Category Archives: Pelvic Pain

Can physical therapy help menstrual cramps?

Did you know that over 80% of women experience painful periods? And for some women, the amount of pressure in the uterus from those cramps can be just as severe as labor pains?

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As someone who has been in labor recently, I can tell you that it is no cakewalk. The truth is that menstrual pain (Dysmenorrhea) is a significant problem for many women. In fact, this study found that in a group of 269 female college students, 84% experienced pain in the abdomen and back, 84% experienced mood swings and 48% experienced dizziness. Another interesting stat from this study: 48% felt like their academic performance was impacted. (and I would bet women out of school probably feel like their work and home life are impacted too!)

With menstrual pain impacting women as much as it does, it is surprising how few effective pain-reducing options we have. Most women turn to pain relievers like tylenol and ibuprofen, but the effectiveness of those in actually reducing the pain isn’t really that great. The great news is that there are many ways in which physical therapy can actually help with menstrual pain, and several studies have shown that many physiotherapy interventions are just as (if not more!) effective as pain medications.

So, what can physical therapy do to help with those painful cramps?

Movement-based Approaches

Movement is what we do in physical therapy, and certain exercises which help with movement of the spine and abdomen can be very helpful in improving pain levels. This study, in particular, found that certain yoga postures–Cat, Cobra and Fish– helped with reducing pain. Another study found that a physical therapy program including aerobic exercise, strengthening, stretching and relaxation led to a reduction in pain during menses.

Modalities

So, modalities sometimes get a bad rap in the physical therapy world. And I get it, they are passive (meaning you, as the patient, don’t really have to do anything), and they are frequently over-used in cases when an active approach can be more helpful. But, certain modalities have been shown to be very helpful in reducing menstrual pain. In particular, applied hot packs were found to be equally beneficial to pain medication in this study! Transcutaneous Electrical Nerve Stimulation (TENS) applied to the low back/sacrum and/or abdomen has also been shown to have excellent results. The great thing about both of these options is that they are easy, reusable and effective options for a woman to use monthly without having to ingest medication.

Manual Therapy Interventions

The research regarding manual interventions for painful periods is honestly not fantastic, however, there have been some studies that have shown that treatments such as connective tissue mobilization, massage and acupressure have been helpful in reducing menstrual pain. When I used to work at a large clinic, many of my female co-workers would seek connective tissue mobilization and other soft tissue mobilizations from colleagues when having painful cramps. Clinically, I have seen that working with someone to reduce muscle sensitivity and tenderness (both in the pelvic floor muscles as well as muscles around the pelvis) does seem to reduce cramping during menses. I’m not positive the exact mechanism for this, but my working theory is that improving the “threat level” from muscles and tissues around the pelvis has effects that transfer to other situations (like cramping during periods), so the “threat level” during this situation is also reduced. I also think that hormones play a role in this as the tissues at the vulva/urethra are sensitive to estrogen, but also impacted by muscles and blood flow. So, hormonal changes that occur within a normal cycle (that lead to cramping, etc) could then be impacted by a decreased blood flow and decreased tissue mobility, thus causing the discomfort from cramping to be worsened.  There you go, that’s my working theory.

So, in summary, if you’re having pretty bad cramping during your periods, know that there are some options to help! Often times, women are the WORST at just dealing with problems they have (and things like painful cramps are often blown off by friends, family members and other healthcare providers!) If this sounds like you, it may be worth seeing a pelvic PT for a consultation to help you build a robust and effective toolbox for managing your pain!

What other options have you found helpful in reducing cramping pain during periods? I always love to hear from you! Have a great week!

Jessica

**Note: If your menstrual cramps are severe and truly limiting your life, make sure that your healthcare provider knows about it! There are some medical conditions which can contribute to severe cramping, and there are treatments available. 

Sex After Baby- 4 Reasons Why It Can Hurt and What To Do About It

“Ok, TMI…but is everyone having sex again? We tried last night and OMG it was awful! So painful!!”

I clicked on the thread in one of my Facebook moms groups, and slowly looked through the comments, hoping to see words of encouragement, support, and most importantly, solid health advice. 

“I know, me too. I just try to avoid it as much as I can.”

“What is sex? LOL”

Then, I began my comment, “Hi, I’m a pelvic PT and also the mom to a 6 month old. I’m so sorry you’re hurting. It’s so important to know that pain is not something you have to live with. There is help out there…”

Why is painful sex after childbirth so overlooked in healthcare? Why do so many women feel like they just have to live with this as a normal “consequence” of having a baby?

This past fall, I went through the craziest initiation process to join one of the most exclusive clubs out there: Motherhood. It has been an incredible and humbling journey for me, especially as a health care provider who specializes in helping women with problems they experience while pregnant and postpartum. Becoming a mother has allowed me to experience and witness first-hand many of the challenges women face after having babies.

Pain during sexual activity is extremely common after childbirth (Note: I said common…NOT normal). In fact, a large study of over 1000 women found that 85% experience pain during their first vaginal intercourse postnatally. At 3 months postpartum, 45% still were experiencing pain and at 18 months postpartum, 23% were still experiencing pain. Let that sink in. When a mother’s baby is 18 months old, 1 in 5 mamas had pain during sex! And the sad thing is that pain during sexual intercourse is SO treatable!! So, let’s get down to business…

Why could sex hurt after a baby? 

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  1. Perineal Trauma from Childbirth

    Spontaneous tearing and episiotomies are very common during vaginal deliveries. In fact, this study looking at 449 women who had at least 1 delivery found that only 3% of them did not have any tearing/episiotomy. Many women are able to heal from tears without problems. However, for some women, these injuries can become sources of pain, especially during sexual intercourse. This is especially true with more severe tears extending into the external anal sphinctor and rectum (grade 3-4 tears). This study found that women who had tears extending into the anal sphinctor were 3-4 times more likely to have pain during intercourse at 1 year postpartum compared to their counterparts. Perineal scars can be very sensitive and move poorly in some women leading to persistent discomfort which can last for years after the baby is born when it is not treated (but guess what? It CAN be treated!)

  2. Hormonal Changes

    Anyone who has had a baby can attest to the crazy hormonal fluctuations that happen during pregnancy and postpartum. One of my very best friends warned me about this telling me that she cried every day for the first week after the baby was born. Guess what? So did I. These crazy hormones can also impact what is happening down below, especially in breastfeeding mamas. Basically, the hormonal changes lead to decreased estrogen in the vulvar tissues often causing thinning and dryness. This is why breastfeeding is associated with painful sexual intercourse early on postpartum. Now, if you are reading this and you are a nursing mama like myself, should you stop to fix your sexual discomfort? Not necessarily. This study found that although nursing was associated with dyspareunia at 6 weeks postpartum, the association was eliminated by 6 months. Meaning, stopping nursing won’t necessarily fix the problem (so don’t let this be your deciding factor in the decision to breastfeed your babe).

  3.  Tender Pelvic Floor Muscles

    The pelvic floor muscles themselves can become big sources of sexual discomfort if they are tender, shortened or irritated after childbirth. Perineal trauma and hormonal changes can lead to tenderness in the pelvic floor muscles, but the muscles can also stand on their own. Many people believe that C-sections protect the pelvic floor muscles from having problems, however, we have to remember that the pelvic floor are one member of a team of muscles (including the deep abdominal muscles, low back muscles and respiratory diaphragm) that work together to provide support and stability to the pelvis. That could be partially why C-section mamas are actually 2-3 times more likely to experience more intense pain during sexual intercourse at 6 months postpartum.

  4. Because Babies are Hard

    I had to add this one in. It’s important to remember than normal sexual function should include sexual desire, arousal, and orgasm. New mamas are exhausted, feeding sweet little babies around the clock, settling into a new routine whether they are returning to jobs or caring for their babies at home,  sleep-deprived from often waking up multiple times a night, changing diapers, and worrying constantly about helping these little babies survive and thrive. And honestly, it can be really hard for many moms to have the same level of sexual desire and arousal that they had prior to having their babies (at least until life settles down– or I’m told–when the babies go to college LOL). When a woman experiences sexual desire and arousal, there is natural lubrication and lengthening of the vaginal canal, and this step is so important in having enjoyable sexual activity. Sometimes, when this step is skipped, women are more likely to experience discomfort with vaginal penetration.

So, what can be done to help?

Realize it is not normal. Don’t just deal with it. And check-in with your Obstetric provider.

The first step is seeing your OB or midwife to make sure everything is ok medically. She should evaluate you to make sure everything is healing the way that it should be healing and that nothing else is going on that needs to be managed medically. I have had patients who have had difficulties healing after tears and needed some medical help to encourage their tissues to heal the way they needed to. I have also worked with women who had underlying infections contributing to their pain, that of course, needed to be treated to move forward. This is not a step you should skip, so don’t be bashful! Tell your doctor what is going on.

Don’t be afraid to use a little help.

I get it. You never had to use lubricant before, and it’s annoying to have to use it now. But guess what? It can make a HUGE difference in reducing discomfort from thin or dehydrated vulvar tissues after babies! So, if you don’t already have a good one, go pick out a nice water-based lubricant to use. Some of my favorites for my patients are Slippery Stuff and Sliquid. I am also a big fan of coconut oil (but make sure to know that using it with condoms can cause condom breakdown).

If you are having difficulty with sexual arousal and desire since having your baby, and you feel comfortable with it (I know, some women don’t!), try using a small vibrator to help with improving sexual arousal and promoting orgasm. Many sex therapists I work with encourage couples to consider using this on days when they need a little assistance attaining the arousal they need.

Educate your sexual partner and empower them to help you

It can be so helpful to include partners in this process. Show them this blog post, so they can understand what could be going on, and empower them to help you! For some women having difficulties with arousal, having their partner do something like clean up after dinner and put the baby to bed so they can have time for a quiet relaxing shower can be just the ticket to helping them become more sexually aroused to decrease sexual discomfort. If you are having problems with painful perineal scars or pelvic floor muscles, consider including your partner in your medical or physical therapy visits so they can understand what you are experiencing. Many pelvic PTs (like myself) will often educate partners in methods to help with decreasing pain , and even in treating the pelvic floor muscles/scars (if both people feel comfortable and on-board with this!).

Go see a pelvic PT!

If you have tender pelvic floor muscles or painful scars, all the lubricant and sexual arousal in the world is not going to fix the problem. Working with a skilled pelvic floor physical therapist can be hugely beneficial in identifying where and what the problem is, and helping you move forward from pain!

A skilled physical therapist will spend time talking with you the first visit to understand your history (including specifics of your delivery), and will perform a comprehensive examination, head to toe, to see how your body moves, where you might not be moving as well as you could be, and how you transfer force through your body. They will also perform an examination of the abdominal wall (especially important for C-section mamas), and an internal vaginal examination of the pelvic floor muscles. Based on this examination, they will be able to work with you to develop a plan to help you optimize the function of your body and get back to a happy and healthy sex life!

This is first in likely a few series of posts I will be doing on postpartum specific problems. I hope you all enjoy! Please please please reach out if you have any questions at all!

Have a wonderful week!

Jessica

 

Interview with Jessica Drummond, MPT, CCN, CHC on Nutrition for Pelvic Pain

This past week, I was grateful for the opportunity to interview Jessica Drummond, MPT, CCN, CHC on the topic of nutrition for pelvic pain. Jessica is incredible, and doing such amazing things for patients with pelvic pain and really, in women’s health in general! Check out the interview below to learn more about nutrition, common dietary intolerances/sensitivities, probiotics, and what steps to take to help yourself (or your patients!) I hope you enjoy! ~ Jessica

(Note: This was my first of what I hope will be many expert interviews! Disregard my initial awkwardness with being recorded (Ha!). If you have any ideas for people you would like me to interview, let me know in the comments!) 

Getting a second chance 

This past weekend, I had the wonderful opportunity to teach Pelvic Floor Level 1: An Introduction to Female Pelvic Floor Function, Dysfunction and Treatment to a group of 40 clinicians in Houston. I love teaching beginner pelvic health classes. First, I am extremely passionate about pelvic health (in case you didn’t notice 😉), so spending a weekend talking about my passion with people who want to learn about it is incredible. Second, I love that I get to play a crucial role in helping a practitioner advance his or her practice to include an entire area of the body that they likely have never examined before. Yep, these participants spend 3 days learning how to perform internal vaginal pelvic floor examinations. And that, my friends, tends to be a game changer.

Inevitably, over the weekend, many clinicians will have the mixture of regret and excitement in discovering that the new techniques they are learning could have helped a prior patient.  And hopefully this comes with the thrill of realizing all of the current clients who are likely going to benefit when they get back to their clinics. But what about that past patient? The one they couldn’t help? The one who didn’t get better?

I’ve been there. When I was getting my doctorate at Duke, I had a professor who once told us,

“If you reach a point in your practice that you are so tied to the techniques you use that you refuse to question them or change your approach, you should retire.”

This powerful statement has stuck with me, and encouraged me to constantly question what I do, mold my approach, and strive to improve to better serve my patients. Many years ago, I worked with a wonderful woman who was seeing me to address persistent vulvar pain (Vulvodynia). We worked together for quite a while, and we saw some improvements. But she continued to have pain. I ended up sending her back to her physician, unsure of what else I could do to help her.  Fast forward 2 years later, I was chatting with her gynecologist and that patient came to my mind. I asked her gynecologist if the patient was still struggling with pain, and unfortunately, she still was. That’s when it hit me: my practice had changed in those 2 years. I was a better, more experienced clinician. I had been to many other continuing education courses, and learned so much more through the patients and clinicians I had worked with.

Specifically:

  • My manual therapy toolbox grew larger. I had attended Stephanie Prendergast and Liz Rummer’s course on Pudendal Neuralgia, and had some good success using connective tissue mobilization and neural mobilization to help my patients with vulvar pain. I had also done coursework in dry needling and found this to be a novel input to make changes for my patients with tender muscles.
  • I had spent hours and hours diving deep into the pain neuroscience world. I had learned how much educating my patients about pain and integrating pain science within the interventions I provided could influence my patients positively and be a catalyst in their healing journeys.
  • I had connected with some fantastic psychological professionals in the area, including a counselor who was extremely talented at helping men and women dealing with chronic pain.

So, I asked the physician if she thought the patient would be open to coming back. We called the patient, and she was. And guess what? She was thrilled that I had thought of her after those years, and wanted to help her in her recovery. And guess what happened? She got better! My approach was different. I referred her to the counselor I mentioned, and he ended up being a huge player in her healing journey. She loved dry needling and connective tissue mobilization, and felt significant pain relief from these treatments. I also took a more active approach with her, got her moving in ways that helped her body not guard from pain, and together, we helped her move forward.

So, why am I telling you this? 

  • If you are a clinician, I hope you go to courses, read journals, and have conversations with colleagues that challenge your practice, encourage you to change, grow and get better! And if that reminds you of patients you could have helped, check in on them! Call them up, and ask them to take a chance on you! In my experience, men and women with chronic pain will be glad that you did! They’ll be glad you want to advocate for them, help them, and that you are passionate enough to still want to make a difference for them, months or years later.
  • If you are a patient who is still not better after failed treatments, try giving a clinician a second try. Send them an email and ask if they have learned anything new that may help you or want to review your case another time. You may be surprised at the results!

I want to hear from you! Have you ever seen a clinician for a second round with different outcomes? If you are a provider, how has your practice changed in the past few years? Have you helped a patient you couldn’t help before? 

I want to meet you! If you are a healthcare provider, I would love to have you at a course! Check out my future offerings here! Unable to make a live course? On-demand webinars are a great option too!

Have a great week!

Jessica

Head, Shoulders, Knees…and Pelvic Floor!

I spent my first few years of practice going deep into the pelvis… and my most recent few years, desperately trying to get out. Now, I know that may seem like a strange statement to read coming from me, the pelvic floor girl. But bear with me. I love the pelvic floor, I really do. I enjoy learning about the pelvis, treating bowel/bladder problems, helping my patients with their most intimate of struggles. I like to totally “nerd out” reading about the latest research related to complex nerve pain, hormonal and nutritional influences, and complicated or rarely understood diagnoses. However, the more I learned about the pelvic floor, the more I discovered that in order to provide my patients with the best care I can possibly provide, I needed to journey outside the pelvis and integrate the rest of the body.

You see, the pelvic floor does not work in isolation.

It is not the only structure preventing you from leaking urine.

It is not the sole factor in allowing you to have pleasurable sexual intercourse.

It is not the only structure stabilizing your tailbone as you move.

It is simply one gear inside the fascinating machine of the body.

And, the incredible thing about the body is that a problem above or below that gear, can actually influence the function of the gear itself! And that is pretty incredible! One of the patients that most inspired me to really start my journey outside of the pelvis was an 18-year-old girl I treated 4 years ago. She was a senior in high school and prior to the onset of her pelvic pain had been an incredible athlete– playing soccer, volleyball and ice hockey. Since developing pelvic pain, she had to stop all activities. Her pain led to severe nausea, and was greatly impacting her senior year. When I examined her, I noticed some interesting patterns in the way she walked. With further questioning, she ended up telling me that a year ago, she experienced a fracture of her tibia (the bone by her knee) while playing soccer. She was immobilized in a brace for about a month, then cleared to resume all activity. (Yep, no physical therapy). Looking closer, she had significant weakness around her knee that was influencing the way she moved, and leading to a compensatory “gripping” pattern in her pelvic floor muscles to attempt to stabilize her hips and legs during movement. So, we treated her knee (She actually ended up having a surgery for a meniscal tear that had not been discovered by her previous physician), and guess what? Her pelvic pain was eliminated. BOOM. If you want to read more about her story, I actually wrote the case up for Jessica McKinney’s blog and pelvic health awareness project, Share MayFlowers, in 2013.

So, what else is connected to the pelvic floor? Here are a few interesting scenarios:

  • Poor mobility in the neck and upper back can actually lead to neural tension throughout the body– yes, including the nerves that go to the pelvic floor. (I’ve had patients bend their neck to look down and experience an increase in tailbone pain. How amazing is that?)
  • Being stuck in a slumped posture can cause a person to have decreased excursion of his or her diaphragm, which can then put the pelvic floor in a position in which it is unable to contract or relax the way it needs to.
  • Grinding your teeth at night? That increased tension in the jaw can impact the intrathoracic pressure (from glottis to diaphragm), which in turn, impacts the intra-abdominal pressure (from diaphragm to pelvic floor) and, you guessed it, your pelvic floor muscles!
  • An ankle injury may cause a person to change the way he or she walks, which could increase the work one hip has to do compared to the other. This can cause certain muscles to fatigue and become sore and tender, including the pelvic floor muscles!

Pretty cool right? And the amazing thing is that this is simply scratching the surface! The important thing to understand here is that you are a person, not a body part! Be cautious if you are working with someone who refuses to look outside of your “problem” to see you as a whole. And if you have a feeling in your gut that something might be connected to what you have going on, it really might be! Speak up!

As always, I love to hear from you! Have you learned of any interesting connections between parts of your body? For my fellow pelvic PTs out there, what cool clinical correlations have you found?

Have a great Tuesday!

Jessica

Wanna read more? Check out this prior post on connections between the diaphragm and the rest of the body!

 

Interview with Sara Sauder, PT on Vestibulodynia, Contraceptives and Bladder Pain

A few weekends ago, I had the awesome opportunity to host Sara Sauder and Kelli Wilson in teaching their course, Vestibulodynia: An Orthopedic and Pelvic Floor Approach. The course was fantastic, and both Kelli and Sara are excellent instructors. Their course is unique in that it 1) focused on a very specific diagnosis (super great for those of us who have been practicing for a while 2) is very small–a max of 12 participants, meaning lots of one on one time with instructors 3) includes a facetime conversation with a well-known pelvic pain medical expert (in our case, Dr. Irwin Goldstein) and 4) allows participants to both perform treatments on instructors and have instructors perform treatments on participants.

Sara and I have been “virtual” friends for quite some time… in fact, I can’t remember when exactly we started e-mailing, but we became penpals of sorts. We share journal articles with each other, and I believe I even told her I was pregnant before I told many of my other friends (truth!). So, needless to say, I was SO excited for us to finally meet in person and become real friends. And, Sara was so gracious to agree to answer some of my questions to share some excellent insight with all of you on vestibulodynia and her course. I hope you enjoy!

JR: First, can you briefly explain what vestibulodynia is to my readers out there who are unfamiliar?

SS: Vestibulodynia is pain at the vestibule.  The vestibule is a specific tissue at the opening of the vagina.  The opening of the vagina itself has a name which is the “introitus”.  The vestibule is part of the introitus.  It is considered part of the vulva even though it may seem that it extends into the space between vulva and vagina.  Hence the name…vestibule.  It’s like a hallway.  Or…an alcove, if you will….
Other than that simple explanation, vestibulodynia can feel like pain, itching, burning discomfort at the opening of the vagina or at the urethra or the bladder.  The aftermath of this sort of pain can result in lots of other things happening, like feeling pain inside the vagina, at the other areas of the vulva including the clitoris.  

JR: Thank you for explaining that further. Now, there are so many pelvic pain diagnoses out there…why a course on vestibulodynia?

SS: Vestibulodynia is truly a common denominator in so much female pelvic pain.  I think that if we can start to recognize the vestibule hurts, then we can get to the root of why someone has pain.  There is a logical way to think about why the vestibule hurts and we if we can understand the true why of the pain, then we can treat it.  In treating that one core issue, we will see that other symptoms that may seem unrelated start to resolve.

JR: That’s a really good point. We see vestibulodynia as a common issue with so many different pelvic pain syndromes. One in particular, that we discussed in more detail at your course, is Interstitial Cystitis or Painful Bladder Syndrome. Now, most people see IC/PBS as a “Bladder Problem,” but you shared some interesting information about the relationship between pain at the vestibule and urethral/bladder pain. Can you explain that for our readers?

SS: The vestibule, urethra and lining of the bladder (including the urachus) are all made of endodermal tissue.  They are all part of the same embyrological tube.  Their needs are the same.  That’s why you often see pain at the vestibule with any bladder symptoms.  That’s why the reverse is true.  You will see bladder symptoms with pain at the vestibule.

JR: That is fascinating, and also helps us to understand why some treatments for one may also be effective for the other (for example, both populations can have an increased hystamine response–especially during allergy season– and may have a decrease in pain with using anti-histamines! Moving on, in your course (which was awesome!), you discussed some of the main causes of vestibulodynia. The role between oral contraceptive use and vestibulodynia was discussed in detail. So many people are surprised to hear that being on birth control could contribute to their vulvar pain. Can you explain that a little bit more?

SS: Any product that affects the body’s sex hormones can affect parts of the body that are dependent on sex hormones.  So, using a combined hormonal contraceptive or any other medicine that affects estrogen and testosterone will affect the vulvovaginal tissue.  These areas are sex hormone dependent, to varying degrees based on their different embryology.  We go into this in super detail in the vestibulodynia course.  The mechanics of it are repeated over and over because if this isn’t truly understood, we, as physical therapists, will never understand what kind of progress is or isn’t possible for our patients.  If a woman is on a medication that will lower their sex hormones and I keep treating her for symptoms of sex hormone reduction, I’ll be banging my head on the wall if I don’t understand that hormonally there are changes taking place that I can’t affect until the patient gets off of or alters that medication.

JR:  That is especially interesting to me, as I have seen several patients (as well as a few close friends!) who have used oral contraceptives develop vulvar pain or pain with sexual intercourse. Now of course, we know that not everyone who takes OCPs will develop vestibulodynia, but it seems like certain individuals may be more susceptible than others. And the current research seems to recognize some of these problems occurring, to the point that now OCPs are no longer the most recommended type of contraceptive for women (especially younger ones). I know this was something we chatted a little bit about with Dr. Goldstein during our facetime chat at your course. (ReadersHere’s an interesting article about contraceptives and vulvar/bladder pain you may find helpful!)

Now, Vestibulodynia can be a tough diagnosis for clinicians to treat. What are the most common mistakes you think physical therapists make when working with women with vestibulodynia?

SS: The most common thing I find with clinicians of any discipline in working with patients with vestibulodynia is that often we completely miss the fact that the patient has vestibulodynia in the first place.  Either the vestibule is completely removed from the assessment because it is pushed aside with a speculum, or it is not assessed via appropriate and specific q-tip testing.  If we miss that we are dealing with issues at the vestibule, we are missing the point.

JR: So, true of many diagnoses! So, wrapping things up…one of the things I love about you is how hard you work to advocate for your patients– it’s amazing! So, let’s say I’m a woman reading this, and I think I have vestibulodynia. What should I do?

SS: If you think you have vestibulodynia, definitely talk to your physician about it.  Explain your symptoms and ask to see a pelvic floor physical therapist.  When you get a referral, call the physical therapist before your evaluation.  Ask if they have treated vestibulodynia, ask how they treat it and ask about their success in treating it.

JR: Thank you so much for taking the time to chat with me about vestibulodynia, and for coming to our clinic to share such an awesome course this weekend! I know we all really enjoyed it and found it super useful in learning to provide the best care we can for the women we treat who are experiencing vulvar pain (and really, pelvic pain in general!)

If you are a clinician who works with women with pelvic pain, I highly recommend Sara Sauder and Kelli Wilson’s course, Vestibulodynia: An Orthopedic and Pelvic Floor Approach. For more information, please check out their website: http://www.alcoveeducation.com/

3377681_origSARA K. SAUDER PT, DPT
is originally from Dallas, has lived in Houston and prefers life in Austin. She received her Doctor of Physical Therapy from Texas Woman’s University in 2010, but began practicing with her Master in Physical Therapy in 2007.  She works at Sullivan Physical Therapy and specializes in pelvic pain and mentors pelvic floor physical therapists through a professional mentorship program. To focus her interests, she authors the blog, Blog About Pelvic Pain. Through this medium she voices her opinion and experiences with diagnoses and treatments for pelvic pain. She has also been a guest writer for popular blogs such as Pelvic Guru, Pregnant Chicken, Scary Mommy and Pelvic Health and Rehabilitation Center’s As the Pelvis Turns. Sara interviews and shadows internationally-recognized specialists alike. She is a member of the American Physical Therapy Association’s (APTA) Section of Women’s Health (SOWH), International Pelvic Pain Society (IPPS), the International Society for the Study of Women’s Sexual Health (ISSWSH) and the National Vulvodynia Association (NVA).  She is as blurry in person as she is in her photos.

Biofeedback for Vulvodynia: An Update 

“Do you do Glazer’s protocol?”

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I have been asked this question several times over the past few years, by searching, hopeful women, looking for help after suffering from vulvar pain for far too long. I generally respond with, “I’m familiar with Glazer’s protocol, and would be happy to discuss it with you. Why don’t you come in for an evaluation and we can discuss treatment options specific to you?” This, in place of the, “I know it, but it’s more than likely not appropriate for you.”

Glazer’s protocol was a popular treatment approach, utilizing SEMG biofeedback to teach patients a method of contracting their pelvic floor muscles, to ultimately “fatigue” the muscles, and with the hope that doing so would relieve pain. Dr. Glazer was one of the first to publish research about treating the pelvic floor muscles in helping women with Vulvodynia, and all of us working with men and women with pelvic pain are grateful for his contributions.

However, as time goes on, we learn more and more. Which is awesome. And as we learn more, we hopefully change how we practice to provide the best treatment we can to our patients. Recently, my colleagues Sara Sauder and Amy Stein (2 fantastic clinicians and educators in pelvic pain) wrote an excellent commentary summarizing the evolution of biofeedback in helping women with vulvar pain. I was thrilled to see their commentary, and I thought many of you would benefit from it as well!

Sara and Amy very eloquently explain how the understanding of treatment to the pelvic floor muscles have changed over the years. Glazer’s protocol was based off the idea that frequent contractions of the pelvic floor muscles (both holding contractions and quick ones) would fatigue the muscles and thus lead to relaxation and pain relief. However, our current understanding of the pelvic floor musculature is quite different.

Shortened, Tender Pelvic Floor Muscles 

Amy and Sara go on to explain that as we have learned about the pelvic floor and seen the presentations of women experiencing vulvar pain, we have found that most women actually present with shortened, tender pelvic floor muscles. Typically, when this is found on examination, the optimal treatment includes a combination of relaxation strategies as well as manual treatment vaginally to encourage lengthening of the pelvic floor muscles. And what about fatiguing them by doing lots of kegels? Well, we have found that when shortened muscles do lots of contractions, they can actually get irritated and more shortened!

So, what’s the place for biofeedback? 

First, it is important to realize that the term “biofeedback” is not exclusive to EMG. Really, biofeedback can be any cueing to encourage a patient to perform an exercise accurately. Sara and Amy give a few great examples: a finger in the vagina to encourage and cue the patient to relax and lengthen their muscles. A clinician teaching a patient the optimal way to harness the diaphragm with breathing. All biofeedback. And what about SEMG? It can offer some help for some patients to learn to relax and let go of their muscles. However, it can also be a little tricky because women with shortened muscles may appear “normal” on SEMG. Why? It’s complicated, but in summary, SEMG reads electrical activity… so, when a muscle is held at a shortened position for a long period of time, the body will adjust to this position as the new normal. Thus, this can “trick” a patient or clinician (especially if SEMG is done to replace an internal examination) into thinking the muscles are relaxed and functioning well, when they are actually shortened.

In summary, Glazer was a pioneer who really helped us in the process of better understanding Vulvodynia. But as all treatments and understandings do, we have evolved and changed to better understand what the most effective treatment techniques are for women experiencing Vulvodynia. Biofeedback should be a part of any treatment program… but SEMG biofeedback will have some utility for specific populations and limited utility for others.

I would encourage you to read Sara and Amy’s commentary yourself! You can find it here. If you are a physical therapist treating this population, you have the opportunity to learn from Sara in person! She teaches via Alcove Education, and has an excellent course: Vestibulodynia: An Orthopedic and Pelvic Floor Approach. My clinic is fortunate to host this course in just a few weeks! (Our course is sold out… but you can find upcoming courses here).

Sara and Amy are excellent clinicians, educators and advocates for men and women with pelvic pain. Sara runs a wonderful blog, Blog About Pelvic Pain, and Amy has created fantastic self-help tools, including her book Heal Pelvic Pain and her instructional DVD, Healing Pelvic and Abdominal Pain. I hope you enjoy these resources! 

Have a wonderful week!

Jessica

The benefits of slowing down

“Ok, let’s try that again, but I want you to do it a little bit more slowly.” 

“Let’s see if you can do that with a little bit less tension.” 

“Do you feel how your neck is working while you’re trying to move your hips? Let’s see if you can do that with only moving your hips.” 

These statements (or variations of them) are ones I tend to make most days of the week. One of the most common things I notice in the men and women I treat with persistent pelvic pain is difficulty in modulating tension. I generally can see this from the moment they walk in my office:

  • Gripping postures, sitting with the shoulders elevated, gripping the chest or the glutes, tightening the back.
  • Minimal variability of movement (basically meaning it is difficult for them to move in different patterns, fully bend and rotate their spines and hips, etc)
  • Altered breathing patterns with poor diaphragmatic excursion

This type of high-tension behavior often occurs in conjunction with a dominant sympathetic nervous system (which we have discussed several times in the past– read here and here). In these cases, the body will feel constantly threatened (makes sense if you’ve had pain for a long time and don’t seem to get better) which can lead to the “fight-or-flight” response being pushed into overdrive. When this occurs, we typically see amped up muscle tension, changes in breathing patterns, and many additional physiological compensations (which you can read more about here). And, I believe this pattern tends to also lead to an overly gripped, hypervigilant pelvic floor muscle group. Then, what I typically see is that instead of the pelvic floor activating with variability, based on the required task at hand (meaning, small amounts of activation for small tasks, and large amounts of activation for bigger tasks), we will instead see loss of force modulation with very high amounts of activation for basic tasks and an inability to let go of that force for simple tasks or tasks that require relaxation (bowel movements, sex, etc).

So, with all of that being said, one of the best things a person with persistent pelvic pain can do is to learn to slow down and control his or her tension patterns. My patients typically begin working on this within the first week or so of treatment, and we continue working on this throughout the initial phase of their care. Basically, our goal is to create awareness of movement–to move mindfully and truly feel what the body is doing to accomplish a task. Typically, as a person becomes more mindful of the movements he or she is performing, we will see an alteration in the force required to perform the movement and this, along with other treatments we are working on, encourages a shift of the body from an overly sympathetic state to a more neutral one. 

So, how can you get started with slow and mindful movements if you are struggling with persistent pelvic pain? 

First, if you are already working with a pelvic PT, talk with them about your tension strategies. Ask her if she has noticed you moving with higher tension and discuss with her integrating slow and mindful movements within your treatment program. If you are not in pelvic PT, or wish to try something on your own, here is one of my favorite exercises to start with:

The Pelvic Clock 

  • This exercise is adapted from a Feldenkrais movement (I believe). I love it because I can integrate diaphragmatic breathing with pelvic floor relaxation, and it encourages awareness of the movement of the pelvis. I tend to find that many people with pelvic pain have difficulty truly knowing where their pelvis is in space and how it moves, and this exercise can help to improve that.  So, let’s get started.

Pelvic Clock

  • Begin in a relaxed comfortable position, lying on your back with your knees bent and your feet resting on the mat (bed, floor, whatevs). Visualize a clock sitting on your pelvis as is shown in the picture above.
  • Start with slow, diaphragmatic breathing. Remember, breathing with your diaphragm will allow the ribcage to expand in all directions, the belly and chest will lift, but the muscles of your neck and shoulders should stay relaxed. If you have not read much about diaphragmatic breathing, read this post and its links before moving forward)
  • Next, we will start to integrate your pelvic floor into your breathing. So, on the next inhale, visualize the breath allowing your pelvic floor to lengthen and relax. This should not be something forceful (ie. don’t push out your pelvic floor), but rather, just focus on letting go of tension as you inhale, allowing the pelvic floor to gently lengthen and the abdominal wall to let go of any tension.
  • Next, we will add in gentle movement of the pelvis with your breath. As you inhale, the pelvic floor will relax and pelvis will gently tilt toward 6 o’clock (allowing the tailbone to fall toward the mat). As you exhale, gently tilt the pelvis back to 12 o’clock allowing the low back to slowly come into contact with the mat. Repeat this slow pattern, focusing on trying to use small amounts of muscle tension to accomplish the task. Remember that this movement and really any other movement should not cause you to guard, tense your muscles or drive up any of the pain you are experiencing.
  • Once you feel confident and comfortable with the previous step, you can begin to add the rotational component. This time, as you inhale, slowly rotate the pelvis around the clock shifting from 12 –> 3 –> 6, ending in the position where your tailbone is gently dropped toward the mat. As you exhale, allow the pelvis to rotate from 6–> 9–> 12, ending in the position where your low back is gently resting on the mat.  Repeat this pattern for several breaths, then try to reverse the motion (inhaling as you move from 12 –>9–>6 and exhaling from 6–>3–>12)
  • Challenge yourself further by trying to allow the pelvis to move through all the numbers of the clock (12–>1–>2–>3… etc).

Remember, there is no rush to performing this exercise! The purpose is awareness– to really feel your pelvis move and shut off any additional tension in performing the task. Did you feel your neck tighten as you were moving? Try again with a focus on keeping it relaxed. Are your legs tightening and moving frequently as you move through the clock? Try to see if you can calm that tension and isolate the movement to your pelvis. Do you feel your pelvic floor gripping as you move? Try to see if you can keep the emphasis on relaxing the pelvic floor during your breathing.

Are you thirsty for more? 

A few of my other favorites for slow, mindful movements are found in both Yoga and the Feldenkrais method. I love Dustienne Miller’s (she’s a pelvic PT too!) home video, yoga for pelvic pain and have had many patients benefit from using it. I also enjoy the Awareness Through Movement lessons with the Feldenkrais Method. Several free online lessons are available here via the OpenATM program.

I hope you have found this helpful! What other movements have you found helpful for pelvic pain? Pelvic PTs and patients, feel free to chime in, so we can all keep learning together!

Happy Wednesday!

~ Jessica

Your Brain is Playing Tricks on You (Part 2): Pain

Ok, before we dive into this post, I wanted to say I am SO sorry for taking so long to get this “Part 2” out there. I was at the American Physical Therapy Association’s Combined Sections Meeting in Anaheim, CA for a week, got home and put a contract down on a new house (YAY!!), and things have just been crazy crazy! So, please accept my apology, and I hope you enjoy this post! Stay tuned for some CSM-y posts in the future!  Thanks for reading!! ~ Jessica 

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“Perhaps it’s time to recognize that the division between mind and body may be no more than a pedagogic device for instructing medical students– and not a useful construct for understanding human health, disease and behavior.”  V.S. Ramachadran, Phantoms in the Brain

Last post, we discussed how the brain can be tricked by both optical illusions and magic tricks. If you haven’t read it yet, you really need to…because it basically sets the stage for our post this week.

So, how does pain play into all of this? 

Well, pain is an output of the brain, much like vision. Meaning, your brain is receiving sensory information from your body (including your mechanosensation, vision, proprioception, hearing, vestibular/balance input, etc), integrating it with your prior knowledge, experiences, emotions and beliefs, and then creating an output. (ie. “This hurts, you better do something about it!” Or, “You just stubbed your toe you baby…you’ll be just fine!” Or, “Oh my gosh! Your back is never going to get better! It’s probably something super serious and dangerous!”).  Just like your brain can sometimes mess with you in relation to your visual input, the same thing can happen with pain. Let’s look at a few examples.

The Phantom Limb

This example ends up being one that is discussed frequently…in fact, much of the current research on pain was inspired by people experiencing phantom limb pain. If you haven’t heard of phantom limb pain before, basically, this is when a person will feel pain in a limb that has been amputated. Crazy, right? We know that clearly the limb itself if not a source of pain, but rather, the brain is still perceiving threat from the area. This can happen for several reasons. One of the main reasons this can occur is that, although the limb itself is gone, the brain will often still have a representation of that limb.

Homunculus

Now, this representation is changeable over time, however, smudging can occur leading to referred sensations from one area to another. This can trick the body into thinking there is a problem with the non-existent hand. Now, normally, you could look down, see your hand, feel it, and that would then confirm for your brain that the hand it actually fine…however, in cases of phantom limb pain, the limb is not there, so reducing the treat becomes much more tricky. The cool thing is, amazing scientists have developed ways to retrain this using things like mirror therapy (Check out this video from David Butler!) and other innovative treatment approaches. So, obviously, I am wayyyy simplifying this phantom limb phenomenon for this blog, and there are other known contributors to phantom limb pain as well, so I really do recommend you read more. Check out this article from Body in Mind which goes into much more detail.

When Perceived Threat and Harm Level Don’t Quite Match

Have you ever had a little splinter that just hurt so much? That you couldn’t get out of your head until is was gone? That’s a little bit of harm…but somehow the brain is perceiving a big problem. Or, have you ever heard a story about a person walking into the ER talking normally with a knife sticking out of their arm? That’s a lot of harm…but somehow the brain is able to perceive a small threat (which is super helpful in that moment so that the person can get to the ER!).

My favorite example of this is Lorimer Moseley’s story of a snake bite in the brush in Australia. Check it out. He’s hilarious and awesome.

Basically, he tells the story of being bitten by a poisonous snake while walking through thick brush in Australia. When the bite occurs, he doesn’t even realize it because his brain at that moment received the bite information and processed it, with the conclusion of “It’s just a stick. There are tons of sticks around here, nothing to worry about.” He doesn’t realize it’s a snake bite until he passes out a while later. Fast forward to a later time, walking through the brush again, feels the same poke and immediately falls down in excruciating pain…only to realize, it was just a stick. Fascinating right? In that second scenario, his brain had the memory of the first snake bite and the trauma from that, thus, the poke felt much more dangerous and threatening than the first time, and he felt a much greater amount of pain.

So, what does this mean for you? 

Basically, just like our brain can be fooled through visual illusions and magicians, we can also be fooled by pain. This is not meant to imply that pain is in your head…but rather, pain can play tricks on you. And what you feel is a problem in your tissues may not actually be a problem there…but rather could be simply the interpretation of your brain based on the information it is receiving in the moment. Pain, just like vision and hearing, is complex. And treating it thus requires a complex and integrative approach.

Wanna learn more? Check out these awesome articles/videos:

Have a wonderful Monday!

~Jessica

 

Your Brain is Playing Tricks on You (Part 1): Visual Illusions

Falling in love is an incredible feeling, isn’t it? One we don’t tend to forget very quickly. At least, that’s how it was for me and Neuroscience. I remember clearly when the falling in love started to take place. Junior year in college, reading a book called  by V.S. Ramachadran, Phantoms in the Brain: Probing the Mysteries of the Human Mind,
for my Neuroanatomy and Physiology of Human Movement class. I remember being glued to that book from cover to cover, only stopping briefly to write down a quick quote or call my parents to tell them the amazing piece of information I just learned (Yes, I still call them to tell them fun things like that :))

The amazing thing, that I’m sure you are realizing too, is that our brains are simply incredible. We have the ability to take in millions of tiny pieces of information in microseconds, integrate it within everything we believe to be true about our world and the universe and then make decisions on what that information means. It’s incredible, really. But did you know that this ultimate perception can lead to misinformation? Did you know your brain can really really mess with you?

Optical Illusions

One of the most well-known tricks of the brain is an optical illusion. Do you see a bunny or a duck?

Illusions DuckBunny

Which square is darker, A or B? (They’re actually the same color!)

128px-Optical_illusion

By Wuhazet – Henryk Żychowski (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)%5D, via Wikimedia Commons

So, how did your brain trick you? Your nervous system is constantly gathering information about the body and the environment through multiple different inputs: visual, mechanical, temperature, proprioceptive (the position of your joints), vestibular (your inner ear). This process is called sensation. Perception, then, is your brain’s interpretation of the information it receives. The brain receives and filters the information from various sensors and then interprets its meaning to create our experience. In these cases, your brain receives the signal (visual input) and then perceives meaning based on the information, and your experience. In the first picture, your brain likely can see either a duck or a bunny depending on how it chooses to interpret the information. In the second one, your brain took into account the shadow that the green cylinder was casting on the board– thus, your brain tricked you into thinking that tile B must be lighter than tile A (although, really they are the same!) And the third one, your brain saw the arrows in the first one as narrowing in the space, and the second as expanding it–even though the lines are the same length. Pretty cool, right?!

Magic Tricks 

I have always loved a good magic trick. I remember seeing my first “real” magic show in Las Vegas at Harrah’s Casino. I was 11 or 12 I think, and was completely mesmerized by Mac King and his comedy magic show. My family just loved it! We were amazed, and couldn’t figure out how he did what he did.

(This is actually pretty close to what that magic show looked and felt like–so enjoy being transported back to 12-year old Jessica’s life!) 

I still love watching a great magic show. From street magicians like David Blaine to bigger than life magicians like David Copperfield or Siegfried and Roy, magicians have the ability to suspend our belief, challenge our perceptions and allow us to believe we are seeing the impossible.

So what are magic tricks? How do they feel so “real” to us watching?

In a way, magic tricks are very similar to optical illusions. Magicians are truly masters at using the brain to fool us into truly seeing something that did not happen. Magic tricks work based on several key principles. First, as we discussed above, your brain constantly creates perceptions based on the sensory inputs it receives from the environment. As was shown in our “illusions” section, the perception does not always directly match the visual input as our brain integrates vision with our previous knowledge, emotions, experiences, etc. to make predictions and ultimately create perception. These predictions are precisely what is exploited during magic tricks. This great article gives the example of the “vanishing ball” trick. In this trick, the magician throws the ball up in the air several times, and finally on the last one, the ball appears to vanish out of the air. But did it really vanish? Of course not! The magician used our brain’s predictions in his favor…thus, we saw the magician continuing to look up toward the ball, we saw the hand move in a “throwing pattern.” and the brain cut a few corners to tell us the ball had been thrown! While we’re busy watching that magician’s face, the ball is then palmed away, and our brain perceives it has vanished! Pretty cool, right? (check out the article for a larger, more detailed explanation!)

Magic tricks also work by confusing our brain with conflicting inputs and playing with our attention. For example, we are much more easily tricked and distracted when we have to multitask and focus on multiple different things at once. This is common with card tricks and other illusions. Emotions (such as humor, story-telling, etc) can also lead to some brain-trickery as it again creates a distraction for the brain, forcing the brain to “predict” to fill in the missing pieces.

It’s really, quite incredible, and learning about all of this actually has made me respect magicians even more as fellow neuroscientists! Check out these excellent articles if you want to dive a little deeper and further understand more of what happens with magic tricks!

Now…You may be thinking… “What the heck Jessica? This is a “pelvic-focused” blog! Why are you writing about optical illusions and magic tricks!?” Well my dear blog reader, you’ll have to find out… Stay tuned for Part 2- Your Brain is Playing Tricks on You: Pain