Patient Awareness Day 2018: Allyson Shrikhande, M.D.

Patient Awareness Day 2018: Allyson Shrikhande, M.D.



Sunday, March 18, 2018, (8am-5pm) Einhorn Auditorium (131 E76th st)  at Lenox Hill Hospital, NYC

Uncovering the Black Box of Pelvic Pain: Understanding the Role of the Pelvic Floor

Allyson Shrikhande, M.D.

- Hello. Good afternoon. So, today we're gonna talk about uncovering the black box of chronic pelvic pain. Okay, So what role does a physiatrist have in pelvic pain? As physiatrists, we are evaluating the muscles, nerves, and joints of the patients who present to us.

Chronic pelvic pain; the definition is persistent, non-cyclical pain to be perceived from the pelvic structures, lasting greater than six months. It is poorly understood, and partly because there is significant overlap in multiple etiologies of chronic pelvic pain, including endometriosis, interstitial cystitis, irritable bowel syndrome, proctalgia fugax and pudendal neuralgia.

More than 300 million adults worldwide, suffer chronic pelvic pain. 15% of men and women. One in six women, aged 18 to 50, and up to 25% prevalence when women of reproductive age. And it's responsible for 20% of all gynecological referrals. Female symptoms of chronic pelvic pain that would present to us at Pelvic Rehabilitation Medicine, would be vaginal burning; pain with intercourse; increased severe debilitating pain during your menstrual cycle; pain with sitting; pain with bowel movement; chronic constipation; incomplete evacuation; a sensation of urinary urgency or frequency; persistent genital arousal; coccyx, buttock pain; pubic symphysis pain; as well as lower abdominal pain radiating to the groin, and sacroiliac joint. So when someone presents to us, we're saying "Where is this coming from?" So we are evaluating the lumbar sacral spine, patient's hips, the lower abdomen, groin and the pelvic floor muscles. Is it more of a nociceptive pain? Is it referred? Are we concerned for any hip pathology, lumbar sacral pathology? Is there anything going on with the bladder? The uterus? And of course, the pelvic floor. Next slide, please. So for chronic pelvic floor muscle pain, the muscles are short, they're spastic, they're contracted, tender and they're weaker and essentially this chronic contracted state restricts the blood flow. And this restricted blood flow will change the pH in the environment. And this drop in pH can stimulate the inflammatory cascade. Essentially, you get this chronic neurogenic inflammation and they have this myofascial pain. Theories behind the chronic pelvic pain. It's multifactorial. There's the global or systemic stress coming from the HPA axis, leading to endocrine abnormalities. There's the dysregulation of the local nervous system, secondary to infection or past trauma as well as anxious disposition with chronic pelvic tensing. And this again restricts the blood flow. You have the inflammatory cascade and you have myofascial pain syndrome and neurogenic inflammation. You can also have inflammation from the genitourinary tract. When this goes on for greater than six months, there can be these chronically activated pelvic nerves and they stimulate the mast cells to release histamine. Next. So this a nice picture of the HPA axis. Essentially where if you're in this chronic stress state, you can have an increase of hormones that can stimulate chronic inflammation in the body. Next slide. So this describes both the peripheral and central sensitization. Essentially, sensitization is a fancy medical term for hyperexcitable, where things are firing too much, and we break it down to the central nervous system, which is the spinal cord and the brain. And then the peripheral nervous system, which is the nerves coming out from the spinal cord. And it is important to really treat both. And when you're looking the picture, we do describe it almost as an elevator going up and down. So you have the ascending signals going from the pain receptors up to the brain. And you have descending signals going from the brain down to the pain receptors. Looking at the central sensitization... Oop. We can go back. Thank you. Looking at the central sensitization, what you have is something called membrane excitability and increased recruitment of the nerve pathways. And you also have a decrease in the descending inhibition. And what that means is you need the signals coming from the top down to stop the pain, but you have a decrease in those descending signals. And then you also have something called uncoupling of pain from the peripheral stimuli. What that means is something such as a soft cotton ball, can cause your brain to feel pain when it shouldn't. Because there's uncoupling of the normal process. And then you also have the peripheral sensitization, okay? So the nerves that come out from the spinal cord to the pelvis. And with that we like to describe something called the sensitizing soup, that can happen which I'll show a picture later. And essentially there's a reduction in these nerves to fire, okay? They're hyperexcitable, so they fire when they shouldn't. Okay, next slide. You can keep going, next slide. So this is a picture of what we like to describe is the inflammatory soup. And it shows the proinflammatory cytokines, substance P, bradykinin, histamine that can stimulate inflammation in the pelvis and contribute to the proinflammatory state that we talk about, that we're trying to inhibit. So when patients come to see us, the first line of treatment is pelvic floor physical therapy, which Amy Stein will be speaking after, so I'll let her elaborate more on that. We also like to use TENS units if necessary. TENS units work by the gate control theory of pain. Essentially you're stimulating the larger delta fibers, in hopes of stopping those painful little C fibers, from going up the spinal cord and reaching the brain. Lifestyle modifications are extremely important. We discuss nutrition tailored to the patient's symptoms. If it's more the bladder, we'll talk about the interstitial cystitis diet, etc. Exercise is extremely important. Sometimes with lifestyle modifications, it's as simple as going over a patient's work life and their desk they're sitting at, their chair, etc. We discuss alternative therapies, referring for acupuncture, and yoga, cranial sacral; we use quite often. We go over different modalities such as adding a cushion or SI joint belt or sometimes oral nerve medications and muscles relaxants are used, depending on the patient's symptoms. So, essentially the treatment algorithm of phase one, again physical therapy; sometimes you'll start something called the Valium suppository, if needed based on exam. Modality is cushions and alternatives therapies can be started early such as yoga, cranial sacral and acupuncture. Phase two, sometimes we'll add other medications strictly, nerve medications that Dr. Berger talked about earlier today. And we'll combine that with trigger point injections and selective peripheral nerve blocks which we'll talk about in a couple slides. And then phase three, is something called alpha-2-Macroglobulin which is under regenerative medicine. And possibly Botox, depending on the patient's physical exam. The goal of the program is to retrain the central and peripheral nervous system, that is hyperexcitable. To reverse the sensitization, you are trying to create space and open up the pelvis. You want to decrease the inflammation. You want to decrease tension and overall improve blood flow. And you want to lengthen and strengthen the pelvic musculature. And this is in combination, of course with physical therapy and neuromuscular re-education. So the protocol we have created at Pelvic Rehab Medicine, what it is, is a series of external ultrasound guided trigger point injections to the pelvic floor musculature. In combination with peripheral nerve hydrodissection blocks. And these are tailored to the patient, and their symptoms and exam. And these are the nerves that we are evaluating when patients come. The ilioinguinal and the genital branch of the genitofemoral, perineal branch to the pudendal, posterior cutaneous nerve of the thigh and the pudendal nerve. And this picture here describes the connection with the pelvic floor muscles, and the nerves and the blood vessels and the veins. So you can see if the pelvic floor muscles are chronically contracted, then the blood flow is diminished. Essentially the nerves surrounding that area are not happy and they start to fire. Treatment options, what's in them, would include a combination of lidocaine and dexamethasone which is a steroid. Lidocaine and something called Traumeel, which is a homeopathic medicine, inhibits interleukin 6. Alpha-2-Macroglobulin; we'll talk more about that later and Botox. This is some anatomy pictures illustrating the connection with the gluteus medius, minimus, the piriformis, obturator and quadratus femoris, the external rotators of the hip which are also involved with the pelvic floor. You'll see the sciatic nerve and medial the posterior cutaneous nerve of the thigh. So this is what things would look like under ultrasound. And with ultrasound, you're essentially finding the bony prominences first, which highlight and brighten white. And you're seeing the vasculature as well in ultrasound. So here in this picture, you'll see that the pudendal nerve is medial to the pudendal artery. And then you have the sciatic nerve as well, right next to the pudendal artery. This is a picture correlating to the posterior sacrum. You'll see the S2, S3, S4. And the pudendal nerve coming out. And you'll see the branches. You have the inferior rectal branch, dorsal nerve of the clitoris, and then, the perineal branch. Another ultrasound picture. This is depicting the piriformis. Which is external rotator of the hip but intimately involved in the pelvic floor and pelvic floor muscle disfunction. This is more caudally looking at the ischial spine again. Sciatic nerve, pudendal artery, pudendal nerve is medial. This would be the picture of what you would see. On the screen, you'll the needle going in, the echogenic needle, highlighting and going in towards the ischial spine. This is a picture of the iliohypogastric and ilioinguinal nerves which are close to something called the anterior superior iliac spine, at the top of your hip. And you see the EO, is the external oblique. IO is the internal oblique. And the TA would be the transverse abdominis. So what we're looking for, lies between the internal oblique and the transverse abdominis, right next to your anterior superior iliac spine. So alpha-2-macroglobulin, so this is the realm of regenerative medicine. And this is in your own blood, in your own plasma. So you're drawing patient's blood, and then we centrifuge it down to something called A2M, or alpha-2-macroglobulin. And what it is, it's a protease inhibitor. And essentially, I like to describe it to patients, it's like a Pac-Man. It's a carrier protein. It's a Pac-Man that eat up the inflammation, which are the growth factors and cytokines and it will carry them out of your body. And the main one that we're inhibiting, is really the interleukin 1 beta. And this can be used into joints, you can use it for muscles, fascia as well as around nerve inflammation. The main studies for the A2M have been for osteoarthritis of the knee, starting in the lumbar sacral spine now as well. And lastly, for wounds that will not heal. So those are the kind of the three areas currently. And the idea again, is to decrease inflammation which will help promote wound healing. This describes the central sensitization phenomenon that we have discussed. And how we call them central sensitivity syndromes. So it really is all interrelated. So we do like to discuss to the patients, other symptoms, other things that may be going on, and it's important to treat them as well, to help calm down overall the central nervous system. And this the final slide which we'll go over, really the intricacies of treating pain, asking about cognition, about memories and past experiences, about treating anxiety as well as mood and how treating everything can really help calm down the stress regulation and affects someone's pain perception. It is important really to work as a team and treat both the signals from above, from below and treat the muscles and joints as well. Thank you very much. Thank you.