Ph101 Why is Pooping so Difficult?

 

toilet

Fiona McMahon, PT, DPT

The number of Americans who deal with constipation issues is massive (4 million)! It seems like every time I mention that I’m a pelvic floor physical therapist, another friend of a friend pulls me aside with bowel movement concerns. Why is it that so many people have issues? And more importantly – what can we do about it? This is the topic of our next Pelvic Health 101 seminar on April 2nd at 7pm.

Not only will constipation be discussed but other bowel conditions, such as irritable bowel syndrome, fecal incontinence, bloating, and hemorrhoids will be addressed. The lecture will also go in depth on the role of fiber, water intake, toilet posture and pelvic floor muscles in having a successful bowel movement. You will even go home with easy techniques that you can implement immediately to help you get that smooth move! Don’t miss out on this FREE event – it’s a MUST for anyone who struggles on the porcelain throne. Seats are going fast!  Light snacks and refreshments will be served.

 

Register at pelvichealth101.eventbrite.com today.

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Check out or upcoming courses!

Pelvic Health 101 Spring 2019

 

 

Building a strong foundation – Treating the pelvic floor in individuals with multiple sclerosis

By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT

MS

What is Multiple Sclerosis?

Multiple Sclerosis (MS) is an “immune-mediated” disease, in which the body’s immune system attacks the central nervous system (1).  The cause is unknown. MS is characterized by injuries (plaques) of the myelin, which is a fatty substance that surrounds and insulates the nerve fibers; nerve fibers themselves may also be attacked. The damaged myelin forms scar tissue that is called “sclerosis,” which is how the disease was named (1,2).  When the myelin, or nerve fibers, are damaged or destroyed at any point on the neural pathway, nerve impulses that are traveling between the brain, spinal cord and the body are interrupted, and as a result, can create a variety of symptoms.(1)

Symptoms:

The more common symptoms seen in individuals with MS are:

  • Fatigue
  • Numbness or tingling
  • Weakness
  • Dizziness or Vertigo
  • Sexual Problems
  • Pain
  • Emotional changes
  • Walking difficulties
  • Spasticity
  • Vision problems
  • Bladder problems
  • Bowel problems
  • Cognitive changes
  • Depression(1)

Types of MS:

There are four disease courses that have been identified in multiple sclerosis:

  • Clinically Isolated Syndrome (CIS) – a first episode of neurologic symptoms in the central nervous system, which lasts at least 24 hours.(1)
  • Relapsing-remitting MS (RMSS) – the most common form of the disease, that is characterized by clearly defined episodes of new or increasing neurologic symptoms (relapses), followed by periods of partial or complete recovery (remissions).(1)
  • Primary progressive MS (PPMS) – characterized by a gradual worsening of neurologic function, from the onset of symptoms, without any relapses or remissions.(1)
  • Secondary progressive MS (SPMS) – follows a course of MS that is initially relapsing-remitting. Most people with RMSS will eventually transition into a secondary progressive course, which is when their neurologic function will gradually worsen over time.(1)

Treatment of MS:

Because of the complex nature of this condition, and because it is not a curable disease, the management of MS requires comprehensive care. One component of that care is physical therapy. A physical therapist will evaluate and address the body’s ability to move and function. Common physical therapy interventions frequently address walking and mobility, strength, balance, posture, fatigue, and pain. However, did you know that physical therapy can also treat issues with bowel, bladder, and sexual dysfunction(1)? These dysfunctions are addressed through treating the pelvic floor musculature and surrounding tissues, which is performed by specially trained clinicians, such as the physical therapists at Beyond Basics Physical Therapy.

 

Bowel Dysfunction:

As previously noted, patients with MS can have various symptoms, including symptoms related to pelvic floor dysfunction, such as bladder, bowel, and/or sexual dysfunction. According to one study from 2016, individuals with MS can have lower anal sphincter pressure (which limits their ability to control stool flow), as well as higher rectal sensitivity (which makes it more difficult for a person to appropriately recognize when they need to defecate). These can increase the occurrence of fecal incontinence (involuntary leakage of stool), as adequate muscle strength and tone are needed to prevent leakage, and appropriate urge is required to ensure a person can get to the bathroom when they actually need to go (3) Even in the constipated individual with MS, there is a decrease in anal sphincter tone, which results in poor muscle coordination, making the release of stool more challenging (3) With these individuals, pelvic floor relaxation is typically needed to allow for easier and complete emptying and to decrease symptoms of bowel urgency.

Several studies from the late 1990s and early 2000s have looked at using biofeedback to help retrain muscle coordination. Biofeedback was applied in two ways: through stick-on electrodes that measured the response of muscles surrounding the anus, and with feedback applied internally in the rectum, with a finger, rental sensor or balloon. With stick-on electrodes, individuals are typically connected to a machine that allows them to see the electrical activity of their muscles, so they can work on controlling them (contract or relax). With internal feedback through a therapist’s gloved finger, with a rectal sensor or balloon, individuals can improve muscle control through gaining better awareness of their pelvic floor muscles. Researchers found that the use of biofeedback yielded some improvement in patient reported disability for those experiencing either constipation or fecal incontinence (4,5).  Physical therapy treatments to address muscle coordination and sensitivity can be helpful to treat those experiencing constipation or fecal incontinence related to MS; however, more research is needed to help enhance care.

Urinary Dysfunction:

As MS impacts the nerve signal transmission along nerve channels, urinary dysfunction frequently occurs (6) The most common urinary disorder seen in this population is urinary incontinence, which is involuntary leakage of urine. Urinary incontinence is related to fatigue and uncoordinated muscle recruitment, which are characteristic of MS, and can have a significant impact on an individual’s quality of life(2) Another common diagnosis is overactive bladder, which interrupts bladder function and causes a sudden need to urinate(6). This may occur, at least in part, due to hyperactive muscles in the pelvic floor that have become too short and tight over time.

Many groups have looked at the impact of physical therapy to directly address weaknesses that develop in the pelvic floor, and are related to urinary dysfunction (6,7) Two separate articles published in 2016 looked at groups of women with MS, and split them into groups to undergo pelvic floor muscle training with and without some form of electrical stimulation. The emphasis of this intervention was to train the pelvic floor muscles how to activate without compensation from surrounding muscles, over the course of several months (6,7) By the end of one study, women in both groups demonstrated increased pelvic floor strength and endurance, decreased symptoms of overactive bladder, and decreased anxiety and depression (6). In the other study, all three groups exhibited a decrease in pad weight, which measured the amount of urinary leakage, as well as decreased frequency of urgency and urge incontinence episodes(7). This research is showing that direct treatment to the pelvic floor muscles help to decrease urinary symptoms in people with MS, as muscle strength and endurance are increased.

Sexual Dysfunction:

Sexual dysfunction is also common in individuals with MS (affecting 40%-80%)(8). Sexual arousal begins in the nervous system with the brain sending signals through the spinal cord and nerves to the sexual organs. These pathways can become damaged due to the effects of MS on the nervous system, which in turn impacts a person’s sexual response or sensation. Symptoms of this may manifest as difficulty achieving orgasm or loss of libido, as well as erectile dysfunction in men, and altered clitoral/vaginal sensation or vaginal dryness in women (9). Other symptoms of MS, such as fatigue, muscle weakness, and spasticity also negatively impact sexual response in this population (8).

Pelvic floor muscles are responsible for rhythmical involuntary contractions during orgasm. These contractions occur when sensory information travels through nerves to these muscles. Continued, uninterrupted stimulation may allow for sexual arousal to progress and build up to a maximum point. Once this point is reached, the pelvic floor muscles, which have been gradually becoming tighter and tighter, get even tighter, hold this tension momentarily, and then release all tension; this is an orgasm (10). Through various research, it has been shown that weak pelvic floor muscles can lead to a decrease in orgasm and arousal (8) and specific pelvic floor muscle strengthening can help improve sexual function, especially in females (11,12,13).

One study that looks at MS-related sexual dysfunction is a 2014 article published in the Multiple Sclerosis Journal. This article took 20 women diagnosed with relapsing-remitting MS, and divided them into three treatment groups: pelvic floor muscle training alone, pelvic floor muscle training with intravaginal electrical stimulation, and pelvic floor muscle training with electrical stimulation applied over a nerve in the leg. The pelvic floor muscle training in each group consisted of teaching each participant how to contract her pelvic floor without using surrounding muscles as a compensation, and then performing both fast and slow contractions, over twelve weeks of treatments. After the twelve weeks of treatment, individuals in all three groups demonstrated significant improvements in muscle power, endurance, and fast contractions of the pelvic floor. They also reported an increase in the total score, as well as the arousal, lubrication, and satisfaction subscores, of the Female Sexual Function Index.8 What this study has shown is, in women with MS, physical therapy can help to treat sexual dysfunction by enhancing muscle response and activity in the pelvic floor.

Conclusion:

All bowel, bladder, and sexual function rely in part on strong and flexible muscles in the pelvic floor. With Multiple Sclerosis, these muscles tend to lose either mobility and then strength, and/or muscle tone and coordination. Either way, the loss of efficient tissue tension, coordination, and strength, makes the performance of these important functions much more challenging. While various medications or other interventions, may also be necessary to help individuals with MS manage their symptoms, physical therapy has been proven to be an important part of the healthcare team. Here at Beyond Basics Physical Therapy, all our clinicians have specialized training to evaluate and treat the pelvic floor, so each one of us is in a strong position to help you manage these symptoms and improve function! Feel free to contact our office at 212-354-2622, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!

Sources:

  1. National Multiple Sclerosis Society. https://www.nationalmssociety.org
  2. de Abreu Pereira CM, Castiglione M, Kasawara KT. “Effects of Physiotherapy Treatment for Urinary Incontinence in Patient with Multiple Sclerosis.” Journal of Physical Therapy Science 2017; 29(7): 1259–1263.
  3. Marola S, Ferrarese A, Gibin E, et al. “Anal Sphincter Dysfunction in Multiple Sclerosis: An Observation Manometric Study.” Open Medicine 2016; 11(1): 509–517.
  4. Chiotakakou-Faliakou E, Kamm MA, Roy AJ, et al. Biofeedback provides long-term benefit for patients with intractable, slow and normal transit constipation. Gut 1998;42:517–21.
  5. Wiesel PH, Norton C, Roy AJ, et al. Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis. J Neurol Neurosurg Psychiatry 2000;69:240–243.
  6. Ferreira, Ana Paula Silva, et al. “Impact of a Pelvic Floor Training Program Among Women with Multiple Sclerosis.” American Journal of Physical Medicine & Rehabilitation 2016; 95(1): 1–8.
  7. Lúcio A, Dʼancona CA, Perissinotto MC, et al. “Pelvic Floor Muscle Training With and Without Electrical Stimulation in the Treatment of Lower Urinary Tract Symptoms in Women With Multiple Sclerosis.”Journal of Wound, Ostomy and Continence Nursing 2016; 43(4): 414–419.
  8. Lúcio AC, D’Ancona CA, Lopes MH, et al. “The Effect of Pelvic Floor Muscle Training Alone or in Combination with Electrostimulation in the Treatment of Sexual Dysfunction in Women with Multiple Sclerosis.” Multiple Sclerosis Journal 2014; 2 (13): 1761–1768.
  9. “Sexual Problems.” National Multiple Sclerosis Society, http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Sexual-Dysfunction.
  10. Lowentein L, Gruenwald I, Gartman I, et al. Can stronger pelvic muscle floor improve secual function? Int Urogynecol J 2010; 21: 553-556.
  11. Bo K, Talseth T, Vinsnes A (2000) Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol Scand 79(7):598–603
  12. Beji NK, Yalcin O, Erkan HA (2003) The effect of pelvic floor training on sexual function of treated patients. International urogynecology journal and pelvic floor dysfunction 14(4):234–238
  13. Zahariou AG, Karamouti MV, Papaioannou PD (2008) Pelvic floor muscle training improves sexual function of women with stress urinary incontinence. International urogynecology journal and pelvic floor dysfunction 19(3):401–406.

The Day in the Life….of a Working Mom Who Loves What She Does and Would do Anything for her Family

By, Amy Stein, DPT (Founder and owner of Beyond Basics Physical Therapy; President of the International Pelvic Pain Society; Author of award-winning book: Heal Pelvic 

Amy was presenting on the benefits of physical therapy in individuals with Multiple Sclerosis(MS) . In addition to our educational outreach, we are collecting money for NYC’s TISCH ‘s MS research arm through the New York City Marathon. Please Click here to donate.  

amy2016I had an amazing, and thank goodness a positive spin during and after my talk at the TISCH Multiple Sclerosis Patient Summit on Sunday. Thank you to Dr. Sadiq, Dr. Kanter, Dr. Williams and Pamela Levin for the invitation to share my expertise. I was so honored and felt blessed to be asked to speak at this conference. There were 1,200 people registered…..no pressure! And when I walked in prior to my talk, I saw the below photos on three HUGE screens! Again, no pressure. I practiced my breathing and my confidence building. Jessica Babich, DPT met me there to set up our table. She was a huge help, considering they wanted me to mic up right away.

I had practiced the material quite a bit so felt confident that it would go well…..and it did! I ran through everything in the 20 minutes I had and then had tons of questions after, of which I could only answer 4 in the time allotted.

A couple questions:

1. Does pelvic PT still work/can it be beneficial while a person is getting botox into the bladder?

Most definitely if the pelvic floor muscles are involved.

2. Does bladder frequency change when you have MS?

It shouldn’t change too much. If it does, as  pelvic physical therapists, we teach you strategies to manage this.

3. How often should you go to the bathroom at night if you have MS?

I am not sure there are any studies on this, but I would say no more than 2 times. We give our patients strategies to help with nighttime frequency as well.

After the Q and A, I felt like I was on cloud nine, because I gave a lot of great info in a short period of time….I sat down, and picked up my phone to take photos and noticed 2 missed calls and multiple texts from my sitter and a friend (my husband was away on a motorcycle trip). I thought….uh oh, because it had only been 30 minutes. Sure enough, the call that all mothers expect at some point, but hope it never happens….My son, Zachary had fallen off the jungle gym and it looked like he needed stitches. Thank goodness for babysitters and good friends! I explained the situation to a few colleagues from TISCH and praised Jessica at her awesomeness for taking charge, and I left immediately. My boy was a champ, and didn’t cry, even when he got the 8 stitches in his head….as I almost passed out!

In the end, amazing meeting and opportunity, and a strong and brave boy. What could a working mom ask for! I count my blessings every day!

J babs and Amy Stein
Jessica Babich and Amy Stein
Screens
These are the big screens I was talking about!
Zacary and Zoe
My Kids, Zachary and

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

Irritable Bowel Syndrome and Physical Therapy

IBSFiona McMahon, DPT

Hello everyone! April was Irritable Bowel Syndrome(IBS) Awareness Month. Although, we are a bit late, we wanted to take some time to talk about IBS and what can be done to help with its symptoms. IBS can present in different ways. People with IBS may experience diarrhea or constipation, or both. At Beyond Basics, we work with issues associated with IBS, from ensuring that your digestive organs move well in order to function properly, to toilet posture, to training the pelvic floor to have the coordination to help you toilet comfortably.

Tips for living with irritable bowel and other digestive symptoms

Posture

Over the years we have used our blog to discuss many different tips, tricks, and techniques you can use at home to make the process of having a bowel movement just a bit easier. The first thing you can do is super simple: sit on the toilet with good posture. There are heaps of ways to sit on the toilet and believe it or not, there is an optimal way to sit and poop. The reason why the way we sit is so important is the anal rectal angle. The anal rectal angle refers to the angle of your rectum. When we stand and sit our angle is more bent or acute, which makes it harder for poop to drop out of out of our rectums (yay!), which increases our chances of continence. But when we are trying to poop, we want our anal rectal angle to straighten out so it is easier to poop and we don’t have to strain. The position that best allows us to do that is squatting, the way one would over an eastern style toilet. Most of us have western style commodes that don’t allow for a nice anal rectal angle opening squat. So we have to get creative. By placing a stool or the now ubiquitous squatty potty under your feet you can simulate a squat and allow for easier passage of stool. For more on posture, check out Sara Paplanus’s blog on posture and bowel movements.

Diet

veggies

Diet is a very important thing to consider when trying to optimize your bowel movements. The first thing we usually consider is fiber. There are two types of fiber. Soluable and insoluable. Soluble dissolve in water and allows the stool to absorb water and adds mass and heft ( in a good way) to your feces. Insoluble fiber does not dissolve in water and can help push the poo out. The fact is we need to balance both types and most of us aren’t getting enough. In addition, some people need more of one type and some need more of the other or else you can end up with increased gas and bloating. Read how you can increase your fiber intake here. If you are having difficulty balancing the two or are not sure which to add, it is best to seek advice from an expert nutritionist in abdomino-pelvic pain and IBS.

Water Intake

The colon, the last stop for poop before it enters your rectum is the place where water is absorbed from the stool. In cases where you are too dehydrated, your body will recycle water anywhere it can, including your stool. If too much water is taken from your stool, it can be dry and hard to push out. We suggest drinking about one half your body weight in ounces of water daily and even slightly more if you are constipated, sweat a lot or suffer from IBS. For example, if you weigh 200 lbs, drink 100 ounces of water to make sure to ease your bowel movements.water-life-crop

Physical Therapy

Pelvic floor physical therapy can help a lot with issues with IBS. In last year’s IBS awareness blog, we discussed the benefits of pelvic floor PT

“Dysfunction in organs can also cause dysfunction in the skeletal muscles that are close by. This is called the visceral-somatic reflex. One of the most common examples is when someone feels left arm pain when they are having a heart attack. The dysfunction in the heart causes pain and spasm in nearby muscles. The same thing can happen when the gut is irritated in conditions like IBS. Typically, people with IBS will feel pain and spasm in the muscles of their abdomen and pelvic floor as a result of repeated irritation in their gut. To add insult to injury, spasm in the pelvic floor, (specifically the levator ani and sphincter muscles) can adversely affect the passage of stool out of the body and make symptoms even worse.

Pelvic floor physical therapy can help symptoms caused by the visceral somatic reflex greatly. At Beyond Basics we have an excellent crew of pelvic floor physical therapists with expertise in visceral mobilization and pelvic floor dysfunction. Our physical therapists can work to eliminate painful spasms, mobilize restrictions, retrain the muscles and teach self-management techniques to keep symptoms at bay, or to eliminate some of the symptoms in the future.”

 

IBS is an important condition that affects many different people. Although there currently is no cure for IBS, there is a lot you can do to make living with this condition more manageable. If part, or all, of the symptoms are from musculoskeletal dysfunctions of the pelvic floor and abdomen, than there IS a cure and we are here to help! If you are suffering, please make an appointment with us today.

Sources

R Saeed. Impact of Ethnic habits on defecographic measurements. Arch Iranian Med 2002; 5(2) 115-16

Ph101 Why is pooping so difficult?

toiletFiona McMahon, DPT

The number of Americans who deal with constipation issues is massive (4 million!)! It seems like every time I mention that I’m a pelvic floor physical therapist, another friend of a friend pulls me aside with bowel movement concerns. Why is it that so many people have issues? And more importantly – what can we do about it? This is the topic of our next Pelvic Health 101 seminar  on  March 30th at 7pm. 

Not only will constipation be discussed but other bowel conditions, such as irritable bowel syndrome, fecal incontinence, bloating and hemorrhoids will be addressed. The lecture will also go in depth on the role of fiber, water intake, toilet posture and pelvic floor muscles in having a successful bowel movement. You will even go home with easy techniques that you can implement immediately to help you get that smooth move! Don’t miss out on this FREE event – it’s a MUST for anyone who struggles on the porcelain throne. Seats are going fast!  Light snacks and refreshments will be served.

Register at pelvichealth-101.eventbrite.com  today.

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Check out or upcoming courses!

pelvic-health-101-spring-2017

The Top 5 Pelvic Messenger Shows of 2015

As we begin 2016, we’re reflecting on some of our favorite shows with The Pelvic Messenger last year. Read on below to learn more about these wonderful radio shows discussing pelvic health and give them a listen! Here they are, in no particular order:

Dr. Paul Nyirjesy: Management of Persistent Vaginitis
“With vaginitis remaining a common condition that leads women to seek care, it is not surprising that some women develop chronic vulvovaginal problems that are difficult to diagnose and treat.  With a differential diagnosis that encompasses vulvar disorders and infectious and noninfectious causes of vaginitis, accurate diagnosis is the cornerstone of choosing effective therapy.”

Dr. Alexandra Milspaw: Healing Chronic Pain, Trauma, & Stress with Neurotherapy
Alex Milspaw, PhD, LPC is a licensed professional counselor in private practice specializing in the treatment of trauma and chronic pelvic and sexual pain disorders. Dr. Milspaw is passionate about her work in utilizing neurotherapies to help her clients experience the healing changes in their lives as quickly as possible.

Jill Fuersich and Jordan Davidson of Endo Warriors: Endometriosis Support Group
Endo Warriors is a face to face and online support organization founded by Jill Fuersich, Jordan Davidson, and Nicole Malachi who were all diagnosed via laparoscopic surgery in 2007, 2004, and 2007, respectively. After failing to find a support group in the New York area, Jill, Nicole, and Jordan combined forces to create a safe haven for women to tell their stories, vent, and receive support from other women going through similar circumstances.

Dr. Darren Brenner: the Diagnosis and Treatment of Bowel Disorders
Dr. Brenner shared with the Pelvic Messenger audience a portion of his presentation and research on the Diagnosis and Treatment of GI Disorders, which was presented at the IPPS Annual Conference in Chicago.

Dr. Charles Butrick: Painful Bladder Syndrome/ IC – What it is and how to treat it
Dr. Charles Butrick is a practicing Urogynecologist in Overland Park, Kansas who has a practice dedicated to interstitial cystitis, the management of urinary and fecal incontinence, pelvic floor reconstruction and pelvic pain disorders. This show discusses what Painful Bladder Syndrome is, its symptoms and how to diagnosis and treat this condition.