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.

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.

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.

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.

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."

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.