May Is Pelvic Pain Awareness Month!

Mayis PelvicPainAwarenessmonth

 Kaitlyn Parrotte, PT, DPT, OCS, CFMT

While there are many causes to be aware of and advocate for, one close to our hearts at Beyond Basics Physical Therapy is pelvic and abdominal pain, and we are excited to report that May is Pelvic Pain Awareness Month! This designation for May was created by the International Pelvic Pain Society last year. So let’s talk a few moments about what is abdomino-pelvic pain, how impactful the diagnosis can be, and what we can do!

According to the American College of Obstetricians and Gynecologists, chronic pelvic pain is described as a “noncyclical pain of at least 6 months’ duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care.”(1) While the incidence and prevalence of chronic pelvic pain in men and women are reported in an inconsistent manner,(2) some estimates compare its global prevalence to asthma (4.3%-8.6%), and another to the prevalence of low back pain (23.2 +/- 2.9%).3 Individuals who suffer from chronic pelvic pain also often present with other complicating factors such as depression, anxiety, poor sleep, difficulty with work, and/or relationship issues. Also, many people with chronic pain are commonly disabled by fear that activity will make things worse.(2) Furthermore, pelvic pain is puzzling as it is a multisystem disorder, which includes sexual, bowel, urinary, gynecological, and musculoskeletal symptoms. It is challenging to determine a clear mechanism of pain with this diagnosis, and the term “pelvic pain” does not take into account the many signs and symptoms that may be occurring outside of the anatomical pelvis.(2 ) 

Due to the complicated nature of this condition, there is a significant economic burden associated with management of it. In the United States, approximately $881.5 million was spent on chronic pelvic pain to cover the costs of direct healthcare. Additionally, approximately $2 billion was spent as an overall cost, which includes direct medical costs and indirect costs, such as those related to absenteeism from work.(3) Besides economic burdens on individuals suffering from chronic pelvic pain, there are also many challenges for the healthcare system to deal with. For instance, while a diagnosis of chronic pain in the United States typically yields more than 80% of physician referrals, it is estimated that only about 15% of individuals with chronic pelvic pain consult primary care providers, and only 40% of this group are referred to specialists for further investigation. (3) Furthermore, if specialist care is involved in the management of chronic pelvic pain, it is often spread between multiple specialties, such as urology, gynecology, urogynecology, colorectal services, pain medicine, and even occasionally spinal services, rheumatology, and neurology. Thus, there is a risk that patients may be passed back and forth between different teams of the same specialty, or between different specialties, and may not receive consistent or effective care.(2)  In a nutshell: chronic pelvic pain can be a debilitating condition that can have significant consequences on an individual’s physical, mental, economic, and social well-being.

Hopefully, if you were not already passionate about raising awareness of pelvic pain, you now have some insight as to why this cause is so important! Now the question lies, what can you do? How can you get involved?

Please consider visiting the website for the International Pelvic Pain Society (www.pelvicpain.org) and donating funds for educational and research programs. Together, we can help bring chronic abdominal and pelvic pain into the forefront of healthcare, to ensure individuals dealing with this condition are receiving consistent and effective multidisciplinary care.

 

Sources:

  1. Andrews J, Yunker A, Reynolds WS, Likis FE, et al. Noncyclic chronic pelvic pain therapies for women: comparative effectiveness. AHRQ Comparative Effectiveness Reviews, Rockville (MD), 2012.
  2. Baranowski AP, Lee J, Price C, Hughes J. Pelvic pain: a pathway for care developed for both men and women by the British Pain Society. Br J Anaesth. 2014;112(3):452–9.  
  3. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141–7.

Questioning Childbirth Status Quo, Part One: Common Labor Positions

The following blog is a repost of Ashley Brichter’s original blog post. Ashley is a  birth educator, birth and post-partum doula, lactation counselor, and friend of the practice. She hosts many classes on childbirth, lactation, and much more. We will provide more information at the end of the post on how you can get in touch with Ashely and how you can sign up for her excellent classes. 


Ashley Brichter

Originally posted: January 22, 2019 

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Hollywood misrepresents a great deal about the childbirth process, but the fact that they show everyone delivering babies while lying on their backs in a hospital bed is accurate. As Ross clearly demonstrates above, lying down with knees apart is the most common way for someone in the United States to deliver. Here’s why you may want to question this:

A baby’s job in labor is to rotate and descend through the pelvis. If we can maximize the amount of space a baby has within the pelvis, we can not only speed this process along but minimize the stress on muscles and tissues within the pelvic bowl (and therefore minimize the risk injury).

How do you maximize the space in your pelvis to encourage the baby’s rotation and descent? The pelvis has four boney landmarks that determine the maximum circumference a baby has to fit through: the pubic bone at the front, tail bone or coccyx at the back, and two sitz bones at the bottom. Let me walk you through two very simple movements to see how you can create the most space between the pubic bone and tail bone and two sitz bones.

If you’re in a location where feeling around on your pelvis would be immodest, make a commitment to try it the next time you’re in the bathroom or back at home.

First, find the space between your pubic bone and tail bone: 

Place one hand on your pubic bone (it’s very low down under the belly, right between your legs. Isn’t it wide!?). Place your other hand on your tail bone. To find your tail bone, invite your hand to feel between the crease of your behind. It is often higher up than most people realize.  You can walk your fingers all the way down the bottom of your spine until you reach the end – and/or lean back on your fingers in order to feel it more.

Once you have fingers on the pubic bone and fingers on the tail bone, lean forward and feel the space between your fingers. Then lean back. In which direction to you have the most space between your fingers, between your pubic bone and tail bone?  When you are leaning forward or leaning back? Try this a few time before you move on.

 Then, find the space between your sitz bones: 

This is best done sitting down on the edge of a chair. Place your hands underneath your bum and your should feel your sitz bones protruding down. If you don’t feel them right away wiggle side to side a bit. You should feel boney points digging into your hands. 

Now, spread your knees out wide (like you’re having a baby!). Feel the space between your fingers. Then, bring your knees in close together (keeping your feet fairly separated). In which position do you have more space between your sitz bones? With your knees together, feet apart, or your knees and feet wide?   

Hopefully when you tried it you were able to feel that there is more space in your pelvis when you are leaning forward and that there is more space in the pelvis when your knees are closer together than your feet. 

WAIT. What? That’s right. I said it. 

Most people deliver their babies on their backs with their knees spread wide because this is the most convenient position for hospital staff. If you’re thinking about a physiological birth, looking for ways to possibly shorten your labor, or looking for ways to reduce the risk of tearing, give some serious through to positions that lend themselves to forward leaning and keeping feet wider than knees!

Let’s take one more look at the tail bone specifically: leaning backwards makes the tailbone stick in. It limits the amount of space a baby has to rotate and it asks your body to push a baby uphill!  Upright and forward leaning positions will allow the tailbone to get out of the way.   Granted, you have to deliver with a provider and in a location that is supportive of this. But that’s for another post!

You can learn more about Ashley on her website: http://overwhelmingmoments.com/

Her blogs are available here

Click here for a list of upcoming events with Ashley

 

 

PH101: I’m Pregnant – Help!

 

Having a baby is exciting, fascinating, and nerve-wracking. If you have never been through the process before, chances are you have a lot of questions and concerns about what changes your body will go through during your pregnancy, what the birthing process entails, and how your recovery will go once you’ve had your baby.

Join us and childbirth specialist, Ashley Brichter, in our Pelvic Health class to discuss the ins and outs of having a child.

Register at pelvichealth101.eventbrite.com   today.

Location:

110 East 42nd Street, Suite 1504

New York, NY

10017

Time: 7pm on  April 30, 2019

Pelvic Health 101 Spring 2019

PH101: Pain and Sexuality: is it all in my head?

 

By Fiona McMahon, DPT

Sex should feel good… really, really good. But when it doesn’t, you may start to wonder, what’s wrong with me? Am I broken? Am I a prude? Am I frigid? Painful sex isn’t something we talk about. No one would look at you twice if were complaining of pain in your elbow, but in your genitals is a different story.

On April 9th, we at Beyond Basics are breaking down those taboos and having an educational seminar, followed by an optional question and answer session at the end. We will discuss the many causes of sexual pain and how physical therapy can help.  The event will be hosted by one of our expert therapists, Stephanie Stamas. Stephanie will give a detailed seminar about pelvic health and take time to clear up some common misconceptions many people have concerning their bodies and sexual function.

Please join us at our office at:

110 East 42nd Street, Suite 1504

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

Here is our line up of this and future classes

Pelvic Health 101 Spring 2019

 

 

 

March is Endometriosis Awareness Month

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

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

 

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

 

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

 

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

 

Mayo Clinic. “Endometriosis”.

. Accessed on February 19, 2019  

 

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

PH101: Running to the Bathroom Again?!

Fiona McMahon PT, DPT

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via Pexels

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

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

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

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Pelvic Health 101 Spring 2019

What To Do About Scars from Childbirth?

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Photo by freestocks.org on Pexels.com

Joanna Hess PT, DPT, PRC, WCS

No one told you that the pain of childbirth doesn’t end with that final push and it doesn’t matter if you had a vaginal or belly birth. If you are the roughly 10% of demigoddesses who delivered without a tear, bless you and your fairy child.* If you are a mere mortal, here are some secrets for post-partum “battle wound” care.

For many mamas, the scars from delivery heal without any intervention. However, in our clinic, we often see hypersensitive or immobile perineal and cesarean scars that affect other parts of the body and can be a reason for the loss of core stability mechanisms, pain with intercourse, and urinary and fecal incontinence.

Scars are the body’s glue and use a complex set of proteins. While scars are never as strong as the original (70% of the original strength), it usually doesn’t cause a problem. The healing process after cutting your finger on that dull knife is the same for a cesarean incision and perineal tear/cut. Immediately after the injury, lots of good inflammation comes into the area to clot and start a loose frame for new tissue to develop. In the first days, collagen and other healing buddies come in to pull the wound together. It’s not particularly organized, but that’s okay because really, priorities are to keep things from getting in. In the next weeks, the collagen fibers will start organizing according to the demands of that particular tissue resulting in a pinkish or red color to the scar. It’s about this time that you can tell if things aren’t going well, namely, the scar shouldn’t be painful. We don’t know for sure why some scars cause problems and others don’t. The best guesses have to do with genetics, tissue tension, hormonal glands, and blood supply. Within 7-12 weeks, not only should the scar not be painful, but it also should move as freely as the tissue around it—without tugging at other places. The scar should be flat and slightly lighter than skin color.

MOVEMENT AND ICE

In the first days, keep good blood flow to the area while managing the pain. For perineal scars, you can work by breathing gently into your pelvic floor and changing your position regularly so that blood doesn’t stagnate in the area. For cesarean scars, working on deep breathing is a safe way to gently move the area without disrupting the healing. You want to keep big movements limited (but really, you’re a mom and movements are a part of life). Use the pain meds as needed so that your muscles continue to function normally. Things like vagsicles (frozen maxi-pads) and support belts can also help with the pain. A regular ice pack for the c-section scar is also a good option. Make sure to place a thin towel between the ice or vagiscles and the skin.

SCAR MASSAGE

At the postpartum six-week appointment, have your physician or midwife check the mobility of the scar. If it is painful or stuck, ask if the scar healed enough to start gentle scar massage. The idea of the scar massage is to give a non-threatening stimulus for desensitizing the area and re-orienting fibers so that the tissue moves freely.

For both the perineal and cesarean scar, if the movement of the scar exceeds pain 2-3/10, start with just desensitization. This can be as simple as tapping the scar or rubbing the scar gently with a towel for 3-5 minutes/day.

For a perineal scar, use a clean finger to slightly push the scar along perineal body up towards the body to create some slack. Then, move the scar away from the center in all directions (north, south, east, west, and in between) to find out which direction is the least mobile. Hold the scar in the restricted direction for 30 seconds. The pain should not exceed more than 2-3/10. Repeat 3-5 more times. You should be able to steadily tolerate more movement within a month.

For a cesarean section scar before 3 months, lift the tissue around the scar in a generous pinch and move the scar up and down, then side to side. Continue along the length of the scar until you find an area of pain or restriction. At this point, spend a little more time and move that area of the scar 10-30 times and keep moving. Again, the pain should not exceed 2-3/10. For a cesarean section scar older than 3 months, you can mobilize the scar in the same movements by direct pressure or skin rolling—up and down, side to side, clockwise and counterclockwise and lifting with skin rolling.

For the new mama, this is easy to incorporate in the precious quiet moments in the shower.

SILICONE

The gold standard of stubborn scars is silicone with or without compression. For hypertrophic scars and keloids in other parts of the body, silicone sheets and gels are the primary non-invasive prevention and treatment. Silicone strips and gels are easily used over a cesarean scar. Silicone is used daily for 12-24 hours for 2-4 months to soften and decreases the height of the scar. The sheets and compression can also help with the hypersensitivity. Because of the proximity to the body cavities, silicone is not advised for perineal scars.

*If you want to try to avoid perineal tearing altogether, ask your birth team to help birth baby’s head slowly and use warm compresses during pushing, stay active during labor, deliver in a side-lying or upright position, and perineal massage in late pregnancy can all help reduce the risk of perineal tearing.

PHYSICAL THERAPY

If you have tried these simple interventions and still find your scar problematic or think your scar is related to pain in neighboring areas, find a women’s health physical therapist to help manage your care. Recent studies show that in 4-8 sessions, skilled physical therapy changes the mobility and thickness of old scars to decrease pain and improve function.

Scar management is widely promoted in post-operative care in orthopedics, plastics, and dermatology—we hope that scar care will soon be standard of care in post-partum care.

 

Joanna practices at our Downtown location

Joanna Lee Hess

REFERENCES

Aarabi S, Bhatt KA, Shi Y, Paterno J, Chang EI, Loh SA, Holmes JW, Longaker MT, Yee H, Gurtner GC. Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis. The FASEB Journal. 2007 Oct;21(12):3250-61.

Agha R, Ogawa R, Pietramaggiori G, Orgill DP. A review of the role of mechanical forces in cutaneous wound healing. Journal of Surgical Research. 2011 Dec 1;171(2):700-8.

Comesaña AC, Vicente MD, Ferreira TD, del Mar Pérez-La Fuente M, Quintáns MM, Pilat A. Effect of myofascial induction therapy on post-c-section scars, more than one and a half years old. Pilot study. Journal of bodywork and movement therapies. 2017 Jan 1;21(1):197-204.

Huang C, Murphy GF, Akaishi S, Ogawa R. Keloids and hypertrophic scars: update and future directions. Plastic and Reconstructive Surgery Global Open. 2013 Jul;1(4).

Lewit K, Olsanska S. Clinical importance of active scars: abnormal scars as a cause of myofascial pain. Journal of manipulative and physiological therapeutics. 2004 Jul 1;27(6):399-402.

Marshall CD, Hu MS, Leavitt T, Barnes LA, Lorenz HP, Longaker MT. Cutaneous scarring: Basic science, current treatments, and future directions. Advances in wound care. 2018 Feb 1;7(2):29-45.

Meaume S, Le Pillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines and use of silicones. European Journal of Dermatology. 2014 Jul 1;24(4):435-43.

Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound in Obstetrics and Gynecology. 2004 Mar 1;23(3):247-53.

Son D, Harijan A. Overview of surgical scar prevention and management. Journal of Korean medical science. 2014 Jun 1;29(6):751-7.

Wasserman JB, Abraham K, Massery M, Chu J, Farrow A, Marcoux BC. Soft Tissue Mobilization Techniques Are Effective in Treating Chronic Pain Following Cesarean Section: A Multicenter Randomized Clinical Trial. Journal of Women’s Health Physical Therapy. 2018 Sep 1;42(3):111-9.

Wurn LJ, Wurn BF, Roscow AS, King CR, Scharf ES, Shuster JJ. Increasing orgasm and decreasing dyspareunia by a manual physical therapy technique. Medscape General Medicine. 2004;6(4).