Dr. Dae

Dae Sheridan, PhD, fabulous, wonderful and fun! has agreed to let me post her info for everyone.

She is a certified sex therapist here in the Tampa bay area, I specifically referenced her in the last post, because she has a wonderful program for adolescent girls and their Mom's.  Call or email her with specific questions.  She is the Bomb!

DrDae@aol.com
813-431-8292

A Difficult age

I recently read an abstract from the Journal of Sexual Medicine (Feb 2009).  The authors, Landry and Bergeron asked the question: "How young does vulvo-vaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents." 
 
Interesting read.

The prevalence of dypareunia (pain with intercourse) in adult women is reported to be between 12-20%.  With vulvar pain being the most common site reported.  Prior to this, younger populations have not been studied in large scale.  First - do we really want to look at how young our kids are being sexually active?  From a medical/research/cultural aspect - of course we do.  As a Mom, I'm sort of hoping celibacy will catch on, and my daughter and I can have this conversation right before she gets married, at 30, with her PhD. in hand. 

Even worse - do we want to think about painful sexual dysfunction in the very young?  As I have treated my share of very young girls (15-19yrs) with severe vulvodynia, I applaud the authors for looking at this very difficult subject.  The results show that 20% of sexually active girls, aged 12-19yrs old reported pain with intercourse.  Of those that reported chronic problems, 67% had significant pain with initial tampon use.  There is a 4-fold increase in the prevalence of chronic dyspareunia with girls that have pain at initial tampon use.  These same girls had difficulty with all non-sexual forms of penetration, pelvic exams, tampon insertion, etc.  

We can not exactly extrapolate the results.  We do not have long-term studies showing that this 20% will be the same 12-20% that carry dyspareunia into their adult lives, but the data is compelling.   When I first started taking courses on pelvic pain, vulvodynia and sexual dysfunction, one of my instructors talked about the importance of educating girls before their first sexual experience.  Teaching them to be aware of the pelvic floor, staying relaxed, and being in control of the situation.  At that time she quoted a study (don't remember from who or where) that showed a higher percentage of chronic dyspareunia in women that had pain at first attempt at intercourse.  This new study shows that it may start earlier.  If our girls have pain with initial tampon use, or with pelvic exams - then we may have a warning sign of potential dyspareunia, and the education process can begin earlier, before it becomes a huge problem in the life of a young adult.

I hope that all girls are having an initial gynecological visit before engaging in sexual activity.  And, I hope that doctors, and parents, are using this visit as an opportunity to educate the girls about sexual health.  I know that girls get sex-ed in school, but the programs are highly political, and many schools are corralled into "abstinence only" programs.  With more and more girls being sexually active at younger ages, abstinence only programs fall far short of giving our kids the education they need to cope with the problems that they may face.

I have always felt that "an educated girl is a safe girl."   If the schools aren't giving our kids complete and accurate information, it is our job as parents to pick up the ball and run with it.  If the parent does not feel equiped to handle it, then consult with a professional.  I have a dear friend here in Tampa, that happens to be a certified sex therapist, who offers "Mom and Daughter" classes on sexuality.  She says the moms often learn as much, if not more than the daughters.

 So, talk it up!

Retention, Infection, Prevention

“An ounce of prevention is worth a pound of cure.”            -  Henry de Bracton 

     My daily work setting has changed.  I am still in my office for a very limited number of patients each week, taking ONLY pelvic pain and TMJ patients, but the majority of my day is now seeing homebound patients through a Home Health Agency.  It is different.  Challenging.  But different.

     This population has a real, constant concern about urinary tract infections (UTI's).  Chronic UTI's make you feel awful, subdue the immune system, are painful and frustrating, and for a lot of people cause incontinence.  The intense urgency felt with a UTI, combined with the physical debility of these people, can make every hurried trip to the bathroom a potential disaster.  An accidental leak can be humiliating, not to mention difficult to clean up, if you are alone.  Being in wet clothing can cause skin break down or irritation.  The frequent trips to the bathroom also increase the person's risk for falling.  Another sad fact is that incontinence is the number one reason that elderly people end up in assisted living facilities.  It is often just too much for the patient and family to deal with. 

 Why so many UTI's?  Retention is often a factor.  For the purpose of this post, I want to sort of reframe the word "retention".  Usually when a medical person says "retention" we all think "complete loss of the ability to void."  Potentially life threatening stuff.  Here, I will use retention as the "loss of the ability to void completely."  When you do not empty the bladder with each void, you end up with a residual volume of old urine sitting in your bladder.  Anyone that has ever emptied a potty chair or urinal knows how quickly urine can become nasty.  Imagine that just hanging out in your bladder, growing bacteria and disease - ugh, right?

So - the best way to prevent infection is to make sure the bladder empties.  For the next several tips, the person taking charge of the situation must have fairly normal mental capacity, so if the patient is in early or middle stages of dementia (Altzheimer type illnesses) these tips will require supervision. 

•  Check the meds.  Many medication used for "mood elevation" list retention as a potential side effect.  Even if the person is not suffering that particular side effect, none of these tips will cause problems, and you may be able to prevent future UTI's. 

 

• Do NOT strain to urinate, I cannot emphasize this enough.  Not only is it bad for the pelvic floor (which  I post about alot), the val salva (straining) maneuver can cause a person to pass out - especially if there are heart, blood pressure, or respiratory problems.
  

 

•  Try to "double void."  After urinating, stand up.  Wait for a few seconds, then sit back down and relax.  Not a great idea if balance is an issue, but good for people that are stable on their feet.

• "Passive void"  After urinating, apply pressure to the bladder, by pushing in and down just above the pubic bone with your hands.  When you are pushing as deeply as possible, lean forward over you hand, and relax your lower body.  The official instructions for this kind of void has patients pushing in with their thumbs; most of my patients have arthritic hands or are simply not strong enough.  I usually have them place their hands over the top of each other, or use their fist to push in.  This does not work well for people with active UTI's, pressure over the bladder is painful.  Wait until the infection is gone before beginning this.

• Relaxing the pelvic floor.  A small step stool placed under the feet while sitting on the toilet is an excellent way to relax the pelvic floor.  This will make voids and bowell elimination easier (a full bowell puts pressure on the bladder - very uncomfortable for a UTI patient).  This is especially helpful if the patient has a raised toilet seat to help them get up and down easily.  Big WARNING:  Small movable stools are hazards for people that are unstable (balance), have reduced mental capacity, or are generally very weak.  If any of these apply to the patient involved, the care giver MUST supervise trips to the bathroom, so that the stool is removed and safely out of the way before the person tries to get up, and when maneuvering to sit down.

I hope some of these tips help.  If you have additional information - please feel free to post a comment!

Intimate Issues

The true feeling of sex is that of a deep intimacy, but above all of a deep complicity.
                                                     - - - James Dickey

 Sex is a complex issue for all couples.  Having a chronic pelvic pain condition intensifies the complexity, and often limits the pleasurable aspect.  Face it;  much of our identity is wrapped up in sex.  Who we are as women (or men), who we are as a couple, or as an individual, all of these have our sexuality as part of the question.

I have posted about the importance of communication, and I strongly recommend seeing a certified sex therapist to help with the process.  And, before you start with "my partner is very understanding, we really don't have sex, but we are OK with that as a couple."  REALLY think about that.  Are you OK with it because you have accepted that this is the way it is - and you love each other, so you'll "get through?"  Do you ignore it so it is a "non issue?"  Just because you don't address a problem, doesn't mean it isn't there.  Just think about the possibility of improving intimacy.  This certainly doesn't require a sex therapist, but if it is an uncomfortable subject for you and your partner, think of the therapist as a guide.

Read the post "Sex, Lies, and Dyspar . . . who?" post for some tips and guidelines for what to do pre and post coitus to limit pain, and improve function.  

For a lot of people this information is not enough.  If vaginal intercourse is extremely painful, there are options.  Rectal intercourse is a little much for some people to get their heads around.  If it is not too "out there" for you, discuss it with your partner - they may not be as oppossed as you fear.   As a warning thought, if your pain is from the pelvic floor muscles, especially tightness or spasm, this option is not going to be less painful.  Be very careful when experimenting with new sexual concepts, both of your physical well being, and of your psychological limits.  Change takes time. 

If you are way outside of your box, allow for awkwardness (and fear),  and be very gentle with both yourself and your partner.   Allow a lot of emotional space.  Set up guidelines early.  Always, always, always have a way out.  You and your partner both need to be very comfortable with saying "no" or "stop."  No questions asked.  It doesn't matter if the block is physical, emotional or psychological, in an intimate situation, all limits must be honored.  Again - a certified sex therapist will help with working through the psycholgical and emotional blocks that come up.

There are also ways to mimic intercourse.  Well lubricated inner thighs can be a sexually satisfying alternative to vaginal intercourse.  And, before you do the "what's in it for the woman?" question, realize that sexual pleasure is more global for women than it is for men.  We really are wired for sex, personally I think more so than men.  Genital stimulation is not the biggest part of sexual arousal, or even orgasm, for most women.  Intimacy, closeness, passion, all the sounds and sensations surrounding sex.  For us it is a"whole body" process, and eliminating the worry and pain of trying for "penetration" can be surprisingly satisfying for both partners.

Oral sex is an option for some.  Many vestibulitis and vulvodynia sufferers cannot stand the stimulation of oral sex.  Again, proceed with caution.  Fellatio (oral intercourse with the male recipient) can be a problem for the woman because of positioning issues.  Most of the positioning options add a lot of abdominal pressure, which can increase bladder pain.  Play with positions, and until you are very comfortable, don't make orgasm a goal.  I also treat people with jaw, neck and headache issues, so if you are prone to these conditions, be VERY careful with oral intercourse.

Please add comments if you have postioning advice, or pre-post coitus tips. 

Brief Discussion

"What are you eating under there?"
               "Under where?"
           - 1st grade potty humor


The under wear question is huge with the vulvodynia/vestibulitis/urethritis population.  Everyone has an opinion, and, as usual, the answer is a very individual choice.

We were all told by our mothers (well, maybe just me) that white cotton, loose fitting, full coverage underwear is the best for our "girl parts."  Granny underwear.  And all of us, as soon as we had any choice in the matter, began exercising our individuality in panties.  Victoria Secret is a modern girl's best friend.  But wait - there is deep, good truth in the advice given to us about white cotton. 

Dyes can be very irritating to the external genitalia.  Unnatural fibres, and some natural ones (silk and wool) can irritate skin and mucous membranes.  Cotton seems to really be the best option for most people.  Even the cotton panel - the underwear industry's feeble attempt to combine beauty with health - doesn't quite cut it, unless the whole garment is made from some breathable cloth.  I have talked  to a few (OK, one) people (person?) that feels most comfortable with spandex - I do not suffer from any of these conditions, and spandex underwear will absolutely irritate the tissues around my vagina.  It is a very individual choice, but cotton really is best for MOST people.

What about style?  The industry has truly changed over the years, bikini briefs, french cut, thong (oh - I will get back to these), classic "granny,"  I'm sure they have a real name - but I've never met anyone that calls it any different.  My new favorite is the boy-cut.  These have the comfort of a brief, but without the elastic at the legs.  Tight fitting elastic around the legs can disrupt blood, nerve and lymph supply to the region - not enough to cause permanent damage, but if the area is already sensitive and irritated, there is no point in pushing it.

It is much easier these days to find pretty, sexy underwear with less irritating qualities.  The severity of your symptoms may dictate your choices from day to day, so if symptoms fluctuate, or if you are not that severe, you may have more options.  Lacy pretty fabrics are still OK, as long as they are breathable fabrics, and are combined with a white cotton panel.  Look for styles that are not binding around the legs, and if you are prone to bladder pain, look for styles with the waist cut either below, or well above the bladder.

Now it is time for me to get on my soap box and rant about thong underwear.  This style was virtually unheard of until the late '80's, except with male strippers.  When they first hit the scene, it was an instant "no panty line" success.  Everyone I knew that tried them hated it, but wore them anyway, because fashion is such a callous dictator.  Remember, this was the era of spandex leggings, wide belts and BIG hair.  Today they are so common that many of my patients and younger relatives can't even imagine wearing anything different.  Convincing people to give up thong underwear often feels like a culture war (I'm showing my age - it may even be a generation gap).  But, it is a HEALTH issue.  

Our rectum and vagina are seperate openings for very good reasons.  The bacteria that lives in our large bowell is essential for breaking down waste at the end of digestion.  There are also yeast in the bowell, and they live in a delicate balance with the bacterias.  None of these things belong in the vagina.  The vagina is a particularly friendly environment for yeast to grow and flourish.  Anyone that suffers chronic vulvar pain knows how bad yeast infections can be, how they can make things worse, or even be the precipitating factor in a flare.  Thong underwear can create a miniature superhighway for migrating yeast.  Direct route from the rectum to the vagina.  Not a good thing, and completely avoidable.

Remember, you always have choices, and the more educated you are about potential consequences, the better your choices can be.  If you are getting ready for prom or some other special occasion, and want to wear a super tight, sexy skirt, or some flowing clingy material - by all means, where the thong.  Be sensible, wear it for the evening, and go back to cotton whities for a few days after.

Share your stories (and opinions).

Pardox - or conundrum?

It is a riddle wrapped in a mystery inside an enigma: but perhaps there is a key.

         -Winston Churchill

 I recently recieved an email from someone with a question about paradoxical contractions of the pelvic floor.  I'd like to apologize to the person that sent the email.  I inadvertantly erased the email while I mused about my reply - so hopefully she will read this (sorry ;-l).

A parodoxical contraction of the pelvic floor happens when the muscles react inappropriately to normal signals from the brain, or reflexively, from the spinal cord.  For instance: during normal bowell movement, the anal sphincter relaxes and is stretched as the stool moves through the opening, when it passes, the sphincter contracts quickly and strongly, ending the movement.  What happens if the sphincter does not relax? or if  it contracts in the middle of the movement? or if relaxation starts to occur, then spasm, then relaxation, then spasm?  or if the normal contraction that occurs at the end of the movement is instead painful and unrelenting like a cramp?

These contractions are "paradoxical." They can interfere with urination, bowell movements and normal sexual function.  They can be painful, or just annoying.  These contractions are one of many forms of pelvic floor dysfunction, and often one of the more difficult to treat.  

When I first started treating pelvic pain, I was emphatic that EVERYONE needed biofeedback (surface EMG).  Over the years, I have found that with a little coaching, most people can learn to sense the difference between relaxation and contraction, even without biofeedback.  However, people suffering with severe paradoxical contraction seem to respond best to biofeedback training.  Often these people feel like things are relaxed, but in reality the contractions may be getting stronger and stronger.  Having visual and audial cues to help sense what the muscles are actually doing is beneficial. 

As with most pelvic floor dysfunctions that result in pain, it is very important to get the muscles to relax.  I have many posts on this: heat, ice, a warm bath, gentle stretching, massage, meditation, whatever it takes.  When relaxation is established, it then becomes the goal to relax during challenging situations (bowell movements, urination, sex).

Everyone is an individual.  Treating paradoxical contractions require diligent effort, patience, creativity and time.   In my opinion, it also requires an experienced biofeedback therapist.

 

If you can add suggestions for things that may help, please do.

Book Review

I have been asked to review “Heal Pelvic Pain” by Amy Stein.  I normally disregard anything that promises to “Heal” conditions, particularly when the scope is as broad as Pelvic Pain.  Amy and her practice, Beyond Basics Physical Therapy in New York City, have an excellent reputation, so I thought I would at least give it a read.

First, let me commend Amy for tackling this project.  The nature of the beast is daunting, and she covers a wide range of pelvic issues, not only pain, but incontinence and other pelvic floor dysfunctions.  Her tone is warm and compassionate, backed up by the knowledge and experience of a veteran pelvic floor therapist. This is the real deal.  

The book gives a simple, easy to grasp overview of pelvic anatomy and the many causes of pelvic pain.  Remember – it is an overview.  Interstitial cystitis patients will be disappointed that the explanations are not specific to them, as will people with endometriosis, irritable bowel, and vulvodynia.  She really gets to the core issues that link all of the problems, and gives really good overviews of each condition, leaving the minutiae to others.  Later chapters discuss different populations, men, children, pregnant and post-partum women.  She even has chapters on healthy eating, relaxing, and better sex (really – this is an achievable goal, and the chapter is worth reading, even if you have given up on having a normal sex-life).

Chapter 3 is my favorite – and most appropriate for my patient population- “End The Pain.”  These are fairly standard exercises for relaxing the pelvic floor, and strengthening and relaxing the muscle that contribute to pelvic pain.  The best part is the easy, direct instructions and the very clear pictures.  Please read this chapter all the way through before implementing the exercises.  There are cautions about causing flares by jumping too quickly into the strengthening portion, and it is a good idea to know where you are going before you begin.  I also like her encouraging tone; exercise is an incredibly important piece of the puzzle, and staying motivated is difficult for all of us.

In “Give Yourself a Massage” Amy discusses how to do self massage: searching for and treating trigger points; abdominal massage; and internal massage.  This is a difficult topic in written format, and there are just not good graphics available to make it easier.  She does an excellent job of explaining the basics, and in a significantly less confusing way than I would have been capable of.  For internal massage I recommend that my patients use the EZ-Magic device, as it makes everything a little easier to reach.  If at all possible, I think it is still optimal to see a physical therapist that can train you on this portion of self treatment directly.  For those that cannot get to a pelvic floor therapist, this book is probably the best available explanation. 

All-in-all, I recommend the book, especially for those that don’t have easy access to a pelvic floor therapist, but also as an adjunct to the treatment you are receiving.

Thanks, Amy!  You’re patients are lucky to have you.

Head Case

“I'm very brave generally, he went on in a low voice: only today I happen to have a headache.”

- Lewis Carroll

Jaw pain. Head ache. Toothache (but wait, the dentist said my teeth are fine). Clicking in the jaw. Yawning hurts. Chewing is Exhausting (or painful). Can’t open my mouth. Can’t close my mouth. Numbness in head or face. No pain. Weird noises. Jaw locks. Talking hurts my head. I wake up with headaches. Resting helps. I grind my teeth. I don’t grind my teeth. I clench my jaws. My ears hurt. My ears are “stuffy,” Flying gives me a head-ache. My neck hurts. My shoulders hurt. I get migraines. I don’t get head-aches.

What is going on here? The list of symptoms looks like a mixed bag of unrelated, even contradictory sensations. But, for people suffering with TMD, or TMJ syndromes, this list will look really familiar.

The TMJ (tempormandibular joint) is the joint that attaches your lower jaw to your head. Like the joints that connect your spine, the two sides work in tandem. Damage to one side, will cause dysfunction in the other. And the most debilitating symptoms may show up in the side with the least damage. The muscular attachments, nerve pathways and patterns of use are a complicated system that delivers a wide range of symptoms if things go awry. Most confusing is that the symptoms listed above may all be present in the same person at different times. This makes it very difficult to diagnose, and treat. There are as many treatment options available as there are symptoms, and the results vary just as widely.

The TMJ association has a new forum for patients that I found to be very interesting. This site is a wonderful place to share information and learn about TMJ dysfunction. The Forum is running a couple of polls on “what has helped you the least?” and “what has helped you the most?” At last count physical therapy was least helpful for 11.1% of those reporting, and most helpful for 33% of those reporting. Interesting. Unfortunately with many of the conditions I treat, nothing works for everyone. On the reverse, something works for everyone. People with chronic pain conditions have to be constantly on the watch for something that will work for them. I would also like to add that some things will work, even if they didn’t work the first time.

For someone in constant, everyday, debilitating agony, I am probably not the best front line of treatment. Having a team of good, supportive doctors on board is essential. Sometimes drug therapy is essential to help with the intense pain while we work on the mechanical imbalances that cause the problem. Having good, compassionate dental or orthodontal care is important. Be warned that some studies have shown bite therapy to be causative, not curative for TMJ. Other studies have shown that it is the best treatment. I have had many patients whose first symptoms came after orhtodontal or dental work to correct a bite, or repair teeth. I have had patients that swear their orthodontist cured them. Jaw surgery is another question mark for cure. I treat a lot of post-surgical patients. Many of them consider the implants to be a miracle cure. Many of them show up in my office 3-5 years later in the same (or worse) pain than they started with. At least the surgical interventions have improved over the years, 15 years ago some of the common practices bordered on barbaric. Be very cautious before undertaking a treatment plan that is very expensive, and irreversible.

As for physical therapy being least helpful (it pains me that we don’t help everybody – but I get it), it is also one of the least invasive. My practice focuses on improving musculoskeletal function, which means a lot of postural retraining, manual therapy and modalities to reduce muscular tensions, and a home program of stretching and strengthening to improve mechanics of the spine, jaw, and upper extremities. Even if it doesn’t help the TMJ, the program will prevent other postural problems in the future.

Please feel free to add a comment, tell us your story, or let us know what was most helpful for you!

Keepin' it on the down low

Recently someone emailed me with a question to clarify a term that I use quite frequently. I apologize to anyone else who has had this confusion, and realize that just because I say something over and over, doesn't mean that it will make more sense each time - anyway, here is the question, and the reply.

"Hi Molly,

I was reading your web site about Pelvic Floor Dysfunction and had a question.

I have had serious pelvic floor problems. I have had two major repairs and an ileostomy. I have had the ileostomy reversed and PFtherapy. I did pretty well for a while, then started having more difficult evacuation. I have changed therapist, which is not easy. I live in Massachusetts, and PF therapists are not easy to find, especially someone good.

I am wondering what "down training" is? I want to ask my therapist, but would like to know first.

Thank you,"

Down training: Using biofeedback as a tool to relax, rather than strengthen, the pelvic floor muscles

There are several ways to go about this, all of them a little frustrating, which is why most of my patients use a home-unit, so at least they get to be in familiar surroundings while trying to relax.

EMG (biofeedback) measures the electrical out put of the muscles. That's it. If the muscles are "high tone" or contracting, there is more output, if "low tone" (weak), or if contractions are very weak, there is less output. When strengthening the pelvic floor, we set a goal to tighten the muscles to a certain level, when the level is reached, there is a noise or some other indicator that you have reached your goal.

When down-training, we set the goal at, or slightly below the resting tone (threshold). Here is where I differ from a lot of therapists. You can set the tone to go off when the tone drops below threshold. When this happens, you know you have achieved your goal of relaxation. I tend to work the other way, and have you work on turning the sound off (when you relax the muscles, the annoying noise goes away) - it just makes more sense to my way of thinking that if you are trying to relax, you really don't want the machine to beep at you every time you finally get there.

soft lights, relaxing music, meditation, maybe a hot pack, at first - whatever it takes to get your whole body to relax. As you get more practiced, then the goal is set to a more challenging level, and perhaps you allow a more functional surrounding, getting your pelvic muscles to relax on demand.

You may be asked to occasionally contract the muscles during a session - this OK, it gives your eyes, ears, and body a reference point between contracted and relaxed. You should not be asked to continue contracting the muscles if you are completely unable to get them to relax afterward.

There are whole protocols on contracting the muscles to fatigue in order to achieve relaxation, and some evidence that it works. For those that it doesn't work on, the effects can be devastating. This method does not fit my treatment philosophy at all, and I refuse to do it, even when specifically ordered by the doctor. To clarify a little more here: If you have tight muscles in your neck, and were asked to do repeated exercises until the muscle could not lift even the weight of your head, you would consider that pretty extreme - especially for an area that has to be active during normal daily function. Your pelvic floor is active whenever you are in an upright position, fatiguing these muscle to exhaustion will give temporarily relief, and some people respond well enough to have lasting effects. Others can't get all the way to fatigue, or the muscles bounce back with uncontrollable spasm, reinforcing the tight, unrelenting contraction and shortening of tissues that causes so many of the imbalances in pelvic floor dysfunction.

Anyway - I hope this clarifies things for some people, and please - ask questions! If I don't know the answer, I will try to research it, or throw out an opinion, or maybe add a different perspective to the subject.

More New Friends ! ! !

I found a relatively new blog that really warrants mention: PELVIC PAIN MATTERS. The blogger, Bonnie Bauman, is an author, a chronic pelvic pain patient, and a fabulous, dynamic person. Her blog is chock full of information, and resources. She is very honest and open about her own journey, addressing her condition with humor and hope, and a single minded focus on finding effective and appropriate treatments.

She has a fabulous physical therapist and a fantastic doctor, and she uses them as constant resources. She also has a section on her blog dedicated to finding and posting information on good providers. So - if you have a doctor or PT or anyone else that has helped you immensely, let her know, she is compiling a list.

Light Touch

There are two kinds of light - the glow that illumines, and the glare that obscures.

~James Thurber

I have spent the past several months researching everything I can find on “Low Level Laser Therapy” or “Cold Laser.”

The amount of information is vast, the quality is confusing, conflicting and difficult to sort through. I managed to talk a few reps into letting me play with demo models, and I sorted through enough information to justify purchasing a machine. So now my task is to try to make sense of all of the information available, and squeeze it into a nutshell that is easier to handle. I am NOT an expert, and my experience is limited. (That was my disclaimer). I hope this helps, but if you decide to seek light therapy for any condition, please discuss it thoroughly with your health professionals.

First – it is perfectly safe. The machines on the market available to clinicians will not burn you. We are all familiar with the concept of surgical lasers, and have seen Hollywood lasers burn through metal, glass, people, even mountains. The class “3” or “3b” lasers, which are the light frequencies used in rehab, will not burn holes through your body or damage tissue.

The treatment has been approved by the FDA for temporary relief of minor muscle aches, joint pain and stiffness, relaxation of muscle spasm and increasing local blood flow.

At this point, I know of no insurance companies that will pay for cold laser treatment. Part of this is secondary to the type and quality of research available. There are foreign studies that are better, mostly Russian, but they are not the studies that insurance companies look at. I reviewed the abstracts on many of the studies cited by some of the insurance companies, and I understand the justification for denial. Even those reviews admitted that “further study” is warranted. They are not ruling out the possibility of payment, they just want tightly controlled, well-designed studies. And here-in lies the problem. Most of the studies available in the US are funded, in fact, PERFORMED, by clinicians with a monetary interest in the companies that make or sell machines, creating an inherent bias. Many of the abstracts I looked at were small samples, or had multiple, uncontrolled variables, and were, in short, not very well designed. There is not a lot of incentive for really good studies. Practitioners are using them, patients are paying out of pocket (and getting results) so there is not a lot of financial incentive to have better studies: if people will pay out of pocket, and the FDA has approved it, do we need 3^rd party payor blessing?

Does it work? We all know the benefits of sunlight. We know that light can be extremely powerful. We know that even tiny laser pointers can span great distances through air, glass, and some plastics. If you hold a flashlight to your hand in a dark room, you see the dense silhouette of bone surrounded by eerie red as the light penetrates your blood vessels. Better yet, put the flashlight in your mouth and puff up your cheeks – sorry, inner child moment. Light can penetrate, and these lasers are fairly powerful.

But how does it work? The theory is that laser therapy increases your metabolic process by exciting the mitochondria. Uh-oh, 8^th grade biology flashback! Mitochondria is the powerhouse of your cells, they produce energy for your cells, and keep everything running. They love light. In fact, it is partially the mitochondrial response that makes sunlight so good for you. It also increases protein synthesis, promotes efficiency at the cell membrane to normalize pressure, and improve exchange of nutrients and wastes. All of this activity on the cellular level is supposed to decrease swelling, inflammation and pain, promote healing and generally make things work better.

But – does it really work? Well, I have only been using the machine for a couple of months, and, again, I am not an expert. The results have been strong enough for me to purchase one. I am still playing with protocols and parameters. Some of my patients have had truly phenomenal results. I am hoping that those that did not have such positive results will benefit from my increased proficiency. When a treatment effects the cellular metabolism, there is risk of temporarily increasing symptoms, especially in the chronic pain population. I tend to error on the very conservative side of caution. My patients that did not get better, also experienced no increase in symptoms. As I get more comfortable with the therapy, I will probably treat (slightly) more aggressively.

Treating the whole enchilada

The people I distrust most are those who want to improve our lives but have only one course of action.

Frank Herbert (1920 - 1986)

I get emails from patients from all over the country, sometimes from around the world. Recently I had the opportunity to converse with a women whose story was very different from what I often hear, but is worth sharing, largely because this could easily happen to anyone with similar problems.

Here is an excerpt of her story:

“I went to a PT for a back/rib injury. She saw on my medical history IC and another condition I have. She said "we're going to ignore those and just focus on the ribs" and asked me nothing about it. It was a huge red flag to me but she seemed so confident with helping my injury that I got pulled in. On the second visit, as soon as I walked, in she very quickly rushed me onto this huge machine. It caught me off guard so I just hopped on and immediately my urethra hurt. I told her and she ignored me and went on with the instructions. I should have gotten right off but slouched down to take some pressure off the urethra. I didn't realize this was a bicycle- looked different and had a big seat, also recumbent. I have a severe case of IC and have had it for 21 years. I tried to ride a bicycle about 7 years and after a few rides and even trying different seats I got very flared up. Been in peri-menopause for 3 years now and my IC is worse in many ways and affected from it, so maybe that's why this was worse than the regular bike. I flared up very badly. This was 2 weeks ago. It hurts to sit on any chair, even the couch. A few other times with very bad flares I have had the same thing but usually only with my hard kitchen chairs, not the couch too.”

The lack of compassion displayed by this physical therapist surprises me, but the lack of education does not. This is a sad, but useful, warning to others that may need to seek help for conditions unrelated to IC. There is a lot of conversation on the IC and pelvic pain forums about how difficult it is to find a physical therapist trained to treat this condition. Finding a PT that is aware of it enough to effectively treat other conditions is just as difficult. This is largely a problem with how we are educated. Until about five years ago, physical therapy schools ignored the pelvic region. Some very proactive schools discussed post-partum rehabilitation. Our school made us buy a very expensive book on “Physical Therapy and Urogynecological Conditions,” I didn’t take it out of the wrapper until 3 years after graduation. Most of my class returned it for full refund. Now, many schools are incorporating a segment on pelvic conditions, but in most schools it is minimal and primarily focused on incontinence.

Our basic education teaches us how organ dysfunction (kidneys, bowel, liver, etc) can mimic or mask musculoskeletal pain. We are taught to screen for these things, so that we are not treating intractable low back pain that could be caused by a severe kidney infection, treatable with antibiotics. But I have never heard an instructor or PT (outside the world of pelvic floor PT’s) say – “Sitting with your low back rounded, working the hip muscles on a wide, flat seat can really cause a flare-up of urethral pain.” For PT’s that don’t work with this population the two seem totally unrelated, and it isn’t even on their radar screen to think about. For those of us that do, it seems elementary.

So what can you do?

• Always – communication is key. Unfortunately for the women in this example, the PT wasn’t listening enough to take her pain seriously. Remember that YOU are the expert about your body, especially when your condition is outside the expertise of your caretakers.

• Having someone trained in pelvic floor work is optimal. Most of us that do this did not start out as pelvic pain specialists. We have widely diverse backgrounds, having done some other type of physical therapy in “a former life.” I did Sports and Orthopedics for years, and am still very comfortable treating orthopedic injuries.
  

• Many places throughout the country are developing “Women’s Health” programs. If there is a clinic with a program in your area, start there. Chances are you won’t be seeing the pelvic pain PT, but at least there is one handy for your therapist to talk to, and get feed-back from

• Bring literature about your condition. There is no guarantee that they will read it, and they certainly won’t have time right then, but any chance to educate even one more health care provider will help increase awareness.

New Friends, New Resources

I have added two new links to the list on this site.

One, a new Vulvodynia Blog, is a great informative site from Poland, written to bring awareness of this devastating condition to the people and powers of Eastern Europe. Conversations with Mikolaj (the creator/moderator) have shown me that awareness over there is about where it was in this country 15 or 20 years ago. It is not diagnosed, rarely (and almost always inappropriately) treated, and the women are given no resources or validation of the physical nature of their illness. The link I put up is for the automatic english translation. It is a little awkward, and some words don't translate at all, but very informative. Please check it out, and if you are aware of good resources, particularly materials that offer instruction for self-treatment, please let them know.

Two - The Vagina Dialogues. OK - you gotta love the name, and Abigail Steidley has a lot of great information. I actually got the link for her site from the Polish blog, (thanks Mikolaj) I often discuss how chronic pain issues effect mental and emotional health, and I am a huge advocate of counseling. Chronic pain does not come with an instruction manual, and while you are busy navigating the turbulent waters of life, illness, and an impersonal medical system, some sort of mental support and help in dealing with all of it is really important. Abigail has taken her training as a life coach and directed it to a population that needs coaches. And cheerleaders! She works with people suffering from IC, vulvodynia, dyspareunia and other painful pelvis syndromes.

Please visit these sites, and let me know if they help!

Doors Close, Doors Open

I am closing Slainte Physical Therapy. It is one of those happy/sad/scary/exciting decisions. The catalyst for all of this change has been the need to spend more time with my family, all the way on the other side of the country. There has been a lot of upheaval during this process - and I have a lot of people to thank for their support.

Francie (my office manager, confidante, friend, and best reality check) has been very supportive - at least after the initial shock in which I was afraid I was losing my best friend along with my business.

My patients. Especially those that have dealt with the moving process while my office is torn down and scattered into boxes and the constant interruptions of people showing up in the middle of sessions to haul away equipment. Of course the factor of me wandering around looking for things that are vital for treatment has increased 1000%.

My family - I keep telling my husband and daughter that I will be a normal person in July - I really don't think they believe me.

Friends, Neighbors, & Colleagues. Pretty much everyone that has listened to the rambling, convoluted story after the innocent: "how's business?"

Anyway - on to OPEN doors. I have found a very small room for rent in a renovated bungalow close to my home. I share waiting room and restroom space with a massage therapist, a school psychologist, a mental health counselor and a MD/Acupuncturist. The business is changing; I am no longer billing insurance, but I will provide documentation for people to submit their own. It's just me! So. . . the phone ringer will be off, and I will return calls at the end of the day. (813) 237-0777. I am trying to go completely paperless (we'll see how that goes), and I will only be in the office part time (Mon/Wed/Fri mornings and Tue/Thu afternoons). I am keeping the same email and web site, so www.SlaintePT.com will live on in cyperspace. In fact, by next week, my husband should have all of the "new patient forms" available for down load on the site. (YAY - go Mike)

This scenario will give me more balance in my life, so I can really stay centered on things that need my focus: My patients & My family


Wish me luck!

Being in it, Staying fit

I am not a fan of pilates. Actually; I am, but not for my pelvic pain patients. Increasing intra-abdominal pressure for the duration of an activity, without giving the "core" muscles a break, seems counterproductive to me, and often causes intense pain for the women I treat. So, when I came across the "New Dawn Pilates" video, I was pretty skeptical. The creator of New Dawn was kind enough to send me a copy, even though I sort of bashed the concept in my initial contact with her (I did promise to keep an open mind). So, I pulled out my little mat and decided to give it a whirl.

LOVED IT!!!! Without reservation. All of my concerns about "pilates" were addressed, with clear instruction and proper caution. The DVD warns you when there is an activity that may be inappropriate for someone experiencing a symptom flare, and lets you skip to the next activity. EVERY activity that my overprotective mind was about to question was accompanied by a "please skip ahead" comment. One bit of caution: if you are at all questioning your ability to engage in an exercise program, please skip these items. They don't seem that strenuous while they are happening, but they can be problematic, so please, heed the warning!

Plus, Jenny Buttaccio (the creator, developer, genius behind this project), is a phenomenal person. I was so excited about the concept, I asked if she would consent to telling her story for us. She is an IC patient, and understands what happens to a busy life that gets railroaded by this horrible illness. She is truly an inspiration, and here is her story:

Molly: I remember seeing somewhere that you are an IC patient?

Jenny: I AM an IC patient. My IC symptoms began almost immediately
following a laporoscopy to remove an ovarian cyst in December of
2005. At times, the pain had almost been intolerable and I had began
to feel as though I was loosing my mind. I was fortunate to be
located in a city where doctors are familiar with IC, so I was able
to get diagnosed in about 6 months rather than average which usually
takes a number of years. At that time, my treatments were aimed at
trying to get me through the crisis, control frequency, decrease
pain, etc. I had just gotten engaged one week before my surgery, so
my initial battle with IC could not have been more UNTIMELY! By the
time I had gotten any treatment at all, I had lost weight, I wasn't
sleeping at all during the night and my hair was falling out! That's
why I say my initial treatments were aimed at trying to get me
through the crisis, I had a wedding to be at, MY WEDDING, in
Minnesota in November 2006 and I was in no condition to go anywhere!

Although most of the crisis is over, I am still trying to find the
right "blend" of treatments that will help my symptoms to be under
control.

Can you tell me a little about your personal journey with IC?

Jenny: Truthfully, IC is difficult. I suppose there could be other
potentially worse things in life, but IC is still difficult. I
believe IC poses a different level of difficulty. It's a discreet,
prolonged and confusing sort of experience. Quickly, you are forced
to become a different person. Suddenly and without your consent, you
are no longer capable of doing the things you usually do. Because
you don't know what is happening with your own body, it can be
difficult to communicate with those around you how you are truly
feeling. All you know is that you don't look sick, yet feel
incredibly bad. You feel as though your life is slipping away and
sometimes, you're not sure how much further down you can slip. In
the beginning, IC is a puzzling roller coaster ride.

I don't mean to paint the picture quite so grim, but things just
began to happen to my body and I had no control over it. I began to
have intense lower abdominal pain and pressure. Sometimes, the pain
was so severe that it was difficult for me to walk up and down three
flights of stairs to my apartment. I constantly had to urinate 20-30
times a day. There were days that I could literally sit on the
toilet (sorry for the visual) for 20 minutes just constantly going to
the bathroom. It was as if every drop of liquid in my body had to
make sure it found it's way out. I began struggling to work. My
social life took a dramatic turn. I could no longer spend time with
my friends. I loved to travel and had just been to Korea 2 months
before I developed IC. Traveling was certainly out of the question.
Honestly, I didn't even want to leave my house. I just kept forcing
myself out of bed each day to go to work. I am an occupational
therapist and I am certain there were days that I felt worse than my
patients. Really, no one had a clue about what was going on with me
because...I looked so "normal."

Once I was actually diagnosed with IC, I began constantly researching
treatments from a variety of approaches. I would spend hours and
hours on the internet searching for what else I may be able to try.
Over the course of 2 years, I have tried many many different sorts of
things. I have only found some minor symptom relief in a handful of
things. Although my symptoms have improved somewhat since the initial
diagnosis, I am still working with my doctors to find something that
will really cause a breakthrough in my IC symptoms.

Was there ever a time that you felt you couldn't exercise, or
wouldn't be able to again?

Jenny: This may sound strange but, no. Not really. Exercise to me has
always been as routine as brushing my teeth. Call me crazy but I
actually love to do it and my body craves a certain level of
activity. At a very young age I began swimming, then running track
and eventually getting involved in gymnastics for 10 years. As an
occupational therapist, I am constantly looking at ways that I can
modify skills, tasks and daily activities to promote a person's
ability to be more independent. My skills as an OT suddenly became
very useful to me when faced with my own chronic health issues. I
knew my ability to participate in exercise had changed, but I
believed I could use my skills as an OT and my fitness background as
a certified pilates instructor to modify some of my favorite
exercises and make them more suitable for me. Keep in mind I was
also heavily motivated by the fact that I was getting married. I was
determined to still look my best on that day! I did ALOT of
research, tried many different pieces of equipment and a lot of crazy
exercises to develop a program that was comfortable and effective. I
liked the exercises I had put together so much that I just kept
working out by myself in my own home.


What was the inspiration for creating this video?

Jenny: I began reading a lot of the IC forums and listening to other people in my life that had various forms of pelvic pain disorders talk about
how they found it so difficult to exercise. Many of the forums
discussed the types of exercises that people with pelvic pain issues
shouldn't do, but there was a lack of resources available about what
people could do. I wanted REAL exercise, exercise that could
actually help tone my muscles, help someone else loose weight and
perhaps even make me sweat a little bit (just a little bit). One day
I had been expressing my frustration to my husband about the lack of
resources and he suggested to me, "Why don't you make a video? Put
your ideas out there for other people who are searching for safe
exercise options." I had the very fortunate advantage of having my
husband, Tom, be a filmmaker/video producer. After talking with some
friends, fellow pelvic pain sufferers and a few specialists, I
decided I would create New Dawn Pilates: a pilates-inspired workout
adapted for people with pelvic pain. I wanted to inspire people to
not give up on having an active life and educate people that with
careful instruction and special modification even pilates could be
permissible among pelvic pain sufferers. Hence, New Dawn Pilates was
born.


Why "New Dawn?" What does it mean for you?

Jenny: I can't take 100% credit for New Dawn. That was actually my
husband's idea after throwing around multiple other titles. I had been driving to one of my patient's houses when I received his phone
call. "I've got it!" He said, "How about New Dawn Pilates."
Immediately, I loved it. See for me personally, my battle with IC
has been about rediscovering who I am now that my life is not going
the way I originally thought it would. There is such a large
emotional component that goes along with dealing with a pelvic pain
disorder. The challenge I think is this, to find some contentment
even in the most difficult of times. For me, the concept of New Dawn
represents the anticipation that a new day will arise in my life
where I am not always sleep deprived and in pain, perhaps joy will
come in the morning and the sun WILL shine again. It's really about
restoring hope to a community of people that often feel as though no
one understands,

Vulvodynia Support

There is a new, patient controlled, support group for vulvodynia sufferers. They have good chat forum, links to various web-sites and news, and some pretty inspiring stories. Please check it out, and if it looks like a good fit for you, by all means join them and add your two cents. Many heads and many hearts can make a huge difference in the lives of women that are dealing with a very isolating condition. In case the title link doesn't work: Vulvodynia Support

V is for Victory!

Vulvodynia, Vulvar Vestibulitis, Vulvar Dysesthesia, Vaginitis, Vaginismus, Vestibulodynia. It reads like a list of alien invaders, and for women afflicted with these conditions, it feels like it. These are words that show up as a diagnosis or diagnostic criteria with nearly 15% of all gynecological visits in the US today. That’s a lot of women, and this number doesn’t reflect the number of women that are mis-diagnosed or undiagnosed.

Let’s break down the laborious terminology here.

· Vulva- (or vulvo-): is a root word that means “external female genitalia,” which includes the inner and outer labia (lips) the clitoris, vaginal and urethral opening, and that little fold of skin-like connective tissue around the opening (the vestibule).

· Vestibul- : see above

· -dynia: pain (vuvlodynia – pain in vulva; vestibulodynia – pain in vestibule)

· -itis; inflammation – typically characterized by: redness; pain (often burning); maybe swelling; and tenderness to touch

· -mus: tightness or spasm

· Dysesthesia – (dys- impaired function; -esthesia: sensation) in this context, the sensory input from the vaginal area to the brain does not match the stimulus. Typically in painful conditions it means the nerve endings are hypersensitive, light touch should not cause searing pain, but for those with dysesthesia, it does.

Basically what we have here is a collection of symptoms that often serve as a diagnosis when no one can figure out WHY the symptoms have appeared. There are a lot of theories as to why this happens to so many women (some studies show as many as 50% of women will have these symptoms in their life-time), and there is constantly new research getting us closer and closer to the cause.

Here are some of the things we know (or suspect) that may predispose a women to having these problems:

· Genetics – a grant has recently been awarded to allow researchers to explore a link with certain genes that may cause an increase in the proliferation of nerve cells and irritant cells in the vulvar area, and genes that effect protein synthesis in these areas.

· Mast cell proliferation – these are the irritant cells mentioned above. Everybody has them, they are largely responsible for that histamine response you get from allergies, but for some reason they seem to be overly abundant in certain areas in certain people. They have proven that there is a hyperactive mast cell response in the bladder lining of interstitial cystitis (IC) sufferers.

· Chronic yeast infections – the constant irritation can cause the nerves to become hyper-sensitive, causing pain and irritation, even after the yeast is long gone. And please remember that thong underwear can carry yeast and other bacteria from anus to vagina very easily.

· Lichen planus, HPV, various bacterial and viral conditions.

· Contact dermatitis – This happens when a product irritates the area, and the nerves remain sensitized even after the irritant is gone. Soaps, perfumes, toilet paper, dyes in clothing can all be irritating. Here’s the kicker: many of the products we use to relieve vaginal itching or burning are hugely implicated in contact dermatitis. Anti-yeast creams are the biggest culprits, and so are anti-itch creams. Even prescription ones are considered to be causative factors. The safest way to handle a yeast infection is to get it cultured before taking ANYTHING, use the most appropriate treatment as recommended – but only once! If you are very sure it is yeast, and you use an over the counter medication, if it doesn’t work be sure your doctor knows what you tried, and the experts recommend that you not use a prescription cream if the over the counter doesn’t work, you are better off to use an oral medication.

· Pelvic Floor Dysfunction – O.K.; if you read this blog even occasionally, you knew I was getting to this. Pressure on the nerves from tight muscles can irritate the already hypersensitive nerves. Trigger points within the muscles can set up pain patterns that mimic vulvodynia pain when the muscle is stretched or tightened. Guarding (tightening up the muscle in anticipation of pain) can lead to vaginismus.

So what do you do? FIRST – go to a doctor! The most important thing is to rule out conditions that can be treated medically. If all the cultures come back negative, it is time to start working on the symptoms.

As a physical therapist, I help you try to eliminate pain. We use biofeedback and visualization techniques to teach you to relax that pelvic floor, and take the pressure off the nerves. We work manually (internally and externally) to eliminate trigger points and to improve the muscular balance around the pelvis. We use electrical modalities including therapeutic ultrasound, and electrical stimulation to help relieve pain. We educate you about avoiding irritants (diet, chemical, mechanical). Once the pain level is controlled, we teach you how to stay pain free, or manage flares as they arise.

A side note on my own personal treatment philosophy: The most effective way to deal with pelvic floor muscle tightness is to work internally on trigger points and muscle spasms. Many of my vulvar pain patients cannot handle vaginal work, and are so uncomfortable with rectal palpation that the costs out-weigh the benefits. With these women, I use as many indirect techniques as possible until we have achieved a comfort level with internal work. With manual therapy, you may experience some extra soreness the next day – but several days (or even two) of agony is too much, and not (in my mind) effective. It is imperative that you talk with your physical therapist during your treatment, don’t undergo weeks of “torture” because you think it might help. If you don’t tell your PT how painful it is, she will assume everything is just dandy. Chances are if she is aware of the problems you are having, she will be able to modify the treatments.

All of this is in cooperation with your medical team. There are medical interventions to help relax the muscles and control the nerve pain, and depending on the acuity of your condition, sometimes the medical interventions are what make it possible for me to do my job.

Diabolical Duo

“There are two things in life for which we are never truly prepared: Twins.”

--- Josh Billings

Scenario 1: “I have always had painful periods; but my mom was very understanding, and bad periods are common in my family. My periods only really put me down for a couple of days a month; and I could deal with that. Then I started getting bladder infections, or so we thought. They didn’t respond well to antibiotics, and very soon I felt like I had constant lower abdominal pain. I was urinating 20-30 times a day, waking up several times a night, and it seemed to get much worse with my period. Finally, I was referred to an urologist that diagnosed me with interstitial cystitis. He started me on rescue instillations, elmiron, and pelvic floor therapy. I feel sooo much better. I still have flares around the time of menstruation, and my periods are still very painful, but my bladder is under control most of the time.”

Scenario 2: “I don’t remember having really bad menstrual cramps when I was younger, but by the time I was in my mid twenties, I began having a lot of lower abdominal pain, which worsened after ovulation every month. I began having overactive bladder symptoms, and occasional bladder pain, particularly if I didn’t make it to the bathroom on time. My gynecologist thought I might have endometriosis, so we did a laproscopy. There were multiple lesions, which were removed, and my symptoms all but disappeared. 2 years later, my symptoms returned, and we did the same thing, this time it didn’t seem to work as well. I got some improvement, but I am still having pain, and for some reason there are more bladder symptoms than before.”

These are pretty common scenarios, and both of these found progressive doctors that were able to hone in on the dominate symptoms and quickly find a diagnosis and get these women some relief. Sadly, in both cases the diagnostic process ended too quickly. I am constantly reminding people that quality medical care requires a team approach, and as patients we must be the captain of our team. Endometriosis and Interstitial Cystitis frequently occur at the same time in the same women. There are many articles on the web that discuss the concurrence of these two conditions; prevalence is listed as high as 80-90% in some articles. That means that the majority of my IC patients are only being treated for half the problem, and many endometriosis patients have not received the urological work-up they need. Symptoms are very similar, so treatment for one often relieves symptoms significantly enough that we feel pretty confidant that we “got it.” If symptoms persist, ask your doctor about more diagnosis.

If you are lucky and your doctor is aware of the comorbidity of these conditions, she may be using the “chicken or the egg” approach and trying to get symptoms of one condition under control before tackling the other. If this is the case, great! But, make sure that communication is open, and that your lesser symptoms are not being ignored. If you are seeing a gynecologist for endometriosis, ask for an urology consult. If you are seeing an urologist for IC, ask your gynecologist about endometriosis. You may be one of the 20% of patients that has only one of these conditions to worry about, but it would be best to know for sure.

Holiday Happiness

“Put a little holiday in your heart” – LeAnn Rhimes

They are here. Tucked behind colorful Halloween and Happy Harvest displays in every store you will find the reds, greens, golds (and this year, refreshingly, jewel tones) of Christmas. And Hannukah. And Thanksgiving (but these are very small, you might miss them). Yes – the holidays are approaching.

For many of us the holiday season can be an emotional roller coaster. For people with chronic pain or bladder issues, or both, the highs and lows of that roller coaster can be extreme. I have a few tips that may help some of you. I would also encourage anyone reading this, if you have more suggestions, please post them as comments.

First, let me say – I love this time of year. From that first drop in temperature, sometimes into the ‘70’s, I start getting excited. I spend the next 4 months anticipating the brilliant falling leaves, biting cold, snow and ice, and all of the things I loved about autumn and winter that I remember about childhood. Hot chocolate by the fire, snow-ball fights with my brother. . . . . Reality check – I live in Florida, none of this happens. But I expect it, any moment. So, I decorate. Like a mad women. I also bake, sometimes compulsively. I really detest shopping, and I am lucky enough to be part of a family that loves phone calls and hand-made gifts more than “presents.” But, I digress:

The holidays are full of many things, but whether happy or hard, they are full. The extra activity, special holiday foods, parties and socializing, adds an enormous amount of stress to lives that are already full. So what can you do?

Number one: Breathe! And take breathers.

Decorating: Do you have to? If you must, do it in segments. It doesn’t have to happen all in a day or in a weekend. Remember if you put it up, it has to come down. So try to stream line into the most important things. If you can afford it, many lawn-care companies are offering set-up and take down services for outdoor lights and decorations, this may be worth checking into. Transitions from Halloween to Christmas can be nerve-wracking, especially if you are like me, and feel like everything has to come down as soon as the holiday is over. Try to keep it simple, and enlist family members to help.

Shopping: There is plenty of time to do holiday shopping, and starting early will make the whole operation more relaxed. Try on-line shopping, and if you really must touch it and feel it before you buy it, many of the large retail stores have “ship to local store” options. You don’t have to walk up and down the aisles, you often don’t have to pay shipping, and you get the best deal available. On-line shopping is also great for obligatory gift giving; clicking through pages of merchandise hoping to see “the thing” for Aunt Betsy, is way easier than wandering up and down the aisle of a store trying to find something that matches her ceramic poodle collection.

If you are one of those people that have to be in the stores at 5:00am on the Friday after Thanksgiving for competitive shopping; try to play it low key. Consider that your “fun” shopping day, try to have as much as possible done before, or plan on coming back after. Stay relaxed, find places to sit, watch people, let every one else be frenzied, you can sit down and watch the show. Face it, as energizing as grabbing that bargain can be, long lines and exhaustion have a way of dampening the fun. If you really don’t feel up to it, meet your girlfriends for breakfast or an early lunch, and live vicariously through them.

Know where the bathrooms are, and if there are lines, try to plan ahead. Having a friend team shop with you is a great idea, so you are not leaving a prized item in the path of the marauding hoards while you are in the bathroom. If you are taking a break, offer to hold the stuff - leaving your friends hands free to grab an extra one of those things you both really wanted.

One last comment on shopping: I am suddenly a big fan of gift cards. They can be combined, so people can get things they really want, even if no one person is able to afford to give it to them, they are the most appreciated gift under the tree with teens and tweens, and, they are tiny! You can do all of your shopping at the store front, never having to navigate any of the aisles. We live in a tiny little bungalow, all of our neighbors understand the need to avoid clutter, and I’m finally getting people to understand that I REALLY would rather have a phone call than more STUFF.

Food and Parties: For those of you on special diets, especially low acid, or low oxalate diets, holiday eating can be like walking blindfolded in a land mine. For me this is choice time. It is much easier to be uncomfortable for several days if I knew what I was getting into when I did it. If you don’t have your diet straightened out, and you don’t know what triggers your flares, be very careful. Eat before you go, it is harder to make good food choices on an empty stomach. Try Prelief or some other anti-heartburn medication prior to the event. It lowers the acidity of food and helps some people immensely. If you know you love chocolate, but you know it is going to cause a flare-up of symptoms – weigh the pros and cons. Is a chocolate chip cookie worth the pain and aggravation? Maybe. Is a handmade truffle of rich creamy dark granache from your best-friends sister’s mother in-law’s secret recipe worth it? Most likely. But make the choice, and make it consciously. Try not to eat things because it is in front of you.

Bring your own water to parties, it is amazing to me how often people only have unfiltered tap water available. If you are susceptible to sugar substitutes, be very careful with any sweet that you are unfamiliar with. They are putting sucralose in many processed snacks, even those that have sugar as a main ingredient. If you are eating out, ask about MSG in foods, and if you are eating at a salad bar, ask about vegetable washes. Even when you are trying to eat healthy, some of us have to be very careful about the additives on our food. Most places will have additive free menu items. Remember, if you have pelvic pain, avoid constipation and diarrhea, both of these will irritate the region, potentially causing a flare.

After the Party: First – during the party pay attention to how you are feeling. If you get stressed, start having pain, or realize that you have spent the entire evening in the line for the bathroom, it may be time to kiss the host and call it a night. At least you made an appearance, and some times that is all that is needed to fulfill a social obligation. When you get home, have the ice-packs or heating pad ready. Even if you think you are “OK” lay down with one (or two, or three) for a while. Put your feet up and breathe, quietly and calmly for a few minutes and try to relax. Give yourself a pat on the back for successful party negotiating!

Incontinence and socializing: Some of my patients suffer urinary incontinence, and even for those that have only occasional problems, Holiday diets and holiday schedules can predispose you to accidents – so if you think there may be problems:

• Wear dark clothes, leaks are less obvious.
• Skirts tend to be easier to “air out” than pants.
• Long shirts or sweaters that fall over your pants or a slim skirt are another good option.
  
• If you leak badly enough to need a change of clothes – dresses are not a good option.
• Bring an extra change of pants/skirt and underwear. The holidays are a perfect time for carrying around large bags of things you might need. An extra change of clothes discreetly left in the coat room in the bag that you brought the hostess gift or side dish in will never be discovered. And it is nice insurance
• If you typically use a pad, where a size bigger, and bring extras
• Even if you don’t wear protection, if there is a potential that you may eat acidic foods and laugh a lot (it’s a party, it’s supposed to be fun) you might want to consider a panti-liner.

Mind Games

“It’s mind games, and he’s already starting too early.” –

Kurt Busch

Chronic pain is a difficult burden. The effect on the lives of patients, families and loved ones is profound. Suffering a debilitating condition, especially one that is poorly understood, with treatments options whose success rates are measured in “percent improvement” in an individual, rather than “percent of cures” in a population, can be very stressful. Emotional, physical, mental, and financial stress all play a large part in the lives of those that are touched by these conditions.

I often recommend some sort of psychological counseling to my patients. I do this because I know that our minds and our relationships are often not equipped to handle the stresses that come with living in chronic pain. A good therapist will help you cope with the pain; a family counselor can help you and family members understand the effects of the condition, and work as a team to live full lives; a certified sex therapist can help you and your partner have a satisfying, fulfilling sex-life, despite your physical limitations.

With all of that said – I’m going to get on my soap-box and do a little rant about chronic pain, especially chronic pelvic pain, and how it is often viewed in the medical community.

Until very recently Vulvodynia (pain in the external female genitalia) was listed as a psychosomatic disorder. Somatization disorder and somatoform disorder are two disorders characterized by pain without pathological cause, or pain that presents as more intense than physical findings warrant. Both of these conditions are a sub category of hysteria, a psychological condition. On a historical note, hysteria literally means “wandering uterus.” It was often diagnosed in the Victorian era as a condition in which the “humor” or essence of the uterus wandered around in a women’s body, eventually reaching her mind, forcing her to act in a bizarre and decidedly undignified manner. There was no similar pathology in men.

Diagnoses of somatoform disorders are rare, but it is often suspected by doctors, especially by doctors who are not psychiatrists. It is a product of medical education. We want to be able to fix people. We believe that our education has equipped us with the tools to do that. When a patient presents in ways that we cannot figure out, or does not responds to treatments that we KNOW should work, it is pretty easy to blame the patient. In her article: “Sex, Lies, and Stereotypes: Women and Interstitial Cystitis,” in the Journal of Sexual Health, Denise C. Webster of the University of Colorado does an excellent job of pointing out the cultural differences between the patients that describe their symptoms, and the physicians that interpret them.

Here are some of the reasons that it is difficult to get physicians to take the very real pain that you are feeling seriously. Somatization disorders are characterized by eleven symptoms. More than two of these (with absence of obvious pathology) will send a red flag in some physicians that there might be a mental component to the problem: nausea, vomiting, fainting, headache, forgetfulness, dysmenorrheal (painful periods); abdominal pain; diarrhea/constipation; dyspareunia (painful intercourse); loss of sexual desire; fatigue. This is a big list, but it is a seriously inter related list. If you have interstitial cystitis (IC), chances are you have or have had some sort of pelvic floor dysfunction as part of your symptoms. A high percentage of IC patients also have migraine headaches, irritable bowel syndrome, and/or vulvodynia. If you have one or more of these conditions, and you start to tell your doctor your symptoms (and remember, he asked!) by the time you are half way into your list, you have probably ticked off three or four or more of the “red-flags” of somatoform disorder, and he has already quit listening to your symptoms, and is trying to figure out your dosage of anti-depressant or anti-anxiety drugs.

The good news is that many doctors are becoming more educated about chronic pain, and about chronic pelvic pain. But what do you do when your doctor is not listening, and you feel like no one believes that your pain is real?

If you feel like your physician is, in general, a good doctor and someone you want on your team, try to educate her. Schedule a time to see her when things are least busy, let the office know that you want a conference or consult, not just an appointment. Come prepared, and try to move the conversation quickly, look at this as a problem solving or brainstorming session, not a chance to vent or criticize previous encounters. Let her know up front that you admire her as a doctor, and appreciate her help; but, be very firm that you feel that she has not done enough in trying to diagnose the cause, or find a treatment that will help. Ask her what your options are, and if she feels she has tried all options, ask for a referral to someone else. If you have done your research, and know of other options that you think may help, bring them up. Your doctor will either explain why she has not used that with you (be sure it is an explanation that you understand), or will admit lack of information, and agree to research it for you. If your doctor dismisses your ideas out of hand, without explanation, it may be time to doctor shop.

Be clear that you know your body. Your pain is real, but not insurmountable. You need a team that will help you live well, choose them carefully.

Bladder Boot Camp

“There are no shortcuts to any place worth going.”

- Beverly Sills

Your bladder is a muscular sack with two tasks – to hold, and eliminate, urine. In a normally functioning bladder, that process works like this: Urine descends into the bladder from the kidney via the ureters. The sphincter muscle at the bottom of the bladder keeps the urine from escaping. When the bladder is full, the muscular lining is stretched, giving the bladder the urge to contract. If your bladder functions normally, you can ignore the urge until it is more convenient, or at least until you get to the bathroom. If you wait too long, the urge will become unbearable and you will have to void.

What is too long? Nurses are notorious for making it through an 8 or 10 hour day before relieving themselves. Months or years of this behavior is bound to cause problems. People with overactive bladder symptom (OBS), or interstitial cystitis (IC) can sometimes last only minutes before the urge becomes too strong (sometimes painful) and they must void. If a person tries to hold urine “too long” they will either lose control (become incontinent), or they will experience pain and spasm, and possibly begin to retain urine. Neither one of these scenarios is desirable.

A normal bladder habit is one in which the person voids 4-6x/day and 0-2x/night. This means in a 24 hour day, if you are awake for 16 hours, you should be going to the bathroom every 3 ½ to 4 hours. If you are one of those 8 to 10 hour people – do yourself a favor and take a lunch break - go to the bathroom, your bladder will thank you. For those of you that are going to the bathroom more often, things are a little more difficult.

There are many reasons that a person may have a small bladder capacity. The muscle may be tight (like a shortened hamstring that needs to be stretched) or prone to spasm. The smaller capacity may be habitual. For instance, if you are pregnant, you get very used to making bathroom runs “just in case” every where you are, by the end of the last trimester, chances are you don’t go past a bathroom without stopping in. After the baby is born, going to the bathroom very often has become a habit, and eventually your bladder thinks that it is normal to go every hour or half hour.

If the problem is not painful, and the bladder does not seem to spasm (which is typically painful), then bladder training may be very beneficial for you. There are several different ways to re-train your bladder. I like to start with the bladder diary, and assess the voiding patterns.

Sometimes the diary will show that someone is only having problems when they consume things that irritate the bladder. I have had people completely “cured” simply by eliminating certain things from their diet. Things to look out for:

· Anything with caffeine – coffee, tea, chocolate

· Alcohol, particularly red-wines

· Citrus – juice or fruit

· Tomatoes (even spaghetti or pizza sauce)

· Anything carbonated

· Hot, spicy things

· Vinegar

Ok – that’s the short list, but most of the “biggies” are on it. Look carefully and be sure that you understand the relationship between what goes in and how quickly things come out. As a side note, water will help to keep your urine dilute, so the urine is not as concentrated, and not as likely to irritate the bladder, so drinking water (a few sips every 10 minutes or so) is highly recommended.

Before I go into the actual training part, remember that if having a full bladder is painful, then bladder training is probably not appropriate for you. Interstitial Cystitis patients particularly, if the lining of your bladder is compromised (Hunner’s ulcers), please question anyone that asks you to start a retraining program to explain their rationale. Be very clear that they understand what the lining of your bladder looks like, and what they hope to accomplish by stretching it.

When I feel it is safe to start someone on a training program, I look at the bladder diary. If you are going on the average 20x/day, that is voiding approximately every ½hour to 45 minutes. I try to take the conservative view, and assume that you can probably make it on a 30-minute schedule. You start with the first void of the morning, then every 30 minutes you stop what you are doing, and go take a comfortable trip to the bathroom. If you have to go at 20 minutes, take a big breathe, find a diversion, and try to ignore it for the next 10. Sometimes if you contract and relax the pelvic floor muscles two or three times (quick flick Kegels), it will help to control the urge. If you do not void at 30 minute, wait until the next scheduled void before you try again. If you absolutely cannot wait until the scheduled void, note the time that you went, and time subsequent voids based on the new time.

This first phase gets you in control of your bladder. You may actually be going more frequently than you would normally, but it is controlled by your brain, not your bladder. If this schedule is managed within a few days, we change the void schedule to 45 minutes. Again, beginning with the first void in the morning, and attempting to void every 45 minutes. After this we add 15 minutes about once a week. Sometimes we have to play with it a little, sometimes 15 minutes is too much to add; sometimes it takes longer than a week to master the new schedule.

Patients with pelvic floor dysfunction have to be extremely cautious when starting a training schedule. The “quick flick” method of controlling urge can have devastating effects on your ability to relax those muscles. “Holding” for too long can cause spasm in the pelvic floor, increased pain, and potential problems with retention. Although many medical practitioners are perfectly capable of establishing and following a bladder training program; for patients with pelvic floor problems I think that it is vital that you are being followed by a trained physical therapist with experience in treating the pelvic floor.

It is very important to pay attention to when it is difficult, and what is going on in your head when you have more frequency. Do you have a work bladder and a home bladder? Which one is easier to play with? Do you need to bring your home bladder to work with you? Stress can play a huge role in bladder activity, and you need to be able to find that place in you where you feel most relaxed, even if the environment is difficult.

Good luck, and safe training!

Lymphedema

In honor of National Breast Cancer Awareness month, I have asked a friend and colleague to write a post about Lymphedema and the importance of Lymphatic Drainage. Kathleen Boyle, PT, LMT, has recently joined me at Slainte Physical Therapy. She is providing an unique blend of Yoga, Physical Therapy, and manual techniques to our clients. We are delighted to have her with us.
Thanks, Kat!

Lymphedema is a swelling in the tissue due to a build up of proteins in the tissue. The lymph system is designed to move bacteria, proteins, and other large molecules from the tissues to the lymph glands where they can be broken down. When a person has a deficit in the lymph system due to scar tissue from injury, surgery, or radiation, or due to removal of lymph nodes or a congenital lack of lymphatic vessels, then these proteins can build up in the tissue and attract water. This can result in increasing swelling over time. This can occur in any part of the body.

One group at high risk for this disorder is women who have undergone surgery and/or radiation for breast cancer. Frequently the treatment can involve removal or radiation of lymph tissue. Many people do not know that after such surgery there are things that can be done to help prevent the onset of lymphedema.

For instance, the pressure changes involved in flying on an airplane can initiate this disorder. A woman who has had breast cancer surgery with removal of lymph nodes or radiation should obtain a compression sleeve to wear any time she is flying. A doctor's prescription is required to obtain the garment. Also, the arm at risk for lymphedema should not be lifting heavy things, like a big suitcase, heavy weights at the gym, or even a heavy purse. Better to carry the purse on the other arm. Care needs to be taken with the hand and arm to avoid sunburn, cuts, and even mosquito bites. Wear gloves to garden and sunscreen outside.

If there has been any damage to lymph nodes or the lymph system of a breast then the arm on that side is at risk. The goal is to avoid any added stress on the lymphatic system for that limb to help avoid development of the disorder. However, if ANY swelling is noted in the arm seek treatment as soon as possible to increase the effectiveness of the treatment. Even if swelling has been present for months or even years, treatment by a trained physical therapist is still very helpful and can greatly improve quality of life.

Treatment has been available in Europe for many years, and over the last few years many more physical therapists in this country have been trained to properly treat this condition. Check to see if your regular therapist has been certified by a reputable organization to treat lymphedema, and if not, seek out a trained therapist. Treatment can include a specialized form of massage to stimulate the function of the lymph system, maximize the function of alternative lymph pathways to drain the area of proteins and fluid. The massage should be accompanied by a wrapping with specific short stretch bandages to provide compression overnight to continue to drain the fluid. These must be applied by a trained physical or occupational therapist to avoid over compression and inflammation. There are specific exercises that can be done with the bandages on. After two to three weeks of treatment many patients will have a reduction in limb size to very close to the size of the unaffected limb. Most of the time a professionally fitted compression garment must be worn daily to maintain the limb in the reduced size, although with very early treatment sometimes a garment will not be needed.

Many patients who develop this condition do not know what it is and many health care practitioners of all types are likewise uninformed. If you have been told in the past that "there is no treatment", or that "you must just live with it", this is incorrect. Please seek out a trained physical therapist. If you have been given a pump to reduce the limb size on a daily basis, please be aware that a compression pump can further damage the lymphatic system if the pressure is too high in any one area and leave you wedded to the pump for life. Seek out a trained physical therapist to assist you.

Haven't Got a Chew

Temporomandibular Joint Dysfunction (TMJ, or, more accurately, TMD) is a syndrome that affects approximately 10,000,000 people in the United States. TMD is a poorly understood collection of symptoms that seem to originate from the temporomandibular (jaw) joint. For years it was bounced around like a hot potato between the dental and medical communities; in some ways, this still happens.

The presentation of symptoms does not necessarily include pain in the jaw, or even the classics: “popping” or “clicking” in the joint. This means that people who suffer from TMJ pain often are undiagnosed, or misdiagnosed. The most common symptom that is not directly related to joint dysfunction, is headache. TMD headaches can be ones sided (mimicking migraines); or two sided (complex migraines, tension headaches, or: we don’t know what is going on, and we need to run many inconclusive and scary tests to rule out the really bad stuff). These headaches are tension headaches, caused from clenching or grinding the teeth, building tension in the temporalis muscles (they are fan shaped muscles on your head; around, above and behind your ears). Tension headaches beginning at the base of your skull can contribute to TMD, and TMD can make these types of headaches worse. If you are prone to migraines, a TMD related tension headache can trigger a migraine. So if your major symptom is headache – you might want to discuss TMJ syndrome with your doctor or dentist. In an article from the Boston Globe: “If Doctors Can’t Help Your Headaches – Should You See a Dentist?” you will read about the benefits of seeking a dentist for help with chronic headaches.

How does Physical Therapy help? Well, in my practice, number one is: POSTURE. If we can’t fix your posture, everything else is palliative. There are many things we do to loosen the muscles, including electrical stimulation, ultrasound, heat, ice, and massage (massage is great, and proven effective for pain relief in TMJ). I have an earlier post on trigger points, which discusses how trigger points work, and mentions the benefits in the treatment of TMD. Trigger Trauma. Still; posture is key. By improving your posture, you take the stress off of the joints; not just off your jaw, it also relieves the stress on your neck and shoulders. Posture training and appropriate exercise also gives you more control of your health.

I was diagnosed with TMD 17 years ago. I am relatively symptom free unless I do something that I know is going to cause me pain, or throw me out of good posture – like wearing high heels. I do it very rarely, for very brief periods of time, and I know that I will pay, but it is a decision that I get to make. I also am in control of my diet. I have not chewed gum in 12 years – the pain that I will deal with for days after is not worth it to me. Carmel, on the other hand, is occasionally worth three days of ice-packs and begging my staff to treat me.

Stress (I mentioned that these are tension headaches, right?) is some what under our control. If you have a lot of stress and tension in your life, you have to get a handle on it. Learn to meditate, and make it a priority. If you are unable control your reactions to the stressors in your life (and yes, keeping your mouth closed, and pretending that things don’t bother you is a reaction,– clenching, remember?), please seek counseling. This is hugely important. Life happens, how you deal with it will determine how negatively it affects you. There is some basic information, and tips on how to deal with TMJ pain at my web-site: Slainte Physical Therapy .

There are factors that affect the joint that we don’t have a lot of control over. Changes in atmospheric pressure can worsen symptoms, especially if your temporamandibular joint has become arthritic. I live in Florida, hurricane season is hard on my jaw patients, and on me. Between the stress involved with the season, and the rapid weather changes, my office gets very busy. At that point it is just symptom relief, and trying to maintain as much of a positive attitude as possible. At least weather is not permanent.

EndoKnowledge

I would like to acknowledge Niva Herzig, MSPT of Marathon Physical Therapy in Boston, and Amy Stein of Beyond Basics Physical Therapy in New York, for their recent article in “Visions,” the professional newsletter of The International Pelvic Pain Society. The article is titled “Physical Therapy and the Treatment of Endometriosis.” Full text of the article can be viewed at www.pelvicpain.org. Click on “provider resources” and choose “read the pelvic pain newsletter” from the pull down menu.

The authors explain in detail how physical therapy can benefit women suffering with the pain of endometriosis. The relationship between pelvic floor muscles, abdominal muscles, pelvic organs and connective tissue can create patterns of pain that can be relieved by manual physical therapy, proper stretching and exercise, and using relaxation techniques. Often, the surgical procedures used to eliminate the endometrial lesions result in scarring. Scar tissue can cause pain, trigger points, and poor movement patterns. Physical therapy can help with all of this.

Endometriosis is primarily a medical condition, characterized by the appearance of endometrial tissue (the tissue that lines the inside of your uterus) around (or in) the tissue of other abdominal organs. This tissue is hormone sensitive, and reacts to the ebb and flow of estrogen that happens during a normal menstrual cycle. This is why endometriosis pain is most common just before or during your period. Some women have endometriosis pain at other times in their cycle, and some are most sensitive when they use or stretch the effected tissues. Endometriosis can occur in women at any age, and is a common cause of extremely painful periods in teen-agers and young women.

I recommend that any woman with painful periods discuss them with her gynecologist. I also feel it is important to track your pain patterns for a while; it helps in the discussion with your doctor, and will help you see patterns that might not have been obvious before. Many pain diaries can be found on the internet. One I found is a Weekly Pain Diary. It is helpful if you think that your pain may be associated with your menstrual cycle. The one shown here has a place at the bottom for comments or "other" – use this area to note what day you started menstruating, and how heavy the flow is during the week.

If you are diagnosed with endometriosis, discuss the benefits of physical therapy with your doctor, but remember that PT is most beneficial as part of a multidisciplinary team. Unless the proliferation of tissue and reactivity to hormones is addressed, you will probably continue to have pain, regardless of the skill of your physical therapist. Let me know how you are doing, and if you have had success with PT, or have information that would benefit others, please post a comment.

Finding a Physical Therapist

Apparently I am not the only one looking for a good physical therapist.

I have gotten several e-mails from people in different parts of the country looking for PT’s that treat pelvic floor dysfunction. The bad news is that there aren’t a lot of us out there. The good news is, there is a growing trend in physical therapy to make these conditions part of the entry level curriculum (inspiring young therapists); and, the APTA (American Physical Therapy Association) has just authorized a clinical specialty in Women’s Health, which will include pelvic floor dysfunctions. The test won’t be available until 2008, but how exciting that this area is progressing so fast.

How do you find someone now?
Start with your support groups. The Interstitial Cystitis Network; Interstitial Cystitis Association; and National Vulvodynia Association; all have referral resources, some you have to e-mail, others post the information on their sites.

The Section on Women’s Health (SoWH) of the APTA has a member directory. You will need to go to the consumer section, hit the pull down and click on “locate a therapist.” This will give you a regional map, in some cases broken down by state. Click on a name in your area. This will give you an e-mail address to the regional or state coordinator. E-mail this person with a specific question, and they should get back to you with some answers. A few cautions – not all SoWH members work with pelvic floor dysfunctions. Some are interested students, some work primarily with incontinence, or obstetrics, or osteoporosis, etc. The regional/state director should be able to match you up with someone that will fit your needs, but they do not necessarily know the specifics on each of their members.

Of course, there are really good therapists that are not on any of these lists. To be on these lists you have to provide information, or in some cases be a paying member, and not all great therapists are good marketers.

Now what? You either have a list of therapists, or you have a phone book, but you still are not sure where to go. So – go shopping. This is probably going to be a pretty long-term relationship, and you need as much information as possible before you get started.

1st - If you are cold-calling out of a phone book, the front office person should know if they do “pelvic floor therapy.” If they do, ask to speak to the therapist that specializes in pfd. You may have to wait a few days for a call back.

2nd – When talking to the therapist, go over these points:

• If you are male, or calling about a child, make sure that the therapist is comfortable (i.e. experienced) with that demographic


• If you have constraints such as traveling a great distance, having to pay out of pocket beyond your means, or limited time availability, ask if the therapist is willing to teach you to self-treat, and work within your availability/budget.


• Ask if they do biofeedback. If the answer is yes, ask if they do “down-training.” Not all therapists do a lot of biofeedback, it’s a professional preference. If they do not, it does not necessarily mean you will get sub-standard care. If they do biofeedback and you have a tight, spasming, painful, or uncoordinated pelvic floor, you want them to do “down-training”.


• How many of their patients have chronic pelvic pain? How many have pelvic floor dysfunction? These questions are redundant, but some times they trigger different thought processes in the PT.


• Do you do internal pelvic floor work? How do you determine if it is appropriate or necessary?


• Do you treat trigger points? Will you teach me to self-treat? (only ask this question if you want to be responsible for that part of your care)


• Will I have exercises and activities that I do at home? (This should be yes)


• If treatment is making my symptoms worse – how will you determine that it is time to try something new?

Once you have found the right therapist, set up the appointment, but if at all possible do a "drive by" before your appointment. Ask if there is paperwork to fill out, and if it would be OK to pick it up in advance. For one, this will help eliminate any anxiety about getting there on time, knowing where to park, etc. Mostly, it will give you a feel for the office. Are the people friendly, is it clean and pleasant? Will you be able to relax and concentrate on getting better? In short - is it a good fit for you?

If any of you find really good therapists out there, let me know, I am trying to build a database. Right now I am looking for therapists in Madison, WI; Kennewick, WA; and Charlottesville, VA.

nICE & HOT

Heat or Ice?
It’s a question I get a lot, and the answer is always the same: “That depends.”

They are both simple thermal modalities that have surprisingly profound effects on your body’s tissue. Both will (sometimes) reduce spasm. Both will (sometimes) quiet hyperactive nerves. Both will (sometimes) relieve pain. Heat may make an inflammatory response worse. Ice will not. Heat will never give you frostbite. Therapeutically applied ice won’t, either; but I’m trying to be fair.

Heat increases blood flow to the area. This opens the capillaries (the smallest part of your blood vessels, where oxygen is actually delivered to the cell). This increased blood flow and opening of the capillaries is what gives your skin that pinkish color under the heat pack. As the tissue warms up, you start to sweat, so your skin is doing its job of keeping you cool. There is a reflex message to the underlying tissues to relax, and let go. Sometimes your body is not happy about the surge of blood flow, and you get a rebound of increased inflammation and pain after the soothing effects wear off. If you are one of those people that says: “heat feels good, but about an hour later, I am in worse pain,” then heat may not be your best option.

Ice increases blood flow, also; but not right away. First the capillaries contract (get smaller) and restrict the blood flow to the tissue. As your tissue become accustomed to the cold, the vessels slowly expand, allowing more blood into the area, trying to warm things back up. This is why if you take the ice pack off in the first few minutes, the skin is white (constricting), and if you wait ten minutes or so, the skin is red (expanding). In the meantime, the reflexes are telling the nerves to calm down, and the muscles are not getting all of that aggravating input from the hyperactive nerves, so they are starting to loosen up. The bad news is that some people are very sensitive to ice. If you are someone that has a really strong, painful reaction to ice; try heat.

Ice is not so bad, in fact I always tell my patients to try it, and it may become your new best friend. (I’m not supposed to have favorites, but I love Ice). It’s a tricky friend, and there are some things to be aware of:
The sensations from ice application come in stages, and if you are aware of them, it won’t be so scary:

1. Cold – duh! It’s an ice pack


2. Burning – some people miss this stage, but for others it can literally feel like you lit a fire under the pack


3. Achy – really achy. There are lucky people that miss this stage. I always feel like I have a giant toothache wherever the ice is. Having someone around to listen to you whine during this phase is always helpful.


4. Numb – Yay! Success! This is the point right?

Now – the whole process should take about 10-15 minutes. If after 20 minutes you have worsening burning or aching – give it up, it might not be the best thing for you.

If the tissues are really constricted, and the object is to increase blood flow, I like to use contrasting heat/cold. Heat for 3-5 minutes. Ice for 3-5 minutes. Repeat for 3-5 cycles. End with ice, to avoid increasing inflammation.

Safety considerations for heat and ice:

• Never fall asleep on a heat pack. I have seen some nasty burns.


• Moist heat is more effective than dry, but can feel comfortable even when it is too hot. If it is AT ALL uncomfortable, get extra padding, or turn it down if you are using an electric pack. (same with dry heat)


• Ice packs are not designed to be constant wear. Take it off after 20 minutes. Put it on every hour if you feel like it, but give your tissue a break in between.


• When heating things in a microwave – remember they are still cooking when you take them out. Test the heat with the back of your hand before applying the pack, and remember that “a little too hot” is still too hot.

What to do with all of this information?
Experiment.

Muscle spasms and cramping tend to respond really well to heat, but I have a lot of patients that prefer ice. Inflammation (swelling, redness, painful to touch) tends to respond well to cold. If you can’t tolerate cold, try cool – it is not quite as effective, but you won’t go through the burning, achy, painful thing either.

There is a wide variety of shapes and sizes of heat and cold packs out there. Shop and compare prices, you can search the internet, or check out your local medical supply or pharmacy. I always go to IC Relief, just because I know the owner, and she is really knowledgeable about Interstitial Cystitis, Pelvic Floor Dysfunction, and Vulvodynia. I especially like the contour style pack (also called “cervical pack” on some sites) because you can use it bikini style across the lower abdomen and bladder, or lay it long ways from the sacrum to the pubic bone, cooling (or heating) the external genitals. For many of my patients, I will put them on a large pack on the low back, a contour over the bladder, and another one between the legs against the pelvic floor.

Internal heat and cold:
This is important for pelvic floor patients. Many of my patients have a much more successful session if they are able to use some sort of internal cooling device after a session. Again – I love the EZ-Fit from the IC Relief people. Read the safety considerations carefully, with this or any product you use internally. Remember that the rectum and vagina are lined with mucous membranes; there are more blood vessels, and less protection than in other areas of the body. Use cool and warm, rather than hot or cold. Moderately warm to your hand will be too hot internally. If you use ice internally, it needs to be something small enough that it melts or warms up fairly quickly (5 minutes of cold, up to 10 minutes of cool). Contrast hot/cold is great for the pelvic floor.

I have patients that use a frozen tampon – be careful if you are sensitive to bleach or the chemicals sometimes used in them.
I tried the frozen condom – too cold, too hard, too big.
The finger of a rubber glove (kitchen variety) filled with water and frozen may work.
Please let me know if you have other ideas, and post them as comments. I know everyone would like to read your ideas!

PNE Paradox

Pudendal Nerve Entrapment (PNE) is diagnosed primarily on the patient’s symptoms.

· Persistent pain in the specific nerve distribution: genital area; around the anus tail-bone sometimes into the gluteal (buttock) muscles

· Pain may be described as: dull, burning, tearing, sharp, aching, or “pressure”

· Pain is much worse with sitting, can be all or partially relieved with standing, significantly relieved with sitting on a toilet seat, or any seat with a cutout that takes pressure off the pudendal nerve.

Patients with these symptoms are often misdiagnosed with chronic prostatits (in the male) and vulvodynia or vestibulitis (in women). In both sexes these symptoms may get you a diagnosis of Interstitial Cystitis (IC) or Chronic Pelvic Pain Syndrome (CPPS). There is a really great article in Urology Times by Penny Allen that discusses these differential diagnoses. The problem with diagnosing all of these conditions is that one does not necessarily rule out the other. You may have PNE, and also have IC. Once you are positively diagnosed with one, your healthcare professionals may stop looking for other conditions that contribute to your pain. Getting the diagnosed condition under control before looking for other factors may be the best course of action; but, if you are showing significant improvement with some symptoms, and other symptoms are no better (or worse), it is time to start digging deeper.

Your pudendal nerve exits your sacrum and travels between two ligaments and your piriformis muscle through a half circle opening (called Adcock’s canal) in your pelvis down to the area it innervates around your genitals. Realize this explanation is very simplified, and I have not figured out how to put graphics onto this blog. There are great images all over the net – follow this link to an article with a nice little schematic and a great picture of the nerve as it travels through the pelvis. (PNE pics) The primary site of entrapment is in Adcock’s canal, and many treatments are focused on this area. Nerve injections are done here; surgical releases are performed at Adcock’s canal, particularly if calcium deposits are found.

Sometimes injections and surgical treatments do not work. This is because there are other ways that the nerve can become irritated, and other ways that pain may show up in your genital and anal area. Trigger points are something I post about a lot. Many trigger points (TP’s), will refer to the external genitals. Common TP’s that I look for are in the adductor (inner thigh) muscles, obdurator internus (which can be accessed externally, or through the vagina), and muscles of the pelvic floor, which are accessed through the rectum or vagina. Often stretching the piriformis muscle and the ligaments involved in PNE will take some of the pressure off the nerve. There is some evidence that hyper-irritation of abdominal organs can cause the PNE to become over active, irritated and painful.

Many physicians that are well versed in treating PNE have begun trying conservative, non-invasive treatments before surgical interventions or injection therapy. Sometimes, if the symptoms are very severe, injections are still the best first-line treatment. If you have these symptoms and your doctor recommends surgery right away, or after only trying injection therapy, ask about physical therapy and other non-invasive treatments first. And Always, Always, get a second opinion before undergoing a surgical procedure, even if your doctor is the best doctor in the field.

Weiss J; Prendergast S; Pitfalls in the Effective Diagnosis and Treatment of Pudendal Nerve Entrapment. The International Pelvic Pain Society. Vision.

Antolak S; Pudendal Neuralgia. Internatioan Pelvic Pain Society. Symposium. Banff, AB, CA. 2003

Language Barrier

“Incomprehensible jargon is the hallmark of a profession.” –
Kingman Brewster

We, in the medical field, use a lot of specific medical terms. This allows precision in professional communication, and helps us avoid confusion. For instance – when you tell your doctor or physical therapist that your shoulder hurts, we really don’t know what you are talking about. For you, “shoulder” can mean the area between your neck and your shoulder, the upper part of your arm, the muscles around your shoulder blade, or the ball and socket joint that moves your arm; for me, it’s the joint, and the structures that act on the joint. When you say “shoulder,” I ask you to point. This is the only way for me to be sure we are talking about the same thing.

Sometimes confusion happens when medical people try to use your terminology to explain things, thinking that they are helping you, then you go see a new health professional, full of everything your doctor said, and the explanation you give doesn’t fit into our language.

It gets worse. Sometimes we use terms in one branch of medicine that have completely different meanings to someone in another specialty. Sometimes a new term will pop-up to explain a phenomenon that is getting more attention. Whole specialty areas can be established around this “new” health concern, and the term can be used by medical professionals for years before it is fully defined. Often, by the time a standard definition is established, the professionals that have been using the term are either so used to it having the meaning they assign (which may be very specific in their head, but have little to do with what other professionals understand that term to mean); or, they are unaware that there has been a standardization of the term.

This has happened with the term “Pelvic Floor Dysfunction.” There is a specific definition, and I am just as guilty as others about using my own version of the term.

Here is the real definition, as established by the International Continence Society, and published in the Journal of Neurology and Urodynamics in 2002:

• "Pelvic Floor Muscle Dysfunction can be qualitatively defined by the tone at rest and the strength of voluntary or reflex contraction as strong, weak or absent or by a validated grading system. A pelvic muscle contraction may be assessed by visual inspection, by palpation, electromyography, or perinometry. Factors to be assessed include strength, duration, displacement and repeatability."

OK – I said medical terms are specific, I didn’t say they were clear. Pelvic floor muscle dysfunction (PFD) is any abnormal quality in the muscle that affects:

• resting tone (spasm, or low-tone)


• strength (weak muscles that indicate stress incontinence are symptoms of PFD)


• duration of contraction (how long can you hold it?)


• displacement (does the pelvic floor lift, bulge, or stay in the same position with contraction?)


• repeatability (after contraction, can you relax it? Can you contract it again to the same level?).

I tend to use the phrase to indicate spasming muscles, or muscles that can’t relax properly. I am aware that weakness and low tone are forms of PFD, but I lean towards labeling the problem differently when these are the factors.

What is my point?
When your doctor or therapist tells you that you do, or do not, have PFD, ask her to be specific in her definition. Pain in the pelvic floor is often, but not always, and indicator of muscle spasm. Trigger points are active in muscle that are tight or spasmed, so if you have trigger points in the pelvic floor muscles, regardless of where they refer, you have PFD. If your muscles are weak, you have PFD. If the muscles are in spasm, you have PFD. If you contract, and the pelvic floor does not lift, you have PFD. If you can't hold the contraction, you have PFD. If you can't relax after contraction, you have PFD. If you can't repeat the contraction, you have PFD. It’s a big list.

As a physical therapist, I think that everyone with PFD, regardless of their symptoms, can benefit from pelvic floor therapy. It is a muscular dysfunction, and that’s what PT’s do. Your doctor may have different ideas, and may feel that different drugs or therapies are indicated for different PFD presentations. You certainly wouldn’t want him to give you a muscle relaxor for PFD if your presentation is weak, low tone muscles, would you? So – ask questions, and be aware that while you may both be speaking English, it is a different dialect, and patience (on both sides) is important.

Dear Diary -

When someone calls my office to set up an appointment for any condition remotely related to pelvic floor problems, I ask them to track behavior in a bladder diary for at least 3 days before the initial consult. I require this of patients with incontinence, pelvic pain, interstitial cystitis, vulvodynia, and urinary frequency. Often the response I get is, “Oh – I don’t need to do that, I don’t leak, and I know how often I go to the bathroom.” This is really good information – but; a bladder diary can tell me so much more.

Different diaries allow for recording of different data. My favorite is from the NIDDK (The National Institute of Diabetes and Digestive and Kidney Diseases). Click here to download a copy in pdf format: Bladder Diary. This diary breaks the day up hourly, with separate sheets for night and day. Each hour you are asked to record what you drank, and how much; how often you urinated, and how much; if you had an accidental leak; if you had a strong urge to urinate; and what activity you were involved in at the time. I know – you think you are going to spend your life filling out a ridiculous form, you already know you go too little, too often, and you don’t drink enough water. But now we have a pattern, and this information will tell me a lot about when you have the most frequency, and maybe some information about why.

For instance: some nights you only have to get up once or twice to urinate, some nights it’s five. Most people are aware that they occasionally have more nocturia (night-time urination), but with a bladder diary we may find out that it happens on nights that they have a glass of wine or soda with dinner. Sometimes the patterns aren’t as easy to see: once a bladder diary showed me that a patient went to the bathroom as often as 4 times in one hour on Monday afternoons – the day her mother-in-law came to visit the grand children. Do you think stress may have been a factor?

Usually the diary is a tool I use to further explore problem areas with the patient. Sometime, just the act of writing things down lets the patient see patterns that they were missing. I had someone schedule for an evaluation because she had severe urge incontinence. While doing her homework before the appointment, she realized that she lost control as she got to her front door after work everyday. She also realized that she worked an 8 hour day without urinating – not even once. She disciplined herself to take potty breaks during the day, and called me to cancel her appointments – complete resolution of the problem.

Even if your healthcare provider has not asked for a bladder diary, it might be a good idea to start one. I only ask for 3 days because I can usually expect some level of compliance in that amount of time; a week would be better, a month would be optimal. Some additional things that you may want to track, especially if this is a problem you have had for a long time, or if you are seeing a new doctor, or just looking for more comprehensive information to give your health care team:

• Bowell patterns. Are you frequently constipated? If so, when? And does it affect your urinary frequency, urgency, or incontinence?


• Menstrual patterns. Do you have more symptoms before, during, or after your period?


• Diet. Some foods irritate the bladder, and most diaries only consider fluids.


• Stress patterns. What is going on in your environment, and in your head? Does any of this have a bearing on your symptoms?

Don’t just write down the bad things; track the simple pleasures in your life. You may find that when you have a really good day – your bladder has a good day, too!

Let's go! Really go!

"The time to relax is when you don't have time for it."
- Sydney J. Harris (1917-1986)

When you have pelvic floor dysfunction, one of the worst things you can do is strain while sitting on the toilet. Normal bladder function includes relaxing the pelvic floor, which sends a message to the bladder muscle (detrussor) to squeeze. When you strain during urination, to force things past the tight, spasming pelvic floor, it confuses the system. Straining during a bowel movement also worsens pelvic floor problems.

I know - you have a life, and sitting on the toilet for 10 minutes every 1/2 hour, hoping to pee, can put a huge rift in that life. As physical therapists, we work on relaxing the pelvic floor muscles (PFM) by down-training with surface emg (biofeedback), I touched on this a little more in the "To Kegel or NOT to Kegel" post. We use manual techniques (see "Trigger Trauma"); we teach you exercises to relax the muscles surrounding the pelvis and pelvic floor; most therapists will either teach some sort of meditation, visualization or "physiological quieting" techniques, or refer you to someone that can.

So here you are, about to learn all of these really great techniques that you know will help you, and you still have to go to the bathroom. NOW! not later, after you have hypnotized your PFM into submission. Now! while your baby is screaming and the phone is ringing and you still haven't loaded the dishwasher or folded the laundry, and what is that weird noise coming out of the cat?

There are a few things you can do while you are sitting there:

• 1st - Breathe! Just take a couple of deep breathes when you first sit down. If you know any of those visualization techniques from your therapist or somewhere else, this is the time to use them.
• Get a stool. A little foot stool to keep in the bathroom to put your feet on while sitting on the toilet. This brings your knees up, similar to a squatting position, relaxing the PFM. This works great - helps with constipation, too.
  
• Passive voiding. This actually works better for people that have trouble emptying, but it can work if the problem is initiating a void: place your fingers just above your pubic bone while sitting up right on the toilet. Press in with your fingers, and lean your body forward over your knees.
• Eat right, with lots of fiber. Avoiding constipation will help to keep the pelvic floor in good shape, and help you avoid the habit of straining.

If any of you have any other tips and ideas - please share. I love comments!

That's so......... Stimulating!

Electrical stimulation in all of its many forms is widely used in physical therapy today. Every therapist has their favorites: favorite machine; favorite treatment parameters; and favorite conditions to treat with it. For this reason, I am not even going to pretend that this post will be a comprehensive guide for you. I will discuss a few standard uses of electrical stimulation with pelvic floor and/or bladder control problems, but be aware that your therapist may be using something completely new and/or cutting edge.

First, let's talk about delivery systems. The Medtronic Interstim device is implanted into your body (by a surgeon, under anesthesia) with a wire that connects directly to your sacral nerve. I’m not going to go into any more detail – that’s a whole different blog subject. There are internal probes that can be used rectally or vaginally. There are superficial pads; these used to be carbon, with sticky gel that we taped or strapped on to people, these days I think most places use self-adhering pads that are patient specific. (That means multiple uses, but only one set per patient). There are point probes, hand held by the therapist while specific spots are stimulated for a short amount of time.

I rarely use the internal probes for electrical stimulation, because for many of my patients, they are cost prohibitive. When I leave it up to my patients, they are often very happy with the disposable pad electrodes, for pain control and calming the detrussor (bladder muscle). If I was treating more incontinence, where strength is an issue, I would use internal probes more often for stimulating the pelvic floor muscles, as it is often difficult for the patient to build the force needed for strengthening. There are some very good home devices out there that use vaginal or rectal probes; all of them require a physician’s prescription.

Reasons to use electrical stimulation:

• Strengthening – really important with weakness of the pelvic floor resulting in incontinence. This is done internally with a probe; the stimulation is turned up until you feel the muscles contract. The therapist will set the times for contraction (on) and relaxation (off).


• Calming the bladder – This works really well for controlling urge incontinence, frequency and urge/frequency disorders. It can be done with pads (placed above the pubis and at the sacrum); internal probes; or Interstim. I am not sure if you actually feel the Interstim – I never thought to ask one of my patients. (Let me know if you are using it, or have used it). With probes and pads, you will feel the electricity like a rhythmic tapping, which will last for the duration of the treatment.

Pain control – This is where we, as therapists, get really creative.

• For vulvodynia, pudendal neuralgia, or vestibulitis I often do something called Interferential electrical stimulation. This requires four pads, out of two channels, the current from each channel interferes with the other. So – If I set the pads up so Channel “A” goes from just above the pubic bone on the Right, to the Left adductor (inner thigh) muscle, and channel “B” does the opposite, then the majority of the electricity is centered on the vestibule. You will typically feel the electricity at the pads, but the treatment is more central. We can do this treatment with different pad placements, but the currents must cross to work properly.


• Constant, pulsed, burst, or modulated waveform settings using TENS (transcutaneous electrical stimulation – often sent home with the patient, looks like a beeper with wires). Each of these waveforms feels a little different, your therapist (hopefully with your input) will make the best decision for you.


• Constant setting with an internal probe.


• Micro-stimulation – I use hand held probes, there are also pad placements for this type of electricity. This is very low-level stim, often sub-threshold, or so minimal you barely feel it. I use it with a combination of acupuncture points, and common trigger point patterns that affect the pelvic floor and bladder.

There are some pain control protocols out there that include stimulating the pelvic floor muscle to fatigue, creating a forced relaxation, that will hopefully carry-over to everyday life. I have never used this method. It hasn’t worked for me with neck, back or shoulder muscles, I have not been willing to try it with the pelvic floor.

I could probably do a 3 hour course on electrical stimulation for pelvic pain syndromes, without even getting into the principals of electricity. This is a very small overview of what is out there. If your doctor or therapist is using something that you don’t understand, ASK! There should be some sort of rationale behind whatever it is.

TMJ Quick Tip

Once in a while I will throw in bits of information that have nothing to do with pelvic floor problems. Tempormandibular Joint Disorder (TMJ, TMD, or TMJD) is another specialty area of mine.

If you have pain or popping in the joint when you yawn, try this:
Put the tip of your tongue on the roof of your mouth, and bend your neck down, chin towards your chest, before you yawn. This limits the opening, but still allows you to get that satisfying oxygen dose your body craves.

"To Kegel, or NOT to Kegel..."

That is the question.

In 1948 Dr. Andrew Kegel noted that the “passage of the fetal head through the vagina during delivery is inevitably attended by muscle injury.” In other words, delivering babies is hard on the pelvic floor muscles. At the time, Dr. Kegel was convinced that having babies caused the lack of muscle tone that led to incontinence. Then he realized that women often became incontinent, even if they never had babies. So what’s going on here?

Well, the theory I like best has to do with cultural norms. We, like most western, industrial nations, use toilets; and sit in chairs when eating; and sit in chairs while working; and socializing. We are a sitting culture. Squatting cultures have very little problems with female incontinence. In pre-WWII Japan, the condition was very rare. Now, as our toileting and sitting habits have been widely adopted by Japanese society, the rate of incontinence there is equal to our own. Interesting, huh? The pelvic floor muscles activate in rising from a full squat, so they are naturally exercised in these cultures just by normal activities of daily living. Since I don’t think our end of the world is going to give up toilets – face it, I’m not even going to give up mine – then we have to come up with another way to keep these muscles strong and healthy.

Dr. Kegel studied the muscle integrity of thousands of women. He developed a system of strengthening these muscles that was three-fold:

• Isolate. Find the muscle, contract it- and try not to let the rest of the body kick in. He had women isolate the muscle by inserting a finger into the vagina, and squeezing around it.


• Resistance. He felt having something to contract against was important. A finger, a penis, a perinometer.


• Feedback. This is where the perinometer comes in. He developed this device so that the women could see how much she was contracting. A pneumatic device (kind of like a partially filled balloon) was inserted into the vagina. As the women contracted the muscles, the pressure in the balloon would make the gauge on the end move. It was the same sort of dial they use on the end of a blood pressure cuff. The woman got instant feedback as to the strength of her contractions.

This probably does not sound a thing like the instructions you were given in your doctor’s office, or the last women’s magazine you read. Mainstream civilization kept the concepts of Dr. Kegel alive, but we lost a lot in translation over the years.

There are many products on the market that provide resistance and feed back: The PMTx, which is very similar to Dr. Kegel's device; MySelf is more high tech, and has an easy to read screen, but; I’m cautious about giving this to my patients with pelvic floor dysfunction, because you lose the visual feedback during the relaxation phase, and the contract/relax timing is cued by the device, so if I want you to relax for longer than you contract, you have to really think about it.

There are lots of products out there that give resistance, without feedback. Vaginal cone weights are common (the link is just one of many examples). I never give these unless the patient is critically weak, and I have evaluated her on EMG (electromyogram) and I am positive that there are no coordination or spasm issues with the pelvic floor. There are also some pretty scary devices out there; some of them show up on the Google ads on this blog. Did I mention that I don’t screen or condone the banner ads that show up here?

So – what about pelvic floor patients? Should they do Kegels (the modified, common ones that every body teaches now), or not? The answer is: maybe.

Before I give strengthening exercise of any kind, I make sure that the person has good control of the muscle. You should be able to isolate the muscle, contract it, and most importantly, relax it. This is true of just about any muscle in the body, not just the pelvic floor muscles (PFM). I use a lot of EMG (biofeedback) training with my patients. It is a very good visual and audio system for learning the difference between a relaxed PFM and a tight one. If the person does not have good control while hooked up to the machine, I will not recommend a series of activities that involve regular contraction of the PFM for a home program. When I am absolutely positive that my patient can tell when her PFM is tight, and can consciously get it to relax and stay relaxed, then we are ready for some strengthening activity. Even at this point I am very cautious. Most of my patients are given programs that include relaxation times that are twice as long as the contraction phase. Even when they don’t present with a pelvic floor dysfunction, I want to make sure they are relaxing appropriately.

The average woman in our society needs to be doing strengthening activities with her pelvic floor muscles. The populations I treat are the exceptions to the rule: people with tight, spasmodic, or uncoordinated muscles; because of this I tend to error on the side of caution. As with any exercise program, before jumping into it, if you feel that you have any problems or medical issues that could be affected by your activities, consult your physician or physical therapist.

Pelvic Floor Therapy

I was checking out the ICN (Interstitial Cystitis Network) message board, and was surprised at the different experiences people have with pelvic floor therapy. The same day a friend e-mailed me a question from the message board and asked me to address it in this blog.

This is the question:
“How often do you guys have PFT appointments? Mine are only once every other week. They just use the probe and it only takes about 20 minutes. I do not feel like it is doing anything at all. Any advice? Also, they tell me to do kegels in the meantime, and I was under the impression that those are bad for IC? Just checking.”

I can only answer from my perspective. I know nothing about this patient, and have not evaluated her, so my answer may not even apply to her situation. During the initial evaluation there is a lot of history taking and discussion. I review their bladder diary, which tells me patterns of frequency; consumption of bladder irritants; incidences of incontinence (rare with IC, but it happens). We discuss life habits, previous and current treatment attempts, and general health history.

Then we assess posture and general musculoskeletal structure – is the pelvis and low back in alignment and working together? Are the muscles of the thigh and hip particularly tight? Weak? Balanced? We then assess the pelvic floor muscles (PFM), visually at first: I have the patient try to contract the PFM, I observe the pelvic floor during coughing or laughing, I look for irritation, discoloration or scarring. I then palpate (gently) the external region for tenderness. Internal exam consists of looking for trigger points in the muscles of the pelvic floor, assessing tone of the muscles and having the patient contract and relax the pelvic floor. This part is especially important for detecting pelvic floor dysfunction. Most IC patients can contract, the question is: do you relax appropriately, quickly and completely? If a patient cannot tolerate intervaginal palpation, I will evaluate by palpating rectally. Often on a first visit, I will not have time to do a complete evaluation, and will leave internal palpation for the next appointment.

The next part has to do with surface EMG (electro-myogram) we call this biofeedback, but it is really just assessment of neurological output of the muscle. On the initial visit I do this superficially, with small round electrodes on either side of the anal sphincter. I do this because the probes are often cost prohibitive for my patients, and I don’t recommend the purchase of them unless I feel it is medically necessary.

All of this information makes up my side of the conversation when determining schedule with a patient. Then comes the patient side of the process. How much is cost a factor? How much will insurance pay? How far do you have to drive? Will travel be detrimental to the process? A 30 minute drive for someone that has to go to the bathroom every 10 minutes will probably make physical therapy (PT) much less effective. How motivated are you toward self-treatment? How ill are you? If you literally cannot get up for more than a few minutes a day, weekly or bi-weekly PT appointments are probably not a good idea.

When all of these factors come together, we determine a schedule. Often I want to see someone more than once a week for the first 2 or 3 weeks. As I teach you more home treatments, you get to see me less. If you need lots of biofeedback training, then I suggest a home unit. It is you alone with the machine' you don’t need to be in my office with unfamiliar surroundings trying to teach yourself to relax. Plus, at home you can do 3 5-minute sessions in a day, rather than 1 20-minute session every 2 weeks. Much more effective!

Evaluation is on-going. If you have increased symptoms the day after treatment, I want to know about it. It sometimes takes a few sessions before we find out how much you can tolerate, without a rebound. We also need to figure out what works for you. I have done visceral massage to the bladder on a patient that absolutely stopped her nocturia (getting up to pee at night), and the same technique on another patient left her in horrible pain and increased frequency for 3 days. Feedback during the session is also very important. The things I do may be slightly more painful than what you are currently experiencing, but if it is so excruciating that you tighten the muscles or cannot breathe, well, expect a really bad day tomorrow. By the end of the 4th or 5th session you and your therapist should have established some pretty clear communication about what works and what doesn’t. Most patients have significant improvement after several weeks of therapy. Remember that keeping open lines of communication is very important. Give your therapist feedback, let her know what you experienced after each session (good and bad), and be sure to talk about your reactions during the session also. If there has been no change (worsening symptoms are actually better than NO change, at least we know we are affecting something), then it’s time to try something new. There are lots of options for treatment, and chances are, after 5 sessions, your therapist hasn’t tried ½ of her tricks.

Next time I'll address the infamous "Kegel."

Sex, Lies, and Dyspar....WHO?

Dysapreunia, or painful sex, affects most, if not all sufferers of chronic pelvic pain. For some, it is the only symptom; for others, it is one of many aggravating factors. Vestibulitis is characterized by burning pain at or around the opening to the vagina, sometimes the entire labia minora is affected. Vulvodynia is often characterized as pain in the introitus (the muscular entrance to the vagina), or may encompass a larger area of pain. Interstitial Cystitis sufferers may have pain only with deep penetration that puts pressure on the bladder. Vaginismus is an involuntary spasm of the pelvic floor, which can be painful in itself, but contributes to other types of pain. Any combination of these symptoms is common.

Some women have pain at arousal, partially because of the blood flow to the area, which increases congestion of the tissues. Sometimes the pain is anticipatory, knowing it is going to hurt, causes tightness and pain. Sometimes the pain is only during penetration, and many women will tolerate very little. Some women cannot tolerate penetration of any kind. Sometimes the pain is during orgasm, when the pain of involuntary muscle contraction overrides the natural endorphins that make sex so pleasurable for most people. Sometimes the pain kicks in the next day, sometimes during sex, sometimes immediately after. Regardless of how or when the pain presents itself, the loss of a pleasurable sex life is an issue that should not be minimized.

Communication is key to having a fulfilling sex-life, regardless of limitations. Remember, the problem is in your body, not in your relationship. Talk to your partner. Open lines of communication, even if it is difficult and painful. Many women are more concerned with the effect that their pain has on the partner's sex life than their own. Chances are, your partner is just as concerned about you. You may need to modify how you define sex, at least when you are having an acute flare-up, or while you are seeking treatment. Sex isn't all about penetration, and it isn't all about direct stimulation. Be creative, and be gentle. If all of this sounds foreign, and maybe scary, consult an expert. Clinical Sexologists, or Sex Therapists, are available in every major city in the US. do your home work. Most states have very strict licensing laws about Sex Therapists. be sure whoever you talk to is appropriately certified.
Some things a Sex Therapist will NOT do:

• Ask you to have sex in front of them to "observe"
• Offer to "demonstrate" with you or your partner
• Belittle your concerns and fears

Sexology is a branch of psychotherapy. Sex Therapists are there to teach you and your partner how to communicate, and explore a fulfilling sex-life. They aren't scary, and they aren't weirdos. They are trained, compassionate professionals.

What else? Well, relaxation is huge. In physical therapy, we do alot of things to help you relax. We use biofeedback (surface emg), so you can tell when the muscles are tightening, even if you can't feel it. We do manual techniques to reduce the muscle spasm (see the Trigger Trauma post dated 1/30/2006). We recommend meditation and relaxation tapes.

Things you can do to help relax the pelvic floor before intercourse:

• Take a warm bath
• Use a moist heat pack on your back and lower abdomen
• Gently warm a safe device that can be placed inside the vagina for 5-10 minutes prior to intercourse. I often recommend the EZ-Fit.
• Apply topical Lidocaine, to numb the tissues. Be very careful with this recommendation, and consult your physician about safety for you. If the surrounding tissue is very fragile or sensitive, there may be tearing with intercourse that you won't be able to feel until it's too late. If the majority of the pain is from muscle spasm or interstitial cystitis, lidocaine will be less helpful. Be aware that for a man, the topical lidocaine that you use will limit his sensitivity, making it difficult for him to achieve orgasm.
• Use a lubricant, but be very particular about what you use. Many of the commercial lubricants irritate vestibulitis and vulvodynia. I have had very good luck with pure aloe vera gel, but even that has irritated at least one of my patients. Some of my patients prefer emu oil, but oils will break down the latex in condoms, making them less effective.

After intercourse try:

• Internal cold. Use a device that will hold the cold for 2-5 minutes. Again, the EZ-Fit works great. I have had patients try to fill a condom with water and freeze it, but they stretch to an enormous size. The finger of a rubber glove will work better for most patients. When using a frozen device remember that the vaginal wall is composed of very delicate tissue, and an ice-cold object may be damaging, so limit the time accordingly.
• Cold packs on the lower abdomen, low back, and/or between the legs to cover the external genitalia
• Another warm bath.

I hope some of these suggestions help. Please comment, with additional ideas, or e-mail me with questions.

Sole Mates

My shoes are special shoes for discerning feet. -
Manolo Blahnik

All of my patients, and friends, and aquaintances know this about me: I am very concerned about posture. It is wierdly satisfying to walk into a business meeting and have the whole room sit up straight in their chairs. It is a little disconcerting when my patients walk in bare-foot, to avoid the lecture about high heeled shoes.

A former patient sent me an abstract concerning ankle position and pelvic floor muscle activity. The authors are Charles Vega, MD and Laurie Barclay, MD. As I only have the abstract, I'm not sure about the details of the study, but apparently the information was intended for continuing education credits. The gist of the article is: When your feet are in dorsiflexion (toes pointing up), there is more activity in your pelvic floor muscles (pfm), and it is easier to build a strong contraction. When your feet are in plantar flexion (heels up, toes down), there is less activity and it is harder to build an effective muscle contraction.

Before we jumped to the conclusion that if you have tight pelvic floor muscles you should wear high heels, lets look at the details. The study was conducted on women that had stress urinary incontinence. Although not specifically mentioned, we can assume that many of these women had weak pfm. The women were tested in neutral standing, 15 degrees of dorsiflexion and 15 degrees of plantar flexion. They stood in these positions for 5 minutes prior to testing. Resting muscle activity and maximal contraction were recorded. The results show that the plantar flexion position (toes down) had less muscle activity at rest than neutral and dorsiflexion. A stronger contraction is possible with the toes up.

So what does this mean for you? The only specific conclusion drawn by the authors was that pfm exercise in conjunction with raising your toes will be helpful in training women with stress urinary incontinence. We get into trouble in medicine when we take information from a study and apply it to a different population without really researching the details. We have no idea what ankle placement will do with a pathologically tight pelvic floor. Even if 15 degrees of plantarflexion will relax the pelvic floor, realize that 15 degrees is not much, perhaps only a 3/4" - 1" heel. This will come as a shock to some of my patients, but I don't have too much of a problem with 1" heels, as long as it doesn't go any higher and they spend some or most of their day in good, supportive shoes. Also, this study only measures the pfm activity, and does not take into consideration the rest of the body. We know that pelvic pain problems can be exacerbated by mechanical imbalances in the spine and pelvis, and wearing heels all day can be very hard on the back, neck and jaw.

I'm still not endorsing high-heels for pelvic pain patients, but picking up your toes when you cough or sneeze (don't fall over) will apparently help to prevent leakage.

National Wear Red Day

Friday, February 3rd is National Wear Red Day.
This campaign is to raise awareness of Women's Heart Health.
Heart disease is the #1 killer of Women in the US.
Check out www.hearttruth.gov for more information.

Trigger Trauma

Trigger points - what are they? How do they effect me? what do I do about them?

Trigger points are small areas of tightness within connective tissue. They are typically found in muscles, but can be found just under the skin. Connective tissue is the "soft" support in your body, the tissue that surrounds muscle cells, muscle bundles and muscles. It makes up ligaments and tendons, and gives texture to skin. When it tightens it causes wrinkles superficially, and tight, inflexible muscles and joints in the deeper tissues. Anyway - not all tight spots in your muscles are trigger points. Some of those hard little knots you get in a tight muscle (go ahead, feel the muscles in your neck, I know you've got a few knots) are tender points. The difference between a tender point and trigger point is that when you press a tender point it hurts right where you are pressing, a trigger point will refer pain somewhere else.

It is still pretty unclear how trigger points are formed. Some theories are: micro-trauma (tiny tears) cause the connective tissue to tighten and scar; habitual tightening of the muscle causes them; we all have them latent in our bodies, and some trauma or pain response activates them. I believe it is a combination of these.
So what does all of this have to do with chronic pain? or pelvic pain? Well, if you have trigger points, your pain may not be where you think it is. For instance, I recently saw a patient that came to me with classic TMJ headaches and jaw pain. (TMJ - temporomandibular joint dysfunction, a painful condition of the jaw joint). This particular patient had no clinical findings to justify their pain. The dentist had cleared the bite; an oral surgeon found the jaw to be fine on an MRI, yet the patient still had pain. The patient also complained of toothache pain that was unfounded. We found trigger points in the neck that exactly mimicked the pain she was having. When the trigger points were cleared, the pain disappeared.

There are many trigger points (tp's) that effect pelvic pain syndromes. TP's in the muscles and skin of the abdomen, around the sacrum, in the muscles of the buttock, inner thigh and low back can refer into the pelvic region and pelvic floor. The muscles of the pelvic floor can contain tp's that refer to the bladder, the bowel or the labia. TP's have some pretty predictable referral patterns, but they are not obligated to conform to our textbooks, they can literally refer to any area of the body. Remember, if you have pain in an area caused from a tp, and you tighten the muscles to protect it, you may cause trigger points that refer somewhere else.

So, theoretically, if you develop trigger points in the abdomen after a surgical procedure years ago, that refers pain into your inner thigh muscles, you may not even notice either of these except a vague "gee - that's kind of tight, I should stretch or exercise more." These points refer to your pelvic floor, a place that most of us are completely unaware of unless there is a problem, here the muscles tighten, causing trigger points that refer to your bladder, which makes you think you have to go to the bathroom more often. Frequency may not be a huge problem for a lot of us, but if you are a school teacher, nurse, flight attendant, or any of the other 1,000's of people that can't go to the restroom every hour (or 1/2 hour, or 15 minutes) suddenly this is effecting your lively hood. So you try to hold it. Your pelvic floor tightens more. When you do finally get to go to the bathroom, you strain to urinate (stop that), and eventually you have a full blown, bonafide pelvic floor dysfunction with all of the pain associated. No one knows how it happened; it seems like a sudden onset, because you were functioning fine a couple of months ago.

So what do we do about it? Find a physical therapist. Someone trained in trigger point work, someone experienced with internal trigger point release.
There are a few different methods of trigger point release. They all seem to be pretty effective, and it depends on where your therapist was trained as to which method s/he will use. Some PT's will use a firm sustained pressure on the point for 30 seconds or more. Some will use a gentle pressure - just enough to elicit the referred response and hold for 8-12 seconds, until the referred pain diminishes. Remember these points did not happen over night, and often take several sessions to clear. For trigger points in the pelvic floor muscles, the therapist will work internally, either through the vagina or the rectum. Also, your therapist will work on posture, stretching and relaxation techniques to try to eliminate some of the mechanical problems that aggravate you trigger points.

There aren't a lot of PT's that do this type of work, and sometimes the travel involved is too great of an aggravating factor to justify several visits a week. Even if you are seeing a therapist 2-3 times per week, sometimes that isn't enough. Your therapist may have you work on your trigger points at home. When I send someone home with instructions for self administered trigger point work, I have them use a device to reach the internal trigger points (face it, we aren't built to do this on our own). My new favorite product is called "EZ-Magic" it is made out of medical grade glass, and has a smooth, rounded tip that won't damage the delicate lining of the vagina or rectum. It's important that you work with a therapist that will teach you how to use it properly, and of course, you should never try to self-treat until you discuss it with your health professionals.

The Elephant in the Refrigerator

Question: How do you tell if there has been an elephant in the refrigerator?
Answer: There are footprints in the butter.

How do you tell if he is still there?
You can't get the refrigerator door to close.

For many patients, chronic pain is like an elephant in the refrigerator. You know he is there. You can see (and feel) the damage that is caused. No one knows what to do about it, and no one wants to talk about it.

Chronic pain is a difficult thing for health care professionals to treat. Even those of us that dedicate our practice to helping people with these conditions often find the situation frustrating. For patients that haven't found the physician or team that really "gets them" this journey can be very confusing, and lonely. Pelvic pain conditions can be especially difficult because so few of the specialist trained to treat these organs (gynecologist and urologists) are knowledgeable about the pain inducing syndromes; such as IC, vulvodynia, and pelvic floor dysfunction. There are areas of the country where finding a professional that is competent in treating these conditions is nearly impossible, unless you are willing, and able to travel.

The good news is that there is a lot of information available to health-care professionals that are willing to learn from it. Unfortunately, as a patient, you may be the only person alerting your doctor to the need to become educated.

The average interstitial cystitis patient seeks treatment for 4.2 years, from 4.9 doctors before getting a diagnosis. Vulvodynia patients have a similar struggle. Most of us don't have the resources, time, or inclination to doctor shop; however, if you have a painful condition that is not resolving, and your doctor does not seem to be looking at new options, it is time to have a very serious discussion.

Talk about the elephant!

This is where the team approach to healthcare comes in. You are the captain of your team. If your doctor has ruled out controllable infections and the big scary things like cancer, and still hasn't found a cause for your condition, discuss possibilities. Do you need to see a specialist? A different specialist? A third specialist?

Once you have a diagnosis - you have decisions to make. Can your current team of professionals help you? If they are unfamiliar with the condition, are they willing to learn? The Interstitial Cystitis Association, National Vulvadynia Association, and International Pelvic Pain Society (see side-bar for web-sites) all have excellent physician information services. Don't write off your doctor and/or therapist if they are unfamiliar with the condition, especially if you are unable to locate an available expert, as long as they are willing to work with you and learn. Even the experts don't have all of the answers, and it is the ability to listen to the patient, and adjust treatment accordingly that brings about the best outcomes.

When talking to your doctor or other professional:

• Be informed. Bring information to share. Web addresses, articles, and books that you are willing to leave with them. They may only skim the information, but they will have it as a reference.
• Be prepared. Write your questions down. Keeping a list of questions that you can add to over several days works better than jotting things down in the waiting room.
• Be patient. Your doctor has a busy practice. If you bombard him with a million questions and info when he doesn't expect it, and has a full waiting room, the conversation is destined to be disappointing at best. Let the office know ahead of time you have a lot of questions, and plan to be awhile
• Be Firm. Your doctor works for you. If an open, compassionate dialogue is not possible, find a new doctor. There is an elephant in your refrigerator, and it takes communication to send it packing.

Exercise and IC

I was recently asked for guidelines on exercises for someone with Interstitial Cystitis. I feel it extremely important that people stay as active as possible, even when their condition limits the amount of time and energy they can commit to an exercise program. Here are key points that I go over with my patients. If you suffer from IC, and are thinking of starting an exercise program, please discuss it with your doctor or physical therapist first.

Exercise and IC

• Posture: This is absolutely key. Good posture increases blood and nutrient supply to the pelvic organs, and reduces stress on skeletal muscles, ligaments and joints. Be wary of sitting on hard surfaces (like work-out benches), many people have no problems with these, but for some, it can irritate symptoms
• Aerobic Conditioning: This is always beneficial. Especially important with IC: REMAIN HYDRATED! Toxins build up in the tissues with exercise unless you flush them out. These toxins are bladder irritants, and need to be diluted. Avoid high impact activities that will jar the bladder and encourage tightening of the pelvic floor.
  Bicycling may irritate the pelvic floor, depending on the seat.
• Core Stability: These exercises are especially beneficial, if not too strenuous, and attention is paid to the increase of inter abdominal pressure. Pilates is rarely a good idea for pelvic floor patients, unless they are in absolutely excellent condition with minimal symptoms.
  Ball activities are great. Sitting on the ball reduces tone in excessively tight PFM muscles, and increases tone in weak muscles.
• Stretching: Very important, but pay close attention to postural alignment, and be gentle.

Avoid Vigorous activity: (Stretching and strengthening), especially if it involves the muscles of the groin, abdominals, buttock, inner thigh or piriformis. Microtrauma to these muscles from over strenuous activity may cause trigger point or activation of latent trigger points that refer into the bladder or pelvic floor region. Don’t avoid working these areas, just be cautious.

Most IC patients know more about their bodies and their condition than any of the health professionals working with them. Listen to your body and pay attention to the signals. There may be increased symptoms if you overdo it at first, but keep working at it until you find a balance that allows you to improve your overall condition without irritating your IC.