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)

Navigating Life with Chronic Pain: Part II

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Fiona McMahon, PT, DPT

Welcome back to our discussion on chronic pain. In our last blog we discussed why one might experience chronic pain and some common missteps and pitfalls that have occurred in our understanding of chronic pain. If you haven’t yet read part one of this blog, I highly recommend checking it out first so you can get the most out of this post. Click here to read it now.

For chronic pain we have drugs, surgery, mental health therapy, physical therapy, and what is called complementary alternative medicine (CAM), which includes modalities like yoga, acupuncture, and mindfulness meditation. We discussed earlier about how some opiods may actually be harmful in treating chronic pain. Unnecessary surgery can also have risks of actually increasing pain post surgically, because it can change the brain’s sensitivity to pain. Because, for most musculoskeletal conditions, a course of conservative treatment is recommended for a period of time before turning to surgery, we will focus on non-surgical, and non medical approaches to chronic pain.

Before we dive into specific treatments, let’s talk about what puts a person at risk for chronic pain. We can divide these risks into modifiable and non modifiable risks. Non modifiable risks are situations or characteristics about ourselves that we can not change. They include socioeconomic status, where you live or have lived, cultural background and genetic factors. Unfortunately, we can’t change these things, but things like alcohol intake, nutrition, and obesity are all things we can change and have been generally understood as modifiable risk factors for chronic pain. Now that we have that in mind, let’s explore different approaches for the management of chronic pain.

 

Mindfulness Practice as Pain Management

Have you tried mindfulness practice? I ask this question a lot. When I ask it, I am careful to frame it in a way that does not give the patient the impression that I think their pain is all in their head, but rather, I try and present it as part of an adjunct to the current physical therapy treatment they are receiving from myself or any of the other PT’s at Beyond Basics Physical Therapy, and any other medical intervention they may be receiving.

Mindfulness and mindfulness meditation are somewhat based on eastern meditation practices.  Not all mindfulness programs are the same, but the basic premise is to allow  the participant to to observe their thoughts, feelings, sensations, and attitudes without judgement. Giving them the opportunity to reframe their thoughts in a positive manner.

It may sound like a small change, but research is really starting to bear out that changing your frame of mind about pain can have some very real results. In a meta-analysis done by Hilton  and colleagues, mindfulness programs were found to have statistically significant positive results on pain, depression, and quality of life.

There are a lot of ways you can incorporate mindfulness into your day to day life. Apps for your phone are really helpful. I recommend both Calm and Headspace. I personally like Calm a bit better, but both are excellent. Headspace is a good starter because it breaks up meditation into more digestible nuggets, which can be a good way to start your meditation practice. Calm, as the name implies, is more soothing.  There are also guided classes you can attend in your area if that’s more up to your speed.

Be patient with mindfulness, I definitely suggest giving it the old college try. Stick with it for a week or two. If it isn’t for you, that’s perfectly okay. It’s not a moral failing, or a psychological one it’s definitely a case of different strokes for different folks.

Psychological Intervention

In a study performed by Macrae and colleagues, it was found that patients who engaged in catastrophizing type behaviors experience post surgical pain at a significantly higher rate. Catastrophizing is envisioning a situation to be far worse than it actually is. A good example for this blog would be a patient with low back pain, jumping to the conclusion that her back pain will prevent her from being able to work and she would end up on the street, secondary to her her lack of ability to secure an income. Although this is a possibility, it really isn’t a realistic one and it fails to entertain the possibility of the back pain remaining stable or getting better.

Mindfulness meditation can help with catastrophizing behaviors, but sometimes you need a little extra help. Psychological interventions, like talk therapy and cognitive behavioral therapy, can help you get a handle on these thoughts and address your current loss of function, secondary to pain in a more productive manner. Cognitive behavioral therapy as well as other forms of therapy have shown improvement in pain symptoms and quality of life in adults, and has shown even more robust effects in children.

Acupuncture

Acupuncture is an ancient form of eastern medicine that is gaining a stronger and stronger foothold in the States. It has been shown to be effective in managing a number of conditions, and chronic pain is no different. Reviews of acupuncture in the scientific literature have found that acupuncture can improve pain and function. The same review found that electroacupuncture had even more robust results for pain and stiffness.

Yoga

Yoga is super hip right now. In fact it now has its own international day on June 21st of each year. It does for good reason. A consistent and solid yoga program has been shown to improve conditions such as low back pain, myofascial pain syndrome, fibromyalgia syndrome, osteo- and rheumatoid arthritis. It can be a great option to continue to add consistent exercise and pain management into your life.

Physical Therapy and Exercise

Exercise is good for you, even if you have chronic pain. The old way of thinking was to put someone on days of bedrest when they have chronic pain. No more. Evidence has shown gentle movement progressing into more functional training can really help with chronic pain. In fact the National Institute for Healthcare Excellence’s (NICE)  osteoarthritis  guideline is  “exercise should be a core treatment… irrespective of age, comorbidity, pain severity and disability. Exercise should include: local muscle strengthening [and] general aerobic fitness”(NICE 2014) . Geneen and colleagues found in their review and meta-analysis of the current literature that just receiving the advice to exercise alone, is not sufficient to produce improvements in pain scales. That’s where the professionals like physical therapists come in, PTs have the knowledge and expertise to prescribe exercise that is not only safe and functional, but hopefully kind of fun. PTs also can diagnose and treat issues such as tissues with reduced mobility and poor alignment to ensure you get the most out of your exercise.

Data show that a prescribed and monitored exercise program by a physical therapist can have good effects on pain symptoms and can help facilitate the production of your body’s own natural painkillers.  Additionally exercise can help individuals lose weight, which can reduce the pressure on one’s  joints and further improve pain.

Aside from exercise and hands on work, we can use modalities like kinesio tape at physical therapy. Kinesiotape has been shown to improve not only pain, but decrease trigger points, improve range of motion and improve disability rates in individuals suffering with myofascial pain syndrome.

Conclusion

Chronic pain is complex. Rarely is there a silver bullet that will cure it. Treatment requires a multidisciplinary approach, which has been shown to be more effective than traditional treatment alone. Start small, where you feel comfortable when adding something new into your treatment approach. You will find what works best for you. A good place to start is here at Beyond Basics. Our staff not only has the expertise to treat you from a physical therapy perspective, they also have the ability to guide you towards other traditional and complementary treatments/practitioners that can help you reach your goal. Your treatment for chronic pain does not have to be and should not be passive, please call and make an appointment today to start your journey.  

 

Sources:

 

Achilefu A, Joshi K, Meier M. et al. Yoga and other meditative movement therapies to reduce chronic pain. J Okla State Med Assoc. 2017;110(1):14-16

 

Andersen T, Vægter H. A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls. Clin Pract Epidemiol Ment Health. 2016;12: 49-58

 

Ay S, Konak H, Evick D, et al. The effectiveness of kinesio taping on pain and disability in cervical myofascial pain syndrome. Rev Bras Reumatol. 2017; 57(2) 93-9

 

Eccleston C, Crombez G. Advancing psychological therapies for chronic pain [version 1]; referees: 2 approved]. F1000 Faculty Rev. 2017

 

Geneen L, Moore R, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews ( Review).  Cochrane Database Syst Rev 2017; 4

 

Hilton, L, Hempe; S, Ewing B. Mindfulness Meditation for Chronic Pain: Systematic review and meta-analysis. Ann Behav Med. 2017. 51:199-213

 

Kamper S, Apeldoorn A, Chiarotto A, et Al. Multidisciplinary biopsychosocial rehabilitation for chronic pain ( review). Cochrane Database Syst Rev. 2014; 9.

 

Macrae W. Chronic post-surgical pain: 10 years on. Br J Anaesth 2008;101: 77-86

 

Mayer F, Scharhag-Rosenberger F, Carlsohn A. The intensity and effects of strength training in the elderly.  Dtsch Arztebl Int 2011; 108(21):359-64

 

Neira S, Marques A, Pérez I. Effectiveness of aquatic therapy vs land based therapy for balance and pain in women with fibromyalgia: a study protocol for a randomized trial. BMC Musculoskelet Disord. 2017; 18(22)

 

Perry R, Leach V, Davies P, et al. An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools. Sytematic Reviews. 2017. 6(97)

 

Saxena R, Gupta M, Shankar N, et al. Effect of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int J Yoga. 2017. 10(1): 9-15

 

Singh P, Chaturvedi A. Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review. Indian J Palliat Care. 2015. 21(1): 105-15

 

     

 

Physical Therapy Month

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Fiona McMahon PT, DPT

October is National Physical Therapy Month. During Physical Therapy Month we take time to inform the public about the benefits of physical therapy as well as focus on a particular issue affecting the lives of our patients. This month the APTA (American Physical Therapy Association) has decided to address the current opioid crisis. At Beyond Basics Physical Therapy, we addressed the treatment of chronic pain and the effect opioids can have in the blog titled “Navigating Life with Chronic Pain: Part 1 “. I highly recommend looking back at this blog to learn more about the pain science behind chronic pain and what you can do to treat it. Keep you eyes open for our upcoming blog, “Navigating Chronic Pain”: Part 2, for more on specific treatments.

For October’s Physical Therapy Month, the APTA has decided to address specific policy changes that need your support to help fight the opioid epidemic. The time for addressing the opioid epidemic is now (honestly, it should have been years ago). According to the APTA, 1 in 3 opioid users report they are physically addicted to opioids, and 4 in 5 new heroin users begin their addiction by misusing opioids. Even more staggering, heroin deaths now outnumber deaths due to gun homicides. This issue is an issue we, at all levels of healthcare must fight.

The APTA is advocating for these 6 policy changes to help fight the opioid crisis

1.Repeal the Medicare Therapy Cap: To allow patients on medicare to receive the care they need from their physical therapist

2. Remove Federal and State Restrictions that Impede Access to a Physical Therapist: Allow patients to see physical therapists without an MD’s referral

3. Ensure Comprehensive Insurance Coverage for Physical Therapy

4. Provide Fair Physical Therapy Copays Under Insurance: Reduce high copays and deductibles for physical therapy to lessen the incentive to turn to cheaper opioids over physical therapy as a pain treatment.

5. Allow Physical Therapists to Perform to the Full Extent of Their Education and Training: Physical therapists hold doctoral degrees and should be allowed to practice their full scope of services.

6. Protect Patient Choice of Physical Therapy Treatment: Patients should be able to select the therapist of their choice, not the one the MD selects.

If you have chronic pain, please choose physical therapy first. It is a much safer and more effective option than opioids. The physical therapists at Beyond Basics Physical Therapy are well trained and experienced in treatment of chronic pain conditions. Call today.

Time to PUMP SOME IRON! September is Healthy Aging Month

WeightsFiona McMahon PT, DPT

The idea of strength training can conjure up many images, like the funny images of  Saturday Night Live’s Hans and Frans, or Arnold Schwarzenegger. It can also be intimidating. The idea of walking into a crowded weight room full of young and fit people, who seem to all know what they are doing can stop a newbie in their tracks. But resistance training has so many benefits, for health, function, and longevity. It goes way beyond looking good in a swimsuit, although it certainly can help with that. In honor of September’s Healthy Aging Month we at Beyond Basics are taking a close look at how adding a safe strength training regimen to one’s daily routine at any age, can boost so many indicators of health and quality of life.

Everyone understands that muscles are essential for everyday tasks like rising from a chair, carrying your shopping, and many other instrumental tasks required for independence. The thing about muscles is they are not static, and as we start to age we lose muscle, especially if we do not work to maintain our muscle mass. Believe it or not, we slowly start losing muscle mass at age 30, (bummer, I know), but after 60 is where things get really crazy. After age 60 we start losing muscle mass at a rate of approximately 15% per year. The less active someone is in their life, the quicker this loss occurs. Low muscle mass is called sarcopenia. You will see this term a lot in this blog. The condition of sacropenia brings with it functional impairments from lack of strength and can put a person in a position where they are more likely to require assistance for everyday tasks. Furthermore, when sarcopenia and obesity occur at the same time, which we often see in the elderly, the functional impairments associated with sarcopenia and obesity are greater than either sarcopenia or obesity alone.

But there is hope. Aging isn’t a slippery slope into weakness and frailty. It is what you make it. Even sarcopenic muscle can respond and strengthen in response to proper training. In fact, it adapts to the demands of strength training at the same rate as younger muscle. Weight training can actually reduce fat and build muscle, helping to reverse the condition of sarcopenic obesity. Many studies indicate that resistance training can prevent and or reverse age related losses in function. Even with all the benefits of strength training. Only an estimated 10-15% of older folks regularly participate in strength training exercise, leaving a huge percentage of the population missing out on strength training’s myriad benefits, which we will cover in more detail below.

Benefits of Strength Training

 

Balance and Fall Prevention

Falls are a serious cause of injury, disability, and death in the elderly. People over the age of 60 have a once yearly fall rate of approximately 30%. Resistance training in combination with balance training under the care of a skilled physical therapist can go a long way to reduce one’s risk of falls. If falling is a concern of yours, please check out our other blog on falls and fall prevention.

 

Pain Syndromes

Pain symptoms in individuals with Fibromyalgia Syndrome improved following a 12 week high intensity strengthening program (Mayer).

 

Osteoporosis

Osteoporosis, a condition characterized by low bone density, increases a person’s risk of fracture. Fracture brings along with it risks of prolonged pain, depression, issues with function, subsequent fracture, and even death. Individuals with vertebral fracture have a 2.7 increased likelihood of death and are likely to have an additional fracture within a year of the original fracture.

There is evidence supporting resistance exercise as a useful tool to increasing bone density in osteoporotic individuals. With people with extreme cases of osteoporosis, there is increase risk of accidental fracture from dropped weights, poor form in transitions and adjusting weight machines. In these individuals, and all individuals for that matter, it is extremely important to work with a physical therapist to construct a safe and beneficial routine.

 

Function

Many studies have found significant improvements in function following a resistance training program. Physical therapists like to use a few specific tests when getting a general idea of someone’s function. A couple of our favorites are the Timed Up and Go (TUG) and the 6 – Minute Walk Test. They measure the time it takes to rise from a chair and the amount of ground covered in six minutes, respectively. Pretty simple, right? In all of the studies I read that were using these outcomes, both TUG and 6-Minute Walk scores significantly improved following strengthening intervention. These tests are really special because they have incredibly strong correlations to functional independence and risk for falls and hospitalization. On top of improving scores in these tests, patient’s themselves also reported improved mobility in their daily lives.

Frequency and Duration

Out of the studies examined, most advised participating in a resistance routine 3-4x weekly in order to see an increase in muscle mass in 6-9 weeks. Continued training will sustain this effect. Most recommended 3-4 sets of 10 repetitions and 65-85% one rep max. Bands and free weights have found to be effective for strength training in older individuals. As stated before, exercise machines tend to have an increased risk of fracture in those with severe osteoporosis and therefore, should be avoided unless one is certain they can adjust the machine with correct form. Repetitions should be slow and controlled. Cardio and weight training are life long commitments.

So Where To Start?

The first place to stop is at your local and experienced physical therapy office. Your PT will be able to determine if you are safe to exercise and what types of exercise will work best for your body and your goals. Will exercise bands work better for you? What the heck is 80% one rep max? When can I progress? Am I doing this right? All of these questions will be answered by your physical therapist. At Beyond Basics Physical Therapy we work to not only improve strength, but also efficiency of movement to allow our patients to get the most from their time with us as well as their time spent doing resistance training. If you think weight training is right for you and are eager to get started, make a call to us at BBPT or to your local PT, to make an appointment today!

Chen M, Jiang B. Resistance training exercise program for intervention to enhance gait function in elderly chronically ill patients: multivariate multiscale entropy for center of pressure signal analysis. Comput Math Methods Med. 2014

Giangregorio G. Papaioannou A. MacIntyre N. Too fit to fracture: exercise recomendations for individuals with osteoporosis or osteoporotic vertebral fracture

Liao C, Tsauo J, Lin L, et al. Effects of elastic resistance exercise on body composition on body composition and physical capacitiy in older women with sacropenic obesity. Medicine. 2013. 96(23)

Mayer F, Scharhag-Rosenberger F, Carlsohn A. The intensity and effects of strength training in the elderly. Dtsch Arztebl Int 2011; 108(21):359-64

Navigating Life with Chronic Pain: Part 1

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Fiona McMahon, PT, DPT

Why Should Everyone Care About Chronic Pain

Chronic pain is the in vogue topic of the day. It is a subject that has pushed its way into American’s awareness for very good reason. According to the American Academy of Pain Medicine, chronic pain currently affects more than 1.5 billion people world wide, affecting work, sleep, and quality of life. Most importantly chronic pain has become dangerous as the opioid crisis has come to a head. Out of the 28,000 people who died of accidental drug overdose, nearly 12,000 died from pain killers, three times as many in 1999, according to the American Academy of Pain Medicine.

What Is Chronic Pain

Chronic pain is classically defined as pain that persists more than 3 months, but it is so much more than that. When pain becomes chronic, it is actually processed in the brain differently than acute pain. This is one of the reasons chronic pain has proven to be so difficult to treat using traditional means.

Pain serves a vital function and is something we need to survive. Pain alerts us to danger like a hot stove or broken bone and compels you to take action. This “take action now” pain is acute pain. Chronic pain lingers and can be totally independent of what is actually going on in the tissue. In fact, the tissue may have healed completely and still pain persists. There are a lot of thoughts as to why pain becomes chronic. It can seem like there is nothing left to treat, and all we can do is blunt it with analgesics and painkillers. But there is more to do. All pain, whether it is acute or chronic is processed by pain receptors, the spinal cord, and finally the brain. By addressing pain at the level of the nervous systems, we can change the way stimuli are perceived in the brain, and hopefully reduce pain.

The book, Explain Pain, by David Butler and Lorimer Moseley does a really superb job explaining this concept. In the book, they explain chronic pain is the body’s response to prolonged exposure to noxious stimuli. (In non medical person terms: basically if you have pain for a long time, the body becomes much more sensitive to things that may or may not be painful or damaging). In states of chronic pain, your body can actually lower the threshold for something to become considered painful in the brain. Meaning, that simple stimuli like tight fitting clothing, or sitting can feel very painful. Your body is doing this, because it is on guard for anything that might hurt it. Chronic pain is your body’s way of looking out for you, but has gone way too far.

This blog is not long enough to dig into all of the varied nuances of how and why chronic pain occurs, but if your interest is peaked, I would highly recommend taking a look at Explain Pain or The Explain Pain Protectometer in order to dig down into the deep and fascinating science behind chronic pain.

False Leads and Dead Ends In Pain

Opiods, Addiction, and Efficacy

The nature of chronic pain has proven to be elusive for patients and healthcare practitioners alike. In the 1990’s, in an effort to finally address chronic pain, opiods became much more widely used. At the time, drugs like Oxycontin were marketed as a safe way to treat chronic pain. The manufacturer of Oxycotin, Purdue Pharmaceuticals, instructed their drug representatives to tell doctors that the rate of addiction for long term Oxycotin users was 1%, according to pharma who help fund these studies. Although one study did indeed find these numbers many other found addiction rates in excess of 40%.

Probably one of the most unfortunate aspects of the push by pharma to prescribe opioids more freely, is despite marketing to the contrary, there have been more and more studies supporting the theory that opioids may in fact be ineffective for the treatment of chronic pain. Studies of worker’s compensation patients being treated for chronic pain indicate that patients on higher opioid dose, return to work more slowly than those on lower doses. Additionally, patients with back pain, who are being treated with long term opiod therapy report greater disability than those who are not on opioids.

Opiods have their place, especially in the treatment of cancer, procedural, and end of life pain, however it is becoming more and more clear that opiods are not the miracle drug we once thought they were in the treatment of long term chronic pain. The increased risks of addiction, accidental overdose, falls and fractures, depression, and severe constipation (which can indeed worsen the pain for which the opiod was prescribed in the first place), make it clear that as a medical community, we need to find a safer and more effective way to reduce chronic pain symptoms.

First steps

If you can find a cause, but at the same time don’t get hung up on it.

This is easier said than done. Often times, by the time patients reach us here at Beyond Basics Physical Therapy, they have folders that are stuffed to the brim with expensive diagnostic tests that read “unremarkable”. This can be incredibly frustrating for someone suffering with very real pain. My first word of advice is, If something doesn’t feel right with your body, don’t stop looking for help, until you find someone who can truly help you. There are many pain conditions like, chronic prostatitis and endometriosis. Which are poorly understood by many providers, that require treatment and or consultation by a specialist. This isn’t to say that the clinicians that are unfamiliar with chronic pain conditions aren’t fabulous providers, but these chronic pain conditions often require a clinician who spends his or her career treating and managing these type of pain syndromes. Basically, don’t allow yourself to be written off by any clinician who tries to tell you your pain isn’t real. It is, but most importantly there are things to be done. At Beyond Basics, we have extensive training on chronic pain conditions, additionally we have multiple connections with physicians, nurse practitioners, and other clinicians who treat chronic pain, that we will often refer too if we feel additional intervention beyond physical therapy is necessary.

I am warning you, before you read this paragraph, I am about to say something that on its face will seem mind numbingly contradictory. Bear with me please, and read the entire passage. If you do get a diagnosis, do not expect an immediate cure of pain. Chronic pain has gone past the point of solely being about tissue damage. A chronic undiagnosed infection, muscle spasm, or injury should be treated to remove the fire or proximate cause of the pain. Just because the pain is gone, does not mean the nervous system will immediately calm down. In chronic pain, treating the proximate cause enables the nervous system to begin to down regulate (or less threat sensitive) with further treatment, but does not always guarantee immediate cure.

This brings me to the problem with imaging. Imaging is a great tool and advances in the ubiquity and affordability of imaging techniques like ultrasound and magnetic resonance imaging (MRI), are allowing more and more people glimpses inside their body. If you have ever looked at an MRI of yourself the feeling is profound. I have been fortunate enough to see both my brain and right hip in mind blowing detail on MRI. It’s amazing, but sometimes knowing where every tear, herniation, and bit of swelling is not only unhelpful, but downright dangerous to some patients.

I am not being hyperbolic simply to drive a point home. Early and unindicated MRI in cases of low back pain has been shown to result in increased time spent on disability and increased cost of care ranging between $8,000-13,000 according to the article by Webster, cited in the sources. The fact is with imaging as powerful as MRI, we get to see almost EVERYTHING and because MRIs are getting slightly cheaper and more common, we are identifying structural changes like disc herniation in people, who might not have had a reason to suspect that there was something wrong in their spine in the first place. Sometimes knowing there is a structural abnormality in your body can cause pain and hypervigilance, when prior to knowing, you may not have had the same quality or as much pain in the first place.. Reports indicate that disc herniation and narrowing of the spinal cord can be seen in up to 57% of people who have no symptoms at all. It’s not a far leap to imagine someone with pain hanging all of their problems on a slipped disc if the MRI shows it. What’s worse, is MRI results are alluring and can often lead practitioners down the wrong path of treatment, because it is an easy answer.

In physical therapy school, my professors drilled into us, with almost religious fervor, treat what you find. A fabulous Physician’s Assistant of mine also told me 90% of what you need to know is in a patient’s history of their present illness. It is so true. You can tell a lot about the origin of the pain by asking questions like, how long has it been around, what makes it worse, what makes it better, and what does it feel like. Imaging can sometimes be a bit of a red herring, rushing well intentioned clinicians towards what they think is a cure, while skipping some crucial information through gathering steps that would aid in a more accurate diagnosis.

MRI’s aren’t all bad. They can be life saving and life improving when they are used appropriately. There are many clinical practice guidelines that guide providers on when it may be beneficial to order MRI or other imaging, however, research has certainly borne out that early imaging is actually counter productive in the treatment of chronic pain.

 

If you find a cause, great. If you don’t, or still feel bad don’t despair

We place so much of our hopes on diagnosis. It seems logical that if there is a cause, there must be a cure. Unfortunately, it is not alway so simple. We went over in the opening paragraphs about how chronic pain is more than what’s going on in a specific body part, it also involves the brain. Sometimes simply curing the tissues is not enough. Sometimes we never know what the cause is. This can be so frustrating for patients. As a pelvic pain specialist, I treat a lot of patients with pelvic floor pain and spasm, who have not yet figured out what specific incident brought the pain on. Rarely, in these cases, is there the “oh, crap” moment, when you realize you have injured yourself. Sometimes the development of chronic pain is like having a water glass. We are all born with water glasses of different sizes. We pour a little water in for something like poor posture, genetics, injury, diet, stress, etc., and when our water glass has overflowed, we develop chronic pain. There is no one definitive cause in cases of the overflowing water glass. Many factors have contributed, and many factors must be addressed in order to treat it properly. That’s why the holistic, mind-body approach is really where it’s at, when we treat chronic pain.

Now that you have a grasp on pain science and how chronic pain can behave differently from acute pain, you can begin to approach treating and dealing with it in a different way. In part two of this blog we will discuss different treatments for chronic pain, including yoga, acupuncture, meditation, of course, physical therapy, and many more. Please stay tuned.

Sources:

AAPM Facts and Figures on Pain. The American Academy of Pain Medicine. http://www.painmed.org/patientcenter/facts_on_pain.aspx. [Accessed June 25, 2017]

Butler, David S, and G L. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print.

Zee A. The Promotion and Marketing of Oxycotin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009;99(2):221-227

Singh P, Chaturvedi A. Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review. Indian J Palliat Care. 2015. 21(1): 105-15

Von Korff M. Long-term use of opiods for complex chronic pain. Best Pract Clin Rheumatol. 2013 Oct 27(5):663-72

Webster B, Bauer A, Choi Y, et al. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work Related Low Back Pain. Spine. 2013. 38(22) 1939-46

Pilates Blog: Balanced Muscle Development

Denise Small  PT, DPT

In today’s Pilates’s blog, we will discuss another of the eight movement principles, Balanced Muscle Development. Using the example of the Pilates swan, we can see how both the front and back of the body are benefitting from the movement.  As we inhale and move our spines into extension, the back of the body, including the spinal muscles, glutes, and hamstrings are lengthening down toward the feet, while the abdominal muscles are lifting in and up towards the breast bone.  Both the back and the front of the body work in opposition to create balance in the body.  We give this exercise often in our practice at Beyond Basics to counter the shortening of the abdominal muscles that occurs with prolonged sitting. When the abdominal muscles shorten, they pull on the fascia of the external genitalia and pelvic floor muscles, contributing to their tightness. Have your PT take you through this exercise on your next visit to feel the full effects of the exercise. Or make an appointment with me for a one-on-one Pilates session.  Your body will thank you!

 

Swan
Jessica Babich PT, DPT demonstrating the swan

Pilates Blog – Concentration

DeniseDenise Small, DPT

Every Wednesday the PTs at Beyond Basics are fortunate enough to listen to lectures from medical professionals who specialize in pelvic pain.  One of my favorite lectures was given by Melissa Farmer, PhD,  a clinical psychologist who specializes in how the brain changes overtime in response to chronic pain.  Melissa spoke about a lot of wonderful things that are being found through research; however the thing that was most interesting to me, was not only that the brain can change in response to persistent pain, but, that the brain can change back to its pre-pain functional self! One of the ways that this can be done is through focused movement.  That is, thoughtful, pain- free movement focused around the area that normally causes pain.  This revelation was very meaningful to me, as one of the basic Pilates movement principles is Concentration.  Pilates believed that if your mind was fully focused on performing the given exercise, you would only need to perform a few repetitions to feel the benefit.  This is very important for patients suffering from chronic pain, as they do not need to exercise to the point of pain to see the benefits. One of the exercises that exemplifies this belief is the Pelvic Clock. The pelvic clock both mobilizes and lengthens the pelvic floor muscles while simultaneously bringing tone to the abdomen. In addition, the movement is very small and specific and requires one’s full concentration. So, it is a great way to directly address the potential causes of pelvic pain, without causing pain in the process!

To begin, lie on your back with your knees bent. See, in your mind’s eye, the pelvis as the face of a clock with the top of your sacrum being 12 o’clock and your tailbone being 6 o’clock. Slowly move from each number as smoothly as possible, while seeing your sitz bones widen as your tailbone drops to 6 o’clock and your sitz bones narrow as you move to 12 o’clock. You can also combine the movement and breath as we have in our other Pilates blogs by inhaling as you move to 6 o’clock and exhaling as you move to 12 o’clock.  If you have any questions, have your PT take you through this exercise on your next visit, or come see me for a private Pilates session. Your Body and Brain will thank you.