Lunch & Learn with Padma Lakshmi
Nurses conference 2012 - Amy Stein MPT
Hi everyone. I do not have a story quite as touching as that but the bravery in doing that and the hope that you give young women, any age woman, is wonderful. I do not have the videos that Dr. Seckin had, so I am up for a lot of competition!
I am here to talk to you about how physical therapists and other practitioners can help patients like MacKenzie and Padma if they have other underlying pain that cannot be found, that cannot be diagnosed and possibly they still have endometriosis, or they do not have endometriosis anymore, but they still have this pain that no one is able to detect.
This is a little about me. You can read it in the bios in the handbook.
The objectives for me today to educate everyone on are to be able to identify and assess abdominal and pelvic floor muscles and any underlying trigger points or myofascial pain; understand musculoskeletal causes of pelvic floor and abdominal dysfunction; overview of physical therapy intervention of pelvic floor dysfunction and how other allied health and alternative practitioners can help.
Statistics show that up to 20 percent of women at some point between ages 18 and 50 suffer from chronic pelvic pain. In 2008 they showed that one out of every four women suffer from pelvic floor dysfunction at some point in their life. Up to 43 percent of all women suffer dyspareunia or painful intercourse at some point in their life, and then that physical therapy has shown 87 percent improvement in vulvar pain.
There are multiple pain generators that can be identified. In a study by Chung et al of 178 patients with chronic pelvic pain 75 percent of them had endometriosis; 89 percent of them had interstitial cystitis and 65 percent of them had both.
Baker said, "Musculoskeletal dysfunctions often contribute to the signs and symptoms of chronic pelvic pain and abdominal pain and in many cases may be the primary factor".
I want to go through some anatomy education of the pelvic floor. The pelvic floor muscles connect from the pubic bone to the tailbone. They help contribute and support the bladder, bowel and sexual function. They surround these organs. Therefore, if there is a dysfunction in the muscles or some of the abdominal muscles, it can refer pain to the pelvic floor and pelvic and abdominal region, as well as the back.
This is a side view of the muscles. The muscles make up the levator ani, the obturator internus, the coccygeus and the piriformis muscle. As well, there are a lot of nerves that come out of this region, the sacral lumbar region, so any type of pain can irritate nerves. As well it can go back and forth; the pain can irritate the nerves and the tissues. It can become a vicious cycle.
This is an example of the pudendal nerve and other nerves in the pelvic floor region. You can see how many nerves there are and how it is so susceptible to nerve irritation as well as any muscular irritation and pain.
The function of the pelvic floor and the abdominal muscles is that they are supportive, they allow for stabilization of the trunk. The pelvic floor as well has a sphincteric function as well as a sexual function.
The role the pelvic floor, and abdominal musculature more specifically, it assists in unloading the spine and it assists in pelvic spinal stability. The pelvic floor alone reinforces urethral closure during increases of intra-abdominal pressure; has an inhibitory effect on the bladder and bowel activity and contributes to sexual arousal and performance. Therefore, pelvic floor dysfunction can result in disorders of the bladder, bowel, sexual function and pelvic pain.
I am just going to go over briefly signs and symptoms that you may hear or see from patients. It is important to realize and to really recognize that these signs and symptoms can be contributive for musculoskeletal causes and/or for endometriosis. Disorders of the bladder that they may describe are urinary frequency, urgency, retention and/or burning, pain, pressure; difficulty with initiation and/or weak stream; incontinence, stress, urge or mixed, as well as pelvic organ prolapse. And examples of diseases or disorders that can cause this, again, endometriosis and painful bladder syndrome.
You can see the bowel symptoms and signs are similar because of where the muscles are located. If there is tightness or hypertonicity or spasm in the muscle it can cause similar symptoms; bowel frequency, urgency, retention and/or rectal burning, pain and pressure; difficulty with initiation; incomplete emptying of the bowel or bladder; incontinence, and pelvic organ prolapse. As well, the patient may describe gas, diarrhea, constipation, bloating and abdominal pain.
Sexual dysfunction can be, and obviously this is for the older, not older, woman, but not for the younger women, the pain can be described at the introitus or deep vaginal pain. It can be described as burning, sharp, shooting, stabbing and knife-like pain; tearing, aching, dull and "nails", they may describe it as nail type pain. As well they could experience decreased libido and difficulty with orgasm.
Common conditions that as physical therapists we see and can treat, as well as the other disciplines, which I will go into later; vulvodynia, vestibulitis, vaginismus, dyspareunia, endometriosis or pain from endometriosis affecting the musculoskeletal system; pelvic floor tension myalgia, pudendal neuralgia, Levator Ani Syndrome, painful bladder syndrome interstitial cystitis, IBS and bowel disorders.
The causes, from a musculoskeletal point of view can be from skin, pain or irritation or myofascial pain, connective tissue tightness or scarring in that region. Muscles can develop trigger points and tightness. Nerves can get irritated, the skeletal mal-alignment can occur. If there is anything, any surgery resulting having to cut a ligament that could contribute to skeletal mal-alignment of the sacroiliac joint or the lumbar region, as well as pelvic congestion. As well, the psychosocial and hormonal issues that contribute to all these dysfunctions.
Common referrals that we see for physical therapy: from the orthopedist, the urologists, the GI colorectal, the GYNs, mental health, nurse practitioners, pain management and pelvic floor dysfunction can and may affect men, women and children.
The onset typically is multifactorial; it is not just one cause that causes their pain and their discomfort. It could be from trauma; a bike accident, a fall, childbirth, physical or emotional trauma. It could be from a previous condition whether it is surgery, hysterectomy, laparoscopy, episiotomy, urinary tract infection or yeast infections; as well as from endometriosis, cancer, poor posture or repetitive motion.
This can cause a vicious cycle. The trauma, the poor postural positions and/or surgery can cause inflammation and weakness, scar tissue, decreased mobility of surrounding tissues, muscles, nerves and organs and more weakness and more pain. The cycle continues.
It is so important to address the person and the body as a whole. You need a proper diagnosis from practitioners that are well educated on these topics. As well, a proper musculoskeletal diagnosis. Mental health issues should be addressed, behavioral modifications, diet, exercise and postural exercises. Again, it is essential to find a healthcare professional trained in pelvic floor dysfunction.
As everyone was mentioning, endometriosis is a fairly new diagnosis and disease that people are discovering can be a huge problem. Healthcare providers are realizing that pelvic floor dysfunction can also be a contributor to some of this chronic pelvic pain. It is essential to find the appropriate practitioner.
Physical therapists are experts in the musculoskeletal system and they are allowed to assess and treat the internal as well as external muscles. That is important to know.
As physical therapists and other allied health providers we take a detailed history. We want to know when the pain started. Questions like, does the period make your symptoms worse? Does ovulation make your symptoms worse? Where is the pain? What makes it worse? What makes it better? Have you had any previous surgeries? Have you been diagnosed with endometriosis? A history of bladder, bowel, sexual dysfunction, as well as if they know anything that caused the onset of their symptoms.
For the objective part we would go through a postural, structural alignment assessment. Is there any scar tissue that is causing the pain? Is it surrounding a nerve that is causing pain in the back or abdominal region? We will look at visceral mobility, is there scarring all around any of the organs that is causing pain and a problem? Trunk, hip, lower extremity palpation is important, range of motion and strength testing. Neural tension, are there issues with any nerves in the abdominal or pelvic region? Movement patterns, motor control, pelvic floor abdominal muscle exam, including the perineal and the internal muscles if necessary. As well as breath control, is the patient contributing all symptoms by having hyper ventilating type - shortness of breath that is contributing to their discomfort.
As you saw before from the videos there is a lot going on in the abdominal region. It is so important to assess what is the contributing factor to their pain. As physical therapists and as nurse practitioners you can assess is the pain also musculoskeletal in nature. Is the psoas muscle, the rectus abdominis, the obliques, are there trigger points in the muscles that are not going away that are contributing to more pelvic and abdominal pain? How are they using the muscles, are there restrictions and tenderness in that area?
The pelvic floor muscles are also important to look at. The urogenital triangle could have trigger points and pain contributing to pain in that region as well as the deep muscles surrounding the rectal area and vaginal area. Are there trigger points and restrictions and decreased motion in that area?
A pelvic floor muscle exam can be...you would basically just insert your finger and you would palpate the lateral muscles, sidewalls as well as straight down towards the rectal region or 6:00. You would also look if are there any skin issues - fissures. You can do a neurological exam, is there decreased sensation? Is there increased sensation? You can do a q-tip test to see if there is tenderness around the vestibule. The urogenital triangle as I mentioned before, the external areas - are there trigger points in those areas, as well as the internal muscles.
Why is this happening? Weakness or disuse, trigger points, connective tissue restrictions, visceral restrictions and just back, hip, SI joint dysfunction can cause pain the pelvic and abdominal region. Are there scar adhesions that are contributing to the pain?
How and where? How it feels? The patient may describe it as a weak feeling, a falling out. Muscle pain is described as ache, dull, pressured, tightness, pulling or spasming. Nerve pain is described as stabbing, burning, itching, shooting and sharp. The patient may say when they go to the bathroom it feels like there are nails, that they feel nails or when they are engaging in sexual activity it feels like nails. An underlying cause of it could be musculoskeletal dysfunction. As well, what I mentioned before it could be in the back, tailbone, abdominal, genital, pelvic, groin, leg and hip pain. What I mentioned before, nerve pain can be mistaken for other diagnosis and symptoms. I have had many patients say it feels like a yeast infection or urinary tract infection but there is no diagnosis of yeast or urinary tract infection. It is actually nerve irritation or nerve pain that is causing vulvar pain, burning, itching, bladder urethral pain and burning, abdominal referring pain, genital and rectal pain.
How does it affect their function? Functional limitations for children as well as adults it could affect their play. You already heard from MacKenzie how it affected her for three years. It is so important to look at the whole picture and get the whole diagnosis from your patient. It could affect school, work, socializing, family, activities of daily living, exercise and/or all activities.
The treatment for physical therapy and acupuncture can be fairly similar because acupuncturists can work with trigger points as well as the meridians, eastern and western acupuncture. Pelvic and abdominal pain - there could be muscle in-coordination. They have had pain for so long that they are gripping the pelvic floor muscles, they are not allowing the proper evacuation of the bladder and bowel. Therefore they are getting retention, so teaching relaxation techniques, learning how not to tense the muscles, including abdominal muscles. The body, when it is in pain, the reaction is to curl up into a ball. That alone can contribute to trigger points and restrictions. It can stretch out muscles that should not have been stretched, like your back and abdominal muscles can tighten and shorten.
I thought this was very appropriate, "Mommy can you help me help my fingers remember how to snap". These women, they are in so much pain and discomfort, they may forget how to use their abdominal muscles and their pelvic floor muscles properly.
But physical therapy is more than just biofeedback. A lot of people associate biofeedback with physical therapy for pelvic floor dysfunction. There is a lot more that physical therapists, and the acupuncturists if they are trained, can do to help pelvic and abdominal pain. Manual therapy to the muscles has proven to help with any trigger points, scar tissue release as well as connective tissue mobilization. It can be internal or external. For our younger population we obviously try to do all external treatment as well as other treatments that I will go over. For those that are sexually active - dilators could be a possibility as well as manual therapy.
Travell and Simons has a great book on trigger points and how they can refer to other areas of the body. Pelvic pain can be caused by any of the muscles mentioned here; the coccygeus, the levator ani, the obturator, adductors of the inner thigh, the piriformis and the obliques and abdominal muscles can refer to the pelvic region. Iliosacral pain, levator ani, coccygeus, gluteus muscles, quadratus as well as rectus abdominus those can also refer to the abdominal and pelvic region.
The iliopsoas muscle, which is your hip muscle goes right through the abdominal wall and that can cause trigger points and refer pain into the abdominal area and into the pelvic floor. It can refer into the rib cage and the back into the groin and the thigh.
So the treatment, in addition to the manual therapy can be stretches, strengthening exercises, core mobility and stability is very important. HEP is Home Exercise Program, massage therapies to do at home, self-care techniques, stretches, relaxation techniques, even just techniques of using a hot pad can help some women.
Behavioral modification is very important as well. Posture, positioning, breathing patterns, relaxation, toileting techniques if they are straining that does not help the pelvic muscles at all, or the abdominal muscles. It can cause more irritation and pain. Adequate water and fiber intake is very important. Eliminating any dietary irritants and education that sex should not be painful.
Physical therapy has been researched to be effective for pelvic and abdominal pain with manual therapy and with or without biofeedback, as well as pelvic floor and abdominal muscle re-education.
The symptoms of pelvic/abdominal pain often do not appear to be of such a nature that the patient seeks out a physical therapist to help... The first step in the process, therefore, can lay with the physician, or with all of you the nurses, who are able to identify signs and symptoms of musculoskeletal disorders.
Again, the vicious cycle - it so important to address all the aspects that the patient needs and to really listen to hear what is causing and contributing to their pain, their anxiety and their tension.
The multidisciplinary approach is key for physical therapists. They can at least assess to see if there are any musculoskeletal disorders involving their pelvic and abdominal pain. The physician, the nurse practitioner, psychological services and stress management are also key. I recommend all my patients, even if they are seeing a psychologist, they may need to see someone in addition, or who has different training; for instance, the cognitive behavioral therapy that was mentioned before. It is so essential to address all components. Acupuncture can be helpful, yoga and nutrition.
Acupuncture I basically interviewed a couple of people for this because this is not my area of expertise. Acupuncture is used to calm an up-regulated nervous system, alleviate symptoms of depression, anxiety and stress, promote better sleep, it is very important to allow your body to heal. Relaxation makes it easier to deal with any pain and discomfort. It helps to relieve pain by releasing endorphins into the system, increases blood flow to the pelvic abdomen, promoting healing. It can break up scar tissue, balance and regulate the hormones, thus promoting normal menstrual cycles, relieve the resulting musculoskeletal pain over the problematic visceral areas.
Mental health support, Dr. Wilson already went into this, so I cannot do the same justice as he did, but I did interview a psychologist. She mentioned that mental health support can increase knowledge to enhance understanding of symptoms, as well as everyday functioning and activities; normalizing and validating their feelings, experiences, reactions; restoring a sense of control; addressing how to educate family and friends; decreasing psychological symptoms; learning cognitive behavioral strategies to manage stress and anxiety, and promote awareness. The goals of a mental health care provider would be symptom reduction; improved understanding of relationships between psychological factors and physical health; improved interpersonal and social functioning; improved health maintenance and behaviors, and quality of life.
Yoga - I am a huge advocate of yoga to help with relaxation, if that is right for you. Yoga may not be the answer for everyone. Sometimes, something like Tai Chi is more helpful because it involves more flowing motions. Every person is different, it is really individualized what helps each patient.
Yoga is the union of body, mind and spirit. It eliminates fear of movement that is due to pain, symptom reduction. It helps to activate the PNS, the parasympathetic nervous system and calm the sympathetic nervous system. When you are in pain you experience the flight and fight reaction that activates the whole sympathetic nervous system. It contributes in central sensitization and then their whole body is hurting. Yoga, and other relaxation techniques and exercises can help calm the central nervous system down. Reconnect and reprogram to equal pleasure and joy with movement and promote awareness and importance of breath and posture.
Nutrition - as a physical therapist we do go over the very basics of nutrition. But if it is something very detailed we may refer out for nutrition. We will go over food basics, the importance, as you know, of the pyramid. Fluid and fiber intake is very important; not getting constipated and aggravating the abdominal muscles and the pelvic floor region. Straining aggravates the pelvic floor muscles and any nerves that are irritated - straining is not helpful in the situation. Increasing anti-inflammatory foods, decreasing inflammatory foods, lactose free diet, gluten free diet, some people respond well to this and some people do not. Again, really figuring out what works for the patient is important.
The goals of nutrition would be to review and analyze current diet and food intake. Food recommendations to alleviate symptoms; easy recipes, meal plans to reduce inflammation, pain, constipation and to eliminate symptoms in the future, education on how to maintain results after returning home. Menu reviews to ensure health eating even when ordering in or dining out; and recommendations tailored to your personal food preferences and lifestyles.
Thank you very much. I want to thank Dr. Seckin and everyone in the Endometriosis Foundation and Padma. I am very glad to be here and to be able to speak on this topic.
Lunch & Learn with Padma Lakshmi