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Patient Awareness Day 2018: Amy Stein, DPT, BCB-PMD

Patient Awareness Day 2018: Amy Stein, DPT, BCB-PMD


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

What is Pelvic Floor Physical Therapy: Self-Help Tips and A Guide to Finding an Experienced PT

Amy Stein, DPT, BCB-PMD

- I've been treating endometriosis-related symptoms for just about 20 years now and the three of the biggest questions that I get are, why do some succeed without surgery, why are some more people successful post-surgery, and why should I consider pelvic floor physical therapy? The answer to that is and the research is now showing that it does take a multi disciplinary approach to improve outcomes and quality of life whether surgery is necessary, medication whatever it is, but also doing these lifestyle modifications and pelvic floor physical therapy in conjunction with possibly acupuncture and dietary changes which I'll go into briefly. The multi disciplinary approach that I'm mentioning, it does require medical care and proper medical care as well as experience in expert pelvic floor physical therapy. The musculoskeletal system which is what we work on and what doctor Schekondier already went into a little bit can effect bladder or bowel, sexual function, and can cause abdominal pelvic pain. You also need to address the mental health, the behavioral modifications, the diet that I mentioned earlier, as well as exercise is extremely important, and postural modifications 'cause what we find is a lot of the patients they've been in pain for so long that they end up scrunching up in a ball on their bed or when they're sitting they hunch over 'cause they're in pain. We teach our patients the tools that they can do so that they could sit upright better. We give them ideas to balls and bolsters and support systems to help so that they're more comfortable. Oh the right one. Sorry. Got it. Pelvic floor physical therapy has proven effective for patients with endo. It helps to free up adhered tissues due to the endometriosis. It doesn't get rid of the scar tissue but it helps to break it up. That's with or without surgery. This is needed to optimize abdominal pelvic tissue mobility. It can help with urinary bowel urgency, frequency, retention, night time frequency, sexual health, as well as improve quality of life. We already went over a picture of the pelvic floor but these are the pelvic floor muscles up at the top. Then you can also see the abdominal area at the bottom in the bottom picture. That's not including the organs that are in the abdominal wall. Those are all the muscles, nerves, the arteries and veins that can be affected from endometriosis as well as musculoskeletal dysfunction. To the left picture is just a picture of scar mobilization that needs to occur in order for the tissues to move better. Sorry, this is sensitive. This is just another example of trigger points I think doctors Schekondier mentioned. To the left is a trigger point just in the abdominal wall, the iliopsoas muscle. A lot of the abdominal wall muscles that were already mentioned, the obliques, the transverse abdominis, they can refer pain into the abdominal region, they can refer pain into the ovarian area and a lot of patients may say I feel like I have ovary pain but yet it could just be a trigger point in the iliopsoas or the quadratus lumborum muscle that's referring. To the right are other trigger points. I don't know if you could see well but there's X marks. You press on those areas and it refers pain into the sacrum area, to the tailbone area. It's really important as a pelvic floor physical therapist and as a physiatrist that they access the various trigger points 'cause that could be a cause of a pain. If we could help reduce some of these symptoms for you, it can help with your overall quality of life. What are the pelvic floor muscles? We already went over it a little bit but the function of them is to support the abdominal pelvic organs. Also, it helps with sphincteric controls so bladder bowl incontinence. The muscles help with sexual arousal and performance and that is very important for everyone's quality of life as well, as well as it helps to stabilize the core. If there's dysfunction in these muscles as well as the abdominal wall, it can result in bladder bowl sexual dysfunction or abdominal pelvic pain. Again, some of the bladder symptoms and bowel that we see as pelvic floor physical therapists are urgency, frequency, retention, incomplete emptying where the muscles aren't able to relax enough to allow the bladder to empty, to allow the bowel to empty. The patients may also complain of pain or constipation, irritable bowel-type symptoms. These are all things that we see in our practice as well as sexual dysfunction. They could complain of pain at the opening, the vaginal opening, or they can complain of deep penetrating pain and that could be again where the trigger points are that I showed you earlier, as well abdominal pelvic pain. They could have trigger points throughout the abdominal wall, nerve irritation, the ilioinguinal nerve, the genitofemoral nerve, any of these nerves can be irritated from the endometriosis because of surgery or all of the above. What is the difference between the overactive or hypertonic pelvic floor muscles and underactive or hypotonic pelvic floor muscles? A lot of people are familiar with kegels and strengthening the muscles, but with the overactive pelvic floor muscles you actually don't wanna do kegels and I'll go into that in a little bit. The underactive is more when there's leaking from coughing, sneezing, lifting. That is appropriate for doing pelvic floor exercises or kegels. Again, if you have overactive muscles, you should not be doing pelvic floor repetitive exercises. There we go. The symptoms that we see and the syndromes that we see, we see symptoms of endometriosis, we see post-surgical and scar adhesions, the abdomino-pelvic neuralgias, vulvodynia, vestibulodynia, clitorodynia, pelvic floor tension myalgia, coccygodynia where there's pain in the tailbone area, painful bladder syndrome, bowel disorders, and fibromyalgia as well as TMJ or jaw pain. Addressing the vicious cycle is so important as we already have mentioned. Basically, whatever the onset is, mechanical, trauma, postural, or surgical, that can create inflammation and scar tissue which can decrease mobility of tissue, muscles, nerves, and organs which can cause pain and or weakness and the emotional stress and the cycle continues. As pelvic floor physical therapists, we look at the body as a whole. We look at the posture, the structural alignment, is there scar tissue and is there mobility around that area in the visceral, in the organs around the nerves, are there restrictions that are contributing to your pain? We look at the trunk, back, hip, leg, abdominal range of motion as well as strength, movement, patterns, motor control of the pelvic floor but not just the pelvic floor, the entire body. Is someone walking with an altered gate because of pain or because of back dysfunction? As well, we look at a functional assessment, sitting posture, standing posture, their exercise routine. Treatment, we assess the tissues and the muscles externally but we also assess the muscles internally and a lot of patients have questions about that because they are fearful that it's gonna be painful. As a pelvic floor physical therapist, experienced pelvic floor physical therapist, we gauge the patient's tolerance to any type of massage techniques and we work with the patient to make sure that they're comfortable and also that they're not fearful of pelvic floor physical therapy. We'll give dilators for home use as well as show the patients manual techniques to do at home with our without a partner, and in addition we do skeletal, neuro or nerve, and visceral or organ mobilization. We also do do biofeedback but that's not the only thing we do. Biofeedback doesn't always require a machine or that sensor that you could see there. Sometime it's just talking to the patient whether they're contracting the muscles when they shouldn't be, relaxing the muscles or having a difficult time relaxing in the muscles. That's a common thing that we see in the abdominal wall as well as the pelvic floor and that can also keep the cycle going with the endometriosis pain. Again, it's really important to address all of these different factors. Teaching relaxation techniques, we teach the patient how we helped them to down train the pelvic floor muscles. Some key notes, and I'll repeat this again, straining aggravates the pelvic floor and abdominal wall. If you have trigger points, it can make it worse. Kegels can also make your symptoms worse because if you already have shortened and tight and painful muscle, doing repetitive exercise can make it worse. I explain it to a patient is if they had back pain or a back spasm, if you go and you have a trigger point there or tightness and you go and you do deadlifts, it's gonna make that back pain worse. It's similar with the pelvic floor muscles. If those muscles are tight and shortened and painful, then doing kegels and repetitive exercise may just exacerbate that pain. Another thing we teach the patients is specific stretches. This is another question I get asked frequently, why when I do this stretch does it hurt? Well I'll tell the patient, it could be 'cause you have tight tissue or trigger points. Let's figure out other stretches that work for you and help with your pain. We also go over alignment and posture. That's important. Whether you're at home, at work, or wherever, making sure that you're setup is as comfortable as it can be with cushions or a back support. We also go over sexual positions because that can be a cause of stress and pain and certain positions can actually help decrease pain. Again, it's dependent on where the pain is. For some person it make be propping the knees up with pillows, for another person it just may be a different position that helps them. Strengthening is important but it should be pain free because if you have trigger points or pain in the abdominal wall and you're doing repetitive strengthening exercises, same thing I mentioned before, that can actually exacerbate your symptoms. Trying to do strengthening exercises that are not painful or don't increase your pain is really important. As well, if there's any abdominal wall separation, it's important to address that and close those muscles. That may be something that a physical therapist would have to teach you but it is something that you can reduce. Addressing back and hip function as well as closely monitoring all of the above and getting the patient back into exercise whether it's five minutes of walking twice a day, swimming, whatever it is, exercise is really important. Whatever you find works for you whether it's yoga, Tai-Chi or walking, it's definitely important to keep trying. Eliminating poor bladder habits is important. Not going to the bathroom just in case. Obviously if you're getting on a subway, I understand or if you're getting into your car, but if you're constantly going to the bathroom, it confuses the signals that go to and from the brain. Making sure that you learn how to control the urge for the bladder, trying to use breathing techniques to calm the bladder down, not hovering over public toilet seats. I know it's a hard thing to do but put the tissue down, put the toilet paper down. Make sure you are drinking enough water. A lot of patients are dehydrating themselves. Makes the bladder more irritated, makes the bowels more of an issue because then they become constipated. Making sure you drink enough water. Avoiding bladder irritants if it bothers you. If you have that cup of coffee a day and it doesn't bother you, that's fine. Or if it doesn't bother your endometriosis symptoms or if you need acid, low acid coffee, whatever it is, but definitely finding the irritants that are making things worse to avoid them. Then the bowel. I know, pretty picture. Most people don't know that your bowels should look like type four. They think that type one is a normal thing but that is considered constipation when they're small little pellets. Making sure that the bowels are soft and smooth and easy. You can use a squatty potty. I'm sure many of you are familiar with that now with the unicorn. Relaxation techniques. We teach abdominal massage to the colon to help with bowel movements as well a proper fluid and fiber intake. Nutrition is key to not just endometriosis and inflammation but also to help with the bowels and help with decreasing in any bladder pain if you have any. As well as with the bowels, also timed voiding. Going at a certain time of day. Again, no straining and no breath holding. That will just keep exacerbating any abdominal pelvic pain that you have. Other modifications. Doctor Schekondier already mentioned a couple but having appropriate cushion. If you have any sitting pain, if you have back pain or abdominal pain using a back cushion. Some people sit on a physio ball because it's just more comfortable and they don't feel so pressed up against a chair. The sexual position modifications that I mentioned earlier, using lubricants that work for you that are non-irritating, using supportive belts that help, standing frequently if you have a sitting job is really important, changing position is also really important. My patients that get on an airplane and it's uncomfortable riding on airplanes, I tell them to either bring your cushion, bring an extra sweater, tuck it under you, try to find different positions that feel okay during your flight as well as stand frequently. Education is extremely important. Sex should not be painful. Abdomino-pelvic pain. Really trying to learn how to reduce the pain and figuring out what works for you is important as well as cardiovascular I mentioned and self care. Then home exercise is key. As a physical therapist, yes we do see you once a week sometimes twice a week, but a home exercise program is so important. It's the first thing that I give my patients. I'll give them as simple as just a breathing exercise and trying to relax the pelvic floor, trying to relax the abdominal muscles. I encourage trigger point balls or massage balls. You could take a tennis ball and use that, massage stick, dilators. That I do encourage you to see a pelvic floor physical therapist to learn how to do, how to use. Different stretches, using heat, using ice, whatever again works for you. Yoga, mind/body therapy. Mindfulness meditation I'm a big fan of for those that it works for. Some people would prefer to do yoga. That's fine as well. Figuring out tools that can help when you have an increase in pain is very important. Key points. Multidisciplinary approach. Not all physicians are familiar with how to diagnose abdomino-pelvic floor dysfunction, trigger points, and nerve irritation. Your physician may not prioritize these symptoms that you're describing, especially if you don't inform the physician. Telling your physician as well what you're experiencing is really important and if they don't know what to do, then hopefully they'll be able to refer you to another physician or pelvic floor physical therapist. As well, bladder, bowel, sexual dysfunction a lot of times does require pelvic floor physical therapy but most people don't realize that but it is a very effective treatment for those that have musculoskeletal dysfunction. In addition, treatment takes time. It depends how long you've had your symptoms, how compliant you are with the physical therapist, and with the physical therapy and your home program. You should see improvement within four to six weeks, four to eight weeks, even a small bit of improvement. If you don't, talk to your physical therapist, tell them what's going on. Hopefully they can modify some things so that you start to feel some relief. If not then you may wanna get a second opinion from another physical therapist. Again, no kegels, no straining. This may only exacerbate your pain. Physical therapy can reproduce your symptoms and that's actually a good sign because that means that those areas need to be treated but over time those symptoms should be getting better with the physical therapy. They should not be getting worse. That's it. If you wanna find a pelvic floor physical therapist, these are three websites that you could look at. Herman and Wallace, the American Physical Therapy Association Women's Health, and the International Pelvic Pain Society. They all have a find a provider on their websites. Again, I have the book and DVD for sale and it goes towards the endo foundation. The middle picture is of what doctor Schekondier was going over, the central sensitization and peripheral sensitization. That is a book that helps for you to learn how to manage those symptoms as well and trying to down train the whole nervous system. The pelvic messenger is a free blog talk radio show. This is just a quote from a patient, actually from a long time ago. When I personally was first realizing how important pelvic floor physical therapy is for patients with endometriosis. She basically just said that after she did have surgery but she also was still having a lot of symptoms. After the physical therapy, her symptoms got significantly better and she was able to go back to a normal lifestyle. That is it. We did declare May as pelvic pain awareness month so look out for some tweets and different things going on in your area. Thank you so much.