Endometriosis Awareness Month

We’re currently in Endometriosis Awareness Month, so let’s talk about it. Endometriosis is a condition during which tissue that normally lines the uterus grows outside of the uterus in the pelvic cavity. Endometrial tissue can be found on the ovaries, fallopian tubes, rectum, bladder, bowels and more. Furthermore, it’s common. Endometriosis is present in roughly 10% of women in the United States, and 176 million women worldwide, most frequently diagnosed in their 20s-40s.1

While not all women with endometriosis experience pain, this is the most common symptom of the condition. Women suffering from symptomatic endometriosis may complain of abnormally painful periods of time throughout their menstrual cycle, starting from a young age. This may not always be during menstruation, but can appear during ovulation, or the weeks preceding or following her period. Women may also complain of low back or pelvic pain. Other common symptoms include painful intercourse, painful bowel movements and gastrointestinal discomfort leading to constipation, diarrhea, bloating and nausea. Most pains and symptoms caused by endometriosis are cyclic in nature, triggered at times throughout a woman’s cycle. Unfortunately, up to 30-50% of women suffering from endometriosis experience infertility.1  

One frustrating aspect of this diagnosis is that while it is a common condition, the average time to diagnosis is frequently over 10 years with 68% of women experiencing misdiagnosis.1 It is believed that, in part, the extended time frame for diagnosis is due to symptoms being misconstrued as normal period pain. An additional factor includes the average time it takes for women to seek help for this condition, estimated at 4.67 years. This is even longer for younger girls and women as well as more severe cases.1

Diagnosis is often multi-step including pelvic exams with your physician feeling for adhesions, followed by imaging and ultrasounds to assess for cysts and other structural abnormalities. However, the only way to officially diagnosis endometriosis is with a laparoscopic procedure. Laparoscopy is a minimally invasive surgery that allows your physician to see what is happening at your tissue level. It allows them to visualize the adhesions that may be causing your pain and it allows them to take samples, or excise and remove them.

Another frustration surrounding endometriosis for the medical community and patients alike is that we do not know the cause of the condition. While theories exist, there is no one accepted truth. Potential causes include: retrograde menstrual flow, genetic factors, immune system malfunctions, surgical history and hormones.

While there is no cure for endometriosis there are a number of treatments available to help manage symptoms. The first line of treatment is frequently hormonal birth control, with surgical intervention being another common choice. Pelvic floor physical therapy is another underutilized, in my opinion, resource for those with endometriosis.

While pelvic floor physical therapy will not treat your endometriosis, it will treat your pain to make you more comfortable. Pelvic floor physical therapists can use manual therapy techniques and exercise to help ease your pain with intercourse, improve your bladder and bowel emptying, decrease pain with bowel movements and urination, improve your tolerance to gynecological exams and tampon use and even decrease your cramping.

Muscular guarding may not be the cause of your endometriosis, but it can be a major contributing factor. Pelvic floor physical therapy can help teach your muscles how to relax and teach you how to manage your pain.

If you need help finding a pelvic floor specialist in your area, let us know! With questions or concerns, feel free to reach me at becky@sullivanphysicaltherapy.com or comment below.

-Rebecca Maidansky, PT, DPT

  1. https://www.acog.org/about_acog/news_room/~/media/newsroom/millionwomanmarchendometriosisfactsheet.pdf

What Can You Do About Blocked Ducts?

Blocked milk ducts are a pain, in every sense of the word. They can cause significant soreness and discomfort for women during breastfeeding or simply moving around throughout the day. Furthermore, if not resolved blocked milk ducts can lead to mastitis, a potentially dangerous infection.  Today, I want to talk about what causes blocked milk ducts and what both you and your physical therapist can do to help reduce associated symptoms and concerns.

Milk ducts, also called lactiferous ducts, are tubes through which breast milk travels from the tissue where it is produced to your nipple, allowing the milk to express from your breast. When the breast is filled with milk that is not emptied by breastfeeding or pumping, the weight of the tissue can press on the milk duct and block the normal flow. Additional causes may include an overabundant milk supply or pressure on the breasts such as a tight bra, as well as poor latching. When the normal flow of milk is blocked for any of the above reasons, a plug can form, resulting in a blocked duct. These blockages can cause significant pain during breastfeeding and wearing tight clothing, but typically resolve on their own in 24-48 hours.

During the early stages of a blocked duct, the breast may feel hardened in the area of the plug and are painful to the touch. Like mentioned earlier, if this doesn’t resolve quickly you may be at risk for developing mastitis. Women are highest risk for developing mastitis in the first 4 weeks of pregnancy, with research showing that 60% of cases occur in this time frame. In the United States, mastitis has a prevalence of 9.5% with that rate rising to 23% in developed countries worldwide.1

Knowing the signs of these conditions is important. While blocked ducts are common and you can attempt many home remedies independently, mastitis needs immediate e medical attention. While a blocked duct feels like a hardened, painful lump in the breast, mastitis will cause the breast to appear red, hot and inflamed. Systemic effects may also be felt such as flu like symptoms, body aches, chills, fatigue and fever. If you start feeling any of these symptoms, call your physician right away.

Fortunately, if caught early, there is plenty that both you and your physical therapist can do to make you more comfortable and help reduce the blockage. Here are some helpful options for managing a blockage at home:

  • Don’t stop breastfeeding. Although it can be tempting to avoid nursing on a sore breast, it can increase the likelihood of a blocked duct. Keeping the milk moving is essential.
  • Try to completely empty your breast milk each time you feed your baby. Use breast compression while your baby is feeding. If there is milk left afterwards, you can pump to further empty.
  • Apply moist heat before nursing for about 15 minutes to help loosen the plug. You can bend over while using moist heat to assist in drainage.
  • Start each nursing session on the side of the blocked duct.
  • Use self massage on the affected breast, starting on the outside of the breast and moving towards the nipple to help express milk.
  • Cabbage! Studies have shown that cabbage leaves can relieve pain from swelling in the breast. First boil the cabbage, then let it cool and separate the leaves. Apply it to the affected area for about 20 minutes, 3-4x/day.

If these techniques are not enough, your physical therapist may have a few other tricks up her (or his) sleeves. Physical therapists can treat a blockage by using heat, massage and ultrasound. Ultrasound is a physical therapy modality that is painless and can help break up a blockage, reducing pain within 1-2 sessions.

You are not alone. These symptoms are common. While not every physical therapy clinic will have the training to treat you for a blocked duct, call around to clinics or clinicians in your area who specialize in women’s or pelvic health. Or, ya know, you could also come see us at Sullivan!

Please feel free to leave questions and comments below or email becky@sullivanphysicaltherapy.com for more information.

-Rebecca Maidansky, PT, DPT

Resources

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5118955/
  2. https://www.aafp.org/afp/2008/0915/p727.html

Is My Pain In My Brain?

I cannot recount the amount of times someone has come to Sullivan PT, sat down in my treatment room, and said something to the effect of “I don’t know, maybe this pain is just in my head.” They usually feel this way because no one has been able to tell them why they hurt or maybe because someone has already said “maybe it’s in your head.” What I usually tell people is this: Yes, the pain is in your brain, but that doesn’t mean it’s a figment of your imagination.

To fully understand why we hurt and what we can do about it, we need an understanding of what pain is. Our body doesn’t have pain receptors. It doesn’t. Our body, instead, has something called nociceptors. Nociceptors are sensory nerves that pick up threatening signals, signals that may mean damage, carry those signals to our spinal cord and then to the brain.  The brain interprets this data and decides whether or not that threatening signal results in pain.

Let’s use an example that I did not come up with but rather heard in a presentation by Adriaan Louw, PT, DPT, pain science guru, at a conference in 2016. The story goes as follows:

If you were crossing the street and sprained your ankle, would it hurt? Of course it would hurt. You would probably sit down and clutch your foot, roll around and yell some unpleasant things, loudly. Now, let’s take this one step further. If you were crossing the street and sprained your ankle, but a bus was heading straight for you, would it hurt? Would you fall to the ground and clutch your foot? Of course not. You would hop right back up and run out of the way, at which point once it was clear you were safely away from this life threatening hunk of metal, you may start feeling that sprain.

So what is this story meant to illustrate? Pain is not a straightforward, simple thing that should be taken at face value. It is a complex experience created by a number of factors, but in all cases pain is felt when your brain decides that your nerves have picked up on something threatening. Your brain determines your level of pain based on the danger it thinks you are in, not the amount of danger you are objectively in.

This system would be great if your nerves never sent false signals and your brain never had poor judgement, but for people experiencing chronic pelvic pain, both of these can happen. Your sensory nerves can become that little boy that cried wolf, but your brain may be more gullible than the villagers. Let me explain further through another analogy.

Your central nervous system includes your brain and spinal cord. This is what collects the sensory input from your body, interprets it, and responds to it. Your central nervous system is like an alarm system. However, just like my crummy, 150 year old building fire-alarm system in graduate school, your alarm system can malfunction. That alarm system was hypersensitive. It went off every morning I made toast and I had to stand beneath it waving a magazine for 5 minutes until I could convince it nothing was about to go up in flames. In someone with chronic pain, the body’s natural alarm system, or the nervous system, does the same thing. In those with chronic pain, the nerves start sending signals to the brain over and over with and without reason. The brain continues to create pain that isn’t in response to any particular tissue damage, or burnt toast.

This is why neurologist and scientist VS Ramachandran wrote “Pain is an opinion on the organism’s state of health rather than a mere reflective response to an injury.” Pain is not an inalienable truth that we necessarily experience, and while we may not be able to stop our pain by wishing really, really hard, we can influence what we feel by how we understand what we’re feeling.

The brain has the ability to be smarter than our alarm system. It has the ability to both heighten the sensitivity of our nerves, making them more and more active and reactive. It also has the ability to calm our nerves by telling them over and over, “yes, I know you sense imminent danger but I promise you there is none.” An important part of this is teaching our brain that pain does not mean damage. Our nerves can be wrong, our brain can be wrong, and we may end up in pain even if nothing is harming us.

Entire books have been published devoted to helping us understand that even though our pain is absolutely, 100% real, we may not be in harm’s way. Research has even shown that understanding pain can quickly and effectively reduce the pain we are actually feeling. One particular study, by the same Adriaan Louw, PT, DPT, pain science guru, previously mentioned illustrated just how powerful understanding pain can be.

In this study, the subject was a 30 year old professional dancer who had a 4 year history of back pain, radiating into both of her legs and thighs. They asked her to fill out some outcome measures, which if you have been to any health care provider recently you may be familiar with. She filled out a few of these forms that indicated how significant her pain was at the time, how affected she felt by her pain while performing daily tasks, as well as how her fears and beliefs regarding her pain affected her symptoms. She then also had an fMRI, which is a type of MRI that measures brain activity by detecting the change in blood flow between regions. 1

The intervention in this study, or the treatment, was a 30 minute educational session allowing for questions and answers, to help her better understand her pain. This session included the alarm system analogy, as well as some additional pictures and information to assist in reconceptualizing pain. The outcome was, in my opinion, quite amazing. Upon completing the same outcome measures just thirty minutes later, she reported less pain, less disability, more positive beliefs regarding her pain, and even decreased brain activity while completing painful tasks as compared to before the education session.

I know, pretty cool.

In summary, I’ll leave you with four points inspired and clearly outlined by Lorimer Moseley in his article “Reconceptualizing Pain According to Modern Pain Science.”2

  1. Pain is not an objective measure of the health of your physical tissue
  2. Pain is regulated by a number of physical, social and emotional factors
  3. The accuracy of your body’s perception of pain as compared to the health of your physical tissue may decline as pain persists and becomes chronic in nature
  4. Pain is your brain and body’s way of expressing that your nerves believe your tissues are in danger

If you have any questions or comments, please leave them anonymously in the comment section below or email me at becky@sullivanphysicaltherapy.com.

Interested in reading further on this topic? Here are two great reads!

  1. Explain Pain by David Butler and Lorimer Moseley
  2. Why Do I Hurt? by Adriaan Louw

-Rebecca Maidansky, PT, DPT

Resources:

  1. Adriaan Louw PT, PhD, Emilio J. Puentedura PT, DPT, PhD, Ina Diener PT, PhD & Randal R. Peoples MS, MD (2015) Preoperative therapeutic neuroscience education for lumbar radiculopathy: a single-case fMRI report, Physiotherapy Theory and Practice, 31:7, 496-508, DOI: 10.3109/09593985.2015.1038374
  2. Moseley, L. Reconceptualising Pain According to Modern Pain Science. Oxford Centre for fMRI of the Brain. Oxford University, Oxford, UK. https://bodyinmind.org/resources/journal-articles/full-text-articles/reconceptualising-pain-according-to-modern-pain-science/

Chronic UTI’s? PT can help.

Urinary tract infections (UTIs) are common. They’re so common that they account for nearly 10 million doctors visits a year, with an estimated 150 million UTIs occurring annually, costing roughly 6 billion dollars in health care expenditure.1,2 So what is a UTI? A UTI is an infection in any part of your urinary tract, including your urethra, bladder, ureters and kidney. This can happen when bacteria gets into the tract, overcoming the bodies immune system, resulting in inflammation and pain.

These infections affect both women and men, however women at a higher rate due to anatomical differences. Women have shorter urethras, located more closely to the anal opening, putting them at higher risk for infection. This is one of the reasons conventional wisdom recommends wiping front to back following using the bathroom.

So what does a UTI feel like? Symptoms of UTIs include:

  • Urgent and frequent need to urinate
  • Difficulty emptying the bladder
  • Burning sensation while urinating
  • Pain in the lower abdomen
  • Cloudy urine or blood in the urine
  • Low back pain, fever and chills (these are signs of a more serious infection)

You may experience some of these and not others.

If you’re feeling any of these symptoms, follow up with your physician. They will likely do a urinalysis. What is a urinalysis, one may ask? It’s an analysis of your urine. This test requires a urine sample that can be cultured for bacteria to assist your physician in determining the cause of your symptoms and the appropriate treatment. If bacteria is found, you will likely be prescribed an antibiotic, and if all goes according to plan you’ll be feeling better in no time.

So what if that isn’t enough? What if you take the antibiotics and your symptoms are still there? That’s a reasonable question and an unfortunately common scenario. The National Kidney Foundation reports that if a woman has a UTI, she is 30% likely to have a recurrence. If a woman has two UTIs, she is 80% likely to have a recurrence. If you’re symptoms persist, your physician will likely have you come back to drop off another sample. If that sample comes back positive, maybe one round of antibiotics wasn’t enough and they’ll prescribe you another one. But what if the test comes back negative? What if they do further testing that comes back negative, too, but you’re still feeling bladder pain, burning with urination, etc.?

Maybe infection is no longer the culprit. Maybe your pelvic floor is.

When your body experiences pain, the muscles surrounding the painful area go into protection mode. They guard to keep your body safe. This can be effective and helpful in the short term, but if our body continues to think we’re under attack when the painful stimulus has been dealt with, it can cause pain to continue. In the case of UTI’s your pelvic floor muscles are the ones that guard in response to a perceived attack on your body, and they’re the muscles that may not realize the threat has resolved even if your antibiotics do the trick.

In these cases, your pelvic floor continues to stay contracted, continues to irritate your urethral sphincter and tissue surrounding the urethra and can even contribute to a tightening of muscles in your lower abdomen surrounding your bladder. All of these angry muscles can mimic the bladder pain and urinary discomfort you experienced during your UTI.

This explains why your urinalysis can continue coming back clear, while your body is very certain something is wrong. So if you have been back and forth to your physician’s office, dropped off samples of your urine multiple times, taken medication, followed all appropriate steps and you’re still sure your bladder is revolting against you, consider pelvic floor physical therapy. An evaluation with a trained PT can help determine whether the muscles are the culprit of your continued pain.

A trained pelvic floor physical therapist can help teach your muscles to relax again and help you improve your control over those muscles so this doesn’t happen again in the future. Using a combination of internal and external manual therapy along with relaxation exercises and stretches can help your muscles calm down and do wonders to manage that UTI-like-pain.

I hope this was a useful read! Feel free to leave questions or comments below- I’d love to hear from you. I can also be reached at becky@sullivanphysicaltherapy.com

-Rebecca Maidansky, PT, DPT

Resources

1.https://www.kidney.org/sites/default/files/uti.pdf

2.https://www.auanet.org/education/auauniversity/for-medical-students/medical-student-curriculum/adult-uti

FAQs: Part 2

4. I have (X) and was told it is not curable. Am I ever going to get better?

The goal of physical therapy is not to cure your disease, but instead to make you feel better. Often times diagnoses like interstitial cystitis and pudendal neuralgia sound and feel hopeless, and pelvic floor physical therapy is not going to treat your disease process. However, when we have a chronic condition that creates pain, our bodies respond to that pain in a number of ways, many of which are productive, and many of which are not.

Physical therapy may not be able to rid you of IC, but it may be able to help manage your symptoms to help you return back to exercise, work or having sex comfortably. The goal of physical therapy is to help you get back to the life you want to be living, not necessarily get rid of the condition. Our goal is to help you figure out how to manage your symptoms or your flares, how to prevent flares from happening in the future, and better manage them to make them less severe and shorter lasting if and when they happen. Our goal is to help you understand your body and your pain so that when you feel your symptoms, you feel empowered to manage them rather than a helpless victim of your condition.

A chronic condition does not need to mean chronic suffering. Pelvic floor physical therapy can help ease your suffering and improve your ability to participate in activities that matter to you as an employee, friend, partner and parent. This can help you feel and live better, even if your diagnosis doesn’t change.

5. I’ve already tried kegels, what else is there?

My answer to this question comes in the form of two additional questions:

  1. Are kegels right for you or your diagnosis?
  2. Are you doing kegels correctly?

Kegels are a big part of pelvic floor PT, but not for every patient or every diagnosis. Furthermore, even if kegels are right for you, research tells us that roughly 50% of people do them incorrectly.

Let’s elaborate on the first question. Kegels, or pelvic floor contractions, are a strengthening exercise. Strengthening is great, if you are weak. However there are plenty of diagnoses and symptoms that don’t necessarily need strengthening. For instance if you are experiencing pain with intercourse due to tension in your pelvic floor, contracting those tight muscles repeatedly may not be the right way to go. The same holds true for many pain diagnoses. If tension in your muscles is causing your pain, strengthening needs to be done carefully and intentionally so as not to increase that tension, and thus that pain.

Now, the second question. Are you doing them correctly? Like I said earlier, research has shed light on just how in touch we are with our pelvic floor. Upon examination, I have seen people do all sorts of things while trying to squeeze their pelvic floor muscles. I have seen people bear down, which is the exact opposite of what you want to do. I have seen people squeeze their glutes, legs and fists. It’s a hard muscle to coordinate, and sometimes it takes a bit more guidance than telling yourself simply to squeeze.

So if you’ve tried Kegels and are wondering what else is out there that can help, my answer is many things. Pelvic floor physical therapists can help guide you through relaxation exercises, stretches, habit modifications, strengthening of the correct muscles, the correct way, and a number of other options to address your pain.

6. What do you think about vaginal weights?

They are rarely necessary. That’s how I feel about vaginal weights. More often than not, when I see patients who have pelvic floor weakness, their muscles are barely strong enough to support the weight of their body during normal day to day activities. If your hand was so weak that you couldn’t type on your computer, you wouldn’t walk around holding a dumbbell.

Typically, strengthening the pelvic floor muscles against the weight of your body or while doing other activities like squatting, lunging, bending and jumping, is enough. This progression takes a minimum of 6 weeks, but could take longer depending on the rate of your progress. The cases where vaginal weights make more sense to me are for high intensity athletes who have gone through an entire strengthening progression, have returned to their sport in some modified fashion, but continue to have symptoms during or after a difficult workout. In this case, vaginal weights may be a helpful tool.

7. Why did you get into this field?

Honestly, this is probably my #1 FAQ. I got into this field rather accidentally. I started my PT career with an interest in outpatient sports rehab and absolutely nothing else. Then I learned that pelvic floor PT existed, and I was not interested at all. Then I learned more about it and met a PT’s practicing in the pelvic world, and I started realizing just how impactful this field can be.

What I love about physical therapy is how well we get to know our patients, and how personal our program creation becomes for them. People suffering with pelvic pain and pelvic floor dysfunction often feel trapped and alone, and pelvic floor physical therapists get to help guide them back to feeling like themselves. That’s what I love about it.

Plus, to quote my colleague Christina McGee, “I like talking about pee, poop and sex.”

Feel free to leave questions or comments below or email me at becky@sullivanphysicaltherapy.com.

-Rebecca Maidansky, PT, DPT