Category Archives: Interstitial Cystitis

Guest Post: There’s a pelvis… in your brain?!

As an educator, one of my biggest rewards is working with students and clinicians as they learn and grow in the field of pelvic floor physical therapy. This past winter, I was fortunate to work with Amanda Bastien, SPT, a current 3rd year doctoral student at Emory University. Amanda is passionate about helping people, dedicated to learning, and truly just an awesome person to be around, and I am so grateful to have played a small role in her educational journey! Today, I am thrilled to introduce her to all of you! Amanda shares my fascination with the brain and particularly the role it can play when a person is experiencing persistent pain. I hope you all enjoy this incredible post from Amanda! 

Have you ever been told your pain is “all in your head?” Unfortunately, this is often the experience of many people experiencing persistent pelvic pain. Interestingly enough, the brain itself is actually very involved in producing pain, particularly when a person has experienced pain for a long period of time. In this post, I’ll explain to you how someone can come to have pain that is ingrained in their brain, literally, and more importantly, what we can do to help them get better.

Pelvis image

Our brains are incredible! They are constantly changing and adapting; every second your brain fine tunes connections between brain cells, called neurons, reflecting your everyday experiences. This works like a bunch of wires that can connect to one another in different pathways and can be re-routed. Another way to say this is “neurons that fire together, wire together.” This process of learning and adapting with experiences is known as neuroplasticity or neural plasticity. It is a well-documented occurrence in humans and animals. If you’re interested in learning more, this is a great article that summarizes the principles underlying neuroplasticity.1

In the case of pain…. well, here’s where it gets a little complicated.

The brain has distinct physical areas that have been found to relate to different functions and parts of the body.

brain areas

Those two spots in the middle that read “primary motor cortex” and “primary sensory cortex” relate to the control of body movements, and the interpretation of stimulus as sensations like hot, cold, sharp, or dull. By interpretation, I mean the brain uses this area to make sense of the signals it’s receiving from the rest of the body and decides what this feels like. These areas can be broken down by body structure, too.

In this next image, you’re looking at the brain like you’ve cut it down the middle, looking from the back of someone’s head to the front. This image illustrates the physical areas of the brain that correlate to specific limbs and body parts. This representation is known as a homunculus.

homonculus

See how the hand and facial features look massive? That’s because we do a LOT with our hands, have delicate control of our facial expressions, and feel many textures with both. Thus, these areas need a lot of physical space in our brains. In this image, the pelvis takes up less space than other areas, but for people who pay a lot of attention to their pelvis, this area may be mapped differently, or not as well-defined. We know that the brain changes due to experiences, and ordinarily, it has a distinct physical map of structures. But what happens when that brain map is drawn differently with experiences like pain?

Studies suggest that over time, the brain undergoes changes related to long-lasting pain. If someone is often having to pay attention to an area that is painful, they may experience changes in how their brain maps that experience on a day-to-day basis. This varies from person to person, and we’re still learning how this happens. Here’s an example: in a recent study, people experiencing long-standing pelvic pain were found to have more connections in their brains than in those of a pain-free control group, among other findings. The greater the area of pain, the more brain changes were found.2 My point here is to provide you with an example of how the brain can undergo changes with pain that can help explain how strange and scary it can feel for some. Read on to find out how we can work to reverse this!

The process that makes pain occur is complex. It often starts with some injury, surgery, or other experience causing tissue stress. First, cells respond by alerting nerves in the tissues. Then, that signal moves to the spinal cord and the brain, also called the central nervous system. The brain weighs the threat of the stress; neurons communicate with each other throughout the brain, in order to compare the stressor to prior experiences, environments, and emotions. The brain, the commander-in-chief, decides if it is dangerous, and responds with a protective signal in the form of pain.

Pain is a great alarm to make you change what you’re doing and move away from a perceived danger. Over time, however, the brain can over-interpret tissue stress signals as dangerous. Imagine an amplifier getting turned up on each danger signal, although the threat is still the same. This is how tissue stress can eventually lead to overly sensitive pain, even after the tissues themselves are healed.3

Additionally, your brain attempts to protect the area by smudging its drawing of the sensory and motor maps in a process called cortical remapping. Meaning, neurons have fired so much in an area that they rewire and connections spread out. This may be apparent if pain becomes more diffuse, spreads, and is harder to pinpoint or describe. For example, pain starts at the perineum or the tailbone, but over time is felt in a larger area, like the hips, back, or abdomen. To better understand this, I highly recommend watching this video by David Butler from the NOI group.

He’s great, huh? I could listen to him talk all day!

Pain alarms us to protect us, sometimes even when there’s nothing there! After having a limb amputated, people may feel as though the limb is still present, and in pain. This is called phantom limb pain. The limb has changed, but the connections within the brain have not. However, over time the connections in the brain will re-route. I share this example to illustrate how the brain alone can create pain in an area. Pain does not equal tissue injury; the two can occur independently of one another.4 Pain signals can also be created or amplified by thoughts, emotions, or beliefs regarding an injury. Has your pain ever gotten worse when you were stressed?

There is also some older case evidence that describes how chronic pain and bladder dysfunction evolved for people after surgery, in a way that suggests this type of brain involvement.5  Another case study describes a patient with phantom sensations of menstrual cramps following a total hysterectomy! 6

So, can we change the connections that have already re-mapped?

Yes!! The brain is ALWAYS changing, remember? There are clinicians who can help. Physicians have medications that target the central nervous system to influence how it functions. Psychologists and counselors can help people better understand their mental and emotional experiences as they relate to pain, and to work through these to promote health. Physical therapy provides graded exposure to stimuli such as movement or touch, in a therapeutic way that promotes brain changes and improved tolerance to those stimuli that are painful. This can result in a clearer, well-defined brain map and danger signals that are appropriate for the actual level of threat. Physical therapists also help people improve their strength and range of motion, so they can move more, hurt less, and stay strong when life throws heavy things at us!  It is SO important to return to moving normally and getting back to living! Poor movement strategies can prolong pain and dysfunction, and this can turn a short-term stressor into long-lasting, sensitized pain. (See Jessica’s blog here: LINK)

Of course, with any kind of treatment, it also depends on the unique individual. Everyone has personal experiences associated with pain that can make treatment different for them. We are still learning about how neural plasticity occurs, but the brain DOES change. This is how we are all able to adapt to new environments and circumstances around us! Pain is our protective mechanism, but sometimes it can get out of hand. While tissue injury can elicit pain, the nervous system can become overly sensitized to stimulus and cause pain with no real danger. This perception can spread beyond the original problem areas, and this can occur from connections remapping in the brain and the spinal cord. For pelvic pain, treatment is often multidisciplinary, but should include a pelvic health physical therapist who can facilitate tissue healing, optimal movement, and who can utilize the principles of neural plasticity to promote brain changes and return to function.

Amanda_Bastien2Amanda Bastien is a graduate student at Emory University in Atlanta, GA, currently completing her Doctorate of Physical Therapy degree, graduating in May 2018. Amanda has a strong interest in pelvic health, orthopedics, neuroscience and providing quality information and care to her patients. 

References:

  1. Kleim, J.A., Jones, T.A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51, S225-S239. Retrieved from: https://www.jsmf.org/meetings/2008/may/Kleim%20&%20Jones%202008.pdf
  2. Kutch, J. J., Ichesco, E., Hampson, J. P., et al. (2017). Brain signature and functional impact of centralized pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study. PAIN, 158, 1979-1991.
  3. Origoni, M., Maggiore, U. L. R., Salvatore, S., Candiani, M. (2014). Neurobiological mechanisms of pelvic pain. BioMed Research International, 2014, 1-9. http://dx.doi.org/10.1155/2014/903848
  4. Flor, H., Elbert, T., Knecht, S. et al. (1995). Phantom -limb pain as a perceptual correlate of cortical reorganization following an arm amputation. Nature, 375, 482-484.
  5. Zermann, D., Ishigooka, M., Doggweiler, R., Schmidt, R. (1998) Postoperative chronic pain and bladder dysfunction: Windup and neuronal plasticity – do we need a more neuroulogical approach in pelvic surgery? Urological Neurology and Urodynamics, 160, 102-105.
  6. Dorpat, T.L. (1971) Phantom sensations of internal organs. Comprehensive Psychiatry, 12(1), 27-35.

 

 

Advertisements

Do we move differently in pain?

For the past few years, my studies in pelvic health have taken me further and further outside of the pelvis.  I have learned and continue to learn how amazingly interconnected our bodies actually are. The pelvis can be influenced by the ankle, the knees—and even the neck! It is amazing and awe-inspiring. This past weekend, my studies took me to the Level 1 Selective Functional Movement Assessment (SFMA), where I spent 2 days learning a systematic way to evaluate movement and identify where dysfunctional patterns exist—head to toe! (How awesome is that?!) There are many different systems and programs out there for evaluating someone’s movement, and honestly, I don’t necessarily think one is superior to the other. I liked this one though, as it made sense to me and the initial screen could be completed in 2 minutes :).

athletic-girl-1388572_1920

So, why is it important to look globally at human movement when a person is experiencing pain anywhere in the body? For lots of reasons, like I said above—but for the purpose of today’s post—because we now know that movement patterns do really change when a person is experiencing pain—and this is helpful initially and important—remember, your brain wants to protect you from experiencing harm! However, dysfunctional movement patterns, although helpful to the body in that moment, can persist and lead to further problems down the road.

Paul Hodges (a favorite researcher of mine!) and Kylie Tucker examined the current theories regarding movement adaptations to pain in a 2011 review published in the International Association for the Study of Pain. They looked at the current research regarding movement variations in pain, and frankly poked holes in the theories where holes needed poking.  They then presented a new theory on the motor adaptations to pain, and that’s what I would like to share with you today.

The theory they presented is based on the premise that movement adaptations occur to reduce pain and protect the painful part. The way in which a person does that actually varies and is flexible. Here are the basics of their theory, simplified, of course. I do encourage you to read the paper if you’re interested—it’s great!

  • Adaptation to pain involves redistribution of activity within and between muscles. Basically, the brain varies which pools of motoneurons fire in a muscle based on the individual and the task requirement. The common goal still is to protect the painful part from pain or injury, but the way the body does this can vary greatly. Interestingly, we know that the motoneurons active before and during pain tend to reduce activity, and the production of force actually seems to be maintained by a new population of units who were previously inactive. Normally, motoneuron units are recruited from smaller to larger pools to allow for a gradual increase in force—but in pain, a person often will have earlier recruitment of larger pools to basically allow for a faster development of force to get away from pain (think fight or flight response!). Also, the new population of active units may be altered to change the direction of the force generated by the muscle (again, aiming to help protect the painful structure). We also can see in some areas, like the trunk, that one muscle may become inhibited (like the transverse abdominis) while other larger muscles become more activated. This again, makes sense with the body’s goal of protection. Quick activation of larger motor units allows for a quick activation of a muscle to help protect and escape pain.
  • Adaptation to pain changes mechanical behavior. Basically, like we just discussed, the redistribution of activity within and between muscles changes the force and output of the muscle. Hodges & Tucker give us a few examples of this. First, they’ve found that when someone has knee pain, the quadriceps muscles fire differently to change the direction of knee extension by a few degrees. They also explain that the changes in muscle firing in the trunk muscles in someone with back pain leads to more stiffness and less control of movements and less anticipatory action. Basically, in each of these cases, the big picture motion stays the same, but there are small changes within how the body accomplishes those tasks.
  • Adaptation to pain leads to protection from pain or injury, or threatened pain or injury. Basically, this redistribution of muscle firing is done to protect against pain—or even the threat of pain. When a person experiences pain, the brain choses a new pattern to move to either splint the injured area, reduce the movement of the area, or alter the force on the area. The interesting piece here is that the body responds this way even when there is a perceived threat of pain! The key with all of this is that the adaptation varies significantly—not one pattern is seen for all types of pain, but the nervous system has a variety of options for protection!
  • Adaptation to pain involves changes at multiple levels of the motor system. So, although we know that the activation of motoneuron pools can change during pain, that alone does not describe the variability we see. We know now that the way the body changes movement can be influenced by structures in the brain, spinal cord or at the local level of the motoneuron. All of this is going to be influenced by the task at hand and the individual (thoughts about the pain, emotions, stressors, and previous experiences)
  • Adaptation to pain has short-term benefit, but with potential long-term consequences. Although the short-term benefit is protection of the painful area and prevention of further pain, this may lead to consequences down the road if the adaptation persists. Of course, we assume in this case that movement in a non-pain state is likely the most efficient and optimal way to move. So, changes over time could produce decreased movement variability, modified joint loading, modifications in walking patterns, joint load and ligamentous stress. Hodges and Tucker state that in order for these long-term consequences to occur, there would likely need to be a gradual maintaining of the compensation, thus that the nervous system did not recognize it being problematic. Basically, the brain slowly adapts to the new pattern and does not recognize the problems it could cause down the road.

Interesting stuff right? The tricky thing is, we don’t really know for certain how these long-term changes can impact the body—but we do know that one of the biggest risks for injury is previous injury. I can’t help but think that movement changes could possibly contribute. But how do we change this in a positive way?  I think the first step is understanding pain, learning what pain is and what pain is, and developing a healthy mindset toward pain—this alone goes a long way! We also have to look closely at our own emotions, our psychological state, our previous experiences, and understand how all of these things can influence how are brain chooses to respond to pain. But then, we need to identify which movements the body has changed, understand how the brain is varying movements to protect against pain, and then slowly provide variability with good force modulation in those movements to help the brain learn optimal, safe and pain-free ways to move again.

What do you think? I’d love to hear from you in the comments below!

Cheers!

Jessica

Can physical therapy help a “bladder problem?” Highlights from my presentation at the Atlanta Interstitial Cystitis Support Group

Jessica IC Support Group

Yesterday, I was fortunate to speak with the Atlanta area Interstitial Cystitis (IC)Support Group regarding physical therapy interventions for men and women with IC/PBS (Painful Bladder Syndrome).  I love working with men and women with IC for so many reasons. First, IC can be a fairly scary diagnosis for a lot of people as there is not one specific known “cause”, nor is there a “cure” that works for everyone. Dr. Google can also cause quite a bit of fear as the newly diagnosed read “horror stories” of people who have suffered for years and years with debilitating pain.

The amazing thing is that often times, bladder pain can actually have strong musculoskeletal components and neuromuscular components that are easily addressed with a skilled physical therapist–but in order to understand that fully, we will have to dive in a little deeper. So, here are some of the highlights from the presentation I gave to this wonderful group last night. (Sidenote: IC/PBS is different in everyone, meaning that some treatments work great for some and not so well for others. This blog highlights physical therapy interventions for IC, but please know that each person with IC will have a different journey toward recovery. I strongly recommend building a network of health care providers and finding the treatment that works the best for you.)

First, we started with a little pop quiz–and we’ll start you with the same, to test your knowledge on physical therapy for people with IC :). 

1. True or False.  It is common for men and women with IC/PBS to have tenderness and banding of the pelvic floor muscles as well as other soft tissues structures around the pelvis.

True. A study by Peters and colleagues in 2007 estimated that 87% of people with IC/PBS also have pelvic floor muscle tenderness.

2. True or False.   Traditional pelvic floor strengthening (Kegels) are helpful in reducing pain for men or women with IC/PBS.

False. For people with tender pelvic floor muscles, traditional kegel exercises are actually contraindicated. The American Urological Association’s Guidelines for the Evaluation and Treatment of IC states that people who are receiving physical therapy with kegel exercises should stop treatment and seek out care from someone with advanced training in working with this population.

3. True or False.  The most recent American Urological Association’s Guidelines for the Evaluation and Treatment of IC/PBS strongly recommends physical therapy for men and women diagnosed with IC/PBS.

True. I know, I sort of gave it away in my answer up above. But physical therapy interventions such as education on IC and dietary modifications, use of cold/hot packs, stress management strategies, managing tender points in muscles, pelvic floor relaxation exercises and managing constipation/sexual pain are considered first-line treatments in the most recent guidelines. Of note, manual physical therapy including connective tissue mobilization is a second-line treatment.

In order to better understand how physical therapy can help someone with IC, we need to look a little deeper into why the muscles around the pelvis become tender in the first place. At my presentation last night, we spent some time discussing the muscles of the hips and abdomen as well as the pelvic floor muscles. If you aren’t familiar with these muscles already, you can take a quick course by reading Tracy Sher’s article here.

bladder in pelvis

We then spent some time discussing some of the reasons the muscles and the soft tissues of the pelvis become tender when someone has IC. Specifically, we discussed the following mechanisms:

1) Tension response to pain: Basically, if the bladder is hurting, I will likely contract the muscles around it to “protect” the painful area. Over time, those muscles can become fatigued and tender.

2) Viscerosomatic reflex: When the brain is receiving a “danger” message from the bladder for a long period of time, there will often be an increase in sympathetic nerve activity (fight or flight response) which can lead to increased inflammation and decreased blood flow in the muscles and the connective tissue around the organ. Over time, this can contribute to tender muscles around the organ. We also often will see that muscles which are innervated by nerves at the same spinal cord level will also have some increased sensitivity and tenderness.

3) Somatovisceral reflex: This is basically the reflex above, but in reverse. Tendernesss in the muscles or a “danger” message from the muscles can also create that same sequelae of events which may lead to increased sensitivity at an organ near those muscles. The cool thing is that we can use this to our advantage because treating the muscles and tender soft tissues can actually help to decrease the bladder irritation!

Typically, for people with IC, we see connective tissue restrictions in the suprapubic area, abdomen, thighs, buttock and perineal area. We also will see tender and sensitive muscles including the pelvic floor muscles, adductor muscles, hip flexors, hamstrings, piriformis and gluteal muscles. Treating these muscles with manual therapy and connective tissue mobilization can help to improve blood flow, decrease inflammatory chemicals and improve the sensitivity in these structures. You can read more about connective tissue mobilization in this blog post by my colleagues over at the Pelvic Health and Rehabilitation Center.

This all ties in very nicely with our current understanding of the neuroscience of pain, which of course, is where we went next.  Much of what we discussed last night can be found in greater detail in the book, Why pelvic pain hurts which I summarized for you a few weeks ago here. The key thing to recognize is that pain is our body’s alarm system— it’s meant to tell us when there is “danger” and to help us protect ourselves. For someone who has had pain for a long time, this system can become sensitized meaning that previous non-painful activities or areas of the body can start to become perceived as painful. This is also influenced by a strong “fight or flight” response which basically can make your body respond like it is constantly under attack. Our brain integrates all of this with our previous experiences, emotions, fears, etc. All of this contributes to a worsening pain experience.  The great thing is that we now know that there is so much we can do to help re-train a brain that is constantly “protecting!” 

30d490ce9760c3202eca35538740017511b77faa

So, next we moved to the most important piece…what can a skilled physical therapist do for someone with IC/PBS? 

 1. Education– knowledge is power and this is such an important component for someone with pelvic pain! We typically will discuss the following:

  • Dietary education
  • Bladder/Bowel habits
  • Sexual function
  • Sleep habits
  • Stress Management
  • Relaxation training/downtraining
  • Neuroanatomy of pelvic pain

2. Desensitizing and retraining the nervous system 

  • Manual therapy techniques (discussed more below)
  • Specific stretches to lengthen muscles
  • Graded motor imagery
  • Posture/alignment training
  • Breathing/Relaxation
  • Setting of appropriate goals, pacing and graded exposure to movements

3. Manual therapy techniques to reduce muscle soreness, improve blood flow,  and desensitize the nervous system

  • Connective tissue mobilization
  • Internal soft tissue treatment to the pelvic floor muscles
  • External soft tissue treatment to the muscles around the abdomen and pelvis
  • Dry needling
  • Scar tissue management

Recent research has shown that manual therapy for someone with IC is very effective in reducing pain. In fact, a multicenter study by Fitzgerald and colleagues in 2012 showed that 60% of women with IC who were treated with soft tissue treatments and connective tissue mobilization saw moderate-marked reductions in pain and improved urinary urgency and frequency.

We closed our discussion last night with a plan of action– reviewing some basic recommendations to get started on improving pain for people with IC.  It was wonderful to meet with this awesome support group! For those of you with IC or bladder pain, the IC Association has a list of support groups that are registered in cities in the US and internationally. They also have great options for online support groups.

If you live in Atlanta or the surrounding area, Judy Eichner is the group coordinator. She can be e-mailed at: icatlanta@live.com.

As always, I would love to hear from you! What have been your experiences with physical therapy IC? Is there anything you would like me to add for future presentations? Let me know in the comments!

Have a great weekend!

~ Jessica

TBT: If you can’t drink coffee…try Barley coffee!

Yes, I realize it’s Friday and I am one day behind on my throw-back. I’m sorry. Anyways, today’s post was published here in 2013 after I presented at the Greenville Interstitial Cystitis Support Group. I always love working with local support groups, and I am excited to be presenting to and learning with the Atlanta Area Interstitial Cystitis Support Group next month!  I had such a wonderful time with those ladies and I was introduced for the first time to Barley coffee–yes, you heard me right–coffee made from Barley. For many people with bladder problems including Overactive Bladder, Interstitial Cystitis/Painful Bladder Syndrome, and Urinary Incontinence, regular coffee is not tolerated well and can exacerbate symptoms. Barley coffee is a great alternative that packs a great taste (I was skeptical too, but it’s true!) but doesn’t have the acid and caffeine which irritate. Check out my post, and give it a try! 

coffee-386878_640

In April 2014,  I was fortunate enough to meet with a lovely group of ladies at their support group for people who have been diagnosed with Interstitial Cystitis/Bladder Pain Syndrome.  (For those of you who are not familiar with this condition, you can read about it here) This is a fantastic group started by Martha Fowler, RN back in 2010. Since then, I can tell you that Martha has been an amazing support for several of my patients! So many times, people feel alone when struggling with pelvic pain conditions, and it’s nice to talk with others who understand first hand what you are going through. For those of you reading this who live in other areas (such as Atlanta, like me!) there are tons of other support groups out there for people with IC/PBS. The Interstitial Cystitis Association (ICA) has a great list here.

Anyways, before we got started, Martha introduced us to Barley coffee—I know what you’re thinking—weird, nasty, gross—but I was shocked that I actually enjoyed this concoction! When I first tasted it, I will admit, I poured myself approximately ¼ cup (assuming I would hate it), but I quickly went back, filled it all the way up and drank the entire thing!  SERIOUSLY! I actually think I may keep this on hand to drink on a regular basis. I have long wanted to cut back on my caffeine intake, and really, this may be the ticket!

Why the need for Barley Coffee?

For people with Interstitial Cystitis (and other bladder/bowel problems), coffee can be quite irritating to the bladder. Coffee is a double-whammy of irritation—not only does it have caffeine, but it is also highly acidic. Mix this together, and you get a very unhappy bladder—and if you have IC/PBS, that equals pain and strong urges to urinate.

What is Barley?

Barley is a grain and a member of the grass-family. You may recognize it from being used as animal food as well as in beer, bread, soups and stews.  The Whole Grain Council (yes, it exists) has listed several health benefits of eating barley including lowering blood sugar, decreasing cholesterol, and possibly with weight loss. And what about drinking it? Well, I will admit it’s not quite the same since you are not actually consuming the grain—but, it seems like a good option for your bladder! And it tastes pretty darn good.

barley

Check out the recipe!

Martha’s Barley Coffee

Ingredients:

1 bag of barley (dry—looks like rice)

Water

Directions:

1. Roast barley over medium heat, stirring constantly until browned.  (WARNING: Per Martha, this may cause some smoke, so make sure your kitchen is ventilated! Stirring constantly reduces likelihood of burning). Best to roast slowly as this decreases the likelihood of burning

2. Allow to cool completely. Store in airtight container until ready to use.

3. Add a few tablespoons of roasted barley to a pot of water and heat over medium. The longer you heat the water/barley the “darker” your coffee.

4. Strain out barley & save for later use! Serve in your best coffee pot with cream/milk & sugar.

I hope you enjoy this wonderful coffee substitute! What other substitutes have you used for dietary intolerances? 

Have a great weekend! ~ Jessica

Book Review: Why Pelvic Pain Hurts

I love books. I love picking out a new book, flipping through the pages, and escaping for a small time into a different world. My love of reading translates so easily into my clinical practice in women’s health and pelvic floor physical therapy. Clients who have worked with me know that I keep a shelf of related books in my practice for them to look through and enjoy. I find books are so helpful for my clients experiencing related problems. Often times, men, women and children with pelvic health problems feel alone and so isolated. The reality is that these issues are private ones–I will often treat clients whose own spouses are not aware that these issues are occurring! And there are SO many great pelvic health books out there! The biggest thing I love about my clients reading books is that it helps the to realize they are not alone. So many other people have these problems too–so many that there are books written about it! I also think that reading information helps the learning process for many so much more than just hearing information spoken by me! My hope in “book reviews” is to share some of those awesome books with you, so you can read them, recommend them and learn from them! Whether you are a patient seeking information, a health care provider, or just an interested individual, I hope these reviews will be helpful!  Enjoy! 

from amazon.com

from amazon.com

I am so excited to introduce you today to a wonderful little book called, Why Pelvic Pain Hurts by Adriaan Louw, Sandra Hilton and Carolyn Vandyken. These authors are all physical therapists and both Sandy and Carolyn are Pelvic PTs. To be honest, I’ve followed Adriaan Louw for quite some time now. I have read some of his other educational books such as Why do I hurt? and I have even listened to his online educational seminar via Medbridge called “Teaching People About Pain.” He’s brilliant–so I knew I would love this book from the moment I heard it was being published! Who should read it? 

  • Men & Women experiencing chronic pelvic pain
  • Clinicians working with men and/or women experiencing chronic pelvic pain
  • Families & friends of people experiencing chronic pelvic pain

What are the details? 

  • Cost: $15.69 on Amazon.com
  • Length: 67 pages with great illustrations, broken into 5 sections.
    • Understanding your body’s alarm system
    • Understanding your extra-sensitive alarm system
    • Understanding your pelvic pain
    • Understanding your Lion and how it impacts you
    • Understanding your treatment options

What’s so good about it?  As you may know by reading my blog, I love how the current understanding of pain is so much more than just tissue damage. Our nervous system is powerful and incredible, and is significant in the pain experience. Often times, clinicians run into difficulty when they start talking with clients about the neuroscience related to chronic pain– mostly because these people have had bad experiences in the past with people thinking their pain is “all in their head.” Louw does a great job of emphasizing that pain is a real experience no matter what situation it occurs under, but that pain does not always correlate with tissue damage. Hurt does not always correlate with harm. This book uses fantastic metaphors and stories to help drive home key points. The book begins in the first two sections by describing the nervous system’s involvement in the pain experience, and goes into detail as to how these systems become overly sensitized in a person experiencing chronic pain. I especially love the pages where the authors highlight all of the situations that contribute to a more sensitized system (such as failed treatments, family concerns, fear/anxiety, ongoing pain, etc.) as I think this is such a big piece for people to understand. The next section focuses on pelvic pain specifically, initially beginning with highlighting one of the major problems in overcoming pelvic pain (the “taboo”). They then go on to utilize a wonderful analogy of a measuring cup being “filled” by the 400 nerves in the body passing information to the brain. This measuring cup “overflows” when a large volume of information is being sent or when emotions/stressors surround the experience (like a flame heating the water in the cup). This metaphor is used throughout the book with treatment focused on helping the water to stop boiling over.  The rest of this section goes through various diagnoses related to pelvic pain, but also emphasizes that the pain experience (from a neurological perspective) is the same in most diagnoses despite the differences in the symptoms. Lastly, the authors describe the difference between tissue problems and a sensitive nervous system.

Your metaphorical pain "cup"

Your metaphorical pain “cup”

Section 4 utilizes a fantastic metaphor of being under attack by a Lion and describes in detail how the body feeling under a constant threat of danger and in a strong protective response can contribute to experiences such as tender areas in the body, mood swings, appetite changes, fatigue… and much more! They also describe the other areas in the brain that are involved with pain and the overlap with different tasks (such as sensation, movement, and even memory!). They also maintain compassion and understanding for the experience unique to people with pelvic pain, and beautifully state, “At the core of being human, being alive, there are certain bodily functions that should not only be pain-free, but enjoyable…when you have pelvic pain, you’re not only robbed of pleasure, but the pleasure is replaced with pain. How unfair is that?

lion

Don’t worry- the book does not end here :). Section 5 discusses treatment options emphasizing that treatment should be aimed at stopping filling or emptying the “cup” or extinguishing the “fire” under the “cup.” Then, the authors systematically go through current treatments including knowledge/education, manual therapy, soft tissue treatment, specific exercises, graded motor imagery, aerobic exercises, medication, sitting posture, breathing/relaxation, sleep, stress management, and activity pacing/graded exposure. Under each of these categories, clear explanations are given as well as recommendations to get started! I could write a whole other blog post on these recommendations…but then you wouldn’t be thirsty for more, would you? So, all of that to say– this was a wonderful book! I strongly recommend it for men and women experiencing chronic pelvic pain– it’s an easy read, cheap, and offers clear recommendations to get started toward pain-free relief. Knowledge truly is power when it comes to recovering from chronic pain. Do you have any questions about the book? Have you read it yet? What books do you love and want me to review next? I would love to hear from you in the comments below! ~ Jessica

How should urgency suppression strategies be modified for the tender or “hypervigilant” pelvic floor muscles?

Urinary urgency, frequency and incontinence are complex and involve the interactions of multiple systems (somatic, visceral and neurological). These three problems are treated commonly in pelvic physical therapy and women’s health physical therapy practices. Urgency suppression strategies were initially developed based on these systems- with the understanding that the pelvic floor muscles were not contributing their part to the system.  In my opinion, this was largely based on the understanding the incontinence/urgency occurred when the pelvic floor muscles were not strong enough to properly hold back urine. But, over time we have learned that this is not always the case. (See my recent post here).

toilet-1033443_1280

So, do the same urgency suppression techniques apply for a tender pelvic floor muscle group? Hhow should urgency suppression techniques be modified for the overactive, shortened or hypervigilant pelvic floor?

To understand this, I first need to introduce you to the standard urgency suppression techniques.

UST Traditional

Now, please don’t take this as “Jessica doesn’t think urgency suppression techniques work,” because that is simply not true. I use these in the clinic all the time—for my patients who are experiencing urgency or urge incontinence and have weak, under-functioning pelvic floor muscles. These techniques work for this population a few different ways:

  • Deep breathing facilitates the parasympathetic nervous system which helps to keep the walls of the bladder relaxed thus allowing the bladder to fill and decreasing urgency. This breathing also helps to decrease the emotional fear that a person may feel (“Ahh, I hope I make it to the bathroom!”) which also will calm urgency due to the impact this has on the brain.
  • Strong, quick, contractions are thought to stimulate the neurological connection between the pelvic floor muscles and the bladder. Basically, quick contractions tell the bladder “it is not yet time to empty” and the bladder relaxes its contractions (which make us feel the strong urge) helping to calm urgency.
  • Distraction/Visualization are ways to get the mind off of the bladder and on to something else. Remember when you needed to go to the restroom, but got busy and forgot you needed to go? This aims to utilize that same mechanism to calm urgency and allow postponement of the urge.

Sounds great, right? And it is—really great for people who are experiencing urgency and have weak, underactive pelvic floor muscles. But what about for the people having overactive/shortened/hypervigilant pelvic floor muscles?

My thought process is that these techniques have to be modified to allow them to be effective for this population. First, we will keep a few steps and here’s why:

Deep breathing & Distraction/Visualization: I actually love these (especially the calm breathing) for my patients with difficulty relaxing the pelvic floor muscles. I often find that people with overactive pelvic floor muscles tend to be in a sympathetic-drive state for their nervous systems. Remember, the sympathetic nervous system is the “fight-or-flight” response. People who have chronic pain or chronic urgency/frequency often will have a significant amount of stress and fear, and I find that this state of their system often facilitates poor breathing patterns and overall increased tension and poor force modulation (meaning, choosing the right amount of muscle activity for the current task at hand). My colleague, Seth Oberst, wrote an amazing post about this very thing recently (I could write an entire post applying all of that to the pelvic floor!). So, we’ll keep these steps—with an emphasis on slow, calm breathing, utilizing the diaphragm and emphasizing relaxation of the pelvic floor with the inhale and returning to baseline with the exhale.

But here’s where we modify:

Quick, strong, pelvic floor contractions: My issue with this component for the overactive or hypervigilant or shortened pelvic floor muscles stems from a few key points. Traditional “kegels” or pelvic floor strengthening exercises are contraindicated for people with pelvic pain (or in my mind, anyone who has a tender, hypervigilant or overactive pelvic floor). Performing quick contractions for this population often will create pain, worsen the patient’s symptoms and actually increase urgency. You heard that right. Did you know that the pelvic floor muscles can actually refer to the bladder? I have had many instances when examining a person’s pelvic floor muscles that he/she reported that even lightly pressing on certain muscles made him/her feel urgency. And we know that somatovisceral convergence (a muscle impacting an organ) is real, and does occur.  So, what do we do about this step?

We use this relationship in our favor.

Instead of quick, hard contractions, the person can perform deep breathing and pelvic floor drops (emphasizing complete pelvic floor relaxation). Although initially, some of my clients will worry that relaxing the pelvic floor muscles will “open the flood gates” this does not typically occur. Instead, relaxation of the pelvic floor combined with breathing will often calm down the detrusor (bladder muscle) activity and allow them to feel decreased urgency.

So, what do these new urgency suppression strategies look like?

 New UST

 What do you think? If you have a tender pelvic floor and/or pelvic pain, I encourage you to give it a try! Let me know what you think! As always, I would love to hear from  you!

~ Jessica