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.  Endometriosis can be worsened with testosterone hormones.  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

Continuing our Education: Vestibulodynia, Vulvar Pain, and Beyond

rose-3142529_1920

Fiona McMahon PT, DPT

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

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

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

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

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

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

On who is an appropriate candidate for physical therapy:

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

On what pelvic floor physical therapy is:

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

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

 

Sources

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

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

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On September 20th, 2017 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health as well as the function of your bowel, bladder, and sexual muscles and organs. We will also be covering how things such as alignment, posture, muscle tone, and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

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

Here is our line up of this and future classes:

Pelvic Health 101 Fall 2017

September is Sexual Health Awareness Month!

pexels-photo-544917

Fiona McMahon DPT, PT

September is here and we at Beyond Basics are taking some time to observe sexual health awareness month. We take pride in our role of providing our patients with treatments to make sex comfortable and pleasurable as well as in our role as sexual health educators. Sexual health is comprised of many factors beyond just your ability to have sex. This article, by no means, exhausts all factors but is a good starting point to learn more about increasing your health as well as your enjoyment when it comes to sex. We will be expanding on some of the conditions featured in this blog in future posts, so stay tuned.

What is Sex

Sex is not a one-size fits all activity and can come in many different forms. Even between straight couples penetrative sex may not be the standard. In fact there are many couples that can not engage in penetrative intercourse for a variety of reasons. This may be because of an injury, medical condition, or simply because intercourse is not gratifying for the couple or there is some other act that is more gratifying. It’s really up to the couple’s choice and preference. A term for sexual activity that is not penetrative is called outercourse.  One type is not necessarily better than another. It’s all about what works for you and your partner’s bodies and desires.

Emotional Health and Sex

Sex is more than how it makes you feel physically, it is about how it makes you feel emotionally. Many things can influence how we feel about sex and how sex makes us feel about ourselves. If sex is making you feel unhappy or anxious it is important to get to the root of the cause, in order to maximize not only your pleasure but also, your well being. Common issues, to name a few, that can negatively affect sexual experiences are listed here:

 

  • Trauma
  • Mismatch between your sexuality and culture
  • Issues with your partner
  • Issues with consent: Consent is a hot button issue in today’s media and on college campuses. Although consent is a broad and important topic, it can be boiled down to a few key points:
  1. Consent can never be assumed, regardless of dating status or previous sexual activity. For consent to be given, it must be given with an affirmative “yes” answer.
  2. Consent can not be given if someone is high on drugs, underage, or drunk
  3. Consent must be given with every sexual encounter and can be withdrawn at any time.

If emotional issues are contributing to a lack of enjoyment with sex, it may be time to reach out to a certified sex therapist.

 

Sexually Transmitted Infections (STIs/STDs) and Safer Sex

Sexually transmitted infections also known as sexually transmitted diseases can have a huge impact on your well being. Up until recently, sexually transmitted infections (STI’s) have been known as sexually transmitted diseases. There was a change in the nomenclature of these infections, because many of them can be asymptomatic and a person may carry and transmit them without knowing they have been infected.

STI’s unfortunately sometimes carry a moral connotation, in that blame is often put on the person who has it. STIs are simply an infection with a bacterial, fungal, or viral pathogen and have absolutely no bearing on the moral character of those infected. They can be transmitted sexually but they can also be spread through the childbirth process, dirty needles, or a tainted blood infusion.

All STI’s are not created equal. For some there are excellent screening tests and treatment, yet for others, treatment or screening or both may not be fully effective yet. Some may be obvious to those infected, while others may go undetected for years. Common symptoms of symptomatic STI’s include:

  • Sores and bumps around the genital and rectal area
  • Painful urination
  • Penile discharge
  • Irregular vaginal bleeding
  • Foul vaginal odor
  • Painful sex
  • Fever
  • Swollen lymph nodes in and around the lower extremities, which may also be present in the upper body as well.
  • It is important to remember these symptoms are non-specific and can be related to a number of other conditions that are not solely related to STI.

STI Complications

  • Pelvic pain
  • Eye inflammation
  • Pregnancy complication
  • Infertility
  • Pelvic Inflammatory Disease
  • Certain types of cancers associated with Human Papilloma Virus (HPV)

Risk Reduction

Because not all STI’s can be cured, (although many can be effectively managed) and the impact to one’s health can be so large, it is imperative to safeguard your health and fertility. Steps you can take to reduce your risk of STI infection include:

  • Abstaining from sex: abstinence is the most effective way to reduce your risk of STI; however, with most adults, this is not an acceptable option.
  • Using a barrier to reduce contact with bodily fluids. Using condoms for penetrative sex (vaginal, oral, and anal) or a dental dam for vaginal oral sex, can help to reduce your risk.
  • Keeping your number of sexual partners low: long term monogamous coupling is associated with a lower incidence of STI
  • Regular screening: Because many STI’s can be asymptomatic, regular screening is key to catching an STI early, treating the infection, and preventing damage to your own body as well as transmission to others,
    • Herpes: Recommended for those at risk for herpes (people having unprotected sex, have had sex with someone who is infected, or people experiencing symptoms such as sores)
    • Chlamydia:  men who have sex with men, as well as women who are under 25 have a greater risk of contracting chlamydia and should be tested for it
    • Gonorrhea: men who have sex with men, as well as women who are under 25 have a greater risk of contracting gonnorrhea and should be tested for it
    • Human Immunodeficiency Virus (HIV): It is suggested that everyone between the ages of 13 and 64 be tested for HIV. If you do have HIV, it is imperative to be regularly screened for other STI’s as it is easier to contract them with an HIV infection
    • People born between 1945-1965: should be tested for hepatitis C as there is a high incidence in this population.
    • New Partners: Before having sex with a new partner, both people should be tested for STI to prevent transmission of new infections
    • HPV: Females should be screened for HPV at least every 3 years if they are 21 to 30.  It is recommended to be tested at least every 5 years for sexually active women over 30. There is currently no HPV screening for males.
      • Two vaccines are now available to help prevent two types of HPV associated cancer. The current recommendation is that both boys and girls receive the vaccine between the ages of 11 and 12 years old. Boys can receive that vaccine between 13 and 21 and girls between 13 and 26 as a catch up period.
    • Truvada: Truvada is a drug that is now available to help prevent transmission of HIV and indicated for use in high-risk populations.

 

When Genital Pain Limits Sex

Both men and women can have pain that is so severe that it limits their enjoyment of sex, or prevents sexual pleasure completely. There are many syndromes and diseases that can cause pain with sex. As we covered earlier, STI’s can influence pain, as well as other conditions such as non-bacterial prostatitis, vulvodynia, vaginismus, pudendal neuralgia, as well as many more. These diseases and conditions can be influenced by poorly functioning pelvic floor muscles and vice versa. Keep an eye out for future blog posts devoted entirely to these conditions.  It is possible to have tight and tender pelvic floor muscles as a result of an infective process, injury, or they may arise on their own idiopathically.

 

What to do if you have pain

First off, don’t panic.  Pelvic pain is relatively common, some studies estimate chronic pelvic pain rates being higher than 25%. You are not alone. It is important, though, to act swiftly to identify the culprit. The majority of pelvic pain is treatable, but the process is much easier when started earlier on in the pain cycle.

Go to your doctor to rule out any infective or disease process that may be causing your pain. The best case scenario is that a short course of treatment will do the trick. Unfortunately, often times the root cause is not identified on the first trip to the doctor and your results may come back negative for any infectious agent or systemic condition. This is common for many of the patients we see at Beyond Basics. If this happens to you, consider going to a pelvic pain specialist, whether physician or pelvic floor physical therapist, for more precise testing.

It is important to remember not all physicians are trained to recognize dysfunction of the musculoskeletal system, although the number of those who are trained is growing. Indications of musculoskeletal dysfunction are: pain that changes with changes in activity or position, pain that does not go away once the original disease or infection is treated or cured, or pain that can not be correlated to a specific systemic dysfunction. It is important to remember that musculoskeletal dysfunction in the pelvis can mimic, or be the cause of, bladder, bowel and sexual dysfunction.

If you believe your pain is musculoskeletal in nature or even think it might be, it is important to be examined by a skilled pelvic floor physical therapist and not all pelvic floor physical therapists are well trained. Pelvic floor physical therapists can determine if muscles and/or nerves are playing a role in your pain, and then treat the dysfunctional muscles and tissues to allow you to return to your old activities. When looking for a pelvic floor physical therapist, it is important to inquire whether or not they do internal work, both vaginally and rectally, and to ask about their training and experience.

At Beyond Basics we are experts at treating sexual pain as well as screening our patients and referring them on to the correct physicians to help treat any systemic causes of pain. We value a holistic approach to treating sexual pain, and strive to provide our patients with the best care possible. If you are in the New York area, another state, or even abroad and are suffering from sexual pain, please consider starting your healing journey with us.  We have an extensive ‘out of town’ program:  URL for program.

 

Resources:

STI Awareness and Counselling Services

American Sexual Health Association: http://www.ashasexualhealth.org/

Planned Parenthood: www.plannedparenthood.org

 

  • Services provided
    • STI screening/counseling
    • HPV vaccine
    • Male reproductive health exams
    • Pregnancy tests and counseling
    • Health insurance screening and enrollment

NYC STI Clinics and Services: http://www1.nyc.gov/site/doh/services/clinics.page

 

Sexual Assault Counseling:

 

RAINN: Rape Assault Incest National Network: https://centers.rainn.org/

-800.656.HOPE

  • Services provided (free or low cost):
    • Counseling
    • Medical Attention/ Hospital Accompaniment
    • Victim assistance/ advocacy
    • Legal/ Justice System advocacy
    • Emergency Shelter

Pelvic Pain Resources:

International Pelvic Pain Society: www.pelvicpain.org

 

International Society of the Study of Women’s Sexual Health: www.isswsh.org

www.pelvicpain.org

 

Heal Pelvic Pain

By: Amy Stein DPT

http://www.healpelvicpain.com/

Healing Pelvic and Abdominal Pain DVD

By: Amy Stein DPT

http://www.healingpelvicandabdominalpain.com/

 

Explain Pain

By: David Butler

https://www.amazon.com/Explain-Pain-David-Butler/dp/0987342665?ie=UTF8&hvadid=49868747328&hvdev=c&hvexid=&hvnetw=g&hvpone=&hvpos=1t1&hvptwo=&hvqmt=b&hvrand=9859257768995611935&ref=pd_sl_1tz644lwle_b&tag=googhydr-20

Healing Painful Sex

By:   Deborah Coady, MD and Nancy Fish, PhD

 

The Pain No One Wants to Talk About

https://beyondbasicsptblog.com/2015/05/13/the-pain-no-one-wants-to-talk-about/ When

When Sex Hurts

By: Andrew Goldstein, MD and Caroline Pukall, PhD

 

Sources:

 

International Pelvic Pain Society:  www.pelvicpain.org

 

International Society of the Study of Women’s Sexual Health:  www.isswsh.org (confirm url)

 

Ahangari A. Prevalence of Chronic Pelvic Pain Among Women: An Updated Review. Pain Physician. 2014;17(2) E141-7

 

Barrow R, Berkel C, Brooks L. Traditionally Sexually Transmitted Disease Prevention and Control Strategies: Tailoring for African American Communities.  Sex Transm Dis. 2008 Dec; 35 (12 sUPPL): s30-9

 

Katz A, Lee M, Wasserman G, et al. Sexually Transmitted Disease (STD): A Review of the CDC 2010 STD Treatment Guidlines and Epidemiologic Trends of Commone STDs in Hawai’i. Hawaii J Med Public Health. 2012 Mar; 71(3): 68-73

Mayo Clinci Staff. Sexually Transmitted Diseases (STDs). http://www.mayoclinic.org/diseases-conditions/sexually-transmitted-diseases-stds/home/ovc-20180594. [Accesses August 17, 2016]

 

 

 

What is Pelvic Floor Physical Therapy

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

May is Pelvic Pain Awareness Month (#PelvicPainAware), supported by the International Pelvic Pain Society (www.pelvicpain.org). As physical therapists who specialize in abdomino-pelvic pain disorders, one of the toughest parts of the job is meeting men and women who have suffered with pelvic pain for years, only to be told by their doctors/healthcare providers that there is no help for them. It is not uncommon to meet a patient who has suffered for 5- 10 years without help before finding us. Musculoskeletal causes of abdomino-pelvic pain are treatable conditions and often times we can start to improve a patient’s symptoms within just a few visits. We are promoting Pelvic Pain Awareness Month because it is our mission to ensure that people know that help exists so they can start living richer and fuller lives. In honor of Pelvic Pain Awareness Month we want to take some time to explain what we do and how it can help with the symptoms of pelvic pain. Please read on to see how we can help you with your pain.

What do pelvic floor physical therapists actually do? Why do they do what they do? What can you expect from your first physical therapy visit?

Physical therapists (PTs) are experts in movement and function, which sounds like a pretty broad topic to be an expert in, and it is. After physical therapists graduate PT school (now-a-days at the doctoral level), they find their niche and specialize. You can find PTs working with high-level athletes, children, infants, people who are recovering from injuries, people with neurological conditions and many other types of clients.

Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but don’t have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to enquire about the experience and level of training your potential physical therapist has had in this specialty.

What is the pelvic floor and what is pelvic floor dysfunction?

Who needs pelvic floor PT? The pelvis performs many important functions of the body. The muscles, nerves, connective tissues and skeletal structures of the pelvic floor help to keep us continent, aid in sexual performance and function, and assist in core stability.

When some or all of these structures of the pelvic floor are not functioning properly, they can cause a multitude of different symptoms. People who are suffering from bowel, bladder, and or sexual problems, as well as those who are suffering from pain in the pelvis, upper legs, abdomen or buttocks most likely have pelvic floor impairments contributing to their pain.

Issues with the pelvic floor can arise from a multitude of reasons. Infections, previous surgeries, childbirth, postural and lifting problems, and trips and falls can all bring on pelvic floor dysfunction. Pelvic floor pain can persist well after the cause of it has been removed. So it is entirely possible to feel the effects of an old infection, surgery or injury, days to years after they occur. Anyone who has had long standing abdomino-pelvic pain, or pain that they can’t seem to get rid of after seeking the help of medical doctors or other healthcare providers is a good candidate for a pelvic floor physical therapy evaluation and possible curative treatment.

What is Pelvic Floor Physical therapy?

Physical therapy is a practice of healing that restores function and reduces pain through the use of techniques to improve bony alignment, reduce trigger points, and improve muscle coordination and strength. Pelvic floor physical therapy is a branch of physical therapy and is built upon these same principles.

What sets pelvic floor physical therapists apart is their in depth understanding of the muscles and surrounding structures of the pelvic floor, beyond what was taught in physical therapy graduate school. What that means for a patient who is seeking the help of a pelvic floor physical therapist, is that his or her pelvic floor issues will be examined and treated comprehensively with both internal and external treatment, provide them with lifestyle modifications to help remove any triggers, and receive specific exercises and treatment to help prevent the reoccurrence of pain once he or she has been successfully treated.

What exactly do Pelvic Floor Physical Therapists Do?

The elephant in the room with pelvic floor physical therapy is the internal exam/ treatment. It can seem a little daunting, especially if you have pelvic floor pain, but pelvic floor therapists are trained to be as thorough as possible while minimizing discomfort.

During the internal exam, your physical therapist will place a gloved finger into your vagina or rectum to assess the tone, strength, and irritability of your pelvic floor muscles and tissues. Internal exams and internal treatment are invaluable tools that are taught to pelvic floor physical therapists. It can tell us if there are trigger points (painful spots, with a referral pattern or local); muscle/tissue shortening; nerve irritation and/or bony malalignment that could be causing your pain directly or inhibiting the full function of your pelvic floor muscles. We can also determine if your pelvic floor has good coordination during the exam. A pelvic floor without good coordination, may not open and close appropriately for activities such as going to the bathroom, supporting our pelvis and trunk, sexual activity, and keeping us continent.

It is essential that we, as pelvic floor physical therapists, also include other assessments when we are examining our patients for the very first time. We employ the tried and true physical therapy exam practices to determine if there is an underlying condition elsewhere in your body, such as a strength deficit or alignment issue that could be affecting your pelvic floor. It’s wild to think of it, but something as seemingly unrelated as a flat foot or a hip injury can be enough to set off pelvic and abdominal pain!

Some pelvic floor physical therapists may have the opportunity of getting a lot of time to speak one-on-one with a patient to determine possible causes of his or her symptoms, educate the patient and to guide them to other practitioners who may optimize their physical therapy results if necessary. We truly can find out so much by just listening to what our patients have to say. A fall, or infection can be significant as well as a patient’s feelings and knowledge about their current condition.

Once we determine the cause of our patient’s pelvic floor dysfunction, we design a plan tailored to the patient’s needs. At Beyond Basics, we have a diverse crew of physical therapists who bring their own training and background into each treatment. What is really beautiful about that, is that all teach and help each other grow as practitioners. It will be difficult to go over every single type of treatment in one blog post, but we will review some of the main staples of pelvic floor rehab.

Manual Techniques

As physical therapists, are our hands are amazing gifts and phenomenal diagnostic tools that we can use to assess restrictions, tender points, swelling, muscle guarding, atrophy, nerve irritation and skeletal malalignment. We also use our hands to treat out these problems, provide feedback to the muscles, and facilitate the activation of certain muscle groups. There have been a great number of manual techniques that have evolved over the course of physical therapy’s history. Let’s go over a few.

Myofascial Release

Myofascial release was developed by John Barnes to evaluate and treat the myo-fascia throughout the body. The myofascial system is the connective tissue that coats our muscles, nerves, blood vessels, and bones, and runs throughout our bodies. Any tightness or dysfunction in the myofascial system can affect the aforementioned structures and result in pain and or movement dysfunction. By treating the fascia directly, therapists can improve their patient’s range of motion, reduce pain, and improve a patient’s structure and movement patterns.

Myofascial release is a more gentle technique that can be useful in cases where a patient is already experiencing a great deal of pain. The therapist will hold gentle pressure at the barrier of the tissue (the point where resistance is felt) for a short period of time, usually less than 2 minutes until the therapist feels the tissue release on its own. The therapist does not force the barrier.

Scar Tissue Manipulation

Scars are almost always a fact of life. From surgeries, to accidents, to conditions like endometriosis, or certain STI’s, almost everybody has one. What doesn’t have to be a fact of life are the muscle, nerve and skin restrictions and overactivity that they can cause. By releasing scar tissue in physical therapy, it has been shown that the surrounding restrictions also decrease their resistance and adherence to the deeper tissues and surrounding organs.

Myofascial Trigger Point Release

Discussed extensively in Travel and Simon’s two volume series, trigger points are taut (firm) points in the muscle that have a consistent referral pattern (they transmit pain to the another part of the body). Trigger points are not only important because they cause pain, they also can affect how the muscle works. This is one of the main reasons our therapists at Beyond Basics are fastidious about ensuring all trigger points are released in the abdomen, back, legs and pelvic floor before transitioning to any core stabiltiy or strengthening exercises that can re activate a trigger point.

People with trigger points in their pelvic floor and surrounding areas can experience pain in the rectum, anus, coccyx, sacrum, abdomen, groin and back and can cause bladder, bowel, and sexual dysfunction. When physical therapists find a trigger point they work to eliminate it and lengthen it through a myriad of techniques. Recent literature has found that trigger point release alone can achieve an 83% reduction in symptoms.

Connective Tissue Manipulation

Skin rolling, ie. rolling of the skin over another layer helps to improve the movement of those two layers and reduce the tension and pulling between them. It feels like a scratch or ‘nails’, and in cases where a patient has more restrictions, the sensation may be more amplified.

One of the great benefits to skin rolling is it increases the circulation in the area to which it was applied. Often times, areas that are tight or restricted are receiving reduced blood flow and oxygen. By bringing blood flow to the area, toxins can be cleared and the healing contents of the blood are brought to the injured area. Skin rolling can also restore the mobility of surrounding joints and nerves, which can help to restore normal function. By allowing the skin to move more freely, pelvic congestion, heaviness and aching can be effectively treated.

Neural, Visceral, and Joint Mobilization

Nerves, organs, and joints can lose their natural mobility over time and cause a whole host of symptoms from pain, to loss of range of motion, and poor functioning of the bodily symptoms. Skilled and specialized therapists can use a variety of active techniques (patient assisted) and passive techniques to free up restrictions in these tissues and organs and improve overall function.

Neural mobilization as the name implies, involves the restoration of neural structures back to their normal mobility: to glide and slide. Neural structures that cannot move properly can cause pain that can radiate down an extremity or into the trunk and can give the sensation of burning, zinging, and stabbing. Some orthopedic therapists practice this type of mobilization; common examples include the sciatic nerve in the leg and the ulnar nerve in the arm. Pelvic floor PTs focus on these nerves when they cause issues, but they also pay attention to nerves that innervate the perineum and genital region (bicycle seat area), such as the pudendal, iliohypogastric, obturator, ilioinguinal, genitofemoral and the femoral cutaneous nerves. By allowing these nerves to move freely, symptoms such as vulvovaginal, penile, rectal, clitoral and testicular pain, itching and burning can be greatly improved.

Visceral mobilization restores movement to the viscera or organs. As elucidated earlier in our blog, the viscera can affect a host of things even including how well the abdominal muscles reunite following pregnancy or any abdominal surgery. Visceral mobilization aids in relieving constipation/IBS symptoms, bladder symptoms, digestive issues like reflux, as well as sexual pain. Visceral mobilization can facilitate blood supply to aid in their function, allow organs to do their job by ensuring they have the mobility to move in the way they are required to perform their function, and to allow them to reside in the correct place in their body cavity. Evidence is beginning to emerge to demonstrate how visceral mobilization can even aid in fertility problems.

Joint mobilization is a common and favorite tool of most orthopedic physical therapists. We love it so much because it can have so many different benefits depending on the type of technique used. Maitland describes types of joint mobilization on a scale between 1 and 5. Grade 1 and 2 mobilizations are applied to a joint to help to lessen pain and spasm. These types of mobilizations are typically used when a patient is in a lot of pain and to help break the pain cycle. On a non-painful joint, grade 3, 4, and 5 (grade 5 requires post graduate training) mobilizations can be used to help restore full range of motion. By restoring full range of motion within a restricted joint, it is possible to lessen the burden on that and surrounding joints, thereby alleviating pain and improving function.

Neuro-education of the Pelvic Floor and Surrounding Structures

The muscles of the pelvic floor must work together and in coordination to perform specific tasks. The pelvic floor has to contract, elongate and relax in very precise ways to perform basic functions like urination, defecation, support the pelvis and organs, and sexual function and pleasure. If your pelvic floor muscles and/or nerves fail to do what they are supposed to do at the right time, problems like painful sex, erectile dysfunction, constipation, and incontinence can occur.

Biofeedback is a modality that allows you to learn how to better control your muscles for optimal function. Biofeedback shows you what your muscles are doing in-real time. It is helpful to teach patients to lengthen and relax the pelvic floor for issues like general pelvic pain, painful sexual activity and constipation or to contract the pelvic floor in order to prevent leakage with activities like coughing, laughing, lifting, running or moving heavy objects. However, biofeedback does not demonstrate shortened muscles and tissues; therefore, in certain cases the biofeedback may seem to be within normal limits but yet the patient has 10/10 pain. In these incidences, manual palpation is more appropriate to identify restricted and shortened tissues and muscles, and myofascial trigger points.

HEP: Home Exercise Program

 

Home exercise programs are essential for each patient. In the case of weakness, a patient will require more pelvic floor, core and functional strengthening and stability exercises. For overactive and pain conditions, the HEP typically consists of relaxation techniques, self-massages (both external and internal), gentle stretching, cardiovascular fitness as tolerated, and eventually pain-free core stability exercises. Both require postural and behavioral modifications and self-care strategies. For more information and detail, check out the book: Heal Pelvic Pain, by Amy Stein or her DVD: Healing Pelvic and Abdominal Pain here.

Conclusion

As you can now see, there is so much out there that can be done for people suffering with pelvic floor dysfunction. This blog is by no means extensive, and there are even more options you and your physical therapist can explore to help manage your pain or other pelvic issues. Pelvic floor dysfunction requires a multidisciplinary approach for most of our patients. Hopefully, this blog helped to paint a picture of what you will experience with a pelvic floor physical therapist. We advise that you seek out an expert and experienced pelvic floor physical therapist in order to help better your life and improve your function.

Sources

FitzGerald M, Kotarinos R. Rehabilitation of the short pelvic floor I. Background and patient evaluation.

Padoa A, Rosenbaum T. The Overactive Pelvic Floor. Springer. 2016

Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1 Upper Half of Body. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999.

Stein, Amy. Heal Pelvic Pain. McGraw-Hill. 2008

Stein, Amy. Healing Pelvic and Abdominal Pain. Video: www.healingpelvicandabdominalpain.com 2013

Travell, Janet G. and Simons, David G., MYOFASCIAL PAIN AND DYSFUNCTION. THE TRIGGER POINT MANUAL, Volume 2, The Lower Extremities, Williams & Wilkins, Baltimore, 1992.

Valovska A. Pelvic Pain Management. Oxford University Press. 2016

Weiss J. Chronic pelvic pain and myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001; 166(6) 2226-31

Spring Pelvic Health 101 is Coming

Fiona McMahon, DPT, PT

Pelvic Health 101 is back with some old favorites like, “Something’s wrong with my what?” and “Why is pooping so difficult?” We have also added a new course on pediatric pelvic floor issues.

If you have questions, we have answers. Join us for lectures and question and answer opportunities with expert pelvic health physical therapists, childbirth educators, and nutritionists. Please reserve your spot early at pelvichealth-101.eventbrite.com. Remember spots fill up quickly. As always, light refreshments will be served.

pelvic-health-101-spring-2017

Upcoming Live Webinar: The Collaborative Clinical Care Model Between Therapists and Pelvic Floor Physical Therapists Involving Clients with Sexual Pain

 

Amy Stein, PT, DPT

WHEN: Monday, February 6, from 12.30-2.30pm at www.saricooper.com/webinars/

INTENDED AUDIENCE: sex therapists, general therapists, pelvic floor physical therapists and other health and wellness providers.

HOSTED BY : Amy Stein, DPT, BCB-PMD, IF and Sari Cooper, LCSW, CST

CEs for LMSW/LCSWs, AASECT

CEs for Physical Therapy

Blog By Amy Stein, DPT

I am so pleased to offer my first cross-disciplinary webinar with Sari Cooper, LCSW, CST, a leading expert in sexual health, sexual pain,and women’s health. She is the Founder and Director of Center for Love and Sex, and is a licensed individual, couples and AASECT-Certified Sex Therapist, sex coach, writer, trainer, supervisor and media expert. She specializes in sexual disorders, sexual avoidance, couple’s communication, affairs, separation, depression, anxiety, and alternative sexual interests.

Sari was trained in the Family Systems Model, which states that if there is a change in one person in the family, than it affects the whole family system.  This directly affects couples in which one partner is suffering with pelvic pain.  Sari helps the couple and the individual work on communication skills and gives them practice exercises to address their emotional and sexual relationship. When it comes to couples sexual function, Cooper feels she almost always asks clients to work with both partners.  Using techniques such teaching couples the importance of outercourse as well as intercourse in order to sustain erotic connection while a partner is being treated for pelvic pain.

Sari recognizes the need for a multimodal approach in treating pain. She has years long experience treating men and women whose pain is musculoskeletal, systemic, hormonal, or related to another condition, in addition to psychological. She is experienced and collaborated with pelvic floor physical therapists and other medical providers to aid in the healing process.

As pelvic floor PTs, we help the musculoskeletal conditions related to sexual dysfunction and we work closely with mental health and sexual health therapists.  In women, we see and have great success with treating conditions  like vulvodynia, provoked or unprovoked vestibulodynia, vaginismus, endometriosis, pelvic neuralgias like pudendal neuralgia, and other pelvic conditions. In men, we successfully treat musculoskeletal conditions related to erectile dysfunctions, non bacterial prostatitis, and genital and pelvic pain.

In our upcoming webinar, Sari will be reviewing some of the education about the female sexual response cycle that she provides couples to help them re-discover pleasure and eroticism while the patient is working with her pelvic floor physical therapist on relieving her pain.

To learn more, sign up for Amy Stein, DPT and Sari Cooper’s LIVE LUNCHTIME  webinar on Monday, February 6, from 12.30-2.30pm at www.saricooper.com/webinars/ CEs for PTs, LMSW/LCSWs, AASECT Therapists/Counselors will be provided.