You all know by now that I’m fairly nerdy. I love reading research articles, trying to understand complex topics, and everything about learning. Honestly, I think that is why I love pelvic health so much! The pelvis is so complicated! There’s so much to know, and the more I learn, the more I truly realize how much more there is to know! As an anatomy nerd, you know I have favorite muscles. I’ve written about the respiratory diaphragm, who is one of my most favorites, but I haven’t spent much time introducing you to my other love~ the obturator internus!
Meet the Obturator Internus
The Obturator Internus (Or OI, as they are known by friends) is a muscle that lives inside your pelvis in the obturator foramen and attaches to the hip via the greater trochanter. You can see it here:
The OI has several major functions for the body. First, it is a deep hip external rotator, and has shown to be active during the movements of hip extension, external rotation and abduction. In fact, this research showed that it was the first muscle to turn on in these motions (which I theorize could be part of it’s connection to the pelvic floor muscles and the anticipatory role the pelvic floor has in movement, pressure management and postural stability). My theory on this makes sense when we look at some of the research on the involvement of the OI in hip stability. This excellent article identifies the obturator internus & externus, quadratus femoris, and gemelli as important synergistic muscles that work together to modulate the position of the femoral head in the acetabulum during movement. This is particularly cool because in many ways, this function is very similar to the pelvic floor muscles! The authors suggest a dynamic stabilizing role for these muscles, making subtle alterations in force to control the femoral head position.
This study also recognizes the stabilizing role the OI can play, particularly when it works as a team with the other deep hip rotators. The authors here highlight that the obturator internus, obturator externus, superior & inferior gemelli (who I affectionately call the gemelli brothers) are essentially fused. And this fusion, actually leads to a decent cross-sectional area and ability for force generation. The orientation of the fibers adds further credence to the view that these muscles are crucial to hip stability.
The OI shares fascial connections and attachments with the pelvic floor muscles, which makes it an even more unique muscle. The iliococcygeus attaches to the arcus tendoneus linea alba, a fascial line that is also an attachment of the obturator internus. Additionally, the pubococcygeus and OI are fascially connected around the pubic bone, and the fascia around the bladder and urethra also is connected to the OI. What does this mean? It means that the OI can be impacted by what happens at the pelvic floor and can impact what happens at the pelvic floor. And research tends to show this. This study showed that the vast majority of people with pelvic girdle pain have obturator internus tenderness. This study found that most people with chronic pelvic pain have obturator internus tenderness with palpation. And here’s another study that found that 45% of people with pelvic pain had tenderness at the obturator internus. Another study found that in people with lumbopelvic pain, experiencing urinary urgency, and central sensitization made them 2x more likely to have concurrent pelvic floor and OI involvement.
Finding the Obturator Internus
One of the cool things about the OI is that it is a muscle that can be palpated both internally via the vagina or rectum, and also externally. The OI is palpated internally with an examining finger angling out toward the hip. You can see the palpation here on my lovely pelvic model.
My finger here is inserted, curving toward the left to access the OI
The OI can also be palpated by examining medial to the ischial tuberosity, then angling in toward the obturator foramen. You can see where palpation would be happening here.
Treating the Obturator Internus
If you think your Obturator Internus is involved in the pain or pelvic floor problems you’re experiencing, the first step is to have it examined. Your PT can palpate these muscles as described above. The muscles should be soft and move well, so they should not be sensitive or painful to touch. If they are, they could potentially be involved in the pelvic problems you are experiencing.
From a treatment standpoint, we can address the OI by first improving the mobility via gentle manual therapy, and then improving the overall hip stability (retraining the anticipatory function through the relationship between the pelvic floor & OI). It usually isn’t the “sole” problem happening. But including it within your treatment can be key to helping you get better!
This week is international men’s health week, so it seemed fitting to write on a topic related to pelvic health in men. Interestingly enough, men are actually an underserved population when it comes to pelvic health. I know, shocking, but it’s true. From a physical therapy standpoint there are way fewer clinicians who treat men than there are who specialize in women’s health or prenatal/postpartum populations. In fact, I can’t tell you the number of men I’ve seen in the clinic who tell me that they were turned away from multiple previous clinics or who saw another provider who clearly felt uncomfortable treating them.
For me, I knew when I started specializing in pelvic health over 10 years ago, that I wanted to treat ALL people. I never limited my training to vaginas, and I always tried to learn to serve everyone. When I opened Southern Pelvic Health last year, I wanted to build a clinic that could really serve ALL people. We treat anyone who comes in the door, and our clinicians and staff constantly strive to be educated to provide a safe and welcoming space for anyone we meet.
So, this brings us to Men’s Health week! Today, I want to talk a little bit about rehabilitation after prostate removal surgery– aka prostatectomy. Prostatectomies are most often performed when a person has prostate cancer, and involve removal of the prostate and the portion of the urethra that runs through the prostate. This is most often done robotically currently. Prostate removal surgeries can have some side effects, and one of the most annoying side effects is stress urinary incontinence. Sexual dysfunction is also a major side effect, and of note, these two side effects are ones that many express feeling unprepared for. These two can have a huge impact on quality of life of many individuals after surgery.
Why does incontinence happen after prostatectomy?
The prostate sits under the bladder, and thus, plays an important role in continence. There is an internal sphincter that is present at the level of the prostate right at the bladder neck, as well as an external urethral sphincter below the prostate, which is part of the pelvic floor muscles. When the prostate is removed, the support and sphincteric control at the bladder neck is impacted. Additionally, the external sphincter can be damaged with the surgery, and patients can also have damage to neurovascular structures, fascia and connective tissue and the urethra itself. This then leads to bladder leakage– most often termed as “stress incontinence” which is leakage occurring with an increase in intraabdominal pressure.
The majority of individuals will have some degree of bladder leakage immediately after the catheter is removed. When looking further down the line, numbers are actually hard to estimate as different authors and surgeons have different ways of defining and measuring leakage. One study found that at 3 months post-prostatectomy 35% had bladder leakage. Another study found that leakage lasting more than a year happened in 11-69% of individuals. Yes, those are vastly different numbers.
How can it be treated?
As I mentioned above, leakage after prostate surgery can be so impacting for patients! And many feel guilty for being bothered by it… it’s the whole, “At least I don’t have cancer anymore…” guilt. But, here’s the thing. Quality of life matters. Yes, not having cancer is HUGE, but YOU matter. Your life matters. And helping you live your best life? Well, that really matters a lot. So, if you’re reading this and feeling frustrated about your bladder problems after surgery (or any other problems for that matter!)– I see you. There’s hope and help available!
Retraining the external urethral sphincter an be helpful for some people after prostate removal, and that’s where we pelvic floor physical therapists come in. The key thing here is optimizing the muscle system, which involves retraining the pelvic floor muscles to help them be able to contract well, relax well, and coordinate. I remember working with a urologist previously who told all patients after prostatectomy to do 10 second pelvic floor contraction holds, 10 times, every hour of the day. And guess what? When I saw most of his patients, they had significant challenges with pelvic floor muscle overactivity, and some even had pelvic pain. Why? Because it was wayyyy more than THEIR pelvic floor muscles needed. The best treatment is the individualized treatment! So, if someone has pelvic floor muscle overactivity, the best treatment is the one focusing on relaxing/lengthening the pelvic floor muscles. If someone has underactivity, the goal should be in regaining strength, endurance and building control. And if a person struggles with coordination, the goal should be retraining timing and control of the pelvic floor muscles.
Research has always focused on strengthening the pelvic floor muscles, and honestly, I think this is one of the reasons we see mixed results in studies. It makes sense, and it really is what I tend to see in the clinic. I was so pleased to see this study come out a few months ago looking at an individualized pelvic floor rehab approach for patients after prostatectomy. In this study, they reviewed 136 patients who had leakage after prostatectomies, and they found that 98 of them actually had muscle overactivity with underactivity. Guess what? Only 13 had underactivity with no tension/overactivity. This is honestly what I tend to see the most clinically. In this study, they individualized treatment based on the examination findings, and they found that 89% of the patients had a reduction in their urinary leakage. 58% achieved what was deemed “optimal” improvements in their leakage. This is good news, and really highlights the benefit of having a comprehensive examination and treatment (not just going somewhere for “biofeedback training”)
When a person is ready for strengthening (generally, after overactivity has been improved), the way strengthening happens actually matters. In fact, it really, really matters. Paul Hodges has done amazing research to help us better understand the continence system in men. In short, the system is different, and requires a different approach to rehabilitation. When the prostate is removed and the loss of the internal sphincter occurs, compensation must take place, and involves the external urethral sphincter, and can also include other muscles (particularly puborectalis and bulbocavernosus). So, it is very important for a clinician to evaluate the entirety of the pelvic floor muscles and not simply focus on the muscles around the anal canal. Hodges has multiple recommendations for how to be as precise as possible with pelvic floor rehabilitation, and you can read more about what he recommends here. After the right coordination, and activation of the pelvic floor muscles happens, it is so important to integrate these muscles into function. A robust home program that integrates the pelvic floor muscles into movement is key to helping a person regain bladder control!
I hope you found this information useful. I have a lot more to say about all of this, but it’s late, and those thoughts will have to wait for another day! Let me know any questions you have in the comments!
If you would have told me two weeks ago that I would have closed the doors to my clinic, Southern Pelvic Health, a week later, and shifted my practice to a virtual one, I would not have believed you. Maybe I was naive (yes, I probably was), but this change came quick to me. It almost happened overnight. And, here we are. I am moving into my second week of working with my patients online. While for many, that seems incredibly scary, I actually think that shifting to an online platform for a while is going to do a lot of good.
Last week, I worked with a few other colleagues to host a webinar on bringing pelvic health online– basically, how do pelvic floor PTs treat most effectively without actually touching their patients? It was a quick production–one built out of necessity–and it sold out in 24 hours because rehab professionals everywhere are trying to figure out how we can still be there for our patients and help them get better during this time. (For my colleagues out there, if you missed it, it’s still available as an on-demand purchase!) I brought together 5 experts from various corners of the country and the world, and we spoke for nearly 2 hours about how we assess the pelvic floor, evaluate patients, and actually help patients get better in a virtual setting. It was full of creative ideas, and also challenged some of the current practice patterns. As you know, I work hard to always question my own practice–learn more–do better– and I’m excited to see what this next period of time does for me as I learn to better and more effectively treat my patients, to be creative with self-care treatments and home strategies, and to use movement to help patients move when my hands are unable to. I will share what I learn with you here, of course.
Pelvic PTs are not the only professionals taking their skills online! Last week, my daughter and I joined a “Frozen Sing-A-long” through a local princess parties company. I have been thrilled to see some incredible resources for people with pelvic floor dysfunction hop online, and I am excited to share some of those with you today!
So, what can you join virtually this week?
Yoga for Pelvic Health
My dear friend and colleague, Patty Schmidt with PLS Yoga, is incredible and specializes in therapeutic yoga for pelvic floor dysfunction. She is bringing several awesome classes online! AND, they are cheap– $15 per class (which honestly, is a HUGE value for the expertise she brings!) So, I do hope you’ll join in:
Yoga to Ease Chronic Pain (including Pelvic Pain): Tuesday March 24th at 5p.m., Monday, March 30th at 5p.m.
Gentle Yoga (Via Vista Yoga)– this really could be great for anyone with persistent pain, I think!: Tuesday, March 24th at 12p.m., Thursday, March 26th at 10 a.m.
Patty also is teaching private sessions virtually at $30 for a 30-minute session. This is a steal, believe me!
I also need to share with you all of the FREE yoga resources through another friend and colleague, Shelly Prosko. Shelly has this incredible library of Yoga options for pelvic health, all available right here.
I hope you are able to partake of these awesome resources. Remember, we are in this together my friends! I’ll leave you with a quote from a much-loved movie in my house, Frozen II, “When one can see no future, all one can do is the next right thing.” Let’s all try to do the next right thing amidst this craziness!
A few weeks ago, my husband returned from spending a few days at Barnsley Gardens Resort, where he helped with a fundraising event for the Atlanta Area Boy Scouts of America. Upon his happy return (for all parties involved– single moms: you are rockstars!), he gifted me with a bottle of my favorite relaxing lotion, scented with lavender and peppermint. It is heavenly, and we both adore it! It has become a tradition that he brings me a bottle every time he helps with the event in November. Why do we both love it so much? Well, 3 years ago, we spent 2 wonderful nights at Barnsley Gardens for a mini babymoon. It was our last getaway as a family of two. I was super pregnant, but we ate delicious food, relaxed in the pool, went on evening walks, and slept in. We had an incredible couples massage also, and this lotion was the smell of the spa. We bought a bottle then, and even now, 3 years later, using the lotion evokes feeling of peacefulness, joy, love, and overall relaxation.
So, what happened there? How do brain-smell associations work? (And I know some of you are sitting there thinking…what does this have to do with the pelvis?)
We’ve all been there, right? When I hear the song “Kiss me” by Sixpence None the Richer, I’m transported back to the middle of the summer working as a lifeguard. I smell sunscreen and chlorine and feel the warmth of the sunshine. When I smell a certain blend of middle eastern herbal tea, I’m transported back to Cairo, Egypt where I studied abroad in college, walking through the busy streets at the downtown market. Our brains are incredible like that. Certain memories impact us, and cause our brains to form neurotags– specific patterns of neural activation based on that single input. This is why all of the pieces of the memory come flooding back to you when you have the evoked stimulus (in my case recently, amazing lavender mint lotion).
Now let’s jump into pelvic health, and particularly, chronic pain. What if the brain forms neurotags about pain? For example, what if a person began having pain with sitting, and let’s say, for this example, they experienced a few situations where they needed to sit for a long period of time, and the pain was just awful. As we have discussed many many times, we know that all pain is produced by the brain, that the brain can play tricks on us, and that the brain does change over time due to pain and many other factors. The brain could then, build a neurotag about sitting. Basically, when the person in the above example goes to sit, the brain will activate the neural pathways to remember pain, negativity, perhaps anxiety/stress about the situation, etc. and instead of amplifying the feelings of peace and love (like my lotion!), the brain will amplify the feelings of distress and pain. What about a painful medical examination? A negative sexual experience?
Fascinating, right? So, what can we do about it?
First, recognize a negative neurotag for what it is– your brain recognizing familiarity. And what it is not– a true interpretation of the current situation.
Next, change up the pattern to trick your brain. If you have pain when bending forward to pick something up, can you try the bending motion while lying down (ie pulling your knees up to your chest)? If you had a negative medical exam and start feeling anxious about your appointment, could you see a different provider at a different office? Perhaps request a different position for the exam? If you have pain with sex, could you alter the experience? Maybe this means a different position, different location, different warm-up?
After that, aim to build new, positive neurotags for your brain. How do we build positive neurotags? It can start by building a positive association for your brain. So, this could mean diffusing a calming oil blend while listening to a guided relaxation track. Once this association builds for the brain, you could then try using the same scent within a typically negative situation (assuming you have also removed the negative stimulus!). For people with pelvic floor pain, we often use gentle manual treatment (either with a finger or vaginal trainers) to provide a safe input to the tissues in a way that the brain will not guard and protect by pain. Now, envision pairing that calming scent with gentle pelvic floor muscle desensitization? The options are endless for creativity in building positive neurotags! Movement can also be great to build positive neurotags! If you find that pain limits what you can do, working with a physical therapist to develop movements you can do, that keep you at minimal to no discomfort can help your brain build neurotags for safety with movement again!
If this is fascinating to you (as you know it is to me!), here are a few other resources to check out:
These amazing Vlogs by Jilly Bond, one of my favorite physios across the pond (You may recognize a certain someone in the second video!):
I was interviewed for an article that was featured this month in Men’s Health! I wanted to share with all of you here! Excited to bring information on male chronic pelvic pain and pelvic floor physical therapy to such a big platform!
In the article, we discussed the scope of the problem, treatment recommendations, and even some details on what good pelvic PT should look like! I hope you all enjoy!
This past weekend, I was fortunate to work with an incredible group of practitioners at a Level 1 Pelvic Floor Course in my home city of Atlanta. I always leave these weekends renewed, excited, and yes, somewhat exhausted ;-). Not only do I get to teach with some pretty incredible colleagues (in this case, Sara Reardon– the VAGINA WHISPERER!!, and Darla Cathcart–who literally is the reason why I practice pelvic health!), but I also get the opportunity to see the transformation of clinicians who start the weekend a little nervous about the possibility of seeing a vulva, and end the weekend confident and empowered to start helping people who are experiencing pelvic floor problems. (Ok, some may not be 100% confident–but definitely on the road to confidence! ;-))
Sara, Darla and I after our first day of teaching. This was before we were rained on and had to run to our hotel!
One of my favorite research studies of all time (yes, I am that nerdy) is always shared at this course with participants. This study by van der Velde and Everaerd examined the response of the pelvic floor muscles to perceived threat, comparing women who have vaginismus (painful vaginal penetration) compared to women who don’t.
Throughout my clinical career, the concept of stress and threat worsening pelvic floor problems has been a consistent thread. I frequently hear:
“My job has been so incredibly stressful this week. I am in so much pain today.”
“Everything started this past year…during that time, my parents had been very sick and it was a very emotionally and sometimes physical stressful time for me”
“I’ve been having a severe flare-up of my pain. Do you think the stress that I’ve been dealing with in going through a divorce/break-up/job change/move/new baby/new house/etc. etc. etc. could be related to this?”
Honestly, I could go on and on with continued statements like this. Stress is a complicated topic, and there are many factors involved that can contribute to an alteration or increase in symptoms when a person is in a persistent stressful situation. So, back to my favorite study. In this study, the researchers had the participants watch four different film excerpts that were considered to be: neutral, threatening, sexually threatening or erotic. They then recorded the response of the pelvic floor muscles using EMG. The results of this study were fascinating. They found that with both the threatening stimulus(which happened to be an excerpt from the movie Jaws) and the sexually threatening stimulus (which was an excerpt from a TV movie called Without her Consent–which frankly, sounds awful to me!) the pelvic floor muscles demonstrated increased muscle activity. And this was true in both the groups of women who had vaginismus and the groups of women who did not. (side note: they also saw that the upper traps had this same activation pattern! Makes sense, right?)
Fascinating right? So, what does this mean? I always tell patients that the pelvic floor can be like a threat-o-meter. When a person is experiencing a threat–this can be a physical or emotional threat– the pelvic floor will respond. You can imagine then what happens when that stressful situation or threat stays around for a long period of time! This knowledge alone can sometimes be so empowering for people in better understanding why their bodies might be responding the way that they are.
So what can we do about it?
If you are dealing with pelvic floor muscle overactivity problems or pain, and you find yourself in a stressful or threatening period of time in life, try these ideas:
Be mindful of what is happening in your body: I encourage people to do regular “check-ins” or body scans throughout the day to feel how their pelvic floor muscles and other muscles might be activating. If you feel any muscles gripping, try to see if you can consciously soften and let go of tension you might feel. After doing this, try to take a slow long breath in and out thinking of letting tension release.
Drop it like it’s hot: Your pelvic floor, that is. Several times throughout the day, consciously think about letting your pelvic floor drop and lengthen. If you have a hard time feeling what your muscles are doing, you can try performing a small (think 10-25%) activation first and then think about letting go of any muscle activity.
Don’t be an island: Know that there are so many resources to help you if you need them! Working with a skilled psychologist or counselor can be incredibly beneficial to many people! And, if your pelvic floor is giving you some problems, always remember that you can go see a pelvic PT– yes, even if you had worked with one in the past! We are always here to help you get through life’s hurdles! Sometimes people end up needing little “refresher courses” along the way to help when the body needs it.
So, what are your favorite ways to manage stress? Fellow PTs- how do you help patients handle flare-ups that happen when life starts to get stressful?
I love to hear from you, and meet you! Always feel free to reach out to me here! If you would like to take a course with me, check out the schedule listed on my For Professionals page! I hope to meet you in person soon!
Meet your newest pelvic health professionals from PF1 Atlanta 2018!
Exercise has so many incredible benefits for overcoming pain, optimizing cardiovascular health, and facilitating psychological well-being. Unfortunately, for many struggling with pelvic floor dysfunction (whether it is in the form of pelvic pain, urinary/bowel dysfunction, or pelvic organ prolapse), thoughts of exercise and fitness are often accompanied by fear. Fearthat moving incorrectly will lead to a worsening of their symptoms. Fearof a set-back. Fearof creating a new problem. Finding an exercise program that will not only be safe, but actually aid in a person’s recovery and pelvic floor health is a fine art. Seeing a skilled pelvic floor physical therapist can be a good step in finding an individualized exercise program, but many may not have the luxury of working with a professional.
Recently, I did some research to help a few my patients find on-demand options for guided fitness that were pelvic floor friendly. I am grateful to have such an incredible community of pelvic health professionals to learn from and learn with, and I wanted to share these fantastic resources with you here. As always, please know that what works well for one person may not work well for another, thus, an individualized assessment is always the best option to determine the most appropriate exercise program for you.
For those with pelvic pain or pelvic floor tension (often the case in cases of pelvic pain, constipation, overactive bladder):
Creating Pelvic Floor Health with Shelly Prosko- Part A: Pelvic Floor Muscle Relaxation.“30 minute practice of releasing the pelvic floor muscles through pelvic floor awareness, visualization and breathing methods, during mindful movements and yoga postures.” Shelly is an incredible physiotherapist from Canada, with a practice specializing in using yoga interventions to help people with pelvic floor dysfunction. Shelly was kind enough to offer blog viewers 10% off her combined package using the discount code: ClientDiscount10
FemFusionFitness by Brianne Grogan– Brianne (also a physical therapist) has an excellent youtube channel, with several playlists offering movement options for those dealing with pelvic pain or pelvic floor tension. Her “Painful Sex” series includes 2 30-minute yoga sequences emphasizing pelvic floor relaxation, and it’s free!
For those with pelvic floor weakness (often the case–but not always! in situations like urinary incontinence, pelvic organ prolapse, diastasis rectus, fecal incontinence):
Mutu System: This is an excellent post-partum recovery program. Very helpful for those with pelvic floor weakness or diastasis rectus after having a baby. This is often my “go-to” for people having these problems that are unable to travel to see a pelvic PT. She does a great job at encouraging appropriate referral for further evaluation as well.
Fit2B: This is an online program with options for purchasing specific programs or for membership. It has a postpartum series, diastasis recti series, prenatal workshop, and foundational courses. I have had patients use this program who really enjoyed it.
Your Pace Yoga by Dustienne Miller:Dustienne has expanded her video library to include videos such as “Optimizing Bladder Control” which includes sequences to support pelvic floor engagement through yoga.
Creating Pelvic Floor Health with Shelly Prosko: Part B Pelvic Floor Muscle Engagement. “40 minute practice that includes engagement of the pelvic floor muscles with various mindful movements and yoga postures integrated with the breath pattern.” Shelly was kind enough to offer blog viewers 10% off her combined package using the discount code: ClientDiscount10
FemFusion Fitness by Brianne Grogan: Brianne has an excellent video series (free too!) on youtube called, “Lift” Pelvic Support. This series includes a progression for safe progression through strengthening to better support the organs in the pelvis.
Pelvic Exercises by Michelle Kenway: Michelle has done excellent work creating videos and ebooks on safe exercise progressions for pelvic floor muscle weakness, prolapse, bowel dysfunction and surgical recovery. Check out her excellent videos here.
I hope these resources are helpful! Did I leave anything out? If you have other wonderful home exercise options that are “pelvic floor friendly” please let me know in the comments below!
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.
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.
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.
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.5Another 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 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:
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
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.
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
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.
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.
Over the past week, and really the past year, the cases of sexual abuse and assault perpetrated by Larry Nassar, a medical doctor with MSU and USA gymnastics, have rocked the nation. The horrific abuse he inflicted on well over 150 young women, under the guise of “appropriate medical intervention” is deplorable, and I know many of us were glad to see him held accountable for his actions with both the verdict and sentencing last week.
In the pelvic PT world, this hit very close to home, and made all of us completely infuriated. For this person to take a completely valid, evidence-based and extremely beneficial treatment technique, and contort it into being an avenue for abuse was unfathomable to those of us who have dedicated our careers to helping men and women with pelvic floor problems. Several colleagues have spoken out about this. Particularly, Lori Mize, the incoming Vice President of the Section on Women’s Health, wrote an excellent post for the Huffington Post, that I would strongly encourage you to read.
Over the next year, I want to highlight a variety of treatment techniques used in pelvic floor physical therapy to help you better understand treatment options, and hopefully alleviate some fear that some of you may have about “the unknown.” In light of these current events, I thought it would be meaningful to start by discussing internal manual therapy techniques for the pelvic floor muscles.
What is it?
Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Before we get started, if you want to better understand the anatomy of the pelvic floor, check out this post by my friend and colleague Tracy Sher. Tender or overactive pelvic floor muscles can occur when someone is experiencing problems like pelvic pain, painful sexual intercourse, tailbone pain, as well as urinary or bowel dysfunction.
These techniques are performed either vaginally or rectally by a skilled medical practitioner who has undergone advanced training to learn to evaluate and treat the pelvic floor muscles. They are only performed once the patient has been thoroughly educated about the treatment techniques and consents to participating in the treatment.
What does treatment involve?
The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles. Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), sidelying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the vaginal or rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening. These techniques can include:
Holding gentle pressure while the patient focused on relaxing and breathing
Holding gentle pressure while the patient performs a contact/relax of the muscles or a pelvic floor bulge.
Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
Sweeping stretches over the muscle belly
Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment. Personally, I tend to prefer more gentle approaches while also focusing globally on improving awareness and calming the nervous system. This is not a “no pain no gain” situation– in fact, most often we see the best results when we are able to keep pain at a very minimal level.
What type of training should the therapist have?
It is very important that the person performing this treatment has had specialized training in this technique. At minimum, they should have attended an initial continuing education course that teaches a beginner level evaluation and treatment of the pelvic floor, generally weekend course including at least 24 hrs of instruction. Many training programs now include a 3 or 4 course series, and I strongly encourage clinicians to complete the coursework to learn how to comprehensively care for their patients. At Herman and Wallace Pelvic Rehabilitation Institute, the organization I am a faculty member of, we have a 4-course series which includes a level 1, 2A, 2B and Capstone. The Section on Women’s Health has a 3- course series and there are now several other companies offering varying training programs. Of course, I’m biased as a faculty member of H&W and if you’re reading this and work in healthcare in pelvic rehab, you should definitely come to one of my courses!
Who does this treatment help?
As I mentioned above, manual therapy to the pelvic floor is helpful when a person has overactive, tender and/or shortened pelvic floor muscles that are contributing to the problem they are experiencing. This can occur when a person has pain in and around the pelvis or if the person is experiencing urinary, bowel or sexual dysfunction.
We are producing more and more research about these techniques every day, but here are a few snippets:
In this study, 50% of the men treated to address chronic scrotal pain saw a significant reduction in their pain.
In this study, 93 people were treated with pelvic floor techniques to address coccyx pain (as well as pain after coccyx removal). Overall, they saw an average of 71% improvement.
This study compared comprehensive pelvic PT to cognitive behavioral therapy for women with provoked Vestibulodynia. They found that 80% of the women in the PT group had significant improvements compared to 70% in the CBT group.
This study evaluated the effects of pelvic floor physical therapy techniques on pain reduction in men who had chronic pelvic pain. Treatment included internal and external techniques and over 70% experienced moderate or robust improvements.
This study found that 62% of women experiencing urinary frequency, urgency and/or bladder pain who were treated with physical therapy interventions, including internal manual therapy techniques, reported feeling “much better” or “very much better” following the interventions.
I hope this was helpful and removed some of the fear from this technique! If you think this treatment may be a helpful one for you, talk with your health care provider! As always, I love to answer any questions you may have!
In continuing my video series with clinical experts, I interviewed Susan Clinton, PT, DscPT, OCS, WCS, COMT, FAAOMPT (Yes, those are a TON of initials!!) regarding balloon training as a treatment for bowel dysfunction. Susan is well-known in our profession as an expert on bowel dysfunction, and her video definitely did not disappoint!
Curious about this treatment? Check out the interview below! If you want to learn more, here are a few research articles that mention balloon training as a treatment tool (this one and this one) Hope you enjoy!
Amanda 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. 
