Beyond Basics’ Marathon Prep Program: The Evaluation

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Fiona McMahon PT, DPT & Jessica Babich PT, DPT
Fiona: Hello everyone, for those of you who didn’t get a chance to catch my blog a few weeks back, Beyond Basics Physical Therapy is joining forces with the Tisch Multiple Sclerosis Research Center of New York to raise money to support multiple sclerosis research, through Team Tisch MS NYC, in this year’s New York City Marathon. Our goal is $2,500  and WE ARE SO CLOSE, if you care to donate, please click here. I will be running the marathon in November, and Beyond Basics Physical Therapy is working to support my fundraising endeavors as well as showing the running community the invaluable benefits of having a sharp, perceptive, thorough and expert physical therapist on your side during training; and that goes for ANY sports training!

I just had my first evaluation with Jessica Babich, PT, DPT,  who is both a pelvic floor physical therapy expert as well as a functional movement specialist with an extensive background in orthopedics and sports-related injuries. Jessica was super thorough, she took an extremely detailed history, she looked at my posture, joint mobility and mechanics, strength, core function, and even how my shoes were constructed to see if they were good enough to run in! The shoe part was super wild!  In this blog you will see where I stand from a physical therapy perspective, and where I hope to go. Both Jessica and I are authors in this blog so keep an eye on who is talking so you can get the full scoop from both the physical therapist and the patient perspective

3 pillarsJessica: When I look at runners,  I first assess the individual as a whole and identify which area in their body seems to be driving inefficiency. I look at the 3 pillars of functional efficiency, (Mechanical, Neuromuscular, and Motor Control) when examining my patients. Within the mechanical capacity, I examine which structures such as joints, muscles, viscera, neurovasculature, etc.,  that could inhibit optimal functional performance.  Specifically with a runner, I am interested in his or her alignment as well as range of motion through their rib cage, spine, pelvis, and lower extremities.  Looking at a patient’s posture in both walking and running, allows me to determine the momentum driving the patient forward. This can be helpful in finding out what and where a dysfunction may be that could affect a runner’s performance. With a runner, I am interested in how he or she initiates his or her run.  Are they able to drive force through their lower extremities into their trunk without spinal compensation.  Does the runner have adequate strength and endurance to maintain appropriate form and movement strategy throughout their run?  I also examine what happens to the patient’s form during walking when you slow him or her down. Breaking down the whole movement pattern and looking at individual parts helps to further expose any problem areas. I examine dynamic stability and controlled mobility to ensure my patients are moving efficiently. From there, I examine the basics, is there a lack of movement (is something stuck or tight) that can affect a runner’s ability to powerfully push off the ground when they run and absorb force when they land.   Lastly, I am evaluating Motor Control.  If the mechanical capacity and neuromuscular function is present, how does this individual choose to move, or what is his or her strategy to get from point A to point B.  This is where a lot of the training comes into play.

 

History

Fiona: I told Jessica about my previous injuries, almost all have occurred secondary to decades of running (It truly is my favorite activity), currently I am feeling some left sciatic pain, which has become fairly bothersome.

.Orthopedic Injuries

  • Right hip labral tear
  • Right knee pain (patellofemoral pain syndrome), which comes and goes but is currently under control
  • Occasional left knee pain (patellofemoral pain syndrome), much less bothersome than the right side
  • Mild to moderate left calf pain, which also comes and goes
  • Right ankle sprain, from a failed handstand (don’t ask), no longer bothersome, but not properly rehabbed

Medical

  • Largely unremarkable, neural tension secondary to Arnold Chiari Type I malformation. Chiari occurs when part of the brain  (the cerebellum) herniates through the skull opening into the spinal cord. It sounds pretty awful, but for me, it’s not too bad and I only experience occasional dizziness as a symptom.

Current Exercise Routine:

  • I’m pretty regimented and break most of my workouts into 2 daily sessions. I run in the morning, currently I am working on speed training and run something between 3 and 8 miles daily, 5-6 times weekly. I am following one of my favorite marathon gurus, Hal Higdon’s plan, which you can see for yourself here.  I have used Hal’s plans for 2 of the 4 previous marathons I’ve run, and I really like how he organizes his plans. I would advise anyone thinking of trying a marathon, to use a training plan.  It allows you to ease yourself gently into upping the mileage, rather than panicking at 5 weeks before the race that you haven’t taken your long runs over 20 miles.  Following my run I do a mixture of stretches, use my stick ( it’s like a foam roller) and a trigger point ball to roll out my muscles. 4 nights a week I do PM weightlifting sessions, which last about 40 minutes. I split my lift into upper body and lower. I do a mixture of stabilizing and traditional exercise. When I’m done I’ll stretch again and this time roll out on a foam roller. In order to support all that exercise I drink a ton of water and try and fill my diet with lots of whole grain carbs, lean protein, and healthy fats (I’m looking at you avocados!)

The Evaluation:

Posture:

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Jessica examining my posture and my ability to tolerate load through the spine using the Vertical Compression Test

     Fiona has a posterior/posterior alignment.  ( This terminology comes from the Institute of Physical Art (IPA), and is a wonderful training program for PTs) Meaning, her ribcage is set posterior in relationship to her pelvis and her ribcage is tipped posteriorly.

Range of Motion (ROM):

 

  • Poor lumbar spine ROM, with an inability to reverse the curve in my lumbar spine
    • Why this is important: my spine should have motion in order to absorb the shock from repeated foot falls, also an immobile spine may inhibit the core stabilizers from firing properly
  • HISL testing ( another IPA test): Positive  at the right (hip) at 90 degrees, with poor glide of the femur down on the left side. Positive at left  (hip) at 100 degrees.
    • How do we translate this into non-physical therapy speak? First of all the HISL stands for Hip, Innominate, Sacrum, and Lumbar. It measures the relationship between the bones of the upper thigh, pelvis, and low back. What my results tell us is that my hips are stuck and cause my innominate (bone in the pelvis) to move too early. This is not so great because it causes the bones further up to have to move extra to compensate. We have to clean this up.

 

Strength and Function :IMG_3010

  • Instead of testing muscles one-by- one, which is commonly done in traditional physical therapy practices,  we decided to take a look at functional movements. Who gives a hoot if I have strong quadriceps while sitting on an exam table, if they can’t function properly during actual running, right?
  • LPM (Lumbar Protective Mechanism)( another IPA test) : absent in all quadrants
    • Dang! Lumbar protective mechanisms refers to the ability to stabilize your spine and protect your core in response to bumps and jostles. I didn’t stabilize at all. This is important because running is essentially a series of bumps and jostles, running on an unstable spine and core can increase your chances of injury as well as reduce your power during push-off in running leading to slower times (HORRENDOUS!).
  • Sagittal Plane Lunge: I have deficits with initiation and weight acceptance on both sides. I compress my arms in prayer position to create stability and when taken away I have a loss of trunk control. My right ankle more unstable than the left.
  • Runner’s Start Jump: difficulty coordinating movement on both sides, but significantly worse with initiation from right side at the ankle.
    • Remember my ankle sprain? Well, apparently that’s still holding me back and decreasing my ability to push off the ground. You could imagine how this could become a problem over the course of 26.2 miles. Moral of the story, see a PT after you hurt your ankle!
    • Also we see deficits in core control again.  I think addressing this with Jessica will really improve my time.

Shoes and wear:IMG_3000 (002)

  • Apparently my shoes were good! Jessica told me that sometimes right and left sneakers can be made in different factories and have different densities, which can really mess you up while running. Also if the back part of you sneaker extends too far it can make your brain think your foot is larger than it is, leading to injury. The wear of the shoe is also important to see if one foot pronates or supinates more than the other. If this was the case, Jessica could work on the alignment of the bones in my feet, ankle and foot strength, as well as teaching me how to tie my shoes in a way that better support my feet.

 

Assessment and Take Away:
Jessica’s Assessment: Fiona, like a majority of our athletes presents with deficits in the 3 major pillars leading to functional inefficiency. The goal of physical therapy, isn’t always to reduce pain, it is to get you to function better, which in turn will decrease wear and tear that contribute to common pain patterns.

Fiona: I can’t say I am surprised by much of what we found. I am slightly disappointed with my core activation finding, because I had been focusing on that particular issue for months and months in the gym. Jessica told me she thought part of my issue was that my lower (lumbar) spine was so rigid, it might be hard for me to get into a place where my deep core muscles can work to facilitate stability. It goes to show, even as a physical therapist, you need someone else to literally watch your back. As a physical therapist, my evaluation showed me that now is the time for help. Although I am strong and spend hours working out, my core stability is something I need more help with, and I simply cannot work my way out of my weakness alone in a gym. I’ve tried long enough. I need gentle manual therapy and proprioceptive neuromuscular feedback to wake my lazy deep stabilizers out of their hibernation and orthopedic work to allow the joints of my spine and pelvis to move more efficiently and effectively. Although this body has its deficits, I’m really proud of what it has done so far, and I’m really excited to see where Jessica will help me go!

 

Plan:

  • Improve the movement of: right foot, trunk, and cervical spine
  • Improve core stability and strength to allow for more power and reduction of injury risk
    • We will achieve these goals through manual work, neuromuscular re-education in order to teach the muscles to activate better and a strong home program to maintain changes made in physical therapy.

 Goals

Jessica: My goal is to treat the mechanical deficits inhibiting her neuromuscular system and then functionally reintegrate the parts into the whole system to enhance performance efficiency.

Long Term Goals:

  • 1: (12 Weeks) | Patient to demonstrate core first strategy with transitional movements to improve stability, energy efficiency and decrease risk for injury
  • 2: (12 Weeks) | Patient to demonstrate optimal ribcage over pelvic posturing for automatic core engagement and decrease mechanical load on system.
  • 3: (12 Weeks) | Patient to improve R foot positioning for stability and push off in gait

 

Home Exercise Program:

So far I have one addition to my workout routine. It is a split stance at the wall designed to wake up my stabilizers before I go running. I stand at the wall with one leg fully extended on my toes and the other bent at the knee and the hip, with my toes pointed up. I hold for 30 seconds per side and then I get going. It has been a couple days since this exercise was assigned, and I’ve done it on about 50% of my runs. Remembering to do your home program is one of the biggest challenges of physical therapy. My strategy to combat this is to leave a sticky note on my door reminding me before I leave the house. I will report back on future blogs to let you know how my strategy worked out.

That’s it for now:

Check out more info and pictures on our instagram and facebook pages

Click Here to Donate to support Team Tisch MS NYC:

 

 

Preparing for the Marathon with Physical Therapy at Beyond Basics!

JHO-Muscogee Moms Contest-Blog

Fiona McMahon, DPT

Hi all! If you have been following our blog, you should be aware that Beyond Basics Physical Therapy and I are teaming up to raise money the Tisch Multiple Sclerosis Research Center of New York with Team Tisch MS. I’m hoping to raise $3,000 dollars to support multiple sclerosis research.  We have currently raised approximately $1,500!. Please support us and click HERE to donate. What puts the fun in this fundraiser ( sorry, not sorry about the pun) is that we get to get donations through running the New York Marathon, which I will be running in November.

I have run 4 marathons before including New York, and even though my timed goals were not lofty ( I really only cared about dragging my body from A to B 26.2 miles later), I relied on PT every single time, to keep my body whole and prevent me from sustaining race ending injuries. This year is no different and this week I will be having my first appointment with Jessica Babich, at Beyond Basics.

 

Why go to Physical Therapy if you are not injured?

No matter how you cut it, physical therapy is an investment. Based on your insurance, co-pays can vary to very little to more expensive, and no matter how much you are paying, the time it takes to go to physical therapy and diligently do your exercises is a finite resource. So why add more tasks to an already arduous training schedule? For me, the answer is easy, I want my body to not only run a faster marathon this fall, but I want to do so in a health way to protect my joints, ligaments and muscles, so I can not only continue to run, hike, ski, and play outside, but also so I can continue working without pain.

But aren’t you a PT, can’t you just PT yourself?

One of the most powerful and surprising lessons I’ve learned through being a physical therapist is, it is really hard to be objective about your own body. Physical therapists are trained to see large scale impairments like weak hip strength, which I know for a fact is something I need to work on, but also small scale impairments in movement, like slightly more pronation on the right foot than the left, those are things another practitioner needs to observe from the outside to diagnose and treat. Having an objective movement analyst ( aka a physical therapist), can help you see weaknesses, and alignment issues that even the most expert observer may miss on themselves. Long story short, you don’t know what you don’t know.

Why someplace like Beyond Basics Physical Therapy

I work at Beyond Basics, so full disclosure, it is the most convenient place I could go. That being said, it is also the best place I could go. Physical therapy clinics come in “flavors” and for someone hoping to truly optimize their performance, Beyond Basics Physical therapy and clinics with the same “flavor” are where to go. What makes Beyond Basics physical therapy so special is the hour one-on-one treatment they offer. This allows us to address all three pillars of movement, efficiently, effectively, and completely. The three pillars are mechanical, ( tightness, or lack thereof, of muscles, joints, fascia and ligaments as well as bony alignment), strength (how strong is a particular muscle and is it strong enough to do it’s job), and finally neuromuscular control, ( do your muscles do the right thing at the right time, this is really important to stabilize the joints of the leg and back, and is often overlooked in some busier physical therapy practice). Other physical therapy practices have a slightly different flavor. They may have a one physical therapist treating 4 patients and hour. Even if time is divided up perfectly equitably between patients, this allows the therapist of only 15 minutes on hands-on treatment to correct mechanical and neuromuscular issues, therefore leaving 75% of the time doing exercises with other patients. That flavor of physical therapy can work for some people, especially those who like to socialize with other patients during treatment, but for me, marathon training is too hard to only get 15 minutes of hands on time and spend 45 minutes doing exercises in a crowded gym. I feel that I am perfectly capable of doing my assigned exercises regularly as part of my home program. I would much prefer to work with a therapist who can tailor my treatment to suit my needs, not one who has to juggle the time constraints of treating multiple patients at once.

How are you preparing for PT?

Beyond Basics Physical Therapy is based out of New York. Like most states in the USA, New York has direct access, so I don’t need to have a prescription to come in. I will be bringing a few things to my appointment that I think are essential: health history, attire, and attitude.

Health History: Health history is a big one. In physical therapy a complete health history includes your current medications, and medical conditions, past injuries ( this is really important, and things like an ankle sprain a few years ago can clue us in on a lot ), and other factors like stress, amount of sleep you typically get, how much you work out and what you do, and diet.

Attire: Another important and sometimes overlooked item on the list. Your physical therapist will have to examine different areas on your body, as well as have access to treat those areas. Loose fitting shorts and an athletic top are a good bet. Even if you are going to physical therapy, for a condition like pelvic floor dysfunction, your therapist may ask you to do exercises, so it wise to bring workout clothes to your appointment. If you are a runner, bring in your shoes. The wear pattern on used pair of running shoes can provide heaps of valuable information.

Attitude: This is super important. Physical therapy is a partnership between you and your physical therapist. For me I already, foresee finding time to do the exercises that Jessica will prescribe to be a challenge. But the fact is, home exercise is part of the deal, and I won’t get nearly as much benefit from physical therapy alone, versus physical therapy with home exercise. Like I said before marathon training is simply too hard to just go through the motions at physical therapy.

 

What are your goals and what do you expect to gain from physical therapy?

Like I said before, I want to stay as healthy for as long as possible, but I would be lying if I said my primary goal wasn’t to increase my time. I want to put my money where my mouth is and put all my old times out in the open. So you can know where I am starting from and where I hope to go.

Here are my past times:

Mount Desert Island 2010: total time 3h 56 minutes 18 second: 9 min per mile pace

Mount Desert Island 2011: total time 4h 05 minutes 21 second: 9 min 22 seconds per mile pace

Sugarloaf 2011: total time 3h 52 minutes 25 second: 8 min 51 seconds per mile pace

New York City 2013: total time 3h 52 minutes 25 second: 8 min 51 seconds per mile pace

Here’s my dream goal for this race:

3 hours and 45 minute at 8: 35 pace.

As you can see, it’s 7 whole minutes faster than my fastest race over 7 years ago . To get there, I can’t get injured and I certainly can’t waste any precious energy during the race running inefficiently. I know that Beyond Basics will give me the best chance to meet my goals.

If you are looking to increase your performance in your sport of choice come see us to make sure you are getting the most power out of your serve, swing, or stride. Click here to access our home page and make an appointment today.

Continue to follow us here, on Instagram, and on Facebook to see my progress in physical therapy as well as my progress towards my goal of raising $3,000 dollars for MS research. If you care to donate please click here to donate to this worthy cause

What is Pelvic Floor Physical Therapy

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

May is Pelvic Pain Awareness Month (#PelvicPainAware), supported by the International Pelvic Pain Society (www.pelvicpain.org). 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. We are promoting Pelvic Pain Awareness Month because it is our mission to ensure that people know that help exists so they can start living richer and fuller lives. In honor of Pelvic Pain Awareness Month we want to take some time to explain what we do and how it can help with the symptoms of pelvic pain. 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 enquire 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 they occur. 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, provide them 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

May is Pelvic Pain Awareness Month

Mayis PelvicPainAwarenessmonth

Fiona McMahon PT, DPT

May is Pelvic Pain Awareness Month: #PelvicPainAware. This is a big deal to us at Beyond Basics Physical Therapy, where we see it as our mission to spread awareness of pelvic pain and dysfunction to clinicians and patients alike. This month is spearheaded by the International Pelvic Pain Society (IPPS), of which, the founder of Beyond Basics, Amy Stein is the president. Amy took time to sit down with me to describe all of the fantastic things that are planned for this month so I can share them with you.

Before we get started, I want to share a little about IPPS, the organizer of Pelvic Pain Awareness Month. IPPS was founded in 1996. It is a society of healthcare clinicians who treat abdomino-pelvic pain conditions in men, women, and children. Their mission is twofold: “To educate healthcare professionals how to diagnose and manage chronic pelvic pain, thereby changing the lives of patients worldwide.” and “To bring hope to men and women who suffer from chronic pelvic pain by significantly raising public awareness and impacting individual lives.” Pelvic Pain Awareness month, is our opportunity to spread awareness among professionals and public alike in hopes of improving outcomes and demystifying pelvic pain.

Now let’s get started with Amy’s interview!

Fiona: Why did IPPS feel the need to start a pelvic pain awareness month?

  • Amy: I felt like it was needed. As president of IPPS, I wanted to make some changes to awareness, and I felt this was a great opportunity to get the word out and stop patients from having to suffer in silence. I wanted it to be abdomino-pelvic pain awareness month, but the phrase was too long.

 

Fiona: What activities does IPPS have planned this month to spread awareness of pelvic pain?

  • Amy: We created a pelvic pain awareness page on facebook and continue to tweet about it @intpelvicpain. We are also doing a blog talk radio interview with Lorimer Moseley, PhD, PT from Adelaide, Australia, on blogtalk radio/pelvic messenger on Thursday, May 18th at 7.30pm EST. Lorimer Moseley has written 270 articles and 6 books on pain. If you want to interview someone who is experienced in the study of pain and the brain, he is a good person to be interviewing. May 17th in New York City, we are doing a local fundraising/ networking event in the Green Room on 23rd street from 6:30-8:30pm to create more awareness locally. On may 25th, 9pm EST, 6pm PST we are doing a twitter journal club. An article on sexual health in women affected by cancer  will be featured, as well as one on vulvodynia, and prostatitis . [Click here to access the articles we will be discussing!] Each year we plan to add on more events for May is #PelvicPainAware both locally and internationally. 

 

 

Fiona: Why is it so important to build awareness of abdomino-pelvic pain conditions? What was the big driver for IPPS in doing this work?

  • Amy: Bringing awareness of abdomino-pelvic pain conditions is one of the main missions for IPPS, as well as Beyond Basics Physical Therapy and I believe it is a mission of many of other clinics, hospitals, etc, that treat pelvic pain. Again, it is such a common experience of many, many patients who visit us, to have gone to various well-known institutions throughout the country for pelvic pain, to be told it is all in there head and that they just need mental health therapy or a glass of wine. This infuriates me STILL (20 years later!), as well as the patients. Often times it will take just one session with an experienced pelvic health physical therapist or healthcare provider to have hope again. Many of our patients have been to 5 up to 10 physicians/healthcare providers and ended up being misdiagnosed, undiagnosed, or told to go home and relax; or even worse, have more sex or switch partners. Yes, pain is processed in your brain, but there is a physical component with most of these patients.

Fiona: Where would you suggest someone who is starting their journey? What resources would you recommend?

  • Amy: I would suggest to look at International Pelvic Pain Society, International Cystitis Association, IC-network, Endometriosis Association, National Vulvodynia Association, American Physical Therapy Association (APTA) or Herman and Wallace “ Find a provider”, for you to find physical therapists and physicians. Even taking that a step further, when you find a provider, do some research: ask how often your provider sees pelvic pain patients,, how long have they been treating in this area, because that can make a difference. If you go to someone who is not as experienced or is not trained, you might hit a roadblock or plateau in your progress.
  •  I would caution against looking up too much on patient-centered forums; however, here are a lot of great blogs out there that can help give you helpful information. There are some great books out there, like Heal Pelvic Pain, and Pelvic Pain Explained, Sex without Pain, and Pelvic Pain Management.  For providers, I want to add that IPPS is hosting the World Congress on Pelvic and Abdominal Pain in Washington D.C. at the Renaissance Hotel in October 11-15th. We have Lorimer Moseley and Paul Hodges flying in from Australia. They both have done extensive research in pain. This year we are doing 9 clusters on different topics with poster and abstract presentations, as well as a post conference on The Pain Revolution, with Paul Hodges, PhD and Lorimer Moseley, PhD, PT

Fiona: If you had to distill your message for May is Pelvic Pain Awareness month, what would you like the public, people with and without pelvic pain to get from this month?

  • Amy: I would like them to know there are resources and providers out there for abdomino-pelvic pain conditions. But remember to do your homework when deciding who and what is best for you. For providers, there are great resources too, including the International Pelvic Pain Society to help better your practice.

We also want everyone to know we are having a give away in honor of Pelvic Pain Awareness Month! Learn more info below!

For Everyone!

IPPS Facebook Page

Twitter: @IntPelvicPain #pelvicpainaware

IPPS

Blog Talk Radio/Pelvic Messenger

 

For Patients!

International Pelvic Pain Society: Find a provider

National Vulvodynia Association: Health Care Provider List

APTA Find a clinician

Herman and Wallace Find a Clinician

 

Give Away Information

Giveaway open internationally ). Must provide a mailing address within 48 hours of notification of winning, otherwise another winner will be selected at random. Click here for full details,
We have several generous donors lined up for the hour and will be randomly giving away the following items during the event:
1 Copy of Amy Stein’s Book “Heal Pelvic Pain” & DVD Healing Pelvic and Abdominal Pain”  (follow @beyondbasicspt @HealPelvicPain2)  (Open to International)
1 Copy of Heather Jeffcoat’s book “Sex Without Pain: A Self Treatment Guid to the Sex Life You Deserve” (follow @SexWithoutPain @TheLadyPartsPT) (Open to International)
1 Copy of Stephanie Prendergast and Elizabeth Rummer’s book “Pelvic Pain Explained”   (follow @PelvicPainExp @PelvicHealth) (Open to International)
1 Gift Card to Soul Source Dilators (link to soulsource.com)  (follow @SoulSourceTD) (Open to US only)
2 EndoFemm heating/cooling pads by Pelvic Pain Solutions (Open to US only)
2 CAPPS Travel Cushions by Pelvic Pain Solutions by Pelvic Pain Solutions  (follow @EndoFEMM) (Open to US only)
2 Multi-Comfort Therapy Pads by Pelvic Pain Solutions (Open to US only)
Official Rules: This giveaway is open to US only (except where specifically indicated as international above). The following guidelines must be followed to be eligible: Use the #PelvicPainAware hashtag during the twitter party from 6PM PST to 7PM PST to be entered into the random drawing. Must follow @IntPelvicPain @TheLadyPartsPT so we may contact you after the event regarding your winnings. Winners will have 48 hours from the time of notification to provide us with their eligible mailing address, or else a new winner will be randomly selected.
 
Twitter Party/Journal Club Disclaimer: Tweets during the 1 hour event are not to be taken as medical advice. We recommend following up with your team of providers to gain your most optimal care.

 

BBPT Health Tip: How to Adjust your Posture to Avoid Shoulder and Neck Pain

shoulder 6

Tina Cardenia PT, DPT

In today’s society, most of us spend time in front of the computer or other electronics for work, school, or pleasure, which contributes to poor postural habits including rounded shoulders and forward head postures. Being in these positions will cause your muscles around your shoulder and neck to accommodate into that rounded position, resulting in inefficient lengthening of some muscles and shortening of other muscles, which results in an imbalance of strength and stability and high potential for injury. Having rounded and inefficient shoulder stability can cause neck and shoulder pain, and can affect your breathing.

The experienced physical therapists have extensive training on evaluating and correcting postural alignment. They can help with posture by identifying where your limitations are and evaluating your flexibility and specific muscle weaknesses that could be contributing to poor postural alignment. They also investigate what may be causing postural malalignments by evaluating your postural strategies in sitting, standing, walking, sports, and functional activities. Focusing on ways to be in a more balanced position will help put less stress and tension through your musculature and joints allowing for increased ease in maintaining proper posture with various movements.

A good way to facilitate a more neutral shoulder blade and shoulder position is with the exercise “Pivot Prone” (Institute of Physical Art, Johnson and Johnson). To start, first turn your head to the right and then to the left. Notice the excursion of movement and if you find it to be difficult or limited. Now, shrug your shoulders up a few inches, rotate your arms back enough where your pinkies are pointing forward and your shoulder blades coming together. Once you feel that your shoulder blades are back relax your shoulder blades straight down. Now rotate your head again to the right and left and notice if there was a change. You should feel an increase in ease of movement and more range of motion. At this point you should be able to appreciate that when you are in a more neutral alignment there is less stress and tension around your shoulders and neck. A common mistake with this exercise is to want to lift your rib cage up when you bring your shoulder blades back, so make sure that the shoulder blades are the only things moving during this exercise in order to maintain a good vertical alignment.

This photo shows the pivot prone maneuver being done step by step 

This exercise is perfect and simple enough to do throughout the day. For example, when you are standing waiting for the train, waiting on line, and sitting at your desk at work or school. By continuously repeating this motion your body will eventually remember it, and down the line you should notice that you automatically will maintain that position!

 

Check out photos from BBPT’s recent inservice on functional mobilization of the shoulder!

 

Without Happy Ankles and Feet, We Don’t Have a Leg to Stand On!

foot

By, Amy Stein, DPT and Fiona McMahon, DPT

Our ankles function to help us do simple tasks from walking down the hall, climbing stairs to advanced tasks like cutting during a high level soccer game. Ankles need two things to do their job well. They need stability to allow us to transfer our weight onto them and mobility to absorb forces, like little shock absorbers when we move. A deficit in either one of these area’s can affect our ability to efficiently do certain activities and may cause pain in the foot and ankle itself or further up the leg.   As physical therapists we evaluate and treat ankle and foot issues to get the athlete or non-athlete back to optimal function.  

Get this, the foot has 26 bones, 33 joints and 100 muscles in it. There is a lot to look at and unfortunately, a lot that can go wrong with the foot. As physical therapists and especially here at Beyond Basics Physical Therapy, we like to use a systematic approach when evaluating the foot and ankle. We look at the foot’s range of motion (how far it can move), its strength, it’s ability to move well (motor control), and whether or not something’s not moving well when it comes to the soft tissue or the joint of the foot. If something’s up with any of these categories we open our tool box and treat using functional manual therapy, neuromuscular and postural re-education and self care!

Things we look at

  • In standing we assess the patient’s baby squat ( or plié, as our former dancers would call it) we are looking to see if there is an issue with the tissue of the foot’s ability to stretch and fold
  • Heel raise: We look at our patient’s’ ability to go up on their toes, aberrant or weird motions tell us about motor control, strength, and joint mobility.
  • Arm Swing: We promise this isn’t to make our patients look silly. It allows us to assess pronation and supination, which are super important motions of the foot.
  • End feel: We will passively move the patient’s foot and ankle through its range of motion to assess how the joint feels. It can tell us a lot about what’s wrong and where it’s coming from.
  • Palpation: We pride ourselves on our hands at Beyond Basics Physical Therapy. One of our PT’s calls it our “brain hands”. Palpation can reveal a ton about what’s going on in the foot.

These are all pretty basic first steps when assessing our patients. They are the starting point, but by no means the finish line. Once we get the big picture we will refine our examination to see what’s going on when our patients are doing their specific sport or activity. Once we get a good handle on  what’s going on we select the most appropriate techniques for our patients. Each patient is different and one basic protocol for everyone isn’t how we roll at BBPT. If you think your ankles or feet could use a little extra TLC, book an appointment today. To get the ball rolling, check out our blog written by our therapist, Denise Small .