If you would have told me two weeks ago that I would have closed the doors to my clinic, Southern Pelvic Health, a week later, and shifted my practice to a virtual one, I would not have believed you. Maybe I was naive (yes, I probably was), but this change came quick to me. It almost happened overnight. And, here we are. I am moving into my second week of working with my patients online. While for many, that seems incredibly scary, I actually think that shifting to an online platform for a while is going to do a lot of good.
Last week, I worked with a few other colleagues to host a webinar on bringing pelvic health online– basically, how do pelvic floor PTs treat most effectively without actually touching their patients? It was a quick production–one built out of necessity–and it sold out in 24 hours because rehab professionals everywhere are trying to figure out how we can still be there for our patients and help them get better during this time. (For my colleagues out there, if you missed it, it’s still available as an on-demand purchase!) I brought together 5 experts from various corners of the country and the world, and we spoke for nearly 2 hours about how we assess the pelvic floor, evaluate patients, and actually help patients get better in a virtual setting. It was full of creative ideas, and also challenged some of the current practice patterns. As you know, I work hard to always question my own practice–learn more–do better– and I’m excited to see what this next period of time does for me as I learn to better and more effectively treat my patients, to be creative with self-care treatments and home strategies, and to use movement to help patients move when my hands are unable to. I will share what I learn with you here, of course.
Pelvic PTs are not the only professionals taking their skills online! Last week, my daughter and I joined a “Frozen Sing-A-long” through a local princess parties company. I have been thrilled to see some incredible resources for people with pelvic floor dysfunction hop online, and I am excited to share some of those with you today!
So, what can you join virtually this week?
Yoga for Pelvic Health
My dear friend and colleague, Patty Schmidt with PLS Yoga, is incredible and specializes in therapeutic yoga for pelvic floor dysfunction. She is bringing several awesome classes online! AND, they are cheap– $15 per class (which honestly, is a HUGE value for the expertise she brings!) So, I do hope you’ll join in:
Yoga to Ease Chronic Pain (including Pelvic Pain): Tuesday March 24th at 5p.m., Monday, March 30th at 5p.m.
Gentle Yoga (Via Vista Yoga)– this really could be great for anyone with persistent pain, I think!: Tuesday, March 24th at 12p.m., Thursday, March 26th at 10 a.m.
Patty also is teaching private sessions virtually at $30 for a 30-minute session. This is a steal, believe me!
I also need to share with you all of the FREE yoga resources through another friend and colleague, Shelly Prosko. Shelly has this incredible library of Yoga options for pelvic health, all available right here.
I hope you are able to partake of these awesome resources. Remember, we are in this together my friends! I’ll leave you with a quote from a much-loved movie in my house, Frozen II, “When one can see no future, all one can do is the next right thing.” Let’s all try to do the next right thing amidst this craziness!
Wow- what a few weeks it has been! I don’t know about you, but it has felt completely surreal to me. My practice, Southern Pelvic Health, which has been steadily growing and serving people around Atlanta was suddenly put on hold, and many of my patients shifted to working with me in a virtual setting. Now, I know you may be thinking– how can you help people without actually touching them? I hope to expand on this in some future posts, because, honestly, I believe this is where we are going to be for a while (SO, WASH YOUR HANDS, and SOCIALLY DISTANCE, my friends!). But, this is heavy on the minds of pelvic PTs across the country. Thinking– how can we, as a profession, still help the people who need it? Make a difference in their lives? Help people control their bowels & bladder, have better and pain-free sex, live their lives without pelvic pain?
So, this post is for all of you PTs out there asking yourselves that! Earlier this week, I partnered together with some of the smartest, most innovative PTs I know– who are leaders in our field, and ALREADY practicing pelvic health in a virtual setting– and we are hosting a webinar to teach all of you how to do just that! So, join us tomorrow for this important event:
TAKING PELVIC HEALTH ONLINE!
LIVE Webinar Event: FRIDAY 3/20 AT 9PM EST
We are bringing an expert panel together to discuss how best to screen, examine, and treat patients with pelvic floor diagnoses—without actually being able to touch our patients! These experts have been ALREADY DOING THIS, with success, and we are so pleased to bring this to all of you!
Join me, Jessica Reale, PT, DPT, WCS, as I lead a discussion with Antony Lo of the Physio Detective and the Women’s Health Podcast, Sara Reardon- the Vagina Whisperer, Juan Michelle Martin- founder of the Zero to Telehealth Program, Julie Granger- virtual health and biz coach, and Susie Gronski- author and educator. We will discuss:
✅ How to get your ideal clients to see the value in virtual Pelvic PT care and convert in-person clients to virtual clients
✅ How to evaluate, screen, and provide pelvic health treatments without being able to physically touch or be present with clients.
✅ How to effectively help your virtual clients without manual therapy or internal examinations
✅ How to market your services in a growing and busy online market and build a practice that is sustainable in the long run.
Plus, Antony Lo has graciously allowed all participants to receive a BONUS link to a recorded virtual session of one of his clients with diastasis recti!
JOIN US FRIDAY 3/20 at 9p.m. EST! Registration is $49.
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?
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.”
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.”
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?
Ok, so I have been SO excited to share this with all of you, but needless to say, I’ve been a little busy with nursing, diapers, and keeping a very active toddler happy.
My two little lovebugs!
Over the past 10 years, I’ve had the chance to treat hundreds of patients in a few different job settings. I’ve also helped to educate hundreds of other health care providers as they journey into pelvic health rehabilitation. I have learned so much through these experiences– both about patient care and creating a positive, motivating and enjoyable clinic environment for patients and clinicians alike!
So, I am thrilled to announce that I will be opening my own practice this fall! I have soooo many more details to share, but for now, I can tell you that I will begin seeing clients on October 1st, and will open scheduling in mid August! (If you want to be contacted first when the schedule opens, send me a message now!)
If you have any questions, please feel free to reach out!! Can’t wait to share more details with all of you in the next few weeks/months!!
I was interviewed for an article that was featured this month in Men’s Health! I wanted to share with all of you here! Excited to bring information on male chronic pelvic pain and pelvic floor physical therapy to such a big platform!
In the article, we discussed the scope of the problem, treatment recommendations, and even some details on what good pelvic PT should look like! I hope you all enjoy!
This past weekend, I was fortunate to work with an incredible group of practitioners at a Level 1 Pelvic Floor Course in my home city of Atlanta. I always leave these weekends renewed, excited, and yes, somewhat exhausted ;-). Not only do I get to teach with some pretty incredible colleagues (in this case, Sara Reardon– the VAGINA WHISPERER!!, and Darla Cathcart–who literally is the reason why I practice pelvic health!), but I also get the opportunity to see the transformation of clinicians who start the weekend a little nervous about the possibility of seeing a vulva, and end the weekend confident and empowered to start helping people who are experiencing pelvic floor problems. (Ok, some may not be 100% confident–but definitely on the road to confidence! ;-))
Sara, Darla and I after our first day of teaching. This was before we were rained on and had to run to our hotel!
One of my favorite research studies of all time (yes, I am that nerdy) is always shared at this course with participants. This study by van der Velde and Everaerd examined the response of the pelvic floor muscles to perceived threat, comparing women who have vaginismus (painful vaginal penetration) compared to women who don’t.
Throughout my clinical career, the concept of stress and threat worsening pelvic floor problems has been a consistent thread. I frequently hear:
“My job has been so incredibly stressful this week. I am in so much pain today.”
“Everything started this past year…during that time, my parents had been very sick and it was a very emotionally and sometimes physical stressful time for me”
“I’ve been having a severe flare-up of my pain. Do you think the stress that I’ve been dealing with in going through a divorce/break-up/job change/move/new baby/new house/etc. etc. etc. could be related to this?”
Honestly, I could go on and on with continued statements like this. Stress is a complicated topic, and there are many factors involved that can contribute to an alteration or increase in symptoms when a person is in a persistent stressful situation. So, back to my favorite study. In this study, the researchers had the participants watch four different film excerpts that were considered to be: neutral, threatening, sexually threatening or erotic. They then recorded the response of the pelvic floor muscles using EMG. The results of this study were fascinating. They found that with both the threatening stimulus(which happened to be an excerpt from the movie Jaws) and the sexually threatening stimulus (which was an excerpt from a TV movie called Without her Consent–which frankly, sounds awful to me!) the pelvic floor muscles demonstrated increased muscle activity. And this was true in both the groups of women who had vaginismus and the groups of women who did not. (side note: they also saw that the upper traps had this same activation pattern! Makes sense, right?)
Fascinating right? So, what does this mean? I always tell patients that the pelvic floor can be like a threat-o-meter. When a person is experiencing a threat–this can be a physical or emotional threat– the pelvic floor will respond. You can imagine then what happens when that stressful situation or threat stays around for a long period of time! This knowledge alone can sometimes be so empowering for people in better understanding why their bodies might be responding the way that they are.
So what can we do about it?
If you are dealing with pelvic floor muscle overactivity problems or pain, and you find yourself in a stressful or threatening period of time in life, try these ideas:
Be mindful of what is happening in your body: I encourage people to do regular “check-ins” or body scans throughout the day to feel how their pelvic floor muscles and other muscles might be activating. If you feel any muscles gripping, try to see if you can consciously soften and let go of tension you might feel. After doing this, try to take a slow long breath in and out thinking of letting tension release.
Drop it like it’s hot: Your pelvic floor, that is. Several times throughout the day, consciously think about letting your pelvic floor drop and lengthen. If you have a hard time feeling what your muscles are doing, you can try performing a small (think 10-25%) activation first and then think about letting go of any muscle activity.
Don’t be an island: Know that there are so many resources to help you if you need them! Working with a skilled psychologist or counselor can be incredibly beneficial to many people! And, if your pelvic floor is giving you some problems, always remember that you can go see a pelvic PT– yes, even if you had worked with one in the past! We are always here to help you get through life’s hurdles! Sometimes people end up needing little “refresher courses” along the way to help when the body needs it.
So, what are your favorite ways to manage stress? Fellow PTs- how do you help patients handle flare-ups that happen when life starts to get stressful?
I love to hear from you, and meet you! Always feel free to reach out to me here! If you would like to take a course with me, check out the schedule listed on my For Professionals page! I hope to meet you in person soon!
Meet your newest pelvic health professionals from PF1 Atlanta 2018!
As an educator, one of my biggest rewards is working with students and clinicians as they learn and grow in the field of pelvic floor physical therapy. This past winter, I was fortunate to work with Amanda Bastien, SPT, a current 3rd year doctoral student at Emory University. Amanda is passionate about helping people, dedicated to learning, and truly just an awesome person to be around, and I am so grateful to have played a small role in her educational journey! Today, I am thrilled to introduce her to all of you! Amanda shares my fascination with the brain and particularly the role it can play when a person is experiencing persistent pain. I hope you all enjoy this incredible post from Amanda!
Have you ever been told your pain is “all in your head?” Unfortunately, this is often the experience of many people experiencing persistent pelvic pain. Interestingly enough, the brain itself is actually very involved in producing pain, particularly when a person has experienced pain for a long period of time. In this post, I’ll explain to you how someone can come to have pain that is ingrained in their brain, literally, and more importantly, what we can do to help them get better.
Our brains are incredible! They are constantly changing and adapting; every second your brain fine tunes connections between brain cells, called neurons, reflecting your everyday experiences. This works like a bunch of wires that can connect to one another in different pathways and can be re-routed. Another way to say this is “neurons that fire together, wire together.” This process of learning and adapting with experiences is known as neuroplasticity or neural plasticity. It is a well-documented occurrence in humans and animals. If you’re interested in learning more, this is a great article that summarizes the principles underlying neuroplasticity.1
In the case of pain…. well, here’s where it gets a little complicated.
The brain has distinct physical areas that have been found to relate to different functions and parts of the body.
Those two spots in the middle that read “primary motor cortex” and “primary sensory cortex” relate to the control of body movements, and the interpretation of stimulus as sensations like hot, cold, sharp, or dull. By interpretation, I mean the brain uses this area to make sense of the signals it’s receiving from the rest of the body and decides what this feels like. These areas can be broken down by body structure, too.
In this next image, you’re looking at the brain like you’ve cut it down the middle, looking from the back of someone’s head to the front. This image illustrates the physical areas of the brain that correlate to specific limbs and body parts. This representation is known as a homunculus.
See how the hand and facial features look massive? That’s because we do a LOT with our hands, have delicate control of our facial expressions, and feel many textures with both. Thus, these areas need a lot of physical space in our brains. In this image, the pelvis takes up less space than other areas, but for people who pay a lot of attention to their pelvis, this area may be mapped differently, or not as well-defined. We know that the brain changes due to experiences, and ordinarily, it has a distinct physical map of structures. But what happens when that brain map is drawn differently with experiences like pain?
Studies suggest that over time, the brain undergoes changes related to long-lasting pain. If someone is often having to pay attention to an area that is painful, they may experience changes in how their brain maps that experience on a day-to-day basis. This varies from person to person, and we’re still learning how this happens. Here’s an example: in a recent study, people experiencing long-standing pelvic pain were found to have more connections in their brains than in those of a pain-free control group, among other findings. The greater the area of pain, the more brain changes were found.2 My point here is to provide you with an example of how the brain can undergo changes with pain that can help explain how strange and scary it can feel for some. Read on to find out how we can work to reverse this!
The process that makes pain occur is complex. It often starts with some injury, surgery, or other experience causing tissue stress. First, cells respond by alerting nerves in the tissues. Then, that signal moves to the spinal cord and the brain, also called the central nervous system. The brain weighs the threat of the stress; neurons communicate with each other throughout the brain, in order to compare the stressor to prior experiences, environments, and emotions. The brain, the commander-in-chief, decides if it is dangerous, and responds with a protective signal in the form of pain.
Pain is a great alarm to make you change what you’re doing and move away from a perceived danger. Over time, however, the brain can over-interpret tissue stress signals as dangerous. Imagine an amplifier getting turned up on each danger signal, although the threat is still the same. This is how tissue stress can eventually lead to overly sensitive pain, even after the tissues themselves are healed.3
Additionally, your brain attempts to protect the area by smudging its drawing of the sensory and motor maps in a process called cortical remapping. Meaning, neurons have fired so much in an area that they rewire and connections spread out. This may be apparent if pain becomes more diffuse, spreads, and is harder to pinpoint or describe. For example, pain starts at the perineum or the tailbone, but over time is felt in a larger area, like the hips, back, or abdomen. To better understand this, I highly recommend watching this video by David Butler from the NOI group.
He’s great, huh? I could listen to him talk all day!
Pain alarms us to protect us, sometimes even when there’s nothing there! After having a limb amputated, people may feel as though the limb is still present, and in pain. This is called phantom limb pain. The limb has changed, but the connections within the brain have not. However, over time the connections in the brain will re-route. I share this example to illustrate how the brain alone can create pain in an area. Pain does not equal tissue injury; the two can occur independently of one another.4 Pain signals can also be created or amplified by thoughts, emotions, or beliefs regarding an injury. Has your pain ever gotten worse when you were stressed?
There is also some older case evidence that describes how chronic pain and bladder dysfunction evolved for people after surgery, in a way that suggests this type of brain involvement.5Another case study describes a patient with phantom sensations of menstrual cramps following a total hysterectomy! 6
So, can we change the connections that have already re-mapped?
Yes!! The brain is ALWAYS changing, remember? There are clinicians who can help. Physicians have medications that target the central nervous system to influence how it functions. Psychologists and counselors can help people better understand their mental and emotional experiences as they relate to pain, and to work through these to promote health. Physical therapy provides graded exposure to stimuli such as movement or touch, in a therapeutic way that promotes brain changes and improved tolerance to those stimuli that are painful. This can result in a clearer, well-defined brain map and danger signals that are appropriate for the actual level of threat. Physical therapists also help people improve their strength and range of motion, so they can move more, hurt less, and stay strong when life throws heavy things at us! It is SO important to return to moving normally and getting back to living! Poor movement strategies can prolong pain and dysfunction, and this can turn a short-term stressor into long-lasting, sensitized pain. (See Jessica’s blog here: LINK)
Of course, with any kind of treatment, it also depends on the unique individual. Everyone has personal experiences associated with pain that can make treatment different for them. We are still learning about how neural plasticity occurs, but the brain DOES change. This is how we are all able to adapt to new environments and circumstances around us! Pain is our protective mechanism, but sometimes it can get out of hand. While tissue injury can elicit pain, the nervous system can become overly sensitized to stimulus and cause pain with no real danger. This perception can spread beyond the original problem areas, and this can occur from connections remapping in the brain and the spinal cord. For pelvic pain, treatment is often multidisciplinary, but should include a pelvic health physical therapist who can facilitate tissue healing, optimal movement, and who can utilize the principles of neural plasticity to promote brain changes and return to function.
Amanda Bastien is a graduate student at Emory University in Atlanta, GA, currently completing her Doctorate of Physical Therapy degree, graduating in May 2018. Amanda has a strong interest in pelvic health, orthopedics, neuroscience and providing quality information and care to her patients.
References:
Kleim, J.A., Jones, T.A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51, S225-S239. Retrieved from: https://www.jsmf.org/meetings/2008/may/Kleim%20&%20Jones%202008.pdf
Kutch, J. J., Ichesco, E., Hampson, J. P., et al. (2017). Brain signature and functional impact of centralized pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study. PAIN, 158, 1979-1991.
Origoni, M., Maggiore, U. L. R., Salvatore, S., Candiani, M. (2014). Neurobiological mechanisms of pelvic pain. BioMed Research International, 2014, 1-9. http://dx.doi.org/10.1155/2014/903848
Flor, H., Elbert, T., Knecht, S. et al. (1995). Phantom -limb pain as a perceptual correlate of cortical reorganization following an arm amputation. Nature, 375, 482-484.
Zermann, D., Ishigooka, M., Doggweiler, R., Schmidt, R. (1998) Postoperative chronic pain and bladder dysfunction: Windup and neuronal plasticity – do we need a more neuroulogical approach in pelvic surgery? Urological Neurology and Urodynamics, 160, 102-105.
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!
“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
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:
“The Pain Illusion” from Body in Mind (as well as literally everyother blog post and article on this site…I’m not kidding, if you’ve never heard of them, take a few minutes…err..hours…days.. and go read their stuff. They’re super super smart.)
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!
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!!
Amanda Bastien is a graduate student at Emory University in Atlanta, GA, currently completing her Doctorate of Physical Therapy degree, graduating in May 2018. Amanda has a strong interest in pelvic health, orthopedics, neuroscience and providing quality information and care to her patients. 
