Sallie Sarrel, DPT
Multidisciplinary pain therapies:
Patient Awareness Day
The Lifecycle of Endometriosis: From Diagnosis to Coping with Disease
Sunday April 17, 2016
Lenox Hill Hospital, Einhorn Auditorium
Good afternoon my name is Sallie Sarrel and I am pelvic health physical therapist here in New York. Dr. Shrikhande did an amazing job talking about the pelvic floor but now we are going to take a quick couple of minutes to explore it a little more and talk about five things your pelvic floor can do for you with endometriosis.
May I present to you, your pelvic floor. Now this is everything that is inside the bone, so it is not bones, then uterus, ovaries and fallopian tubes. Your whole pelvis itself is lined with muscles and ligaments and nerves and fascia and everything else. If you have a problem in one of these muscles you are also going to have a problem in muscle on the other side because everything is symmetrical.
Pelvic health physical therapy: How many of you knew, show of hands, that there are physical therapists that specialize specifically in the pelvis? Good, lots, so I started these lectures about five years ago, no one would raise their hand. How many have been to a pelvic physical therapist before? Very good, I love to see that! I love to see that so we are the multidisciplinary approach so we work with say a physiatrist and a surgeon all at once. We are sort of – they use to refer to us as the gatekeeper that ties everything together. We have advanced specialized training beyond our doctorate level of education. Usually most of the pelvic PTs have had up to two years or more of specific education just in the pelvis. You will hear from my colleague Jessica in just a few minutes and now she is offering nutrition education for physical therapists. It is amazing how highly specialized we can be. All of our therapy takes place in a one-on-one setting and we are one-on-one with the patients for the whole hour. That is one of the advantages of working with a pelvic floor physical therapist is we are there for you. We are part of team you.
Let us talk a little bit about five thing pelvic physical therapy can do for you.
Number one; it can create a better floor. Well you saw just a few minutes ago exactly how many muscle are lying inside here. And those muscles support everything that not only goes on above the waist but they support everything that goes on below. Your foot affects the pelvic floor, your hips affect the pelvic floor and everything else in between. Some of our symptoms of pelvic floor pain include lower urinary tract pain, urinary leakage, urgency, frequency, bowel and rectal pain, nausea, vomiting, cramping, constipation, diarrhea, I know, I have such a fun job. This is all I talk about all day long. My parents are so proud of me. You can get a lot of nerve dysfunction and spasming around the pelvic floor or you can get a lot of itching or stinging in the vulva or vestibule. You can get, I actually have some patients here they get they think it is recurrent yeast infection, it is actually spasms around the pelvic floor nerves and the therapy can help with that. You can have pain inserting a tampon. Somebody asked this morning about pain inserting the Diva Cup. Diva Cup pain is pretty common with some pelvic floor dysfunction. You can have hip pain, lower back pain, joint pain, discomfort sitting or standing for prolonged periods of time and that is because upright, that pelvic floor is loaded. We ask all our patients to lie down a lot and now you can all go home and when they want you to do something at home you can say, “No, the therapist told me to lie down” right? Also, if your pelvic floor is really tight, in the absence of endometriosis it can cause very heavy menstrual cramping, very painful cramps and when you add endometriosis on top of that it is really very difficult for you to balance anything. If your muscle are not working great you are going to have a lot of fatigue. Think about it – if your arm was spasmed like this for hours on end do you think you would be like the whole rest of your body would be all good and happy? No! What happens is you are just worn out and fatigued from the spasming.
These are some examples of pictures of pelvic floor related pain. How many of you have pain in these areas? I will include myself in this. I sat on a bike seat in November and I thought like that was it I was going in for surgery right afterwards until I was very nice to myself and I went to my pelvic floor physical therapist. Within three sessions the pain resolved entirely because when you sit on that bike seat you are mashing against the pelvic floor. Even I have to remind myself that not every pain in the pelvis is endometriosis and you really have to weed through what is which pain.
The second thing our pelvic floor can do for you is it can interrupt and mediate the superhighway of pain that our bodies experience as women with endometriosis. We just had a great lecture on pain processing from Dr. Shirkhande and what I have to say is that pain is the sign that something in our body is wrong. When you have endometriosis you have been sending that signal for so many years your brain has gotten simply overwhelmed and you need to send a different signal and you need to use something to send a different signal. Pelvic PT is one of the things that can mediate that pain signal for you. We use all sorts of techniques like cranial sacral, like lymphatic massage, like exercise is really big to send a better message to your brain to stop that central sensitization that the previous two speakers spoke about.
Our third thing that pelvic floor therapy can do for you is it can clean up endometriosis’s associated mess. Endometriosis’ laundry list is very long. The cause of pelvic pain is multifaceted. Not every pain is endometriosis. Even after the disease has been removed pain may remain. We can talk about this being because of central sensitization, which we spoke a little bit about but we can also remind ourselves that between 60 and 80 percent of women with endometriosis also experience interstitial cystitis. In fact, they are experienced so often together they have been coined the evil twins of pelvic pain. So many women have horrible pelvic floor spasms, not just because of endometriosis, but because of interstitial cystitis. Interstitial cystitis also can cause frequency and urgency and burning and lots of things like that. It is so important to treat both of them.
Now we have developed a triplet through the years and through our research called pudendal neuralgia and Dr. Shirkhande explained exactly why if you have some pelvic floor pain why you can get that connection into the pudendal nerve as well. Studies can demonstrate that women with endometriosis have a higher tone throughout the pelvic floor. Maybe if the day you got endometriosis when your period started at thirteen if it was cut out you would not automatically get this pain signal to go to your brain to spasm the pelvic floor. But we typically do not get treatment so early and they have found in multiple studies that when you have endometriosis your pelvic floor sends a signal to your brain to make it tighter because it is trying to guard against the pain. But then eventually, after a while, say six months, and I do not know how many of us were diagnosed in just six months, the brain sends a signal to keep that spasm there. It becomes this game of trying to relax the floor so you get this hypertonic floor and pelvic physical therapy is tremendously helpful in learning how to relax that.
The fourth thing pelvic floor physical therapy can do for you it can possibly increase fertility and prevent post-surgical adhesions.
This summer a ten-year retrospective study on the efficacy of manual physical therapy to increase fertility in females with endometriosis was released. In this study it concluded that women with endometriosis who received a specific kind of therapy called Barral Visceral Manipulation had higher incidences of spontaneous natural pregnancies after endometriosis surgery. It is also a very good relaxing therapy so we recommend that for multiple reasons. The other study that I point out is that abdominal adhesions are major and expected complication of surgery and sometimes those adhesions are why you need a second or a third operation. A 2013 study in rats determined that visceral manipulation when provided post-operatively lowered post-surgical adhesions. There is actually video where they do this technique on these little tiny bellies of mice. They are showing on abdominal re-operation that the visceral manipulation is quite helpful.
What is that visceral manipulation? It is a technique developed by a French osteopath and it evaluates the structural relationship between the viscera, fascia and ligamentous attachments inside the pelvis. What you mostly feel is that the therapist has their hand on your belly and they are working the inner relationships between these ligaments and this fascia and they are trying to get a better connection between these organs and your brain to stop that sense of sending that pain signal.
The fifth thing that pelvic floor physical therapy can do for you is attack that endo belly. Who here suffers a little bit from the endo belly? Yeah, all right, so one of the things we talk about with endo belly it is like that out pouching. There are two reasons why we can get endo belly that are all muscular. The first is that the iliopsoas or the hip flexor muscles run right on the sides of the belly and when they get a sugar point in them that responds to visceral stimulation or visceral disease, that means disease inside your belly, these trigger points love to balloon out, to get an out pouching of the belly. The other issue is that the pelvic floor itself is there to provide support for your body. If everything inside that body is balled up and tied up like a knot how can the floor beneath it provide the support it needs? It pushes up and when your pelvic floor is so tight that it can no longer have any length or strength to it you get an out pouching. That is why a lot of people mention endo belly is worse at the end of the day. That is because your pelvic floor is spasmed and so learning how to do some relaxation techniques and learning to get some length back into the core and the pelvic floor can be tremendously helpful. What we love to do in terms of pelvic floor therapy is not only treating manually, so yes, I do put on a glove and I am not a gynecologist but I do have to work the muscles inside your pelvis a lot of the times. Not all pelvic floor therapy is internal but some of it may be so people get scared of that and what I have to say is I can do plenty without working inside but if I do have to work inside, again, it is about that team. I do not ever force treatment on someone. It is a give and go situation. If you are not there then we find a different way to treat you. But we also love to incorporate Pilates and supervised exercises for the core and the glutes to help you balance out your pelvic floor so you will not get that endo belly.
So now, everybody stand up. Jessica is our next speaker. She is going to come on up. They asked me to do a demo and we are going to begin with a standing pelvic floor opening. So my ladies in the front you need to take a big step forward, the rest of you may have to peek out into the aisles, I did not set the room up. Everybody is going to put their toes at 10:00 and 2:00 I am going to caution anybody who has had inguinal hernia surgery or an active inguinal hernia, we are not going to do this exercise. Hands on hips and we are going to sink down and open up our pelvis. I always lecture in a dress but today I wore leggings, it was like a whole thing. You can tuck your tailbone towards the front and now you can wag your tail and bring it towards the back. So, tuck the tailbone and I really want you to drop the tushes because if you are midway in between you will not feel it in your pelvic floor at all. Then, while you are there just tell your body to let go and you will feel your pelvic floor drop. Good, all right.
We are going to do one last breathing exercise. You can stay standing for this. Everybody can close their eyes. You are going to take one hand and put it on your belly button and you are going to inhale through your nose and fill your belly and exhale though your mouth and let your belly pull away from your hand. Inhale and fill, exhale and pull away. Now you are going to inhale and fill your belly and open up that pelvic floor that pelvic bowl and exhale pull everything away, inhale and exhale. Good.
Thank you very much this is the beginning of your pelvic floor down training. I have appointments available on Wednesday. I will see the rest of you all there.