Category: Pelvic Pain

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

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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 

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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!

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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

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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. (Readers: Here’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 

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“Do you do Glazer’s protocol?”

think-thinking-reflect-light-bulb-622166

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

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“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

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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

~ jesspreale ~ 2 Comments

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)], 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

Mindfulness, Meditation and Pain

~ jesspreale ~ 11 Comments

“If you get the inside right, the outside will fall into place. Primary reality is within; secondary reality without.” ~ Eckhart Tolle, The Power of Now: A Guide to Spiritual Enlightenment

meditation-338446_1920

Within many traditional clinical practices, mindfulness-based or meditation-based exercises are considered alternative, eastern, touchy-feely or even “voo-doo.” It is often seen as a complementary treatment that may be helpful…but really isn’t going to “treat” the client. I’ve had many clinicians I respect significantly tell me that they don’t use guided meditation within their practice for this exact reason. Respectfully, I have to disagree with that sentiment. I recommend mindfulness-based relaxation or guided meditation to my patients on almost a daily basis, and I believe strongly that there are so many benefits in this practice for a person struggling with persistent pain.

Pain Neuroscience 

To understand why meditation is helpful in overcoming persistent pain, it is crucial to understand what pain is, and to truly grasp the role of the brain in pain (Summary: No brain, no pain). If you are new to this blog, or new to pain science in general, you have a few prerequisites before you move forward:

Ok, I could go on and on…but I won’t. So, we’ll move on.

What is Meditation/Mindfulness Training?  

Mindfulness is described here as a “non-elaborative, non-judgmental awareness of present moment experience.” There are a few different types of mindfulness based meditation practices, usually broken into:

  • Focused Attention: This involves focusing attention on a specific object or sensation (i.e. focusing on breath moving, or focusing on a certain space). If attention is shifted to someone else, the person is then taught to acknowledge it, disengage, and shift the attention back to the object of meditation.
  • Open Monitoring:  This is a non-directed practice of acknowledging any event that occurs in the mind without evaluation or interpretation
  • Variations: There are multiple variations of these practices, usually trending toward one variety or the other. For example, there are guided relaxation exercises which will shift the focus from one body part to another, meditation exercises based on focusing on a color moving through the body, etc.

Meditation and the Brain 

The cool thing is meditation has been found to have some pretty profound effects on the brain. This meta-analysis of fMRI studies aimed to determine how meditation influenced neural activity, and the results were pretty interesting. They found that brain areas from the occipital to frontal lobes were more activated during meditation, specifically areas involved in processing:

  •  self-relevant information (ie. precuneus)
  • self-regulation, problem-solving, and adaptive behavior (ie. anterior cingulate cortex)
  • interoception and monitoring internal body states (ie. insula)
  • reorienting attention (ie. angular gyrus)
  • “experiential enactive self” (ie. premotor cortex and superior frontal gyrus)

Basically, the authors state that all of these areas are characterized by “full attention to internal and external experiences as they occur in the present moment.”

For more information on how meditation impacts the brain, check out this great TEDx talk by Catherine Kerr:

 

Persistent Pain Implications

Now, you may be thinking, why does that matter for a person experiencing persistent pain? Well, it matters because for most people, pain does not solely exist in the present, but rather, is an experience influenced by a complex neural network, integrating 1) what you know about the pain 2) how dangerous you feel it is 3) your history relating to that pain 4) your fears/concerns/worries about the future 5) how this problem relates to your family, job, relationships, home, etc. and 6) so so much more. (including everything helpful and unhelpful your health care providers have told you about your pain.)

Here’s an example. Let’s say you start having some back pain one day after bending over to pick up something off the floor. Happens right? But, what if you used to have back pain years ago and had an MRI that showed degenerative changes in your spine? And what if you have a two year old you have to carry around frequently? What if work has been difficult recently and you’re worried your job is in jeopardy? What if you had a physical therapist tell you that you should never bend down like that or you would “hurt your back?” The amazing thing is that all of these experiences, histories, thoughts, emotions are seamlessly integrated by your brain to determine the immediate “threat level” of your low back, and create an overall pain experience (ultimately, designed to be helpful and protect you against harm).  This story is a real one, and actually happened to a patient of mine…by the time she came into my office, she couldn’t bend forward at all, had severe pain, and was very worried about the level of “damage” in her low back. But, the truth was, she had really just moved in a way that her body chose to guard, and nothing was really “damaged” at all. After a quick treatment session, she was back to full motion without any pain. Now, am I magical in “fixing” backs like that? Yes. But that’s besides the point. But really, all I did was remove the threat level by taking her back to the present moment (ie. Your back is not damaged. Bending is totally fine and functional to do. This is going to get better really soon.) and restore movement to a system that was guarding against it.

So, what does this have to do with meditation/mindfulness? Well, at it’s core, meditation is about changing awareness and improving focus to the present moment. This can then change the “pain story” to decrease the threat level for the present moment, and thus help a person move toward recovery.

Does it work? 

The best part is that it actually seems to make a significant impact (although, of course, we need better larger studies!) Of course, it is just one piece of the puzzle–but I really believe it can be an important component of a comprehensive program to help someone experiencing persistent pain. And, the research actually is trending toward it being beneficial too. In fact, meditation and mindfulness-based stress reduction has been shown to be helpful in reducing pain and improving quality of life in men and women experiencing chronic headaches, chronic low back pain,  and non-specific chronic pain.  There have not been many studies looking specifically at chronic pelvic pain, but there was one pilot study I found, and it also seemed to show favorable results in improving quality of life.  Will it take you 10 years of channeling your inner guru to see the benefits? Actually, the research seems to indicate that changes happen pretty quickly. This study actually found improvements after just four sessions.

Getting Started 

If you are experiencing persistent pain, or are a human who happens to have a brain, you would likely benefit from using meditation as part of your daily exercise program (Yes, I consider meditation exercise!) There are so many fabulous resources out there to get started in practicing mindfulness/meditation. Here are a few of my favorites:

Books that are helpful in understanding meditation:

The Power of Now, by Eckhart Tolle- $10 on Amazon 

Peace is Every Step, by Ticht Naht Han- $8 on Amazon 

Free Guided Meditation Exercises ONLINE/APPS-Note, I find different people tend to enjoy different guided meditations/programs. Try a few different ones here, or even go on to youtube and do a little search. You may find some you love and some you hate, and that really is ok. Try to find what works best for you!

Relax Lite with Andrew Johnson– available free on itunes and as an app!

Breathe to Relax– available free on itunes and as an app!

Headspace– available free on itunes and as an app!

Insight Timer– available free on itunes and as an app!

Sattva Meditation Tracker & Timer- available free on itunes and as an app!

Guided Meditation for Pelvic Pain– by Dustienne Miller, PT, available free on her website.

Tara Brach– Great resources with meditations, lectures, and more!

I hope this is helpful for you! What other resources do you enjoy for relaxation/mindfulness/meditation?  Please feel free to share in the comments below!

Wishing you a very merry Christmas and a happy new year!!

~Jessica

 

 

Why get Pelvic PT first? And, join me for a webinar Thursday 12/10!

~ jesspreale ~ Leave a comment

If you didn’t know, December 1st was a day that all PTs came together to share with the public all of the benefits of seeking PT! My colleague, Stephanie Prendergast, founder of the Pelvic Health and Rehabilitation Center in California, wrote an amazing blog post on why someone should get pelvic PT first. I thought it was great (as you know…I post lots of Stephanie’s stuff), and Stephanie gave me permission to re-blog it here. So, I really hope you enjoy it. If you aren’t familiar with Stephanie’s blog, please check it out here. You won’t regret it. 

On another note, I will be teaching a live webinar Thursday 12/10 on Pelvic Floor Dysfunction in the Adult Athlete. I really hope to see some blog followers there! Register for it here.  

Now… enjoy this great post by Stephanie. ~ Jessica 

Why get PT 1st? Here are the Facts. By Stephanie Prendergast

very-small-getpt1st

Vaginal pain. Burning with urination. Post-ejaculatory pain. Constipation. Genital pain following bowel movements. Pelvic pain that prevents sitting, exercising, wearing pants and having pleasurable intercourse.

When a person develops these symptoms, physical therapy is not the first avenue of treatment they turn to for help. In fact, physical therapists are not even considered at all. This week, we’ll discuss why this old way of thinking needs to CHANGE. Additionally, we’ll explain how the “Get PT 1st” campaign is leading the way in this movement.

We’ve heard it before. You didn’t know we existed, right? Throughout the years, patients continue to inform me the reason they never sought a physical therapist for treatment first, was because they were unaware pelvic physical therapists existed, and are actually qualified to help them.

Many individuals do not realize that physical therapists hold advanced degrees in musculoskeletal and neurologic health, and are treating a wide range of disorders beyond the commonly thought of sports or surgical rehabilitation.

On December 1st, physical therapists came together on social media to raise awareness about our profession and how we serve the community. The campaign is titled “GetPT1st”. The team at PHRC supports this campaign and this week we will tell you that you can and should get PT first if you are suffering from a pelvic floor disorder.

Did you know that a majority of people with pelvic pain have “tight” pelvic floor muscles that are associated with their symptoms?

Physical therapy is first-line treatment that can help women eliminate vulvar pain

Chronic vulvar pain affects approximately 8% of the female population under 40 years old in the USA, with prevalence increasing to 18% across the lifespan. (Ruby H. N. Nguyen, Rachael M. Turner, Jared Sieling, David A. Williams, James S. Hodges, Bernard L. Harlow, Feasibility of Collecting Vulvar Pain Variability and its Correlates Using Prospective Collection with Smartphones 2014)

Physical therapy is first-line treatment that can help men and women with  Interstitial Cystitis

Over 1 million people are affected by IC in the United States alone [Hanno, 2002;Jones and Nyberg, 1997], in fact; an office survey indicated that 575 in every 100,000 women have IC [Rosenberg and Hazzard, 2005]. Another study on self-reported adult IC cases in an urban community estimated its prevalence to be approximately 4% [Ibrahim et al. 2007]. Children and adolescents can also have IC [Shear and Mayer, 2006]; patients with IC have had 10 times higher prevalence of bladder problems as children than the general population [Hanno, 2007].

Physical Therapy is first-line treatment that can help men suffering from Chronic Nonbacterial Prostatitis/Male Pelvic Pain

Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) affects 2%-14% of the male population, and chronic prostatitis is the most common urologic diagnosis in men aged <50 years.

The definition of CP/CPPS states urinary symptoms are present in the absence of a prostate infection. (Pontari et al. New developments in the diagnosis and treatment of CP/CPPS. Current Opinion, November 2013).

71% of women in a survey of 205 educated postpartum women were unaware of the impact of pregnancy on the pelvic floor muscles.

21% of nulliparous women in a 269 women study presented with Levator Ani avulsion following a vaginal delivery (Deft. relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014 Feb 121: 1164 -1172).

64.3% of women reported sexual dysfunction in the first year following childbirth. (Khajehi M. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015 June; 12(6):1415-26.

24% of postpartum women still experienced pain with intercourse at 18 months postpartum (McDonald et al. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015)

85% of women stated that given verbal instruction alone did not help them to properly perform a Kegel. *Dunbar A. understanding vaginal childbirth: what do women understand about the consequences of vaginal childbirth.J  Wo Health PT 2011 May/August 35 (2) 51 – 56)

Did you know that pelvic floor physical therapy is mandatory for postpartum women in many other countries such as France, Australia, and England? This is because pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex.

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse?

Physical Therapy can help with Stress Urinary Incontinence

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse? 80% of women by the age of 50 experience Stress Urinary Incontinence. Pelvic floor muscle training was associated with a cure of stress urinary incontinence. (Dumoulin C et al. Neurourol Urodyn. Nov 2014)

30 – 85 % of men develop stress urinary incontinence following a radical prostatectomy. Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months postoperatively. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9).

Physical Therapy can help with Erectile Dysfunction

Several studies have looked at the prevalence of ED. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years. The prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years.1

Physical Therapy can help with Pelvic Organ Prolapse

In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone a hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. (Susan L. Hendrix, DO,Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6.)

Pelvic floor physical therapy can help optimize musculoskeletal health, reducing the symptoms of prolapse, help prepare the body for surgery if necessary, and speed post-operative recovery.

Did you know….

In many states a person can go directly to a physical therapist without a referral from a physician? (For more information about your state: https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf)

You need to know….

Pelvic floor physical therapy can help vulvar pain, chronic nonbacterial prostatitis/CPPS, Interstitial Cystitis, and Pudendal Neuralgia. (link blogs: http://www.pelvicpainrehab.com/patient-questions/401/what-is-a-good-pelvic-pain-pt-session-like/, http://www.pelvicpainrehab.com/male-pelvic-pain/460/male-pelvic-pain-its-time-to-treat-men-right/http://www.pelvicpainrehab.com/female-pelvic-pain/488/case-study-pt-for-a-vulvodynia-diagnosis/)

Pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex: http://www.pelvicpainrehab.com/pregnancy/540/pelvic-floor-rehab-its-time-to-treat-new-moms-right/

Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months in postoperative men following prostatectomy. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9). (Link blog: http://www.pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

A study from the University of the West in the U.K. found that pelvic exercises helped 40 percent of men with ED regain normal erectile function. They also helped an additional 33.5 percent significantly improve erectile function. Additional research suggests pelvic muscle training may be helpful for treating ED as well as other pelvic health issues. (link blog:http://www.pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

….that you can and should find a pelvic floor physical therapist and  Get PT 1st.

To find a pelvic floor physical therapist:

American Physical Therapy Association, Section on Women’s Health:

http://www.womenshealthapta.org/pt-locator/

International Pelvic Pain Society: http://pelvicpain.org/patients/find-a-medical-provider.aspx

Best,

Stephanie Prendergast, MPT

stephanie1-150x150Stephanie grew up in South Jersey, and currently sees patients at Pelvic Health and Rehabilitation Center in their Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.