Book Review: A Guide to Better Movement

One of my New Year’s resolutions was to build a better morning routine to help me use my time more optimally during the day. Part of that morning routine includes reading for 30 minutes over breakfast…and I have to tell you, it’s my most favorite part of the day. My first book of the year was Todd Hargrove’s  A Guide to Better Movement, and I really really loved it. So much so, that I just needed to share it with you!

Guide to Better MOvementI was first introduced to Todd Hargrove through his blog post back in October, “Why do muscles feel tight?” I loved it, was hooked, and ordered his book the same day. Todd is a pretty smart guy, and has a unique background being a prior attorney and current Rolfer and Feldenkrais practitioner. I love learning from people who are not physical therapists because I find it challenges my viewpoints and helps me to see my clients from a different perspective. Todd’s book did not disappoint.

Who should read it? 

  • Anyone who likes moving, should move, and wants to move better
  • Athletes (yes, this includes any of you who exercise regularly) who want to make sure they are caring for their bodies
  • People experiencing persistent pain
  • Practitioners working with humans who move
  • (Is that broad enough for you?)

What are the details? 

  • Available on Amazon.com for $17.95, paperback  (Click hereA Guide to Better Movement: The Science and Practice of Moving With More Skill And Less Pain)
  • Length: 277 pages, broken into the following sections:
    • Introduction
    • Part 1: The Science of Moving Better
      • Defining Better Movement
      • Learning Better Movement
      • The Brain Maps the Body
      • Motor Development and Primal Patterns
    • Part 2: The Science of Feeling Better
      • The Science of Pain
      • Movement and Threat: Central Governors
      • Movement, Thinking and Feeling
    • Part 3: The Practice of Moving Better and Feeling Better
      • Strategies to Move Better and Feel Better
      • Lessons in Better Movement (pgs 149-277)

What’s so great about it? As you may know, my studies recently have sent me deep into the world of neuroscience, so I love reading books that integrate the whole body rather than just focusing on specific tissues. Hargrove does an excellent job of not only teaching the science related to movement and pain in a way that is easily understandable by clinicians and patients alike, but also offers strategies and lessons for improving movement and shifting away from a pain state. He uses excellent analogies throughout his book that all people will be able to relate to and understand. On another note, his book is full of great quotes… and I’ve always been a sucker for a good quote… so you’ll see some of my favorites here :).

In the first part, the science of moving better, Hargrove discusses the essential qualities of good movement (coordination, responsiveness, distribution of effort, division of labor, position and alignment, relaxation and efficiency, timing, variability, comfort and individually customized). I especially love his section on relaxation and efficiency as I believe this to be a huge factor for the men and women I treat experiencing chronic pelvic pain. So often, these people end up in states of chronically over-activating musculature to perform tasks, and I believe changing this can make a big difference for them. “Efficient movement requires skill in relaxation… thus developing movement skill is often more about learning to inhibit the spread of neural excitement rather than extending it.” 

Next, he goes on to explain the process for learning better movements diving in to the motor control system, and then explains how the brain maps the body and the ways in which those maps can change over time. “The current organization of [a person’s]  sensory  maps already reflects a lifetime of effort to organize them in an optimal way to perform functional goals.”  He uses a great analogy here of a skiier going down a hill. The first trip down, the person has endless options on the path to take down…but after going again, and again, deep grooves in the snow are formed and it can be difficult to take alternate paths.

downhill skiing

Lastly in this section, he discusses motor development and primal movement patterns and the importance of training foundational movements with large carryover into a variety of functional tasks.

Part two, the science of feeling better goes into our favorite topic–pain science. Hargrove does a fantastic job of explaining pain and gives a plethora of examples and analogies to help the reader understand very advanced topics. Two of my faves from this section are,”Although nociception is one of the most important inputs contributing to pain, it is neither necessary nor sufficient for pain to exist,” and, “Pain is an action signal, not a damage meter.” This section also explores different options for moving past pain and discusses how the central nervous system responds with threat in order to protect the body. The last chapter in this section looks at movement and emotion and explains the way we now understand the mind to relate to the body. (Hint: the mind and the body are ONE).

The last section of this book, the practice of moving better and feeling better discusses strategies for improving movement and key components of training movement variety. Hargrove summarizes his thoughts on this in the following way, “Move playfully, experimentally and curiously, with full attention on what you are doing and what you are trying to accomplish. Focus on movements that are the foundation for your movement health, and have a lot of carryover to many activities, as opposed to movements that are specific and don’t have carryover. Move as much as you can without injury, pain or excess threat, wait for the body to adapt, and then move more next time.” 

Hargrove ends the book by providing 25 lessons to help improve movement. These are based on the Feldenkrais Method (which I liked as I currently use some of these principles and movements within my clinical practice.). Each lesson offers options for progressing and provides guidance for attention and variations.

So, in summary…. I loved this book. I have already recommended it to clients, and plan to use some of the movement lessons within my practice. I hope you love it too!

Have you read any other great books recently? I’m looking for my next one to read! 

~ Jessica

Mindfulness, Meditation and Pain

“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

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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 Nowby 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!

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

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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.

Guest Post: Rib cage position, breathing and your pelvic floor

I am thrilled today to have my colleague and friend, Seth Oberst, PT, DPT, SCS, CSCS (that’s a lot of letters, right?!), guest blogging for me. I have known Seth for a few years, and have consistently been impressed with his expansive knowledge and passion for treating a wide range of patient populations (from men and women with chronic pain, to postpartum moms, and even to high level olympic athletes!) Recently, Seth started working with me at One on One in Vinings/Smyrna, which is super awesome because now we get to collaborate regularly in patient care!  Since Seth started with us, we have been co-treating several of my clients with pelvic pain, diastasis rectus, and even post-surgical problems, and Seth has a unique background and skill set which has been extremely valuable to my population (and in all reality, to me too!). If you live in the Atlanta area, I strongly recommend seeing Seth for any orthopedic or chronic pain problems you are having–he rocks! So, I asked Seth to guest blog for us today…and he’ll be talking about your diaphragm, rib cage position, and the impact of this on both the pelvis and the rest of the body! I hope you enjoy his post! ~ Jessica 

The muscles of the pelvic floor and the diaphragm (our primary muscle of breathing) are mirror images of each other. What one does so does the other. Hodges found that the pelvic floor has both postural and respiratory influences and there’s certainly a relationship between breathing difficulty and pelvic floor dysfunction. (JR note: We’ve chatted about this before, so if you need a refresher, check out this post) So one of the best ways we can improve pelvic floor dysfunction is improving the way we breathe and the position of our ribcage. Often times, we learn to breathe only in certain mechanical positions and over time and repetition (after all we breathe around 20,000 times per day), this becomes the “normal” breathing posture.

Clinically, the breathing posture I see most commonly is a flared ribcage position in which the ribs are protruding forward. This puts the diaphragm in a position where it cannot adequately descend during inhalation so instead it pulls the ribs forward upon breathing in. The pelvis mirrors this position such that it is tipped forward, causing the muscles of the pelvic floor to increase their tension. (JR note: We see this happen all the time in men and women with pelvic pain!) Normal human behavior involves alternating cycles of on and off, up and down, without thinking about it. However, with stress and injury we lose this harmony causing the ribs to stay flared and the pelvis to stay tilted. Ultimately this disrupts the synchrony of contraction and relaxation of the diaphragm and pelvic floor, particularly when there is an asymmetry between the right and left sides (which there often is).

Rib Flare PRI

Rib PRI

Jessica has written extensively on a myriad of pelvic floor issues (this IS a pelvic health blog, after all) that can be caused by the altered control and position of the rib cage and pelvis that I described above. But, these same altered positions can cause trouble up and down the body. Here are a few ways:

  1. Shoulder problems: The ribcage is the resting place for the scapulae by forming a convex surface for the concave blades. With a flared, overextended spine and ribs the shoulder blades do not sit securely on their foundation. This is a main culprit for scapular winging (something you will often see at the local gym) because the muscles that control the scapulae are not positioned effectively. And a poorly positioned scapula leads to excessive forces on the shoulder joint itself often causing pain when lifting overhead.
  2. Back pain: When stuck in a constant state of extension (ribs flared), muscles of the back and hips are not in a strong position to control the spine subjecting the back to higher than normal forces repeatedly over time. This often begins to manifest with tight, toned-up backs that you can’t seem to loosen with traditional “stretches”.
  3. Hip impingement: With the pelvis tilted forward, the femurs run into the pelvis more easily when squatting, running, etc. By changing the way we control the pelvis (and by association the rib cage), we can create more space for the hip in the socket decreasing the symptoms of hip impingement (pinching, grinding sensation in groin/anterior hip). For more on finding the proper squat stance to reduce impingement, read this.
  1. Knee problems: An inability to effectively control the rib cage and pelvis together causes increased shearing forces to the knee joint as evidenced in this study. Furthermore, when we only learn to breathe in certain positions, it reduces our ability to adapt to the environment and move variably increasing our risk for injury.
  2. Foot/ankle: The foot and pelvis share some real estate in the brain and we typically see a connection between foot control and pelvic control. So if the pelvis is stuck in one position and cannot rotate to adapt, the foot/ankle complex is also negatively affected.

So, what can we do about this? One of the most important things we can do is learn to expand the ribcage in all directions instead of just in the front of the chest. This allows better alignment by keeping the ribs down instead of sacrificing position with every breath in. Here are few ideas to help bring the rib cage down over the pelvis and improve expansion. These are by no means complete:

**JR Note: These are great movements, but may not be appropriate for every person, especially if a person has pelvic pain and is at an early stage of treatment (or hasn’t been treated yet in physical therapy). For most clients, these exercises are ones that people can be progressed toward, however, make sure to consult with your physical therapist to help determine which movements will be most helpful for you! If you begin a movement, and it feels threatening/harmful to you or causes you to guard your muscles, it may not be the best movement for you at the time. 

**JR Note: This squat exercise is very similar to one we use for men and women with pelvic pain to facilitate a better resting state of the pelvic floor. It’s wonderful–but it does lead to a maximally lengthened pelvic floor, which can be uncomfortable sometimes for men and women who may have significant tenderness/dysfunction in the pelvic floor (like occurs in men and women with pelvic pain in the earliest stages of treatment).

Here’s another one I use often from Quinn Henoch, DPT:

Our ability to maintain a synchronous relationship between the rib cage and pelvis, predominantly thru breathing and postural control, will help regulate the neuromuscular system and ultimately distribute forces throughout the system. And a balanced system is a resilient and efficient one.

Seth-Oberst

Dr. Seth Oberst, DPT is a colleague of Jessica’s at One on One Physical Therapy in Atlanta, GA. He works with a diverse population of clients from those with chronic pain and fatigue to competitive amateur, CrossFit, professional, and Olympic athletes. Dr. Oberst specializes in optimizing movement and behavior to reduce dysfunction and improve resiliency, adaptability, and self-regulation.

 

For more from Seth check out his website and follow him on Twitter at @SethOberstDPT

Yes, Men can have pelvic pain too.

Confession: I treat men. Lots of them. Seriously, I think my schedule is often about 30% men. This shouldn’t have to be a confession. You shouldn’t be surprised, or shocked by this, but you possibly are. I mean, my female patients are often surprised when they see a male walking out prior to their appointments. I’ve seen that same surprised look on a friend’s (or family member’s, or random person at the bar who happened to ask me what I do for a living’s) face. For some reason, pelvic floor problems are typically seen as a “woman’s problem,” and this is so so unfortunate. It’s unfortunate, because it means that many men feel embarrassed or awkward seeking help for a problem seen to be “unmanly.” It’s unfortunate, because SO many of the men I treat end up seeing close to 5-6 physicians, plus 2-3 physical therapists/chiropractors/acupuncturists, etc. before they actually end up in a place that offers them hope. And it’s unfortunate, because it means that many many men end up suffering with pain for way longer than they should. And this just has to stop. < Rant ended>

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So, today, we’re going to talk about Pelvic Pain in Men. First, you should know that pelvic pain in men is not that uncommon. In fact, this study estimates that close to 1 in 10 men experience chronic prostatitis/chronic pelvic pain syndrome. Often times, pelvic pain is first diagnosed as prostatitis, and I think this happens because of where the pain is located. Prostatitis means inflammation in the prostate… but not all men with the diagnosis actually have inflammation present in the prostate. In all seriousness, I encourage men who are having pelvic pain and receive this diagnosis to ask for a culture. Make sure your prostate is really the one who should be blamed. In some cases, it is (like with bacterial infections). But, often times, these cultures come back negative. So ultimately if the pelvic pain doesn’t go away after a few months, men will often get the diagnosis of chronic nonbacterial prostatitis (which is now categorized as Type 3 chronic prostatitis) or chronic pelvic pain syndrome.

Now, you may be thinking, “Jessica, where are you going with all of this?” Well, these men are the ones I generally end up treating. They’ve had pelvic pain for a long time. Haven’t really responded that well to many medications. And still have pretty significant pain levels. <<Side bar: Today, we’re going to talk about the musculoskeletal aspects involved in pelvic pain in men; however, we never want to downplay the role that other systems and structures can play in pain. So, make sure you are working with a multidisciplinary team and are thoroughly evaluated medically.>>

The symptoms of myofascial pelvic pain in men can include the following: 

  • Pain (which can be sharp, dull, achey, burning, pulling, etc) localized to the lower abdomen, hips, buttock, anus, perineal body, penis, scrotum and/or tailbone.
  • Changes in urination, including urinary urgency/frequency, pain with urination, difficulty starting a urine stream, intermittent or slow urine stream, dribbling after urination and/or urinary leakage.
  • Changes in bowel function including constipation, difficulty emptying bowel movements, pain during and/or after bowel movements.
  • Changes in sexual function including premature ejaculation or erectile dysfunction and/or pain related to sexual function.

So, what can a physical therapist do to help a man with pelvic pain? 

Well, a lot. First, you should know that pelvic pain is complicated (I would argue that all pain really is) and when someone has been in pain for a long time, their pain experience becomes multifactorial. We know now that when a person has had pain for a long time, his or her brain changes the way it processes the signals from the area, and many people develop what we call “central sensitization.” This study found that this happens commonly in men with chronic pelvic pain, which should come as no shock to those of you who read my blog regularly. How exactly is the brain involved in all this? I’m not going to repeat myself here…but I will tell you, to stop here if you don’t know it already, and read this, this and this.

Ok, back to what we can do to help these men experiencing pelvic pain. Let’s break it down:

  • Identification of the musculoskeletal and neuromuscular structures involved: A skilled pelvic PT will perform a comprehensive examination to observe movement patterns and identify structures that could be a component of the pelvic pain experience (including neural, muscular and connective tissue)For many men with pelvic pain, the pelvic floor muscles can be some of those components. These muscles are actually fairly similar anatomically to the pelvic floor muscles in women (although different, of course!). These muscles can be evaluated externally via palpation or internally via the anal canal. Typically, assessing both ways is the best option as it gives us a comprehensive picture of what is happening from a muscular standpoint.

 

  • Nervous System (Brain) Training: I could really just stop here…because this is our primary and most important goal in physical therapy. This should (and will eventually) be a series of posts in itself.  Basically, we know that the brain protects a person against “threatening” areas, movements, etc. when a person is experiencing persistent pain. We want to slowly teach the brain that the areas it is protecting are no longer a threat. We want to widen the “safety net” of the brain to allow for more variability in movement, and we can do that through manual therapy, downtraining the nervous system(restoring breathing patterns, guided relaxations, stress management, etc), restorative exercise/movement, and lots of behavioral education.
  • Manual Therapy Techniques: Musculoskeletal structures are often significant components of chronic pelvic pain in men, like I mentioned above. This includes the pelvic floor muscles (both the external, superficial layer of muscles around the penis and perineum as well as the deeper layers of muscle) as well as the muscles around the pelvis (gluteal muscles, adductors, hip flexors, low back muscles, etc.). Many men will also have restrictions in connective tissue around the pelvis, as well as possibly decreased nerve mobility in some of the nerves around the pelvis. Manual therapy techniques performed both externally and internally help to restore tissue mobility, improve blood flow, and improve the movement of the spine and joints around the pelvis.
  • Improving Bowel, Bladder and Sexual Habits: As mentioned above, pelvic pain is often accompanied by bladder, bowel or sexual symptoms. Part of helping a client move toward better function means making sure that habits are supporting the best possible outcome. So, we look at everything from dietary habits, toilet positioning, sexual positioning/habits, as well as even sleeping habits to make sure we are addressing as many components of the “pain picture” that we can.
  • Restoring Movement Patterns:  As we have learned previously, movement patterns are often changed/adapted when a person is experiencing pain. Although this can be a helpful adaptation short-term, these adaptations can often contribute to problems as time goes on. So, our goal is to observe these patterns of movement and identify asymmetries or dominant patterns in order to add some variety to movement and improve the fluidity of movement patterns. Basically, we want to restore the large variety of movement that you used to have before you were dealing with pelvic pain.
  • Much, much more… I know, this is a catch-all subheading. But honestly, there is SO much more that we can do to help someone with pelvic pain depending on the specific case and it would be impossible to get it all in within one blog!

So, basically, what I’m trying to say is that if you’re a man who is having pelvic pain, it’s time to do something about it! I really do recommend seeking out a pelvic PT who is skilled in treating persistent pelvic pain, and comfortable in treating men (Come see me if you live in the metro Atlanta area!). And, if you’re a pelvic PT and don’t feel comfortable treating men? Then, I want you to read what I’m about to write with the kindest, gentlest undertones… It’s time to get comfortable. I’m serious, and I’m talking to you blog reader who only accepts female clients. I understand that some women feel awkward about this…but men need us! They’re hurting, and they need help, so I really think it’s time to get comfortable. Go to a course, seek out mentoring, or whatever you need to get comfortable…but I think we all need to take responsibility to start providing these men with the care they need!

Wanna read more? Check out these great posts by my colleagues on male pelvic floor problems:

As always, I love to hear from you! Please feel free to comment with any questions or thoughts about any of this! Let’s keep the conversation going!

Wishing you an early, happy Thanksgiving! 

~Jessica

 

 

 

Dyssynergic Defecation (or…when the poop just can’t get out)

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I’ll admit it… I like treating pooping problems. I know that grosses some people out, but it’s true. I think it’s because bowel problems really really impact people’s lives. I mean, pooping is a super basic human activity–so when it’s not working the way it should, it’s really awful.

I have recently had quite a few patients who are having difficulty evacuating their bowels. Now, there are multiple reasons why this could occur (I know, I’ve written about constipation a lot already, see here for evidence)–but today, we’re going to chat about one in particular, dyssynergic defecation or sphinctor dyssynergia.

What exactly is dyssynergic defecation? 

Basically, your pelvic floor muscles work with your colon reflexively. When your colon is contracting to push the poop out, and you are sitting on the toilet ready to empty your bowels, the muscles should relax and open to allow this to occur.  Sometimes, this relationship becomes dysfunctional, and basically, you think you are pushing and relaxing the sphinctor muscles, but instead, the muscles are contracting and closing the sphinctor. I know what you’re thinking– Jessica, I would know if I were actually contracting my muscles instead of relaxing them while I poop. But, no, you wouldn’t. In fact, many patients are shocked when I show them the actual coordination of their muscles.

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Typically, incoordination of the pelvic floor muscles is paired with poor coordination of the abdominal muscles, and often impaired sensation of the rectum. Dyssynergic Defecation is diagnosed typically by an anorectal examination, and anorectal manometry/defecography testing (like this, with an MRI, or by assessing muscle activity with EMG while the person attempts to expel a balloon, or other testing options)

Why does it happen? 

Dyssynergic defecation is very common in people who have constipation. In fact, this review suggested that close to 40% of people with constipation have this incoordination pattern. There are several factors that can contribute to dyssynergic defecation. This review estimated that close to 30% of adults with dyssynergic defecation patterns had constipation as children, and found that 46% had frequent straining to empty hard stool. But there are other factors that can contribute as well, such as:

  • pregnancy
  • traumatic injury
  • low back pain
  • history of sexual abuse/trauma
  • poor behavioral habits related to bowel health
  • nothing (like many other things, we sometimes just don’t know why it happens)

What are the signs and symptoms? 

As we discussed previously, dyssynergic defecation is extremely common amongst those struggling with constipation (typically meaning < 3 BMs per week, as well as symptoms of abdominal discomfort, bloating, and/or difficulty emptying bowels). This article looked at the most common reported symptoms of those with dyssynergic defecation, and found that many experienced the following:

  • Excessive straining to have a bowel movement
  • Feeling of incomplete evacuation after a bowel movement
  • Abdominal bloating
  • Frequent hard stools
  • Frequently utilizing digital maneuvers to empty stool (this means, using a finger to either help pull stool out of the rectum, or using a finger to press inside the vagina to help empty)

What can you do about it? 

The great news is that men and women (and kids too!!) with a dyssynergic defecation pattern can respond very well to conservative treatment! Pelvic physical therapists are typically the providers of choice when it comes to helping people with these problems, and work closely with GI and Colorectal Physicians to help these men and women. Treatment typically involves a few different components:

1. Developing amazing bowel habits. You know that has to be first on my list. If your bowel habits are not stellar, we can try to help your muscles all we want, but you will still have difficulties emptying. So, first things first, we need to make sure your dietary habits rock, you have a great bowel routine, and you know how to sit on the toilet in the most optimal way. Wondering what that toilet position is? Check out this sort of funny, mostly weird video by my favorite potty comedians and stool developers (pun intended), Squatty Potty.

2. Surface EMG Biofeedback training to improve muscle coordination: Biofeedback training uses surface electrodes placed at the anal sphinctor muscles and the abdominal muscles to identify the type of pattern a person uses to expel a bowel movement. Once we identify the pattern you currently use, we can work together to improve the pattern so that your sphinctor muscles relax when you generate abdominal pressure to empty your bowels. Seems pretty basic, right? But the right biofeedback training can make a HUGE difference–and the current research really supports this treatment for anyone with this problem. (See this article, this one, that one, and this one!)

3. Making sure your pelvic floor muscles are strong, FLEXIBLE, and well-coordinated. So, we’ve talked in detail about the pelvic floor muscles on this blog. Remember, we all want muscles that can contract AND relax. And, for dyssynergic defecation patterns, the relaxation component is extremely important! Often times, people who have difficulty relaxing their muscles to have a bowel movement tend to have tender, overactive pelvic floor muscles to begin with. So, treatment will also focus on improving awareness of the pelvic floor muscles, learning to relax the muscles (dropping and lengthening them), and often will include some manual therapy (yes, internal vaginal or rectal) to help reduce the tenderness and improve the mobility of the muscles.

4. Balloon retraining. People love hearing about this one… but it really is an awesome and effective treatment for so many men and women!! (Research supports it also– see here and here!) This treatment basically uses a small balloon that is attached to a catheter and is inserted into the rectum, and slowly inflated. Often times, people with dyssynergic defecation patterns have decreased sensitivity in the rectum, so they will not feel the presence of stool (or a balloon!) in the rectum when they typically should. Based on what we find initially, we can use the balloon to improve the sensation in the rectum. We can also use a slightly filled balloon to work on proper expelling techniques. I know what you’re thinking, Wow Jessica, this sounds like a super fun and awesome treatment. I know, but honestly, it’s very very helpful for people who need it!

Now, this just scratches the surface in terms of what all we pelvic PTs do to help with dyssynergic defecation. But, I wanted to get the conversation started! This tends to be a topic many people don’t talk about… in fact, I have had men and women travel SO far just to get the initial diagnosis! And, I need that to stop… hence this blog post today. Lastly, if you are having problems with constipation and think you may have this problem– Go see a GI/Colorectal Physician! Honestly, make an appointment today! And, contact your local pelvic PT. If you live in Atlanta or the surrounding area, give me a call! It’s time to get your bowels back in order (or even in order for the first time!).

I always look forward to hearing from you! So please, ask any questions or make any comments below!!

~ Jessica

You don’t have to just deal with your bowel problems! CLICK HERE to schedule a virtual consultation with our team today to start feeling better!

Painful scars? Yes, you can do something about it!

 

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I can’t help it. Every time I think scar, I think… Scar (and yes, I used to have a much better picture of Scar from The Lion King for you…but I had to remove it in my attempt to make sure I’m not violating anyone’s copyright laws!)  I was going to try to think of some funny way to explain why scars and Scar are the same… but I can’t… I relate it to the 50,000 times I have watched The Lion King... so I’ll leave it at that.

Scars can be a big pain though– literally! I have treated women who even after several years cannot tolerate pressure on a c-section scar. Men who have nice huge abdominal scars that ultimately contribute to problems with constipation. And moms who have discomfort near their perineal tears every time they have sexual intercourse.  The truth is that scar tissue is often something skilled physical therapists will evaluate and treat as part of a comprehensive program in men and women with pelvic floor dysfunction(and really, with any type of problem!). And the best part– treating scar tissue can make HUGE differences!

So, what is a scar? 

When there is an initial injury (and yes, a surgical incision is an “injury”), the body goes through three phases of healing: Inflamation, Proliferation and Remodeling. Through this process, the body creates scarring to close up the initial injury. Scars are composed of a fibrous protein (collagen) which is the same type of tissue that is in the tissue the body is repairing (i.e. skin, etc).  The difference, however, is that scars are not quite organized the same way as the tissues they replace, and they don’t really do the job quite as well. (i.e. scars are much more permeable to UV rays than skin is). Scars can form in all tissues of the body– even the heart forms scar tissue after someone has a heart attack (myocardial infarction).

How do scars lead to problems? 

After the inflammation and proliferation stage of healing, comes the remodeling. This stage can take months to years! During this time, the body is slowly adapting and changing the scar to the stresses on the tissue. Have you ever noticed that some scars initially are pink and raised and then over time become light/white and flat? That’s remodeling.  Ultimately, there are a few major reasons why a person might develop pain from a scar:

  • Adhesions: Scars are not super selective when it comes to tissues they adhere to. So, sometimes, scars will adhere to lots of tissues around them and this pull can lead to discomfort.
  • Sensitivity: Scars can become very sensitive for a variety of reasons. Sometimes, small nerves can be pulled on by the scar which can lead to irritation. Other times, people themselves will have a significant amount of fear related to the scar. This fear, can often make people avoid touching the scar, and that, along with what we know about how our brain processes fear and pain (See this post, this one, and this one), can lead to a brain that is veeerrrryyy sensitive to the scar. Along with this, muscles near scars can become tender and sensitive. This can occur due to the scar pulling on the muscle or due to the sensitive nerves in the area.
  • Weakness/Poor Muscle firing: So, we know that when our tissues are cut, the muscles around the tissues are inhibited (have you ever seen someone after a knee replacement? It can be quite a bit of work to get those muscles to fire immediately after surgery). That’s why it’s important to get the right muscles firing and moving once a person is safely healed. Moving the right muscles improves blood flow too which promotes healing.
  • Changing Movement: Painful scarring can lead to altered movement. We can especially see this with postural changes after c-sections or other abdominal surgeries, but movement patterns can change with scars all around the body. We also know that abnormal movement patterns over time can lead to dysfunction and pain.

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What can we do about it? 

There are several ways physical therapists can help decrease pain from scars. Can we actually break-up/melt/eliminate scar tissue? I don’t really think so– honestly, scars are made from strong material and truly breaking up the scar is typically something that has to be done surgically– but most of the time, that is not necessary. We can decrease pain from scars by:

  • Improving the mobility of the scar: Gentle techniques to massage the scar and the tissues around the scar can facilitate blood flow to the area and decrease some of the pulling on the tissues around it. There is a thought as well that scar tissue massage can disrupt the fibrotic tissue and improve pliability of the scar (basically, help the scar organize itself a little better, and ultimately move better), and help to promote decreased adhesions of the scar to the tissues around it. Unfortunately, there really is not a lot of great research out there about scar tissue massage. However, this review published in 2012 found that 90% of people with post-surgical scars who were treated by scar massage saw an improvement in either the appearance of the scar or their overall function–which is very promising!
  • Desensitizing the scar and the nervous system: This is where I think we can make huge changes–both by improving someone’s worries/fears about the scar (calming the nervous system) and by slowly desensitizing the scar and the skin around the scar to touch. This is a slow process, but over time, many people who initially can barely tolerate pressure on the scar can be able to easily touch and move the scar without discomfort.
  • Promoting movement: So, we talked about how muscles can become inhibited or tender after a surgery? Part of improving scar tissue related pain is helping the muscles around the scar move well and learn to fire again. This can include some soft tissue treatment to the muscles to reduce the tenderness of the muscles, but ultimately leads to learning to use the muscles again in a variety of movement patterns. Movement is amazing for the body and can not only improve blood flow, but decrease pain too!

Wanna learn more? 

Several of my colleagues have written wonderful information about scar tissue! Check out this great, article and free handout by Kathe Wallace, PT on abdominal scar massage! My colleagues at the Pelvic Health and Rehabilitation Center have also written a few blogs on scars, which you can find here and here.

Have a great rest of your week!

~ Jessica

Pelvic Floor Problems in the Adult Athlete: Pelvic Floor Muscle-related Pain

I love the changes I’ve seen in our culture over the past 10 or so years. Healthy foods? Regular exercise? Joining gyms, boxes, studios, programs? This has become the norm for many people—and, that is so awesome! I love to see people being more active, taking responsibility for their health, and really striving to care for their bodies throughout their lifespans.

However, with this change and shift toward more activity, I have started seeing some pelvic problems become more common. And I don’t blame the exercise—I really don’t! I will stand firm in my belief that there is no such thing as a bad exercise—but all exercises require proper form and performance.  Sometimes when we consistently perform exercises that we may not be able to do correctly, problems can creep in.  I don’t see this to scare anyone off from exercises– please don’t think I mean that! But I think it is important to remember that Pain is never normal. Bladder leakage? Bowel problems? Sexual pain? Also never normal. 

So, the next two posts are going to address two of the major things I am treating regularly in higher level athletes. Today we are going to talk about Pelvic floor muscle pain, and next week I will post about stress incontinence. Let’s get started.

Pelvic floor muscle-related pain

What is it? This problem occurs when the muscle of the pelvic floor become tender, overactive or hypervigilant(basically contracting with too much intensity to guard/protect the pelvis) Often when this happens, people will feel pain in the lower abdomen, groin, hip, buttock or low back—or may feel actual vaginal/rectal pain. The pain may also be associated with changes in bladder function (like increased urinary frequency, urgency or leakage), bowel function (like constipation or difficulty emptying bowels) or sexual function (typically pain or discomfort during intercourse.) However, sometimes people will experience pain without any of these other symptoms at all.

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Image attributed to Open Stax College. CC https://commons.wikimedia.org/wiki/File:1115_Muscles_of_the_Pelvic_Floor.jpg

Why does this happen? This is the kicker–We don’t always know exactly why. However, there are some common reasons why the pelvic floor muscles might begin responding this way. First, we have to remember that the pelvic floor is just one part of a team of muscles that work together to modulate pressure within the abdomen and pelvis. So, the diaphragm, transverse abdominis, multifidus and pelvic floor work together to control intra-abdominal pressure, and pre-activate to support the spine and pelvis during movement.

Dysfunction in any one of these muscles can lead to problems with others. For example, I often find tender, irritated muscles in women after childbirth, especially those who have a diastasis rectus (separation at midline between the two rectus abdominis muscles). This separation impacts the stability at the abdominal wall, generally leading to gripping of the internal and external oblique muscles, alterations in ability to breathe optimally, and thus gripping at the pelvic floor muscles. We see a similar pattern occur in men and women with hypermobility. We can also see dysfunction creep in as a motor adaptation when someone has a history of low back, hip, neck, knee or other musculoskeletal problems.

In terms of athletes in particular (and yes, this includes those of you doing Crossfit, Barre, personal training, yoga, pilates, and other regular exercise— YOU are an athlete J), I often find that when a person lacks dynamic stability, the pelvic floor will compensate to give that stability. If a person is then doing regular exercise and does not have the adequate control, form, or force modulation to perform, these compensations become more prevalent and can then lead to pain.

What can you do about it? If you think your pelvic floor may be a contributor to pain, the first step is to seek evaluation. It can be helpful to initially seek a medical evaluation to rule out other potential pain contributors (ovarian cysts, inguinal hernias, etc.). Then, I do strongly recommend seeking an evaluation by a skilled physical therapist with advanced training in pelvic health. If you are living in a state that allows self-referral to physical therapy (like Georgia!), you can see a physical therapist without a physician referral; however, if in doubt, check with your local physical therapy office.

Treatment for pelvic floor related pain in athletes typically focuses initially on re-establishing the optimal function of the pelvic floor muscles within the team of muscles we spoke about earlier. This is done by teaching the patient how to relax the pelvic floor muscles, use the amazing diaphragm in the proper coordination with the pelvic floor and abdominals, and often includes manual therapy to help reduce muscle tenderness and/or improve connective tissue or neural mobility around the pelvis. A skilled pelvic floor PT will not only assess the pelvic floor muscles, but will examine you from a whole-body perspective—watching you move in various motions, looking at your hips/back/knees/ankles and assessing the soft tissues that could be contributors to your symptoms. This allows us to not only identify which tissues are contributing to the pain you experience, but also to identify any abnormal movement patterns which could be leading to the compensation in the first place.

Once the pelvic floor muscles are no longer hypervigilant/tender/overactive, we focus on restoring healthy movement. This includes integrating the pelvic floor and its team within those movements—the right way!  Typically at this point, we progress the athlete to his or her specific movements—whether that is Olympic lifting, squats, or a yoga warrior series—teaching the athlete proper form all while integrating the right muscle firing patterns to adequately stabilize.

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Do I have to stop exercising while in PT? This is always a tough one. I totally recognize that many adult athletes love their work-out routines and benefit so much by them—physically, socially, and emotionally. Sometimes there will be particular exercises that are aggravating symptoms or worsening the problems the person is experiencing. In those cases, I often will recommend holding off on those movements for a short time period. While holding off on some exercises, we often can still work together to find exercises and movements that are appropriate and totally acceptable to keep performing! I know this period can be frustrating for patients as it is difficult to take a break from something you love, but I promise, it’s short! Our goal ultimately is to get people back to the activities they love as quickly and safely as we can!

If you are having pelvic pain during exercise, and you live in the Atlanta area, I would LOVE to see you! Feel free to contact me or call my office for more information!

I always love to hear from you! Please let me know if you have any questions or feel free to chime in if I left something out! Happy Thursday!

~Jessica

Do we move differently in pain?

For the past few years, my studies in pelvic health have taken me further and further outside of the pelvis.  I have learned and continue to learn how amazingly interconnected our bodies actually are. The pelvis can be influenced by the ankle, the knees—and even the neck! It is amazing and awe-inspiring. This past weekend, my studies took me to the Level 1 Selective Functional Movement Assessment (SFMA), where I spent 2 days learning a systematic way to evaluate movement and identify where dysfunctional patterns exist—head to toe! (How awesome is that?!) There are many different systems and programs out there for evaluating someone’s movement, and honestly, I don’t necessarily think one is superior to the other. I liked this one though, as it made sense to me and the initial screen could be completed in 2 minutes :).

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So, why is it important to look globally at human movement when a person is experiencing pain anywhere in the body? For lots of reasons, like I said above—but for the purpose of today’s post—because we now know that movement patterns do really change when a person is experiencing pain—and this is helpful initially and important—remember, your brain wants to protect you from experiencing harm! However, dysfunctional movement patterns, although helpful to the body in that moment, can persist and lead to further problems down the road.

Paul Hodges (a favorite researcher of mine!) and Kylie Tucker examined the current theories regarding movement adaptations to pain in a 2011 review published in the International Association for the Study of Pain. They looked at the current research regarding movement variations in pain, and frankly poked holes in the theories where holes needed poking.  They then presented a new theory on the motor adaptations to pain, and that’s what I would like to share with you today.

The theory they presented is based on the premise that movement adaptations occur to reduce pain and protect the painful part. The way in which a person does that actually varies and is flexible. Here are the basics of their theory, simplified, of course. I do encourage you to read the paper if you’re interested—it’s great!

  • Adaptation to pain involves redistribution of activity within and between muscles. Basically, the brain varies which pools of motoneurons fire in a muscle based on the individual and the task requirement. The common goal still is to protect the painful part from pain or injury, but the way the body does this can vary greatly. Interestingly, we know that the motoneurons active before and during pain tend to reduce activity, and the production of force actually seems to be maintained by a new population of units who were previously inactive. Normally, motoneuron units are recruited from smaller to larger pools to allow for a gradual increase in force—but in pain, a person often will have earlier recruitment of larger pools to basically allow for a faster development of force to get away from pain (think fight or flight response!). Also, the new population of active units may be altered to change the direction of the force generated by the muscle (again, aiming to help protect the painful structure). We also can see in some areas, like the trunk, that one muscle may become inhibited (like the transverse abdominis) while other larger muscles become more activated. This again, makes sense with the body’s goal of protection. Quick activation of larger motor units allows for a quick activation of a muscle to help protect and escape pain.
  • Adaptation to pain changes mechanical behavior. Basically, like we just discussed, the redistribution of activity within and between muscles changes the force and output of the muscle. Hodges & Tucker give us a few examples of this. First, they’ve found that when someone has knee pain, the quadriceps muscles fire differently to change the direction of knee extension by a few degrees. They also explain that the changes in muscle firing in the trunk muscles in someone with back pain leads to more stiffness and less control of movements and less anticipatory action. Basically, in each of these cases, the big picture motion stays the same, but there are small changes within how the body accomplishes those tasks.
  • Adaptation to pain leads to protection from pain or injury, or threatened pain or injury. Basically, this redistribution of muscle firing is done to protect against pain—or even the threat of pain. When a person experiences pain, the brain choses a new pattern to move to either splint the injured area, reduce the movement of the area, or alter the force on the area. The interesting piece here is that the body responds this way even when there is a perceived threat of pain! The key with all of this is that the adaptation varies significantly—not one pattern is seen for all types of pain, but the nervous system has a variety of options for protection!
  • Adaptation to pain involves changes at multiple levels of the motor system. So, although we know that the activation of motoneuron pools can change during pain, that alone does not describe the variability we see. We know now that the way the body changes movement can be influenced by structures in the brain, spinal cord or at the local level of the motoneuron. All of this is going to be influenced by the task at hand and the individual (thoughts about the pain, emotions, stressors, and previous experiences)
  • Adaptation to pain has short-term benefit, but with potential long-term consequences. Although the short-term benefit is protection of the painful area and prevention of further pain, this may lead to consequences down the road if the adaptation persists. Of course, we assume in this case that movement in a non-pain state is likely the most efficient and optimal way to move. So, changes over time could produce decreased movement variability, modified joint loading, modifications in walking patterns, joint load and ligamentous stress. Hodges and Tucker state that in order for these long-term consequences to occur, there would likely need to be a gradual maintaining of the compensation, thus that the nervous system did not recognize it being problematic. Basically, the brain slowly adapts to the new pattern and does not recognize the problems it could cause down the road.

Interesting stuff right? The tricky thing is, we don’t really know for certain how these long-term changes can impact the body—but we do know that one of the biggest risks for injury is previous injury. I can’t help but think that movement changes could possibly contribute. But how do we change this in a positive way?  I think the first step is understanding pain, learning what pain is and what pain is, and developing a healthy mindset toward pain—this alone goes a long way! We also have to look closely at our own emotions, our psychological state, our previous experiences, and understand how all of these things can influence how are brain chooses to respond to pain. But then, we need to identify which movements the body has changed, understand how the brain is varying movements to protect against pain, and then slowly provide variability with good force modulation in those movements to help the brain learn optimal, safe and pain-free ways to move again.

What do you think? I’d love to hear from you in the comments below!

Cheers!

Jessica

A Pain in the Tail…bone (Part 2: Treatment)

“Due to the dearth of research available and the low levels of evidence in the published studies that were located we are unable to recommend the most effective conservative intervention for the treatment of coccydynia. Additional research is needed regarding the treatment for this painful condition.” 

This statement comes from a 2013 systematic review on conservative treatments for coccydynia… isn’t it so encouraging? We discussed what coccyx pain meant, the causes, and the examination approach last week in Part 1 of “A pain in the tail…bone.”  Today’s post will take a close look at my approach for treating people with tailbone pain and what we do know in the current research. Unfortunately, as you see from the comment above, research for the best treatment for tailbone pain is significantly lacking…so we’ll have to rely on my clinical experience as well as the knowledge from courses I have attended and practitioners I have collaborated with in the past.

So, what should treatment for tailbone pain include?

1. Pain reducing strategies: Day one of treatment should always include recommendations for reducing pain by changing some basic daily habits. Typically, this includes:

  • Cold packs/hot packs: Basic, I know, but they feel good and can help a sore coccyx feel better after a long day. I prefer ice, but others prefer heat. I recommend using for about 10-15 minutes, a few times per day or as needed. Recent recommendations always include using cold/heat as needed.
  • Alignment, & Cushions when needed: Alignment, especially in sitting, is very important for reducing pressure on the tailbone in the initial phase of treatment. Slumpy postures actually put more pressure against the tailbone and neutral postures distribute weight to the bony parts of our pelvis more evenly. Along with this, firm comfortable chairs tend to support a more neutral posture, but cushy couches or chairs usually promote a more slumped posture. As I mentioned in my previous post, many people with tailbone pain tend to develop a side-twisted sitting posture. It makes sense– they’re trying to unweight the tailbone–but over time, this “wonky” sitting can lead to low back pain, and that’s not fun for anyone! So, we need to learn to sit up comfortably, and a good tailbone cushion can be a helpful tool for that. Note: Donut cushions don’t tend to help as much with tailbone pain unless the pain is totally referred from the pelvic floor musces. These unweight the perineum due to the center cut-out, but they don’t unweight the coccyx.  A cushion that has a back cut-out, like the ones pictured tend to be more helpful.
  • Coccyx cushion from Amazon.com

    Aylio Seat Cushion
  • Body Scanning or “Check-ins”: Many people with tailbone pain will clench muscles around the tailbone as a protective strategy–usually the glutes and the pelvic floor to be precise. As we discussed previously, these muscles can refer to the coccyx, so it is important that we decrease this hypervigilant clenching pattern. I typically recommend scanning the body, or checking-in, a few times a day to feel if muscles are clenched hart or relaxed. If you feel any clenching, try to drop the muscles and allow them to let go.
  • Pelvic Floor Drops: As mentioned previously, many people with coccyx pain have tender and over-contracting pelvic floor muscles. Pelvic floor drops are exercises that encourage a completely relaxed pelvic floor. Typically, these pair well with breathing exercises as functional diaphragm use can encourage appropriate pelvic floor relaxation.
  • Stretches: My favorite stretch for someone with coccyx pain is what I call “The frog.” This stretch not only helps to stretch out the buttock muscles, but also is a position of optimal relaxation for the pelvic floor! This is often done with a person lying on their back with knees pulled up to chest and held open. Alternatively, a wide kneed child’s pose can also promote relaxation for the muscles. Other stretches to open the pelvic or stretch the muscles around the pelvis can also be helpful–but this one is my go-to on day 1.
mark-zamora-1412579-unsplash
Photo by Mark Zamora on Unsplash. Arms can be reached out in front. You can also place a pillow underneath you while you lean forward if that is more comfortable

2. Manual Therapy Techniques: The goal of manual therapy should be to decrease soft tissue sensitivity/pain and to improve the mobility of the coccyx, SI joint and low back if indicated. Typically we do the following:

  • Soft tissue treatments: This should not be a horribly painful experience! Skilled clinicians can help to improve sensitivity and tender spots in the buttocks, hips, low back muscles and pelvic floor muscles. For the pelvic floor, this can be done externally, vaginally (in women) or rectally. Specifically, the coccygeus, iliococcygeus, pubococcygeus and obturator internus muscles should be evaluated and treated. Sometimes dry needling can be helpful also in reducing soft tissue sensitivity.
  • Coccyx Mobilization: The coccyx can be mobilized some externally with a person in sitting (I use what is called the “closed-drawer technique” here). The best way to mobilize the coccyx is with internal rectal treatments. Internal rectal mobilizations or manipulations can include direct mobilization into flexion or extension, distraction of the coccyx and mobilization into sidebending. The most recent review I found published in 2013 found 3 studies looking at intrarectal manipulation for coccyx pain and all of them did show some improvements in pain for patients…but from a research standpoint, 3 studies is hardly anything and to be honest, the studies weren’t that good. So, we’re stuck with some of my clinical opinion 🙂 I believe intrarectal mobilization can be hugely beneficial for patients! And, I shouldn’t have to say it–but it should always be done by someone trained and skilled in performing it.
  • Lumbar & SI treatment: I highlighted in part 1 that many men and women would tailbone pain often have low back and SI pain as well. In these cases, these areas should be addressed and treated through manual therapy techniques as well as specific exercise recommendations

I often will also use a little bit of taping to help support what I do manually and give my client some input on what I want their bodies to do. I like kinesiotape the best for this and use a few different techniques depending on the person. McConnel tape can also work well.

3. Retrain the Nervous System: Our brain rules– remember, pain is our brain’s alarm system to tell use there is a problem and to protect. A person who has had coccyx pain for a long period of time may develop a sensitized nervous system–and it is so important that this be addressed! So as not to re-invent the wheel, you can read more about it in my previous post reviewing the book, Why Pelvic Pain Hurtsand in my previous post summarizing my presentation to the Atlanta Interstitial Cystitis Support Group. 

Side-note: Pain neuroscience is currently not discussed often enough in the research regarding treatment for coccydynia. I think this is a huge problem–we know that experiencing pain for a long period of time truly impacts the nervous system and we can’t ignore that! This case study showed 2 patients treated for tailbone pain–one was acute, treated immediately and got better quickly. The second had pain for over a year before being treated and did not get as good results– could this “brain retraining” be the missing piece? I think it can’t be ignored.

4. Manage Bowel, Bladder and Sexual Problems: Remember, the pelvic floor muscles attach to the tailbone, so it is so common for people with tailbone pain to notice bowel, bladder or sexual symptoms.  This should always be addressed with good behavioral education and appropriate treatment techniques. I’ll leave it at that…because each one could be a few blog posts in and of themselves.

5. Return to Normal Function: I talk about this in almost every post, but ultimately, our goal is always to get you back to moving, sitting, exercising, etc. as quickly and effectively as we can. As pain decreases, our goal is to retrain the system to function optimally. We do this by retraining proper patterns of muscular activation (yep, diaphragm, pelvic floor, abdominals, low back…with all of the other muscles!), teaching movement with lots of good variation, and a lot of education.

So, that about sums it up… PTs out there, did I miss anything important? I would love to hear from you and start a discussion!

For those of you out there dealing with tailbone pain–please let us know how we can help you better! If you have not tried working with a pelvic physical therapist in the past, I do strongly recommend it!