Marathon Training: Two Perspectives

sneaker.pngAs we creep closer and closer towards marathon weekend, our very own Tina Cardenia PT, DPT, CFMT and Victoria LaManna (Vicky) PT, DPT, CLT, PRPC were kind enough to share their stories about preparing for the 2018 New York City Marathon. Vicky will be running her first marathon on November 4th, 2018 in order to raise money for Multiple Sclerosis Research. Tina was gracious enough to volunteer her expertise in orthopedic physical therapy to help Vicky have the best run possible for a great cause. If you are interested in donating to support MS research, please donate here and read more about their stories below. If you are interested in hearing more about our orthopedic and sports program here at Beyond Basics Physical Therapy, give us a call at 212-354-2622.

From the Runner’s Perspective

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Victoria LaManna (Vicky) PT, DPT, CLT, PRPC

This year I am participating in my first ever marathon in the NYC Marathon for Team TischMS. Truly, this is my first ever 5k, Half Marathon, or Full Marathon. I am traditionally an anaerobic, (short bursts energy) exerciser. I have played soccer, dabbled in Muay Thai kickboxing, yoga, and weight lifting for exercise. The mind-body challenge of running a marathon (and doing it all for a great cause!) appealed to me. But where to start?

Luckily, I am in a profession that specializes in exercise, injury screening, and prevention, as well as injury rehabilitation. One of my co-workers has also run a few marathons and pointed me in the right direction for a training schedule. To further help ensure success in my training process, I also started physical therapy and made sure I got on my co-worker Tina’s super busy schedule.

vicky.pngShe first tested my core strength, checked hip mobility and strength, as well as spine and rib cage mobility. All areas that are important for efficient running. Tina found that I had poor core-first responses to outside forces, meaning that every time my foot hit the ground while running, my core was not firing to connect my lower extremities to my trunk. This could definitely be why I was experiencing right low back pain with running, and it could actually lead to further injury and result in not being able to RUN at all! Tina also found limitations in my breathing, rib cage, and thoracic mobility. Other than back pain, my first main complaint a few weeks into training was that I could not breathe. While you could chalk that up to poor conditioning, it was something that was felt immediately in runs – as if I just did not have the capacity to take a breath in. This is where we started our treatment – rib cage and thoracic spine mobility.

From there, Tina continued treating based on observation of my running pattern. She continued to work on hip, spine mobility and core control based on what she saw was insufficient in my running. My breathing improved greatly, as well as my mobility. I began to run completely pain-free with ease.

About 2 months away from Marathon Day, I injured my right foot trying to complete a 16-mile training run. I was unable to walk without pain and was limping around the office. Tina quickly observed that I had a bone in my foot and ankle that were compressed and out of alignment. Her work to align my foot and ankle, working all the way up again through my hip and trunk helped me to get back to pain-free running.

I am all set to run the NYC Marathon Sunday, November 4th! I am incredibly thankful to Tina for helping me to get through my training pain-free, manage an injury along the way, and quickly get me back on track for race day. And I am thankful for Team TISCH for allowing me the opportunity to join their team and support a great cause that affects many men and women.

Are you training for a marathon? Looking to improve your running form? OR even improve your golf swing? I would highly recommend seeing a physical therapist for an injury prevention screen for any and all sports, recreation or exercise. Setting yourself up for optimal movement and mechanics will enhance your activity, as well as reduce the risk of injury. It worked for me!!

 

From the Therapist’s Perspective:

Tina Cardenia PT, DPT, CFMT

Tina head shot

Victoria LaManna is such an inspiration. She volunteered to run the NYC marathon this year with little to no running experience and I was lucky enough to help prepare her! I have been working with Victoria for the past 6 months and I am amazed by how far she has come and how much she has already accomplished. Each week during our PT sessions there were a couple of things that I would look at to monitor her progress. I would observe her running, assess her core with tests called the Lumbar Protective Mechanism* and the Elbow Flexion Test*, her standing posture, her single leg stance, double leg squat, single leg squat, her glut and hamstring strength and how it connects to her trunk, and trunk rotation range of motion.

I saw that Vicky’s main limitations when I was observing her run were her limited trunk rotation towards the right, poor landing control on both of her legs especially her right one, and running with her feet turned out. One of the main things I looked for when observing Vicky run is the force transfer through her body from her feet to her trunk, and how the force translates through the rest of her body. It looked as though the force transfer wasn’t as efficient as I would have liked and this repetitive stress through her back and legs could potentially lead to injury.

tina and vickyVicky’s limitation with trunk rotation correlated to one of her complaints of having difficulty breathing during her runs. It seemed as though she was only able to get a good breath through only one side of her body. Upon examination, I found that she was limited into rib cage expansion especially on the right side. After some rib mobilization and breathing inhalation retraining and working thoracic spine rotation Victoria was able to rotate more symmetrically and reported an increased ease of breath with running.

Vicky’s lack of control with landing while running meant that she had a lack of eccentric (the motion of an active muscle while it is lengthening) control through her pelvis, causing compression through her back every time she lands. This could explain the low back pain Vicky has been experiencing. To address this, I worked on increasing the mobility and range of motion through her hips, pelvis, and back. I then worked on retraining her body with specific neuromuscular techniques called Proprioceptive Neuromuscular Facilitation (PNF) and specific exercises to help Vicky create a core first strategy with her running. This means, with every step and every movement Vicky is able to initiate with her core muscles first, which prevented her from overusing her bigger muscles which tend to fatigue quickly and can lead to injury and pain.

Vicky was running with her feet turned out causing poor force absorption from her feet up to her body. This style of running can also result in muscle overuse injuries and pain over time. This could have also been contributing to her complaints of shin splints while running. To work on this, I evaluated Vicky’s foot and ankle mobility, her knee tracking with squats, and single leg squats. With knee tracking, I noticed that she went into valgus with both of her knees, but it was worse on her right. Valgus means that her knees were “knocking in” which was an issue of having weak hip strength as well as lack of mobility and flexibility through some of her leg muscles and joints.  I did a lot of manual work to restore good range of motion and mobility and a lot of muscle retraining and drills to train Vicky to use those muscles appropriately and to be able to carry it over into her running.

After all this training and all the hard work that Vicky has been putting into running, Vicky’s running form now looks great! She has much more mobility through her trunk, is able to control her landing much more efficiently and is able to connect her feet for a better push off during running! Even as Vicky increased her mileage, she kept reporting to me how much easier her runs have been feeling, how much easier it was to breathe and how much more ease of motion she had through each run, and I couldn’t be more proud of her hard work!

*The Lumbar Protective Mechanism and the Elbow Flexion Test are special tests that come from the Institute of Physical Art. If you would like to learn more about their approach to PT, click here.

Breast Cancer Awareness Month

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Photo by Miguel Á. Padriñán on Pexels.com

Fiona McMahon, DPT

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

Signs and Symptoms of Breast Cancer

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

Detection

Recommended Screening:

Mammogram

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

 

Genetic Testing

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

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

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

Mastectomy and Physical Therapy

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

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

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

Sources:

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

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

http://www.beyondbasicspt.com/lymphedema

Pelvic Health 101 is back! Come to Our First Class on September 20th

On September 20th, at 7pm we will be kicking off our fall 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.

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 Fall 2018

It’s all connected: How pelvic floor dysfunction can contribute to hip pain

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Kaitlyn Parrotte, PT, DPT, OCS, CFMT (practices at our midtown office)

Hip pain can have a significant burden on function and quality of life. While there are many causes, prevailing research shows that hip pain is common in both athletic and older populations (1,2). In athletes, groin pain accounts for 10% of all visits to sports medicine centers, and groin injuries account for up to 6% of all athletic injuries (1). In older adults, a diagnosis like osteoarthritis is common, and is ranked as the eleventh highest contributor of global disability (2). While research often focuses on specific populations of people or diagnoses, when put together, it reveals that general hip pain is a common problem affecting a significant portion of the general population. There are many diagnoses that exist to describe hip pain, with the ultimate goal to develop the most effective course of treatment. Traditionally, when someone with hip pain visits a doctor, a physical examination will be performed, which includes assessing for tenderness, swelling, or redness, and determining the range of motion at the hip joint. The doctor may also recommend imaging, such as an x-ray or MRI, as well as lab tests (3). While this can provide a physician with valuable information, such examinations have the risk of missing causes of pain from nearby structures, such as the pelvic floor.

 

The pelvic floor muscles are three layers of muscles that attach to the lower aspect of each half of the pelvis from side-to-side and from the pubic bone to the tailbone, front-to-back. These muscles support the pelvic organs, as well as contribute to trunk stability, and play a significant role in bowel and bladder control and efficiency, as well as sexual function (4). The muscles that make up the deepest of the pelvic muscles, include the levator ani and coccygeus, as well as the obturator internus on the sides (5). The pelvic floor is interconnected to many key structures in the body, and dysfunction here can affect seemingly unrelated parts of the body. Below are two cases of unresolving hip pain, where assessment and treatment of the pelvic floor helped to promote a return to recreational activities.

 

Case 1: A BICYCLIST

A 32-year-old male professional cyclist came to physical therapy with complaints of pain in his right hip and groin, mainly with prolonged sitting and cycling. This began soon after he suffered severe bruising on his right hip from a fall, with a tear of two hip muscles (tensor fascia lata on the front and gluteus medius on the side). Prior to this, he had a history of multiple leg injuries due to cycling, but had never complained of any pelvic floor issues. Upon examination, decreased hip range of motion was also discovered. Initially, he received ten sessions of “standard physical therapy,” which included stretching, joint mobilization, soft tissue release, dry needling, and exercise.

However, after only minimal improvement, he was referred to a pelvic floor specialist for further evaluation where increased muscle tone and tenderness in multiple pelvic floor muscles (both obturator internus muscles and both iliococcygeus muscles) were discovered. Also, weakness of a pelvic floor contraction was also noted (6). Based on response to treatment, his hip pain decreased significantly from his current treatment of pelvic floor dysfunction, though it was completely missed in the initial testing.

But how does pelvic floor dysfunction contribute to hip pain? The correct treatment was missed because this connection was missed. Consider the anatomy and mechanics of the hip and pelvis. The gentleman described above is a professional cyclist, which means that whenever he is on his bicycle, he must flex (bend) his hip up to 90 degrees. More hip motion does not tend to occur because it would cause the pelvis to become unstable on the small seat (7). When the hip is bent, the femoral head (ball of the ball-and-socket joint) must flex (bend up), abduct (move to the side), and rotate in towards the groin (8). As the pedal is pushed downward, the hip moves into an extension (straightening) position. Although the hip never reaches a fully straightened position when cycling because he is seated, the hip moves through between 40 and 43 degrees of total motion with each cycle of the pedal (7). So, when the hip is moving into that straightened position, that femoral head must extend (move back), adduct (move sideways toward the groin), and rotate out away from the groin. While the movements of ball of the hip are small, as they are occurring with the confines of the socket in the pelvis, it is important to remember what muscles are in close proximity (8).

Besides the extensive list of hip flexors and gluteus muscles, there are several muscles that sit on the inner side of each hip and the bottom layer of the pelvis – the muscles of the pelvic floor. The two muscles that are of the most interest in this case are the obturator internus and the iliococcygeus muscles, as tightness and tenderness were found in each pair. The obturator internus muscle contributes to the walls of the pelvic floor, on each side of the pelvis. and sits on the inner side of the hip joint. The iliococcygeus muscle attaches on one end into the tendinous arch of the obturator fascia, so there is only dense connective tissue joining this muscle and the obturator internus (5).

When the hip is in a bent position the obturator internus muscle abducts the hip, or moves it to the side, away from midline; however, when the hip is extended (straightened) this muscle rotates the hip outward. For the iliococcygeus muscle, its role is one of support for the pelvic contents and lifting for the pelvic floor (5). Considering all these factors, it can be theorized that when the hip is in a bent position at the top of the pedaling cycle the obturator internus is activated through the abduction (sideways) motion of the ball of the hip, and continues to be activated as the hip straightens since the ball is rotating outward. Furthermore, because the iliococcygeus muscle is attached to the obturator internus muscle through a dense strip of connective tissue, it must work harder to help support this obturator muscle throughout the cycling activity. Thus, these muscles have become overused and shortened with regular and intense cycling required of a professional, who likely had some abnormal muscle activation or movement strategies prior to his pain due to previous injuries.

With the specially trained pelvic floor physical therapist, the pelvic floor connective tissue was mobilized internally over two treatment sessions, in addition to the cyclist performing hip stabilizing exercises. After the first session, there was an immediate and significant improvement in hip range of muscle and pelvic floor muscle contraction; furthermore, sitting pain was resolved. After the second session (7 days later) this gentleman was discharged from PT as he was pain free in sitting and cycling. In a follow up call one month after discharge, he was still pain free without altering training (6). This dramatic change occurred because the release of connective tissue in the pelvic floor decreased tension and trigger points in the obturator internus and iliococcygeus muscles. Thus, his hip range of motion and pain were normalized, and he was able to return to competitive cycling without restrictions.

Case 2: A RUNNER

A 45-year-old female was referred to physical therapy by her gynecologist with an initial diagnosis of left hamstring strain, toward the top of the thigh, related to distance running. This woman was an experienced marathon runner, who ran an average of 30-40 miles per week. She presented to her first PT appointment with pain in her left sit bone, with diffuse aching radiating into her left buttock and pubic bone; she stated her pain began about 4 months prior to her first PT session. The mechanism of injury was “pulling a muscle” while trying to avoid falling on a trail run. At that time, she immediately felt pain near her sit bone, but was able to complete her run. Eventually, as her symptoms progressed, she stopped running, and was only able to tolerate about 15 minutes of sitting. By her fourth PT visit, her pain had decreased, but continued mildly with sitting and shifted into her left pubic bone. She also reported a deep ache that could not be touched from the outside. She was referred to a pelvic floor specialist for further evaluation; upon internal assessment of the pelvic floor, significant tenderness and reproduction of the “deep ache” was found in her left levator ani and obturator internus muscles, as well as increased muscle tone. Furthermore, contraction of these muscles was weak, and she presented with poor relaxation of the same muscles. (9).

The hamstring muscles attach to the sit bone, and in running help to extend the hip and control the knee (10). Due to the location of this woman’s complaints, initial treatments focused on pain management, such as sitting on a wedge or donut to relieve pressure on her sit bone, as well as core strengthening exercises like the plank, and gluteus and hamstring strengthening exercises. Since the patient reported relief of sit bone pain, except with prolonged sitting by her fourth visit, it was logical to directly address the hamstring and gluteus muscles; however, these are not the only muscles in the area of the hip (9).

When this woman was assessed by a pelvic floor specialist, weakness, tightness, and tenderness were discovered in her obturator internus and levator ani muscles on the side of her pain (9). As discussed in the first case, the obturator internus muscle makes up part of the wall of the pelvis and sits just inside of the pelvis, past the hip joint (5). With running, an efficient hip will move between 50 degrees flexion (bending up) and 10 degrees of extension (straightening back) (10). Thus, when the hip is flexing, the obturator internus is likely assisting with abduction of the ball of the hip joint, and when the hip is extending the obturator internus muscle is likely active in outward rotation of the ball (5,8). The levator ani muscles attach from the pubic bone in the front to the back portion of the pelvis, and play an important role in stabilizing the pelvis and the pelvic contents (5). Considering the mechanics of running, the obturator internus and levator ani muscles were likely working hard to promote a good running pattern, and when she tripped on a run, these muscles were overexerted. Then they continued to overwork to compensate for the pain and weakness demonstrated by her hamstring muscles.

In addition to exercises for hamstring and gluteal muscles, internal release of the left levator ani and obturator internus muscles was performed, as well as gentle isometric contractions for strengthening and lengthening of pelvic floor for relaxation. After 7 additional sessions over a 2-month period, this woman’s pain had decreased greatly, she was able to tolerate sitting for more than two hours, she was able to hop on her left leg without pain, and her hip and pelvic floor muscle strength improved. After six months, she had returned to running, and had recently completed a marathon without pain (9).

Conclusion

In summary, augmenting treatment with the addition of direct pelvic floor interventions in each of the above cases significantly improved each person’s remaining symptoms, and allowed them to return to their prior activities without restrictions. This demonstrates the importance of considering the pelvic floor in the diagnosis and treatment of hip pain – these patients both had injuries that were initially missed because the pelvic floor was not considered as a possible cause of hip pain, yet emerging evidence is linking pelvic floor dysfunction to otherwise intuitively unrelated injuries. This also highlights the need for further research in this area to minimize the occurrence of unnecessary procedures and medications, and to ensure that individuals can return to their daily activities with minimal disruption of their quality of life.

If you or someone you know is struggling with unresolving hip pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information! We are offering free phone consultations at both offices for a short period!

Thank you so much for reading our blog.

Katie Parrotte, PT, DPT, OCS, CFMT practices at our Midtown Location

K5 (2)

 

SOURCES

  1. Prather H, Colorado B, Hunt D. 2014. Managing hip pain in the athlete. Physical Medicine and Rehabilitation Clinic of North America, 45(4), 789-812.
  2. Cross M, Smith E, Hoy D, et al. 2014. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Annals of the Rheumatic Diseases, 73(7), 1323-1330.
  3. Osteoarthritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/ osteoarthritis/diagnosis-treatment/drc-20351930.
  4. Continence Foundation of Australia. Pelvic Floor Muscles. Retrieved from: https://www.continence.org.au/pages/how-do-pelvic-floor-muscles-help.html.
  5. Drake R, Vogel AW, Mitchell AWM. 2009. Grey’s anatomy for students. Elsevier Health Sciences.
  6. Navot S, Kalichman L. 2016. Hip and groin pain in a cyclist resolved after performing a pelvic floor fascial mobilization. Journal of Bodywork and Movement, 20, 604-609.
  7. Timmer CAW. 1991. Cycling mechanics: a literature review. Journal of Sports Physical Therapy, 14(3), 106-113.
  8. McGalliard M, Sizer PS, Ezell D. 2016. Current concepts of orthopedic physical therapy, 4th edition. (p. 7) Orthopedic Section – APTA.
  9. Podschun L, Hanney WJ, Kolber MJ, et al. 2013. Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International Journal of Sports Physical Therapy, 8(4), 462-471.
  10. Running Biomechanics. Retrieved from https://www.physio-pedia.com/Running_ Biomechanics.

Beyond Basics is Visting Brooklyn!!!!

Brooklyn

 

Fiona McMahon PT, DPT

Have you got pelvic floor questions? Have you desperately wanted to go to one of our PH101 classes, but can’t swing 7pm in midtown in the middle of the week? Well, I have great news and GREATER news. I know, right… how much great news can you handle? The first bit of awesome, is that Beyond Basics’ Physical Therapists’, Dr. Fiona McMahon and Dr. Sarah Paplanus are hosting a forum and open discussion on pelvic floor health and treatment on Saturday, April 28th at The Floor on Atlantic (310 Atlantic Avenue in Brooklyn) at 12 noon. We will be there to explain the ins and outs of the pelvic floor, what can go wrong with it, and best yet, how you can heal it. It is a must go to event. RSVP here. Also, it’s FREE!

So what’s the other news, Fiona? Well, it’s that although we are not in Brooklyn, we have opened another office just across the river from Brooklyn, Beyond Basics Physical Therapy Downtown. In enlarging our footprint we hope to expand access and convenience to patients living downtown and in Brooklyn. We will be hosting a Grand Opening and 15 year anniversary celebration at our new location: 156 William St, Suite 800 New York, NY 10038 on Thursday, April, 26th from 4pm – 7pm. Come and enjoy food, drinks and meet our Physical Therapists. RSVP here.

 

 

Endometriosis as a Feminist Issue

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Fiona McMahon PT, DPT

March is endometriosis awareness month. March is also women’s history month. It seemed like the perfect time to discuss how poor detection and treatment of the disease affects the welfare, social, economic health, physical health,  and quality of life of women. Endometriosis is a feminist issue.

Here, at this blog, we have extensively discussed treatment and various options for endometriosis. Although there are many treatments available for managing endometriosis, the time it often takes to get a proper diagnosis and referral to competent clinicians is often so long, that the disease may progress to a point where pain is a lot harder to treat and fertility is impacted. Endometriosis is a gynecological disorder, that according to the Women’sHealth.gov currently affects more than 11% of women in the United States.

Older material, in fact, posts on this page used to define endometriosis as a condition in which endometrium (the lining of your uterus) grows outside the uterus. Now, in most of the recent literature referring to the tissue growing outside the uterus, call it endometrium like, because the tissue bears some resemblance to endometrium but isn’t quite the same. Endometriosis can show up clinically in a whole host of ways. It is estimated that up to 59% never have symptoms and may only discover that they have endometriosis, if they have abdominal surgery and legions are spotted. Infertility may also be the only symptom. For those who do have pain symptoms, it can be really bad and debilitating. If you have heard of endometriosis before, you are probably aware that it can make periods intolerable, but that’s not the whole story. Endo, as it is called for short, can cause pain that extends well beyond menstruation, it can cause issues with constipation, low back pain, urination, bowel movements, and fertility. Pain with endo can be severe. It can keep you from work, and school, or even land you in the hospital. The time a woman spends trying to get a diagnosis for the pain caused by endometriosis can take up to 11 years according to the American College of Gynecology fact sheet cited below.

What Causes Endo?

As you may have gleaned from the intro to this story endo is poorly understood and frequently misdiagnosed. Up until recently, we weren’t even entirely sure what the deposits left by endometriosis were. The research community is divided on what causes endo and have offered many different theories to its origin, but the specific cause of endo is unknown.

We do know endometriosis is an estrogen dependent disease, which is why it affects mainly women. One common theory of how endometriosis is caused is the theory of retrograde menstruation. This theory posits that endometriosis is caused by shed endometrium that escapes the uterus and deposits itself in the abdomen. This theory is supported by animal studies that have produced endometriosis like legions when endometrial tissue was deposited in the abdominal cavity. The theory fails to explain cases in which endometriosis deposits are found far away from the uterus in tissues like the lung. It also fails to explain the rare cases of men who develop endometriosis with estrogen therapies. In many circles, this theory is falling out of favor and is completely disregarded by others. Another similar theory is the lymphatic vascular theory. This theory hypothesizes that endometrium travels to outside spots via the lymphatic system. Again, this theory doesn’t explain the rare cases of male endo nor does it explain that the tissue found in these outside sites. It also fails to explain that the tissue found outside the uterus is “endometrium like” and is different than normal endometrium within the uterus.

The theory of coelomic metaplasia is based on the fact the both endometrium and peritoneal tissue comes from the same embryonic ancestor, coelemic epithelium. The theory posits that certain immunologic or hormonal factors may transform this tissue into the implants we see in cases of endometriosis. The third theory is the embryonic rest theory. It purposes that endometriosis caused by stem cells derived from the embryonic müllerian system become transformed in endo deposits. This theory is supported by the rare cases of men with endo, as they, as embryos, have the same embryonic müllerian system, before it regresses as the male embryo develops.

What’s kind of crazy is the level of pain a women experiences is not directly related to the amount or size of the endo deposits she has. One theory of why a women with very little endo found surgically can have a lot of pain, is the concept of centralization, where the brain becomes more likely to perceive stimuli as painful. Read more about this process in our blogs  Navigating Life with Chronic Pain 1, and Navigating Life with Chronic Pain 2 here.

One, all, some, or none of these theories could explain how endo is formed and maintained. The truth is we don’t fully understand the pathogenesis of this disease, yet. We need to know the cause. If we know the cause we may be better able to design treatments to ease the pain of endo and optimize the fertility of its suffers. Knowing the cause of endo will at least, aid in diagnosing the disease earlier or possibly curing or preventing it all together, which brings us to our next section.

 

Why does it take so long to get an endo diagnosis?!

Here’s the deal. The gold standard for endometriosis diagnosis is laparoscopic exploratory surgery with pathological biopsy confirming a lesion. Before laparoscopic surgery was a mainstay of medical practice, it was often believed that endometriosis was a disease that did not affect adolescent girls, as it was only seen in laparotomy, a more invasive technique reserved for more severe symptoms and conditions. When laproscopy became widely available in the 1980’s the diagnosis of endometriosis grew rapidly in all women and especially adolescent girls.

There are other tools available to detect endo but they are not definitive like surgery and may miss cases. Even laparoscopic surgery can miss endo especially in adolescents, because the endo deposits may be better disguised because of its color, usually clear or red in younger girls. Endo is also not suspected often until after the start of a girl’s first menses, new recommendations suggest that abdominal and pelvic pain complaints in girls be investigated for endo at the start of breast bud development (Brosens) as endo was found in between 50- 62% of adolescent girls undergoing laparoscopy for chronic pelvic pain ( Agarwal and Chaichian).

Doctor’s need better, less invasive tools to detect endo and get women out of pain. Although laparoscopic surgery is considered non invasive, the recovery from it can be difficult, dissuading patient and physician alike from using it as a diagnostic procedure. There is emerging science working on less invasive ways to screen or even detect for endo. More research dollars should be spent to develop early diagnosis and treatment in order to save women the years, lost work and education secondary to pain, and infertility from prolonged endometriosis.

Conversely, women without true endo are undergoing surgery needlessly, sometimes sustain hysterectomies to “cure” endo that is in fact not even there (also hysterectomy does not cure endo, Endo by its definition is a disease that occurs outside of the uterus). 25% of 4000 women studied who underwent hysterectomy for suspected endometriosis pain, were found to not actually have endo, which is outrageous on so many levels. 1. Hysterectomies do not cure endo. 2. Infecting infertility and the risks of major surgery on a woman who does not need it, regardless of whether she has endo or not, is awful. 3. Those 25% of women who had their hysterectomy likely have more pain and were not given a proper diagnoses so they can pursue the proper intervention for their pain.

Why is Endo Such a Big Deal as Feminist Issue?

Endo is a disease the effects women and only in very rare cases, men. If you get 10 of your gal pals in a room, statistically 1 of them will have the condition. Before I start in with this next argument, I want to make clear, that a diagnosis of endo does not necessarily impair one’s success later on in life; however, it can make achieving life’s milestones a lot more challenging.

Girls with painful endo symptoms miss more school a month than girls without endo (Brosens), setting them up for a harder battle to succeed academically and potentially limiting college options. In the workforce, they may continue to miss more days limiting their chances for raises and advancement. These missed opportunities have the ability to compound and further place women with endo at an economic disadvantage.

As women, it is sometimes harder to have our pain taken seriously. In a shattering article in the Atlantic, Joe Fassler, describes the ordeal his wife had to go through to have her potentially life threatening ovarian torsion taken seriously. He recounts how many times his wife was told to buck up, while she was actually in the process of losing her ovary. He also sites the disturbing statistic that women wait approximately 25% longer than men in the ER for pain relief. There is evidence to support that if you are a woman of color, you are even less likely to be given an analgesic at all when you go to the ER for pain. The fact our pain, as women, is taken less seriously means that in order to get a timely diagnosis women may have to scream louder and longer just to be heard.

The longer women wait for diagnosis, the more likely the pain is likely to enter a centralized state in which stimuli that were previously not painful are perceived as pain. Centralized pain is a lot harder to treat and will take longer to resolve than non centralized pain, possibly leading to more time out of the workforce, and requiring more money spent on treatments. Women with endo must be taken seriously. Our financial independence and personal lives require it.

What Can I Do If I am In Pain?

So we talked about the larger systemic issues affecting women with endometriosis. But what are some realistic steps you can employ to help with your pain?

  • Get moving! A review by Bonocher and colleagues, found exercise may help women who are already suffering from endometriosis related pain. The pain caused by endometriosis is thought to occur because of inflammation caused by endometriosis implants outside of the uterus. Exercise has been shown in repeated studies to increase anti-inflammatory chemicals in the blood and therefore reduce pain caused by inflammatory processes.
  • Stretch it out. Zahra Rakhshaee, published a 2011 article that found yoga could ease painful periods and may be helpful in managing the symptoms of endometriosis. In this study, a yoga routine consisting of daily 20 minute sessions had a significant effect in reducing pain in the study participants.
  • Put a pin in it, or you! Acupuncture is an ancient Chinese healing practice and can be used to treat many conditions. In a review by Leong in 2014, acupuncture reduced painful periods in 92% of study participants. The review also cited an article in which 73% of participants reported an improvement in their symptoms versus 42% receiving a placebo (fake) treatment
  • Physical therapy treatment can be helpful in treating many of the issues associated with endometriosis. In a study by Wurn in 2011 , physical therapy was shown to have a significant effect on reducing pain and improving sexual function in women who have endometriosis. Physical therapists are trained healthcare practitioners who can guide you in strengthening and stretching programs to help ease your pain, apply hands-on techniques to restore mobility lost due to endometriosis and other conditions, as well as guide you through lifestyle modifications you can make to ease your pain symptoms.

If one or all of these methods of pain management strategies sounds like they will work for you, Beyond Basics Physical Therapy, as well as other specialized clinics can help guide you. We at Beyond Basics, have an excellent team of physical therapy practitioners who are experts in the field of pelvic health, who do one on one, hands on work, who can develop an appropriate exercise plan tailored to your needs, and can guide you through other lifestyle modifications to help reduce your pain. We also partner with acupuncture and yoga professionals who offer services on site at our Midtown clinic. We hope to see you soon as you begin your journey of healing.

For more on PT and how it can help endo pain, check out Amy’s Video

What do we do for everyone affected by endometriosis or pelvic pain?

Seems pretty bleak, doesn’t it? It’s not. Collectively women and endo specialists are working to advance the awareness, diagnosis, and multidisciplinary approach to treating endo. It is an exciting time with new discoveries being presented in the literature, and more women and doctors becoming outspoken about this condition. But we have a heck of a long way to go to help out our sisters with endo.

The first thing you can do is speak up. If you feel you have not been diagnosed correctly, seek a second opinion. Also feel free to share the articles below with your doctors in order to broaden their exposure to endometriosis, I particularly like Brosen’s article. Share this blog and others on endo so more women and practitioners know about it. For those of you with the resources to do so, consider donating to an organization like the Endometriosis Association or the International Pelvic Pain Society (IPPS). Both are organizations that study and advocate for effective diagnosis and treatment for people with pelvic pain, including those with endo, as well as advocate for a multidisciplinary approach to healing. Together, we can improve society’s awareness of this disease and reduce the challenges that endo has on women.

 

ACOG. Endometriosis Fact Sheet. https://www.acog.org/about_acog/news_room/~/media/newsroom/millionwomanmarchendometriosisfactsheet.pdf. Accessed March 12, 2018

Agarwal N, Subramanian A. Endometriosis- morphology, clinical presentations and molecular pathology. J Lab Physicians. 2010; 2(1)-19

Bonocher C, Montenegrow M, Rosa e Silva, et al. Endometriosis and physical exercises: a systematic review. Reproductive Biology and Endocrinology. 2014, 12:(4)

Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Human Reproduction. 2013; 28(8) 2-26-31

Dickasen M, Chauhan V, Mor A, et al. Racial Differences in opiate administration for pain relief at an academic emergency department. Western Journal off Emergency Medicine. 2015; 16(3) 372-80

Chaichian S, Kabir A, Mehdizadehkashi A, et al. Comparing the efficacy of surgery and medical therapy for pain management in endometriosis: A systematic review. Pain Physician. 2017; 20 185-95

Fassler, Joe. How Doctor’s Take Women’s Pain Less Seriously. The Atlantic. October 15 2015

Leong F. Complementary and alternative medications for chronic pelvic pain. Obstetrics and Gynecology Clinics of North America. 2014, 41:(3): 503-10

Mowers EL, Lim CS, Skinner B, et al. Prevalence of endometriosis during abdominal or laparoscopic hysterectomy for chronic pelvic pain. Obstet Gynecol. 2016 Jun;127:1045–1053.

Rakhshaee Z. Effect of three yoga poses (cobra, cat and fish) in women with primary dysmenorrhea: A randomized clinical trial. Journal of Pediatric Adolescent Gynecology. 2011;24(4):192-6

Sasson I, Taylor H. Stem cells and the pathogenesis of endometriosis. Ann N Y Acad Sci. 2008; 1127: 106-15

Stratton P, Khachikyan I, Sinaii N, et al. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obset Gynecol. 2015; 125(3) 719-28

Womenshealth.gov. https://www.womenshealth.gov/a-z-topics/endometriosis . Page last updated: March 05, 2018. Accessed March 12 2018

Sources:

Wurn B, Wurn L, Patterson K. Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual therapy: results from two independent studies. 2011;3(4)

Continuing our Education: Vestibulodynia, Vulvar Pain, and Beyond

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Fiona McMahon PT, DPT

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

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

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

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

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

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

On who is an appropriate candidate for physical therapy:

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

On what pelvic floor physical therapy is:

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

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

 

Sources

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

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