What is Pelvic Floor Physical Therapy

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

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. 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

How to Travel with Pelvic Floor Dysfunction

Fiona McMahon PT, DPT (She, her, hers)

airplane-backlit-clouds-1262304

It’s that magical time of year in New York City, that I call “Goldie Locks Time”. It is that brief stretch of one to two weeks right after the cold of winter has left us and right before the sweltering hot gritty city summer descends upon us. It is the time of year that the weather is so supremely pleasant, that the hustle and bustle of the city slows and usually frenetic New Yorkers actually take time to stop and smell the roses, literally. My pediatric patients begin to grow giddy as school is wrapping up in a couple weeks. It is a time when many New Yorkers start looking forward to their summer escapes back to their home towns across the country or vacations to new and familiar locales alike. Having the time and resources to travel is a luxury, but for those with chronic pelvic pain, it can seem like a really daunting task. People often wonder, “how can I fly across the country if sitting for more than 20 minutes causes my pain?”, “how will I keep from flaring?”, “How do I negotiate the demands of travel so I can actually enjoy my time away?”. Although travel can be really daunting, there are steps that you can take to ease your journey and help you enjoy your time at your destination. Below are some considerations for travel I hope that you will find helpful.

Hydrate- Even if You Have Bladder Problems

Recirculated air is the worst and is inevitable when flying, but is also something you should consider with bus, car, and train trips. Long and even short haul flights can leave you feeling parched and dry which can cause issues with many pelvic floor symptoms. It is really important to not get on the plane dehydrated. In the week or so preceding your trip, be extra mindful of trying to get enough water. A popular guideline we use at BBPT with to try and consume at least one half your body weight in water in ounces. For example, if you weigh 150 pounds, drink 75 ounces of water. Being properly hydrated will decrease irritation within the bladder and can even reduce frequency, reduce your chances of constipation, and ensure the tissues of your body have good mobility. Also be sure to hydrate on the plane and in the airport. Water sold at airports is usually overpriced and has the downside of being packaged in environmentally unfriendly plastic. To save money and the planet, I suggest bringing an empty reusable water bottle through security. Once you are through security you can fill it up and keep on your hydration game. One thing to remember is to take your water bottle out of your bag and place it in the screening bin, so you won’t lose time having security check inside your bag to verify that your bottle is indeed empty.

Prioritize Pooping

In my world, it’s all about poop. Traveling can lead to some gnarly cases of constipation, which makes virtually every pelvic floor complaint worse. We talked about keeping up with your hydration, which is a really good first step. Making sure that you have a enough time to eat, chill, and have a solid BM before rushing off to the airport is really important. So when possible, Try and carve out at least an hour of pre-travel chill time before heading out the door.

Food

Eating well is so important. Many of our patients have diets that make them feel better. When travelling, food can be a wild card. With the change in routine associated with travel, it can be all too easy to throw a diet that is working to the wind. A huge change in dietary routines is one of the top reasons I see people flare. Although indulging in margaritas and other treats can be so much fun, be aware of how it will affect your symptoms and overall enjoyment of your trip. It is good to come prepared if possible. Packing snacks that you know don’t make you feel like garbage if you are going to place where you are unsure of what the food situation will be like, will help.

Choose your Seat

The idea of sitting on a long haul flight is daunting especially for those who have pelvic and or sitting pain or bladder issues. There are travel cushions you can bring with you to ease your symptoms. If you don’t typically use a travel cushion, check out my cushion hack bellow using a jacket.

seat.jpg
The cushion hack: If you find you have sitting pain but no cushion, use your coat or sweatshirt to fashion a cushion

Choosing seats next to the bathroom when possible can go a long way towards reducing stress for folks with bladder issues. Additionally ,opting for an aisle seat can also be helpful. To the extent possible, try to get up and move to reduce the pressure on your pelvic area.

Manage Travel Stress

Travel is a stressful thing for most of us. There is so much out of our control and there’s no amount meditation or mindfulness that can change that. That being said, meditation and mindfulness practice can help how you deal with how you react to  cancelled flights, lost baggage, the works. Allowing yourself a quiet moment to breathe before and during your travels can help you re center and get back to enjoying the journey. Both Calm and Headspace make really awesome guided meditation apps that you can use while waiting for your flights.

 

Get out There!

This world is so big and beautiful. It can be really hard if pelvic pain is holding you back. Try these tips out on smaller trips to see if they help you! If you find that you are still having pain that holds you back, see a pelvic floor physical therapist who can help you get out there!

Beyond Basics Physical Therapy offers intensive week or weeks long treatment to those who live out of town and do not have regular access to pelvic floor physical therapy. If you are feeling like taking a trip to the Big Apple, NYC, check out more about our out of town services here.

 

The Special Care Needs of the LGBTQ+ Community

Happy Pride Month!!!!

We are reposting an old post broadly discussing the LGBTQ+ community, with special focus on transgender individuals. Please keep checking back as we continue to discuss specific issues relating to the care of the LGBTQ+ community.  

Amy Stein PT, DPT and Fiona McMahon PT, DPT

rainbow flag

Who are LGBTQ+ individuals?

At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc.  They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.  

Never Assume. Listen, Ask.

We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community.  First rule of thumb:  with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.

 As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us.  Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.  

We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in trans care. Hormones, either testosterone, estrogen, lupron, puberty blocking, testosterone suppressing can be used in many patients, but are also used specifically to aid in transition in transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options.  There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration.  Hormones can be administered via injection, pellets, patches, creams, gels, and pill form.  It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc.  Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals.  Progression of hormones can be monitored for each patient and according to patients wants and needs.  

For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs.  Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that  can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.

How is care for the LGBTQ+ community funded and regulated?

Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.

How can physical therapy help?

At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction.  We also specialize in orthopedics and functional manual therapy.  We treat the LGBTQ+ community and we welcome any questions at desk@beyondbasicspt.com or call 212-354-2622. We are happy to help and look forward to hearing from you!
Resources: Center of excellence for transgender health.

WPATH center for care Endocrine Society

  • speaks on hormone therapy (however some information may be out of date).

 Adolescent Health Center

Marathon Training and Racing Wellness: Why I Chose Tina

Molly Team Tisch MSMolly Caughlan PT, DPT

I am very excited to announce that I will begin training soon and will be running the New York Marathon for the first time. I will be running as part of Team TISCH MS alongside my awesome and inspirational co-worker, Fiona McMahon. We are working together to raise a combined $10,000 dollars to support multiple sclerosis research. You can donate to my personal fundraising page here. This is an incredible opportunity that I feel so honored to be a part of. I decided to run the marathon as part of my New York and life bucket list. I see marathon training as a perfect way to get to know all of the five burrows. Running has always been my way of getting to know the city I’m living in.

I have trained for several 5K, 10K and half marathon races, but only one full marathon. My first (and only) marathon I call my “almost marathon” took place in Savannah, GA in November, when the weather should be sunny and 70s. Unfortunately, due to a heat index of 105 and with several hundred participants fainting due to heat exhaustion, they cut the race short and made everyone turn around at mile 14. I was relieved, frustrated, exhausted, and incredibly HOT. My 6 months of training in the hot Atlanta summer had not prepared me for the intense humidity that made me feel as if I were swimming and not running.

Beyond Basics Physical Therapy has generously offered physical therapy services to me to help me meet my marathon training goals. First and foremost, I’d like to complete my training and marathon without any major injuries. In previous races, I’ve been fortunate to not have any serious injuries and just minor aches/pains. My main problem areas are my right sacroiliac joint and right foot feeling occasionally unstable and achy. Second, I’d like to finish in under 4 and a half hours, meaning little to no walking breaks. My pace is on the slower end (around 10 min/mile) and I’m hoping to increase my pace. My third goal is to get the most out of my training and to fully enjoy the whole process.

My co-worker Tina Cardenia will be my physical therapist and I could not be more thrilled to be working with someone so incredibly talented, intelligent, and experienced. Tina has an extensive background working in an orthopedic setting and has completed the intense certification process in Functional Manual Therapy (CFMT). Tina uses this strong framework to look at the body as a whole and bring its function to optimal capacity.

These next 6 months will be intense, but I’m excited to push my body to new limits and finally cross “marathon” off the list. With the help of Tina, Team TISCH, and Beyond Basics, I am excited to take on this new challenge. I’m confident that I’ll meet all the goals I’ve set out for myself and look forward to November as they come into fruition.

Both Molly and Tina work in our Midtown Location.

PT Molly

 

Navigating Life with Chronic Pain: Part II

king-sigma-wasylko-nikon-72743

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 how some opioids 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. Nonmodifiable 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 observe their thoughts, feelings, sensations, and attitudes without judgment. 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 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 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 from 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, but 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

 

     

 

Bringing Things into Balance: The Relationship Between Low Back Pain and the Pelvic Floor

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

Back Pain or Fitness (2)The Occurrence of Low Back Pain

Low back pain is the most common cause of disability and lost work time among working-age adults in industrialized countries (1). In fact, the worldwide prevalence of chronic low back pain has been estimated to be 11.9% of the population on a given day, and 23.2% of the population in a one-month period (2). That is a significant number of people! Determining effective treatments for low back pain can be challenging for various reasons: 1. there are no clearly defined risk factors that predict the development or outcome of low back pain; 2. most patients do not present with any significant findings physiologically or anatomically; 3. and pain can generate and spread at numerous locations within the nervous system, and can constantly change (1).

Treatment of Low Back Pain

There are many challenges associated with low back pain diagnosis and outcomes. Because of this, and the fact that so many people across the globe are impacted by it, there are many options out there for treating this condition. Some methods that have been proven to be effective are spinal manipulation (a high-velocity thrust applied directly on the vertebrae, or backbones, to improve movement and decrease pain), trunk coordination, strengthening, and endurance exercises (to target deep abdominal and back muscles that help to stabilize the spine), general fitness exercise, and patient education (1). These types of interventions are certainly helpful and have allowed many individuals experiencing low back pain to return to their daily lives. However, perhaps the areas that are being addressed with these interventions are not getting to the whole story… There is another area of the body that plays a significant role in the stability of the back but does not regularly get addressed with standard treatment to low back pain: the pelvic floor.

Treating the Pelvic Floor to Address Low Back Pain

Several studies have looked at incorporating pelvic floor-specific strengthening programs in the treatment of chronic low back pain. One study looked at women who were experiencing low back pain and urinary incontinence (the involuntary leakage of urine) (3), while two others looked at individuals experiencing chronic low back pain independently in men and women (4, 5). In all three studies, investigators compared “routine” physical therapy to routine physical therapy plus the addition of pelvic floor strengthening. Results revealed that incorporating pelvic floor strengthening decreased low back pain, decreased the incidence of urine leakage in the case of urinary incontinence, improved function based on specific questionnaires, and increased pelvic floor strength and endurance (3-5). This strengthening was completed by either performing isolated pelvic floor contractions (4, 5), or performing abdominal and pelvic floor muscle contractions while performing specific stabilizing exercises (3).

The Relationship Between the Pelvic Floor and the Low Back

Why did strengthening the pelvic floor make a difference in the above studies? This is likely because the pelvic floor is one of the muscle groups that contributes to overall spine stability; the others include the diaphragm, the transverse abdominis (a lower abdominal muscle), and deep muscles in the low back (3). Several studies out of Norway and Sweden have revealed that in women without pain, the pelvic floor activates just prior to arm or leg movement (6-8). This is important because it reveals that when the pelvic floor is working efficiently, it provides stability to the trunk and pelvis, allowing for functional postures and movements to occur.

Conclusion:

The pelvic floor is an important stabilizer of the spine and pelvis, and activates just prior to movement to allow for efficient function. When an individual is experiencing low back pain, not only do the abdominals and low back muscles require strengthening, focusing on the pelvic floor can help to eliminate pain and resume daily function.

If you or someone you know is struggling with unresolved low back pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!

Thank you so much for reading our blog.

K5 (2)

Katie Parrotte, PT, DPT, OCS, CFMT practices at our midtown location.

If you have questions about orthopedic, pelvic, or sports physical therapy, including back pain, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

Sources

 

1. Beattie PF. 2016. Current concepts of orthopedic physical therapy – the lumbar spine: physical therapy patient management using current evidence, 4th edition. (p. 3) Orthopedic Section – APTA.

2. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012; 64 (6): 2028-2037. doi:10.1002/art.34347.

3. Ghaderi F, Mohammadi K, Sasan RA, et al. Effects of stabilization exercises focusing on pelvic floor muscles on low back pain and on urinary incontinence in women. Urology. 2016; 93: 50-54.

4. Mohseni-Bandpei MA, Rahmani N, Behtash H, et al. The effect of pelvic floor muscle exercise on women with chronic non-specific low back pain. Journal of Bodywork & Movement Therapies. 2011; 15: 75-81.

5. Bi X, Zhao J, Liu Z, et al Pelvic floor muscle exercise for chronic low back pain. Journal of International Medical Research. 2012; 41 (1): 146-152.

6. Sjodahl J, Gutke A, Ghaffari G, et al. Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the active straight leg raise in women with and without pelvic girdle pain: an experimental study. Clinical Biomechanics. 2016; 35: 49-55.

7. Stuge B, Saetre K, Hoff BI. The automatic pelvic floor muscle response to the active straight leg raise in cases with pelvic girdle pain and matched controls. Manual Therapy. 2013; 18: 327-332.

8. Sjodahl J, Kvist J, Gutke A, et al. The postural response of the pelvic floor muscles during limb movements: a methodological electromyography study in parous women without lumbopelvic pain. Clinical Biomechanics. 2009; 24: 183-189.

Be a Bladder Whiz! Healthy Bladder Tips for All!

Fiona McMahon PT, DPT and Amy Stein PT, DPT

bathroom-ceramic-floor-127726

 

So we busted some myths in our last Pelvic Floor Myth Buster Blog, where we discussed whether or not holding your pee causes urinary tract infections. If you haven’t gotten a chance, check it out here. People living with bladder conditions, like pain, hesitancy, frequency, post void dribbling, and incontinence know that an unruly bladder can be really disruptive. In this blog, we are going to take some time to discuss some practical tips and tips you can employ right now to tame an unruly bladder. Many of these tips come from Amy’s book, Heal Pelvic Pain, available here.

So what are we working with?

Male or female, we all have the same basic structure of the bladder, with a few exceptions. Here’s what everyone has in their lower urinary tract.

Detrusor Muscle: Forms the body of the bladder and is responsible for squeezing the bladder to empty its contents. It spends most of its time relaxed in order to allow for bladder filling.
Trigone Muscle: Forms the neck of the bladder, and is a powerful sensory organ. When the trigone stretches in response to the filling of the bladder, it sends a message to the brain that it’s time to pee.
Internal Urethral Sphincter: Smooth muscle (involuntary) which seals off the exit of the bladder and allows for continence.
External Urethral Sphincter: Striated or voluntary muscles which also seals the exit of the bladder.
Urethra: This is the tube that leads out of the bladder and is the pathway for urine into the outside world.

Sex differences:
Many men have a prostate. The prostate is a sex organ and is responsible for keeping the semen at the right pH to fertilize a waiting egg. It wraps around the urethra and lives just under the bladder. It also provides a mechanical buttress or support for the bladder, lessening the load on the pelvic floor. Because of its proximity to the urethra, problems with the prostate can cause problems with the bladder. An enlarged prostate, which can be a part of aging, cancer, or infection, will restrict the flow of urine out of the urethra, resulting in a weak stream, painful, burning urination, and difficulty urinating (however, the same thing happens with tight pelvic floor muscles with or without prostate involvement, which makes bladder issues super confusing).

Another important difference between guys and gals are the respective length of their urethras. Male urethras are a lot longer than female urethras. This is one of the reasons women are more prone to bladder infections. In a female, bacteria have a lot easier time making the trek to the bladder because of the shorter urethra.

So how do I help my bladder?

Posture

If you are having problems fully emptying your bladder or you have post void leakage (dribbling following going to the bathroom) consider your toileting posture. People with bladder issues should sit on the toilet (even dudes), to allow the pelvic floor muscles to relax and allow the bladder to fully empty.

Stretch!

Here’s a great stretch from Amy Stein’s book, Heal Pelvic Pain available here in hard copy and digital download.

pelvic health book pics 001

Here’s how to do the stretch

1. Lie on a firm surface-on a mat on the floor or on a hard mattress. Bring your knees up to your chest and then let them relax and rotate out to the side so that they flare outward. Use your hands to hold your knees in this position.

2. Stretch as you deep-breathe for six to eight breaths. Do not bounce, and do not push hard. Just gradually and progressively fill and empty your lungs.

3. Hold the stretch for 30 to 60 seconds. Do three repetitions, two to four times a day. 

Bladder Training

If you have bladder frequency or leakage with urge now is the time to try and train your bladder to hold more urine. Keep in mind you should start treatment to address pain with physical therapy and in certain cases, with medication, to allow you to be successful with bladder training. I always tell my patients to start their bladder retraining at home, where a bathroom is available to take the stress out of possible leaks or not being able to find a bathroom. Start by simply waiting to go to the bathroom 5-10 minutes past your first urge to urinate. Use behavioral strategies, such as deep breathing and pelvic floor drops, mindfulness, gentle stretches, distraction, and others. If you don’t have to go after 5-10 minutes, Great! If you do, go to the bathroom. As waiting 10 minutes becomes easy, stretch your time to 20 minutes and so on until you are able to go 2-3 hours in between urination.

 

Diet

This can make such a huge difference. My boss and Beyond Basic’s founder, Amy Stein, writes in her book Heal Pelvic Pain, that we should really try to get eight 8-ounce glasses of water a day, and try to finish them at least two hours before bed, to reduce your chance of needing to go at night. We call this symptom, nocturia.

As far as things we chew on, many foods can irritate the bladder, but not all foods bother everyone in the same way. It’s all about experimenting to find your triggers. Some common foods include food high in sugar, spices, acid (like tomatoes and citrus), tannins (like in wine). John’s Hopkins has a really good list, which you can access here. This list is totally overwhelming at first blush, but remember my bladder irritant may not be yours. Typically you will know shortly after eating the offender, on the same day. So the best thing to do is to try the suspected bladder irritants one at a time to see if you can identify a triggering food or drink.

Manage Constipation

The bladder does not have a lot of space, where it lives. In front of it lies the pubic bone, behind it lies a vagina for some of us, the rectum, and then the sacrum bone. The bones sandwich the bladder like bookends. Although these bones have some movement, which we treat, it’s not enough to allow for much more space for the bladder if your rectum is full of poo from being constipated. With an overfilled rectum, the bladder gets squashed against the pubic bone. With a squashed bladder, you may not empty it as well, feel urgency, or even experience bladder leakage. Therefore, avoid constipation at all costs! We advise our patients to drink more water and eat more soluble and insoluble fibers.

 

Physical Therapy Can Help Cure!

Physical therapy is considered a mainstay and the number one treatment for musculoskeletal causes of bladder disorders and bladder and urethral pain. Expert pelvic floor physical therapists (PFPTs) are clinicians who can find the cause of your bladder issues and provide you with a customized plan that will provide you with the best results possible. PFPTs can work to relax spasmed muscles, treat constipation contributing to bladder issues, improve your toilet posture, reduce tightness and shortening of tissues around the bladder, abdominal and thigh region that can contribute to bladder dysfunction, as well as strengthen weak muscles. If you are experiencing bladder issues, please come to see us. There is so much we can do to help!

fiona2018amy2016

If you have questions about orthopedic, pelvic, or sports physical therapy, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)