Nurses Conference 2013 - You Are Not Your Pain: Empower Yourself With Physical Therapy
- Sallie Sarrel, PT, ATC, DP
I am Dr. Sallie Sarrel. I am a doctor of physical therapy. I own a practice here in New York and in New Jersey; the New York practice is new, this month actually. I specialize in endometriosis and chronic pelvic pain. I am so happy to have been invited here by the Endometriosis Foundation of America. I speak all over the world. I have spoken in China, Brazil, Columbia and it is such an honor to come here and speak in a place that meets my mission, which is to diagnose earlier with proper diagnosis and encourage a full quality of life for women. And to me, to be with this organization it is like coming home. I am so happy that you all came today.
Let us talk a little bit about pelvic health physical therapy. Pelvic health physical therapy is a multi-disciplinary approach to the body. I always say we are never too old to add to your tool box. Like Padma said this morning "You shouldn't just shove the pain away or use treatments to shove the pain away". Physical therapy is something that works with the team you are working with. We work with your gynecologist, we work with your nutrition and we put everything in a toolbox so that you can help yourself with what we are using. It is performed in a private one-on-one treatment setting so no, I am not doing pelvics in the middle of the big physical therapy gym. This is advanced training, this took above and beyond my doctorate three years of training and like I said we are a crucial team member to treating endometriosis.
Today I am going to talk a little bit about the physiology of pain. We had a snippet of that by the acupuncturist that just spoke. And the deal is that the brain and the pelvis they can be friends and they can work together and be happy and they send happy signals and everything works great. Or, they can be complete and total foes, meaning that they are working against each other for you to have the quality of life that you are looking for.
Pain is a sign that something in our bodies is wrong. It is a response to noxious or bad stimuli that is damaging the tissue. Nociceptors or free nerve endings are receiving these stimuli and they are getting damaged. Damage can occur in three ways, mechanically, pressure, growth (tumor or something like that); thermally, by burning or scalding, and chemically with ischemia or toxic substances in your body or even infection. So here is the deal; all three types of that damage happened in a patient with endometriosis. So first we have the mechanical pain because there is endometriosis in there and that puts pressure on all the tissues. The other thing is if someone receives cautery or it is lasered out again and again and again, you are getting a burning or scalding. I do not know if we show videos of what that looks like but there is actually eschar, which is what we see in burn patients all over the inside of the patient in somebody who has been burned repeatedly through non-excision based surgeries. Then also there is chemical because there are minor infections that go on. Somebody was saying that they had peritonitis. You can get ischemic, you can get cell death constantly, and too, you can have all three types of damage going on and assaulting these pain fibers over and over again.
The pain fiber, there are two different kinds. There are ones that are found in the somatic structures, so that is the skin, the bone, the connective tissue and the joints. And then there are also pain fibers found in the visceral structures, the liver, GI, uterus and ovary. So here is the deal. Does endometriosis only hit only one kind of pain fiber? No, I think somebody shook their head, I felt like... So, if this is your pelvis, you have bone, you have connective tissue, you have skin obviously, and you have visceral structures. So once this signal of pain is being sent from all these structures, even though the disease may be in your uterus, may be in your ovary, may be in your fallopian tube, the pain signal is sent from every structure that is down in your pelvis.
And then the transmission of pain it goes actually to a part of your spinal cord that nociceptor fiber goes into the dorsal horn of the spinal cord. It goes up the spinal cord into the brain stem and then it forms connections within your brain. It is very hard, so your pain is in your pelvis when all of a sudden the pain actually has created neural pathways in your brain. And here is the thing, here is the real kicker; Nociception and recognition in the brain happens within the first six months of onslaught of pain. The average woman goes eight to ten years before she is diagnosed. Show of hands, who was diagnosed within the first six months of feeling pain? Show of hands, how many of us took eight to ten years to be diagnosed? Twenty-three years? Twenty-eight years? Right? So, all these neural pathways have really been able to set up camp. It is very, very difficult, and this is why I love coming to an event that is geared towards nurses, especially high school nurses.
You are the gatekeepers of care. You are the first people that meet the patient, that meet the young women the day they have pain. What do you do? I have pain, I call the doctor's office, I get the nurse first. My little girls I spend a lot of time working out of training rooms and working in middle schools and high schools as an...trainer and physical therapist. They have cramps, who do they go to first when they're there? They go to the school nurse. You are the gatekeepers of care. So instead of them taking eight to ten years to diagnose and the neural pathways have really taken a hold of this woman you could cut down that time just by mentioning endometriosis and just by advocating for your women to have care, for your young women.
The key to approaching ongoing pain in the patient, now post-excision because we hope that they have gotten their way to excision, is physical therapy. I have recently done a lot of work with a doctor named Maurice Chung and we were out at a social event. He does a lot of work with endometriosis and IC but he made a fantastic analogy; he says, "Endometriosis is a lot like this house. All your houses are in a row and this is the endometriosis. Now, this could be your hips, this could be maybe your bladder, this could be your back pain, and here is the thing, they took care of that endometriosis in excision surgery, right? Suppose this house caught on fire - that is like having endometriosis. The house is on fire. While this house is on fire what do you think happens to this house and what do you think happens to this house? They catch on fire too. Once we treat this we treated endometriosis as aggressively as we can with the excision surgery, with proper care, proper diagnosis with a good team, all of these other houses still have the embers that flew onto them. Physical therapy, and we discussed a little bit of acupuncture, are great ways to calm the rest of the fire, and feel better and get back to the best quality of life you can have.
Today we are going to talk a little bit about the pelvis. It is a compound structure that's role really is to close the outlet. The outlet at the bottom closes so mostly you do not leak urine, you do not leak feces and the goal is to close that structure. It has a pelvic floor, and it has bones, and muscles and fascia, ligaments and viscera. There are all these muscle groups in here. This is why I brought the pelvis with me so I could show you. Because although when we were in China they did a live pelvic floor evaluation I did not really think it was so appropriate here.
This is the bottom of your pelvic floor and these are filled with muscles. If you are going through life, eight, nine, ten years and you have horrible pain and all you can do is just basically double over all of the time, these muscles that sit at the bottom of your pelvis - and you can see all of the organs that are inside - they go into spasm. There is a great article by Fred Howard that talks about how 90 percent of women with endometriosis have spasms within the pelvic floor and the associated musculature. The principle function of the pelvic floor is to provide support for all the organs. If the anatomy is distorted by endometriosis it is very hard for that pelvic floor to provide the support that it needs.
Here we go, we have a nice - I just showed you all these muscles but this is your pelvic floor. This is a sling like muscle called the levator ani group and a lot of patients get a lot of their rectal pain from this group in here. This is obturator internus a lot of your pit pain comes from there, mostly because those with...disease the ovary affects the obturator internus pretty directly. You can see that everything that goes on in the bottom of this pelvis is muscular. I had a patient this week and her husband came to therapy, which I think was wonderful that he was showing support, and I went to do the exam and for ten minutes while I was doing the exam he stood there and he said, "Ya mean there are muscles in there?" The whole body of the pelvis is muscle. It very important when you - once the disease has been excised, the muscles themselves need a little help to be ready to go back to life as normal.
Sometimes inside the muscles we get myofascial trigger points. Who gets that, like your neck hurts here and they push on it and then they get a headache. Does anybody here get that, yeah a few hands. You get that in all of these. Usually it is from what is called a shortening of the sarcomeres, which is the actual muscle fiber. Then the muscles try to elongate really quickly and you get a little ball in the muscle. Once you get one trigger point, one begets another, begets another and begets another, so you get a lot of it. They can mimic gall bladder disease, they obviously can mimic endometriosis, bladder disease and even cardiac symptoms. They come from trauma, which we have plenty of so people say they come from the surgery itself because it is so traumatic. Chronic muscle overload, nerve compression, structural asymmetries, postural stress, pelvic torsion, hypermobility, hypomobility, tight clothing - basically the kitchen sink. You get a trigger point on everything. In the pelvic floor trigger point you get pain around the tailbone. I am going to point just in case there are... Some of your pain around your tailbone can come from a trigger point and you get pain in the coccyx, which is this little tiny bone. You can get pain in the rectum, pain in the genetalia itself. There is also a specific trigger point that causes you to have frequent urination and have that sense of burning all the time. It comes with back pain as well. In recent studies patients felt an improvement of symptoms with the PT given to the pelvic floor directly on trigger points.
The other thing that we work with in this pelvic physical therapy is the fascia. The fascia is the "endless web" between all cells, muscles, nerves, ligaments and organs. It is connective tissue filled with collagen fibers that are wavy or parallel, or sometimes confused. Sometimes they are wavy where they are supposed to be parallel and parallel where they are supposed to be wavy. Usually that is what happens in the case of adhesions, the tissue just did not lay down in the pattern that it was supposed to lay down in. Fascia is a tricky thing. It is supposed to be flexible and it is supposed to be strong. Sometimes it is strong where it is supposed to be flexible and flexible where it is supposed to be strong. You can get dysfunction within the fascia itself. This fascia is supposed to provide support for the whole body and if it gets confused and it binds where it needs to glide what happens is your body just does not know how to adapt. That is one of the things that we work on in physical therapy through myofascial release, through cranial sacral and through many other techniques.
Myofascial release is a soft tissue therapy used to treat dysfunction and restriction in this fascia that - and usually that restriction results in pain. This dysfunction can arise from psychogenic disease, overuse, trauma, infectious agents, surgery, postural issues and inactivity, so basically like everything we live through every day with endometriosis. The fascia once injured or inflamed will fail to provide its glide until it is encouraged. It has to be gently encouraged back into health. There are certain forms of myofascial release that serve to down regulate that fight or flight mechanism that we walk around living in constantly. And they really help the body recoup from years of trauma. I happen to use cranial sacral for that particular technique.
Visceral manipulation is another form of myofascial work. It was developed by a French osteopath, Jean-Pierre Barral. It evaluates the structural relationship of the viscera and the fascia and all the ligamentous attachments. Tension patterns form through this fascia and the body compensates by creating fixed points and chronic irritation within the organs itself. The body is constantly trying to respond to the disease that is in it. Also, if you have adhesions for those of us who had surgery, if you have bowel adhesions this is one way - this is a technique that you can use, the gentle light touch technique that you can use to help bounce the body around the adhesion. You cannot break the adhesion but you can help get the body adapted to the adhesion. It provides proprioceptive input from this organ that may have the adhesions to the brain to send a different message. The key to breaking that pain pathway that we were talking about is to send a new message, to drive the train down a new track that says, "I'm healthy", instead of "I'm in pain" and visceral manipulation is one technique to use.
Another issue with the pelvis and so not all physical therapy, especially women's health with physical therapy is done internally. My teenagers that I work on I never do internal work. It is bad enough when you are a teenager that you have this disease and your association of your pelvis it is like disease and doctors and ultrasounds and colonoscopies and all that. We want to create a healthy message between the brain and the pelvis, and what I say "a happy pelvis". I do not do any internal work on young teenagers. What I do do is I work the muscles in close proximity. I work piriformis, I work obturator internus, I work on all of the gluteals and all of the abdominals. Now abdominals provide so much support when that floor is in spasm. It provides so much support against the pelvic floor that they can kind of cover a spasm here or there. The abdominal fossa, especially co-surgically, can go into spasm and you can get a horrible trigger point that mimics endometriosis. Actually, next month I am going to give a whole presentation down in Washington, DC about how the abdominals can create like a false pelvic pain. The other thing is you have to have your respiratory diaphragm working to expand to get the lungs moving and also to calm the system. The way that you breathe really helps calm the system rather than amp it up. The calmer the system is the more the system is going to be able to regroup.
There are many things that I do. I do stretching, I do manual therapy, I do strengthening. But one of the things that I do in my practice is I use yoga and Pilates in a one-on-one custom designed program to help treat the associated musculature of the pelvis.
Today, the Endometriosis Foundation of America asked me to do a little demo and I need some volunteers, who are preferably wearing pants because we are going to crawl around. Please don't hesitate, come on up, if you want to volunteer just come up, I need two. I watched all you walking in today. [unclear] The first pose that I would use to treat pelvic pain would elongate the muscles in the back and will also going help strengthen the core. Are you ready? So this is my demo, Ms. Kim - yay!
The first thing Kim is going to do is she is going to jump her feet apart, right. Can people see? We are going to come on up to the stage, please do not fall off. We are going to do triangle pose, we are going to jump our feet apart. Now put your arms nice and wide. You are going to turn one foot towards the side, then we are going to reach, reach, reach, reach and down (outstretched arm touching outward turned foot). I usually have patients hold it for 30 but they yelled at me that I was taking up too much time. We are going to come back up, jump our feet together and here we go, jump our feet apart again. You are going to turn the other foot sideways and we are going to reach, reach, reach, reach, reach and come over. This is one way of opening up all the muscles I described before and then you are going to come up and jump your feet back together.
Should we do maybe one more because they were - you know what, I think maybe we will do toe taps. I am going to do one more in the interest of time. So come on down to the stage. I usually say, "Come on down to the mat" but I do not have a mat here. (Laid down floor, knees bent, feet on floor.) If you could put your head at that end, lie down. You are going to inhale, exhale with your leg up to 90 (degrees), inhale, exhale with other leg up - good (both legs bent at knees off the ground). I am going to let go so it is all up to you, you are going to keep your sacrum on the mat. Inhale, reach the left leg away holding the shape. Good. And exhale, come forward. Inhale, reach the leg away, exhale come forward - good. Now inhale, now we are going to make it harder. Exhale, reach the leg away, inhale back. Exhale, reach the leg away, inhale back. Now let us try to keep that shape. Exhale, reach the leg away, inhale back, exhale, reach the leg away - good. Are you ready? Inhale, exhale, reach both legs away and inhale. Exhale, bring both legs away, and inhale. Exhale, drop the one leg, and drop the other.
One of the things that this particular - we have patients doing exercises within the first few weeks of surgery because you have got a cut into the abdominals and you really want to take a chance to rehab all of the muscles and get them stronger. That is one way that we do it.
As a physical therapist my governing body is the APTA, or the American Physical Therapy Association. The APTA came up with this new mission statement for vision 3030, like vision 2030. And what it is, and what it says is, "Physical Therapists help you move forward". And being a physical therapist I have to honor my professional organization. Endometriosis places an unimaginable, unimaginable burden on our bodies, on our minds, on our families and in our hearts.
I first heard this APTA mission statement of move forward on probably the worst day I ever had with my battle with endometriosis. I was in the car on my way home from an egg harvest that failed to yield even a single egg for my last and only remaining ovary. Yet between all the tears and all the grief and all the anguish that was that day I heard this on the radio advertisement for physical therapy, and it said, "Move Forward". I thought these words are very true. This is exactly what I do, professionally and personally. We, as a community of 190 million women we move forward. This is the crux of what physical therapy can provide patients with endometriosis. We do not cure the disease, we do not remove it from the body. I do not do anything hormonally but we teach the body how to live life to its fullest, we move forward. Move again, breathe again, play again, laugh again, enjoy sex again, go to school again, whatever makes you happy. Find what makes you happy and move forward. This is what you need to do without being overwhelmed by your pain. And this is what physical therapy or women's health physical therapy can help you do. You can move forward through the pain, through the darkness, through the trauma and have a happy and healthy life. Thank you very much.