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.