Happy Smells, Memories, and Neurotags

A few weeks ago, my husband returned from spending a few days at Barnsley Gardens Resort, where he helped with a fundraising event for the Atlanta Area Boy Scouts of America. Upon his happy return (for all parties involved– single moms: you are rockstars!), he gifted me with a bottle of my favorite relaxing lotion, scented with lavender and peppermint. It is heavenly, and we both adore it! It has become a tradition that he brings me a bottle every time he helps with the event in November. Why do we both love it so much? Well, 3 years ago, we spent 2 wonderful nights at Barnsley Gardens for a mini babymoon. It was our last getaway as a family of two. I was super pregnant, but we ate delicious food, relaxed in the pool, went on evening walks, and slept in. We had an incredible couples massage also, and this lotion was the smell of the spa. We bought a bottle then, and even now, 3 years later, using the lotion evokes feeling of peacefulness, joy, love, and overall relaxation.

So, what happened there? How do brain-smell associations work? (And I know some of you are sitting there thinking…what does this have to do with the pelvis?)

We’ve all been there, right? When I hear the song “Kiss me” by Sixpence None the Richer, I’m transported back to the middle of the summer working as a lifeguard. I smell sunscreen and chlorine and feel the warmth of the sunshine. When I smell a certain blend of middle eastern herbal tea, I’m transported back to Cairo, Egypt where I studied abroad in college, walking through the busy streets at the downtown market. Our brains are incredible like that. Certain memories impact us, and cause our brains to form neurotags– specific patterns of neural activation based on that single input. This is why all of the pieces of the memory come flooding back to you when you have the evoked stimulus (in my case recently, amazing lavender mint lotion).

Now let’s jump into pelvic health, and particularly, chronic pain. What if the brain forms neurotags about pain? For example, what if a person began having pain with sitting, and let’s say, for this example, they experienced a few situations where they needed to sit for a long period of time, and the pain was just awful. As we have discussed many many times, we know that all pain is produced by the brain, that the brain can play tricks on us, and that the brain does change over time due to pain and many other factors. The brain could then, build a neurotag about sitting. Basically, when the person in the above example goes to sit, the brain will activate the neural pathways to remember pain, negativity, perhaps anxiety/stress about the situation, etc. and instead of amplifying the feelings of peace and love (like my lotion!), the brain will amplify the feelings of distress and pain. What about a painful medical examination? A negative sexual experience?

Fascinating, right? So, what can we do about it? 

First, recognize a negative neurotag for what it is– your brain recognizing familiarity. And what it is not– a true interpretation of the current situation.

Next, change up the pattern to trick your brain. If you have pain when bending forward to pick something up, can you try the bending motion while lying down (ie pulling your knees up to your chest)? If you had a negative medical exam and start feeling anxious about your appointment, could you see a different provider at a different office? Perhaps request a different position for the exam?  If you have pain with sex, could you alter the experience? Maybe this means a different position, different location, different warm-up?

After that, aim to build new, positive neurotags for your brain. How do we build positive neurotags? It can start by building a positive association for your brain. So, this could mean diffusing a calming oil blend while listening to a guided relaxation track. Once this association builds for the brain, you could then try using the same scent within a typically negative situation (assuming you have also removed the negative stimulus!). For people with pelvic floor pain, we often use gentle manual treatment (either with a finger or vaginal trainers) to provide a safe input to the tissues in a way that the brain will not guard and protect by pain.  Now, envision pairing that calming scent with gentle pelvic floor muscle desensitization? The options are endless for creativity in building positive neurotags! Movement can also be great to build positive neurotags! If you find that pain limits what you can do, working with a physical therapist to develop movements you can do, that keep you at minimal to no discomfort can help your brain build neurotags for safety with movement again!

If this is fascinating to you (as you know it is to me!), here are a few other resources to check out:

These amazing Vlogs by Jilly Bond, one of my favorite physios across the pond (You may recognize a certain someone in the second video!):

Your Brain is Playing Tricks on You, Part 2: Pain

Guest Post: There’s a Pelvis….in Your Brain? 

What neurotags have you noticed in your life? Fun? Serious? I want to hear them all!

On Creating Agency as a Patient

Agency is defined as, “the capacity of individuals to act independently and to make their own free choices.” What does this mean for healthcare? How does the healthcare consumer maintain and create agency while also navigating the complexities of medicine?

A few weeks ago, I traveled to Washington DC to teach a group of 40+ physical therapists and occupational therapists about working with people who are dealing with various types of pelvic pain. Over this 3-day course, we covered topics related to diagnosis, medical management, manual therapies, movement interventions, and much more. On the third day of the course, I gave a lecture on “trauma-informed care.” What is trauma-informed care? Trauma-informed care means the “adoption of principles and practices that promote a culture of safety, empowerment and healing.” While we do focus on how widespread trauma is, the varying ways people experience trauma, and strategies to develop sensitivity, respect and consideration for the needs of our patients, we also strongly emphasize the importance of treating all patients in this way.  One of the key pieces in doing this is helping a person develop a strong sense of agency– the ability to make their own educated decisions and partner alongside their healthcare professionals, instead of being the recipient of directed care.

The idea of agency can seem fairly basic. Shouldn’t every patient feel like they can make their own decisions? Shouldn’t they feel like their healthcare providers are all members of the same team? But, that is often not the case. When a person loses this agency, they can end up in situations where things start happening to them, instead of with them, and this can create difficult and sometimes traumatic experiences. This could be a mother who feels pressured to have a birth intervention she was really not comfortable with having. This could be a person being scolded for not being “compliant” with their recommended home exercise program (as opposed to their clinician understanding what happened and partnering with them to fit exercise in their lives). Or, it could be feeling pressured to continue a painful examination that they otherwise would choose to stop.

There are many reasons why losing one’s agency is detrimental. Remember, the pelvic floor muscles respond to threat. So when a person is in a situation where they feel threat (whether that is due to stress, a difficult situation, or other circumstance), the pelvic floor  will activate. When someone is dealing with something like pelvic pain, sexual pain, and other diagnoses, this can lead to a problem becoming worse. So, how can you maintain your agency as a patient?

  1. Ask Questions. All the Questions. “The only stupid questions are the ones that are not asked.” If you aren’t understanding what is being recommended to you, ask more questions for clarification. Your healthcare provider should always be happy to answer any questions you may have to help you make the best decisions for your care. This also applies to times when you are in the middle of a treatment/procedure/etc. Ask away.  Try saying:
    • “Would you mind explaining my options again?”
    • “Can you clarify what the benefits and risks would be to…”
    • “Are there any risks in not moving forward with that treatment?”
    • “What are the reasons you think I need to…”
    • “I’m sure you have a busy day, but it would really help me if you could answer a few questions.”
  2. Don’t be afraid to slow things down. If your treatment session or medical appointment is going a direction you are uncomfortable with, or if something is happening that you don’t feel like you understand, feel free to take a break. Try saying:
    • “I need some time to think about that.”
    • “I would like to take a few minutes to consider my options.”
    • “I would prefer not to move forward with that today.”
    • “Can you explain _______ to me again?”
    • “I’m not sure I understand all of my options.”
    • “I’d like to go home and think about all of this. I’ll let you know what I think at our next visit.”
  3. Bring a friend. If you know that you tend to get overwhelmed at your appointments and have difficulty expressing your needs or how you feel, consider bringing a friend/partner/spouse who will have your back! Tell them in advance what you want their role to be and how they can help you! This could be stepping in to ask for some time to consider options, asking a provider to slow down and repeat their explanation, or simply being a person to be present with you during a difficult appointment.

I hope these tips have been helpful in helping you develop strategies to create agency as a patient. If you are a healthcare provider, I urge you to reflect on your own practices. Do your words and actions support your patients in maintaining autonomy? support agency? Do you unintentionally pressure patients into participating in treatments or exams that they may not feel comfortable with? Do you shame patients when they don’t follow your recommendations? None of us are perfect. I truly believe that most health care providers have the best of intentions. But, we can all do better. Reflect on our own words, habits, body language, and be better partners for our patients!

What other strategies have you found to help you improve your agency as a patient?

~ Jessica

 

 

Back Pain and Breastfeeding? Here are 5 Tips to Help!

Did you know that last week was international breastfeeding week? I know this event and really, even discussions about breastfeeding can lead to lots of thoughts amongst mamas. Pride, having accomplished something challenging. Sadness, if your breastfeeding journey did not necessarily go as planned. Fear, as to whether your baby is actually getting enough milk and growing the way she should. Joy. Guilt. Happiness. Anger. The list goes on.

I think it’s important that while we recognize that breastfeeding has incredible benefits, we also recognize what is most important– a fed and growing baby and a healthy happy momma. There is so much that goes into the decision a parent makes about how to feed their baby, and it’s important that we help all feel supported and loved– not judged and put down. (Again, let’s build each other up, parents!!)

Musculoskeletal pain postpartum is fairly common. A 2019 study of 400 breastfeeding women found that around 37% experienced neck pain and 22% experienced low back pain. Another 2015 study looked at the experiences of 229 individuals after giving birth. Around 50% experienced back pain and 25% had an onset of back pain at 2 or more weeks postpartum. (This later onset makes a lot of sense to me based on the big changes in movement and positioning that often happen after having babies.)

So, if you are having back pain after childbirth, you’re in good company. I’ll add here that while this is indeed common, it if not normal. This is good news, because it means that we actually have strategies to help this improve.

What can a nursing mama do to help these aches and pains?

1. Be sure you are using good mechanics when you feed your little one. My daughter takes 20-30 min to feed and ate every 2-3 hours after birth (and now, at 9 weeks old, still eats every 2 hours or so during the day–but sleeps more at night!! Yay!). That means that she feeds anywhere from 160-360 minutes each day. That is a long time to be in the same position. So, to minimize aches and pains, aim to sit with support at your back. If possible, find a comfortable place to feed your baby where your body can relax and you aren’t having to work to stay in a good position for feeding. Also, be sure you bring your baby to your breast not your breast to your baby. If you are having to bring your breast to your baby, you’ll inevitably slump down and holding that position for 20-30 minutes makes my back hurt just thinking about it.

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My first little nursling, Emma, after she just finished eating.

These recommendations also hold true for my pumping and bottle feeding mamas. Pumping also leaves you in one position (unless you have one of the new styles of pumps like the Elvie– more to come later on that!!) for a long period of time, so being sure you have a comfortable place to pump and feed your baby is key!

2. Use pillows and cushions to provide support. Remember, 360 minutes in one position each day can be touch. Try using pillows like the boppy, brest friend, or others that support the baby being lifted to the breast. I actually find for my daughter that I like the boppy more when I sit in my glider or recliner, but I prefer the brest friend when I’m sitting in bed (used with a pillow under it for positioning). Right after birth, depending on where I was sitting, I sometimes just preferred using a few pillows, or using a football hold position to nurse. So, try a few options and see what helps you get into the most optimal position.

If you are bottle feeding, using pillows and supports like this can still be helpful to keep you in an ergonomic position and support your baby during your feed.

3. Change it up. When it comes to posture, the current thought is along the lines that there is not one perfect posture per se, but rather variability in posture and movement seems to be important. So, changing up your position to feed can sometimes help. This can mean feeding in a wrap or a carrier (I have yet to master that!), or nursing while lying down (my most favorite!). Sometimes mixing it up like this can make a big difference.

4. Take movement breaks between feeds. This goes along with Tip #3. Movement breaks like this feel amazing to me after nursing my little Mary. The following movement sequence is meant to take you out of the position you’re in to feed, and help restore some variability. Doing a short movement series between feeds like this can really help improve these aches and pains.

Cat-cow: I love this exercise because it allows your spine to move well into flexion and extension. This can feel great when you have been feeding for so long or holding your baby in a slightly flexed position. Pairing this with breathing can be fantastic as well (and helps to get your deep core–including your pelvic floor–involved). To do this, inhale while your back extends and your head comes up. Exhale while you arch your back, tucking your pelvis and allowing your head to drop down.

Wall Angels: This is another of my favorites. This exercise stabilizes your low back while encouraging movement at your shoulders and mid-back. It feels AMAZING if you have been sitting for a while at a computer…or in this case…sitting for a while and feeding a little one!

Reach and Roll: This exercise is a good one to get some movement in your shoulders and thoracic spine. Keep your pelvis “stacked” and your knees and hips bent to 90 degrees to encourage movement through your upper back.

Child’s Pose: This is a nice position to open your hips, lengthen your spine and extend your shoulders. As a bonus, a wide-kneed child’s pose also encourages lengthening of the pelvic floor muscles, so this is a favorite exercise of mine for individuals with pelvic floor overactivity or pelvic pain. **If you are fairly early postpartum, you may not want to lengthen your pelvic floor this way. So, in your case, consider keeping your knees together rather than wide.

5. If pain persists, seek help! This could mean seeing a lactation consultant if you are needing help positioning your baby. It could also mean seeking an evaluation with a physical therapist who has experience working with people postpartum (usually, this primarily includes pelvic health PTs). While back pain can be very aggravating, it is often very treatable. We usually see good results for people experiencing this, very quickly.

I hope this helps some of my fellow nursing mamas! If you have any questions or comments, feel free to reach out!

Have a wonderful weekend!

~ Jessica

Introducing Mary Lynn Reale!

Hi friends, colleagues, and blog readers!

I know I’ve been a little MIA. But, I want to assure you it was for a good reason! On Friday, June 14th, I delivered my sweet second daughter, Mary Lynn! She weighed a whopping 6 lbs 10 oz, and is absolutely perfect! I delivered her via Caesarean, and I plan to write about that, and particularly about recovering from a Caesarean in a future post (or probably series of posts!). That being said, I am still very much so recovering myself!

I have some interesting posts in the works, and exciting new ideas for this blog and for learning that I hope to role out in the next few months! In the mean time, I am going to go enjoy some sweet baby snuggles!

Cheers,

Jessica

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Video Interview with Dr. Ken Sinervo: Internationally- Recognized Endometriosis Expert

Happy Endometriosis Awareness Month!

Did you know that Endometriosis affects more people that inflammatory bowel disease?

Did you know that 10-15% of women (and some men too!!) suffer with endometriosis?

Did you know that they often see 7+ physicians before being diagnosed with the condition?

Endometriosis is so common, and often can be a very life-impacting condition. As a pelvic PT, I often treat individuals with endometriosis, helping them with the musculoskeletal and neuromuscular sequelae of the condition. I have also helped many patients navigate the healthcare system to ultimately receive the appropriate care they so desperately have needed.

In honor of Endometriosis Awareness Month, I asked Dr. Ken Sinervo, the medical director for the Center for Endometriosis Care in Atlanta, GA to spend some time with me discussing this important diagnosis. Dr. Sinervo is an expert in treating endometriosis, and I can’t tell you how lucky I am that his office is about 20 minutes from mine! He is also a kind and humble person and a compassionate physician, and I was so excited to interview him for this post!

In the video below, we discuss: 

  • What is endometriosis and where does it occur?
  • What are the current theories on the causes of endo?
  • How can it be treated?
  • Excision vs. Ablation surgery
  • How to find an Endo expert
  • For pelvic PTs: How do you identify patients who may have endo?
  • And, as an extra bonus, cherry on top, Dr. Sinervo describes the research he is involving in trying to identify potential markers to actually test for endometriosis!!

I hope you enjoy the video as much as I enjoyed interviewing him! I apologize in advance if our video cuts out a little bit, but I don’t think it impacts the incredible content (Our weather in Atlanta was a little struggly, so I think my internet had some difficulties!).

 

Your First Visit to See a Pelvic PT

I started writing this post a few different ways. Over the past several years, I have had handouts and brochures detailing out what is included in a first visit with a pelvic PT, but I liked the idea of something a little less formal. So, I started writing a letter to that new pelvic PT patient, and I hope it helps you (and your patients!!) feel more comfortable getting started! 

Hello there soon-to-be pelvic health PT patient:

We are SO thankful you are trusting us in partnering with you in your healing journey. We’re very glad you’re here. I realize that taking this step and actually scheduling a visit with a pelvic floor specialist can be nerve-racking, and you should be quite proud of yourself for taking this important step! I want to take a few minutes to talk with you about your first session in pelvic PT. I find that much of the fear and uncertainty people may feel with a first visit is often connected with this “unknown.” So, I hope today I can take some of that away, so you can feel more comfortable on that first day. So, let’s get started:

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Your arrival to the clinic 

Before you arrive to the clinic, you likely had a good amount of paperwork to fill out (Sorry about that!). Some of it is the standard healthcare type stuff, but there also is a more specific questionnaire. This questionnaire gets fairly personal. You’ll see questions in it about your bladder health (how often you pee? what do you drink? are you leaking urine?), your bowel function (are you constipated? do you strain when you have a bowel movement? do you leak stool?), your sexual function (are you sexually active? do you have difficulties with pain during sexual activity? problems with arousal or orgasm?), and any pain you’re experiencing (where is your pain? what worsens or improves it? how much does it hurt?) I’ll also ask you about your medical history, your medications, and if it applies to you, your history of pregnancies and childbirth, etc. I know this is a lot of detail, but this is very helpful for me in providing your care! Please feel free to put as much or as little detail on this as you feel comfortable doing. We will have a chance to discuss all of this in person.

Nice to meet you, let’s get personal!

After you and I meet, I will take you back to a private room, and we will chat about what’s going on. This is when we’ll talk about your story, what brought you here,  what are the challenges you have been facing, what has been your journey, and what are your goals you want to reach. We’ll also discuss the questions you answered on that detailed questionnaire, and I may ask you some other questions to get more information about the challenges you have been dealing with. I know it can feel a little weird for some people to share details about your bowel habits or sexual function with a person you just met, but believe me, for those of us who practice in this specialty, we talk about these things all the time. As we are chatting, please feel free to tell me anything at all that you think might be important. Don’t hold back…believe me, I most likely have heard all of this before. On that note, please know that I want you to feel comfortable and safe in the clinic, and if you would prefer not to discuss something, that is totally okay too. Just let me know!

Your Exam

After we chat, I will talk with you a little bit about what I think may be going on from a musculoskeletal, movement, and/or behavioral (habits) standpoint. At this point, I usually pull out some images, a model of a pelvis, etc. and will talk with you about what normal anatomy and physiology looks like in the pelvis and about what I think may be happening with the problems you are experiencing. Then, I will let you know what I am recommending we examine to get a better idea of your function. This often includes:

  • A “Big picture” movement exam: I will watch you walk, stand, sit, and move in many different directions. I will look at how your spine moves (from your neck down), your shoulders, hips, knees, and ankles. I also look at your balance and preferred postures, and I’ll even watch how your breathe (yes, breathing really does matter!). While we do this, you’ll also let me know if any movements are challenging for you or lead to any pain, and this helps me understand how your body as a whole is moving.
  • Specific tests/movements: After the global movement screen, we may go through some specific tests. This can include tests to see how you transfer forces or control pressure through your pelvis by lifting a leg or moving in a certain way, tests to see  how the nerves in your spine glide and move, or tests to see what structures are contributors to pain you may be experiencing.
  • Myofascial palpation: Next, we’ll see what tissues are tender or not moving well around your abdomen, pelvis, or elsewhere if we need to. This includes gently touching the muscles around the belly, hips,  and legs to see if anything feels uncomfortable, and may include lifting and moving the skin and tissues under the skin to see where there may be restrictions in tissue movement.
  • Pelvic floor examination: After that, we will look more closely at the muscles of your pelvic floor. Because the muscles of the pelvic floor live inside the pelvis, the best way to examine them is by doing an internal vaginal or rectal examination. For this exam, you would undress from the waist down and lie down on a mat table, covered with a sheet. We don’t tend to use stirrups for our exams (which most people are grateful for!). We start by looking at the outside tissues. We’ll ask you to contract and relax your pelvic floor muscles, and gently bear down to see how your muscles move (Don’t worry if you’re not sure what to do, we can help teach you!). We may ask you to cough to see how the muscles move reflexively. Then, we often will lightly touch on the outside of the muscles to see if anything feels uncomfortable or sensitive to you. We may check how certain tissues move, if that applies to the problems you are experiencing. After that, we can examine the muscles in more detail by inserting one gloved and lubricated finger into the vaginal or rectal canal. We can then feel the muscles to see if they are tender or uncomfortable, assess the muscle strength and endurance, and assess muscle coordination.  *NOTE: While an internal exam is a very valuable examination technique, some people do not feel quite ready for this, or would prefer not to have an internal exam. If that’s the case, be sure to let me (or your pelvic PT) know, and we can offer some other options.  Also, remember that our exam should not be a painful experience for you. Your pelvic PT should tailor the examination to your needs, so that you leave feeling confident and comfortable, not flared-up and in pain.

Our Plan 

After we finish the exam, we should have a clear picture of what areas we can address to work together to help you achieve your goals (whether your goals are to have less pain, stop leaking, start pooping, or something different all together!). So, our next step is to talk about our plan– what you can get started on today, and what our steps will be to help you reach the goal you want to reach.  We also will talk about how often I am recommending you to come see me, and how long I think we might work together. Sometimes I’m really good at estimating this, but sometimes I’m wrong. We can adjust along the way if we need to.

I hope this helps you to feel more comfortable and more confident when coming in for pelvic PT! If you need help finding a skilled pelvic PT in your area, please check out this previous post. 

Please let me know if you have questions at all I can help answer! Have a wonderful week!

~Jessica

 

 

Y’all, I’m published in Sexual Medicine Reviews!

Last summer, Sara Sauder asked me to collaborate with her and Amy Stein on a submission to Sexual Medicine Reviews, highlighting the role physical therapy can play in helping men and women with sexual dysfunction. I was thrilled to have the opportunity to collaborate with Amy and Sara, and for the next year or so, we worked together to create “The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment.”

In this article, Amy, Sara and I discuss the role the pelvic floor muscles play in sexual health and common dysfunctions that can occur. We also discuss the process of physical therapy evaluation and treatment for sexual dysfunction, as well as the evidence regarding the efficacy of such treatments. Submitting to a peer-reviewed journal was humbling and exciting, and honestly, gave me much more respect for the process. I have been wanting to get involved with research for some time now, and I hope that this will be a springboard to more involvement and more writing.

The journal gives authors access to full-text of the article for the next 45 days, and I am excited to have the opportunity to share it with all of you!! Please let me know what you think of the article, and enjoy!

CLICK HERE to access full text of, “The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment.” 

All the best,

Jessica