclusion

As you can now see, there is so much out there that can be done for people suffering with pelvic floor dysfunction. This blog is by no means extensive, and there are even more options you and your physical therapist can explore to help manage your pain or other pelvic issues. Pelvic floor dysfunction requires a multidisciplinary approach for most of our patients. Hopefully, this blog helped to paint a picture of what you will experience with a pelvic floor physical therapist. We advise that you seek out an expert and experienced pelvic floor physical therapist in order to help better your life and improve your function.

Sources

FitzGerald M, Kotarinos R. Rehabilitation of the short pelvic floor I. Background and patient evaluation.

Padoa A, Rosenbaum T. The Overactive Pelvic Floor. Springer. 2016

Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1 Upper Half of Body. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999.

Stein, Amy. Heal Pelvic Pain. McGraw-Hill. 2008

Stein, Amy. Healing Pelvic and Abdominal Pain. Video: www.healingpelvicandabdominalpain.com 2013

Travell, Janet G. and Simons, David G., MYOFASCIAL PAIN AND DYSFUNCTION. THE TRIGGER POINT MANUAL, Volume 2, The Lower Extremities, Williams & Wilkins, Baltimore, 1992.

Valovska A. Pelvic Pain Management. Oxford University Press. 2016

Weiss J. Chronic pelvic pain and myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001; 166(6) 2226-31