Help, I’m having pain in my left ovary!

 

 

 

 

 

 

OBGYN’s hear this complaint frequently and of course, will examine your reproductive organs.  However, most one sided lower abdominal pain is not due to problems of the either ovary, but mainly due to  muscle tension that crosses the same region where the ovaries are located.

 

It could be a hip or back muscle.

This image shows your hip flexor, called the iliopsoas muscle.    The x’s show where trigger points of this muscle are typically located. The red dots show the areas where people complain of pain

 

 

 

This image shows a back muscle called the quadratus lumborum or QL for short.

 

 

 

Both of these muscles can refer pain into the lower abdomen as shown in the shaded red dotted areas. This can commonly be interpreted as ovarian pain.

How to self-treat:

Hip flexor stretch:

Begin in a half kneeling position with your front left knee bent at a 90 degree angle. Next, squeeze the glutes and tuck in your tailbone, while gently lunging forward to feel a stretch in your right hip flexor. Switch sides. Do 2x 30 second holds, twice a day.

Quadratus Lumborum stretch:

Straddle a chair. Side bend to the left side and imagine you are trying to lift your right ribcage up and drop your right hip downwards, to feels a stretch on right side of the body. Switch sides. Complete 2 x 30 second holds, twice a day.

If pain persists or gets worse, see a women’s health physical therapist.

Chronic Pain: New Science provides Solutions for Complete Recovery (Part 1)

Chronic pain is a worldwide epidemic, affecting 1.5 billion people1.   In the USA we spend over $635 BILLION dollars treating chronic pain, visiting multiple medical practitioners, getting  tests, injections, prescription medications, and surgeries2.     With all the amazing advances made in treating cancer, diabetes and heart conditions, the numbers of people suffering with chronic pain has not lowered; in fact it’s increasing.

The good news is that we have learned more about pain in the past 10 years than ever before. The fields of neuroscience, physical therapy, psychology and nutrition have unearthed a treasure trove of knowledge to help people truly heal from chronic pain. There are a number of non-invasive, low risk self-help treatments that people with chronic pain can do simultaneously while they receive treatments by their doctors, physical therapists and other health practitioners to achieve total chronic pain relief.

Chronic Pain Defined

Chronic pain is pain that lasts longer than the normal tissue healing time of 3-6 months. Note: this blog does not include the pain caused by active cancers nor end of life pain issues. So, by the end of 6 months all tissues (skin, muscles, fascia, tendons, ligaments, nerves and bones) should be completely healed barring no major complications such as infections, disease processes or re-injuries.

3 Phases of Healing

Below is what our body does after getting a physical injury:

Inflammatory phase 3-7 days from original injury: when you feel most pain or see redness and swelling. Swelling shows that your body is doing an excellent job of healing and prevents further injury to the area.

Repair (Proliferation) phase 2-6 weeks from original injury: depending on the tissue (skin heals faster than bone). New collagen is laid down, like weaving a basket or sewing up a hole in your socks. Collagen replaces the torn, strained, or fractured tissue.

Remodeling phase 3-6 months from original injury: this phase starts when production of new collagen stops. New collagen is usually stiff, inflexible and needs to be remodeled, lengthened, and strengthened to your pre injury state and function. This is best achieved by going to physical therapy and doing your exercises.

Acute Pain Process

If the normal healing timeline takes 6 months at most, why do so many people experience chronic pain for years, sometimes decades past the original injury? Before we can understand how pain becomes chronic, here’s how our nervous system and brain works when we are experiencing acute injury pain.

When we first sprain our ankle, specialized sensors in our skin called “nociceptors” are activated (see red “Nociceptive Information” ).  Nociceptors are not pain sensors- rather pressure sensors, chemical sensors and stretch sensors. In fact, we don’t have actual “pain sensors” in our bodies. Nociceptors sense that your ankle ligament is overstretched or your muscle fibers are torn and sends this information to the brain.

 

Brain is our Protector

Your brain’s main role is to protect your body, so when your brain receives the nociceptive signals about the overstretched/torn tissues, it also checks your surrounding environment and assesses the situation to decide how best to protect.

Let’s say you twisted your ankle in a pothole while crossing a busy NYC street. You need to run quickly or you may be hit by oncoming cars. The brain decides that you need to get to safety first so it allows you to run on your injured ankle WITHOUT PAIN by sending pain reducing chemicals to the area. Once you are safely on the sidewalk, the brain sends pain signals to your ankle so you immediately take your weight off your foot. Your brain has effectively protected you from harm both by decreasing and increasing pain. This whole process happens in milliseconds.

 Brain is the Boss of Pain

Our brains are capable of learning and creating new nerve pathways throughout our whole lifetime. This is called “neuroplasticity”3.  Areas of the brain that are used very frequently show high levels of activity (as seen in brain MRI scans) and may actually increase in size4.  Before iPhones and Google Maps, London cab drivers had to memorize the whole intricate street map of the city before they could get their licenses. Studies show that they actually have enlarged areas in the brain associated with memory. The brain changes based on how we use it.

The brain is the center where the actual sensation of physical pain originates from and gets relief. People who experience chronic pain have a brain and nervous system that has learned to be in a heightened state, always on guard awaiting the next danger signal. What leads to this “faulty wiring” of our brain and nervous system?  Some factors include:

  1. Childhood and early social experiences – did you suffer loss/lack of love or did you feel safe and supported? These experiences affect how we respond to both physical and emotional pain.
  2. Daily thoughts and self-talk – are they positive or tend to be negative/fear based?
  3. Current social interactions – are they mostly supportive, like seeing a good friend, petting your cat or stressful, like fighting with your spouse/children?
  4. Your Expectations- are you afraid of bending forward because years ago a doctor said it could flare up your back pain? 5,6

Nutrition, exercise, restful sleep plays just an important role in total healing which we will discuss in the next few blogs. While we can’t change what happened to us in the past, the good news is that our brains can relearn healthy patterns to lower/stop chronic pain.

While receiving medical care from your doctor, you can simultaneously  retrain your brain to learn healthy processes, decrease fear based movement patterns, use mindfulness to stop negative catastrophizing thoughts, breathing techniques to lower fear/anxiety and much more.

At EMH Physical Therapy, we offer a chronic pain recovery program, called re·lieve, which educates patients in the new science of pain and teaches them a scientifically proven self-help program along with providing any needed manual and movement therapies.

Stay tuned for Part 2 of  “Solutions for Complete Recovery of Chronic Pain”.

References

1.Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: Institute of Medicine of the National Academies; 2011.

2.Darrell J. Gaskin, Patrick Richard. The economic costs of pain in the United StatesThe Journal of Pain 2012;13(8):715

3.Draganski B, May A. Training-induced structural changes in the adult human brain. Behav Brain Res 2008;192:137-42

4.Johansson BB. Brain plasticity in health and disease. Keio J Med 2004;53:231-46.

5.Seifert F, Maihofner C. Functional and structural imaging of pain-induced neuroplasticity. Curr Opin Anaesthesiol 2011; 24: 515-523

6.Sandkühler J. Learning and memory in pain pathways. Pain 2000; 88: 113-118

7.Jensen M. Magnetic resonance imaging of the lumbar spine in people without low back pain. New Eng J Med. 1994;331: 69-73.

8.Katharina A. Schwarz, Roland Pfister, Christian Büchel. Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends in Cognitive Sciences, 2016

 

 

 

POOPING 101 – Part 1

What is one thing we all have in common? What brings us all together? We all poop!  How much do you know about your bowel movements? What does it mean when your stool is a different color, shape, texture? What leads to constipation or diarrhea? How can we have a healthy bowel movement and how often should we have a bowel movement?

 

I am writing this blog in two parts to help you have a better understanding of the mysterious #2, because pooping is an integral part of our daily life and can tell us a lot about our health.

DIGESTION

Lets start from the beginning, how food travels from entry to exit:

1. ORAL CAVITY & ESOPHAGUS Digestion begins in the mouth, as saliva helps break down starches. The esophagus is the portal to which the contents travel to our stomach. No digestion occurs here, but “heart burn” can occur when there is backflow from the stomach up into the esophagus through the cardiac orifice seen above.

2. STOMACH Now that the food has made it to the stomach, acids break down proteins. Food spends approximately 2-4 hours here before traveling to the small intestine through the pyloric sphincter

3. SMALL INTESTINE  In the small intestine, over the course of 4-6 hours, our body continues to break down starches and proteins and tackle a new molecular compound called carbohydrates. Juices secreted from the pancreas and liver help break down starches, fats and proteins.

4. LARGE INTESTINE What’s next? You guessed it, the large intestine, which absorbs 1000- 1500 mL per day, leaving 100-150 mL along as hardened feces to the rectum. Digestive contents spend the longest time here, approximately 24-72 hours. It travels through the ileocecal valve up the right side of the abdomen through the ascending colon, across the transverse colon and down the left side into the descending colon.

5. RECTUM Using strong peristaltic waves, our bodies push stool into the rectum. That’s when we have our first urge to defecate. We have stretch receptors which tell our bodies to relax an involuntary muscle called the internal anal sphincter while we close our external anal sphincter (EAS) to keep feces from coming out until we are ready.When we sit on the toilet, our EAS relaxes along with our puborectalis muscle. This relaxation combined with a gentle increase in intra-abdominal pressure pushes fecal matter out. Placing our knees higher than our hips, via a squatty potty or stool, helps relax the puborectalis muscle even more, allowing from easier elimination as shown below. The external anal sphincter (EAS) changes its tone based on what it senses. If it senses liquid, such as diarrhea, the EAS increases its tone. If it senses, gas, it allows that to be selectively released. If it senses solid stool, our body can override our urge to defecate until we are at a toilet, so we can hold it in when necessary.

When we sit on the toilet, our EAS relaxes along with our puborectalis muscle which surrounds the rectum tightly at rest creating the “anorectal angle”. When the puborectalis relaxes it allows the rectum to have easier passage. This combined with a gentle increase in intra-abdominal pressure pushes fecal matter out. Placing our knees higher than our hips, via a squatty potty or stool, helps relax the puborectalis muscle even more, allowing  easier elimination.

GOOD DEFECATION TECHNIQUE

A healthy bowel movement (BM) should not involve straining or pushing. The action of defecation is a part of the parasympathetic nervous system, which helps the body soften and relax. The first step to a good BM is making sure you are in a comfortable, safe place. Have you ever noticed it’s easier “to go” at home versus in an unfamiliar place?

If we lose our ability to properly relax with a bowel movement we may start to strain with defecation, which over time is injurious to our body.

Here are some quick, easy tips for a healthy BM.

  • Sit with your knees above your hips, feet resting on  a child’s step stool or “Squatty Potty”
  • Place both hands on your abdomen, or, if you have jaw tension, support your head in your hands
  • Draw up or contract your pelvic floor muscles as though you are trying to hold back gas
  • Relax your pelvic floor muscles as though you are trying to release gas
  • Note how the stomach muscles relax and bulge forward
  • Relax the pelvic floor muscles and think of widening the rectal opening
  • Imagining your body is a tube of toothpaste, pushing from the top down, brace and breathe out
  • You can use certain sounds such as “grrr” and “shhh” to help gently increase intra-abdominal pressure to pass stool

If you feel like you are unable to perform an easy BM even with taking fiber, drinking water, or are spending too much time in the bathroom, straining often, or experience frequent constipation and bloating, consult a pelvic floor physical therapist.  We’ll assess if restricted pelvic floor, abdominal muscles are hindering your function. We perform gentle manual therapies to restricted muscles/fascia of both internal and external pelvic areas, visceral mobilization  to help the organs move optimally and “do their thing”,  use biofeedback to retrain the pelvic floor muscles so they don’t contract when they are supposed to relax, teach breathing techniques and other home exercises.

Stay Tuned for “Pooping 101 – Part 2”!

 

 

 

Hey Women! Let’s learn about your lady parts!

With women’s rights being a hot button issue recently, it got me thinking: how many women really know and explore the parts that make them a woman? (Disclaimer: I’m not forgetting those in the LGBQT community who have different anatomy and identify as a woman. You do you, girl!)

So ladies…What’s down there? Grab a mirror and play along.

 

 

 

 

 

 

 

 

Externally you will see three openings:

  1. The urethral opening which is closest to the front of your body (where we eliminate pee)
  2. The vaginal opening in the middle (where intercourse occurs and also the birth canal)
  3. The rectal opening below (where we eliminate poop)

The urethral and vaginal openings are housed in the first skin layer,        called labia majora (with pubic hair) and just underneath, the labia minora (hairless layer) that protect these openings.

Also protected by the labia just above the urethral opening is a small sensitive, nerve filled structure with two hidden “legs”  that surrounds either side of the vaginal opening called the Clitoris. The head of the clitoris is very sensitive and serves in sexual function for arousal when stimulated.

 

 

 

 

 

 

 

The clitoris is considered the most erogenous zone on the female body.  Stimulation of the more than 8,000 nerve endings here can lead to the rhythmic, quick flick pelvic floor contractions that we interpret as pleasurable. Yes, I’m talking about orgasm!

Now that you are acquainted with the anatomy use a mirror to check your own lady parts. Then do some of the following movements:

  1. Try a Kegel: contract pelvic floor like you are stopping the flow of urine or don’t want to pass gas. You’ll  lifting of the pelvic area upwards
  2. Try a reverse kegel: bear down like trying to pass a bowel movement. You should see the pelvic area gently bulge outward
  3. Cough or laugh. You should observe an initial lifting up/in of the pelvic floor, with a quick relax back to normal position

 

Let’s take a look at the Pelvic Floor muscles.

In this image, the external skin is removed and you are now looking at the underlying muscles. These muscles are important stabilizers of the pelvis and serve many functions: bowel and bladder control, core stabilizers, involved with sexual function and support of bladder and other visceral organs.

You can check your pelvic muscles by inserting one clean finger into the vaginal opening to the level between 1st and 2nd knuckle. Assess your strength by squeezing the inserted finger (doing a kegel) by contracting your pelvic floor muscles.  You should feel a ring of tension around your finger and feel a gentle pull upwards toward your head.

Assess for tension in the muscles by stretching directly to the right, left, down and diagonally up/right, diagonally up/left, down/right, down/left. No need for direct upward pressure as this is where your urethra is located.  A healthy pelvic floor should feel no pain, only pressure or stretch.

I hope this helped you to feel more comfortable and aware of your female anatomy. In a study published in the International Journal of Sexual Health, scientists found that women who had a positive view of their genitals were more comfortable in their skin, more apt to orgasm, and more likely to experiment in bed. So go ahead and get to know your lady parts.

Remember:

A healthy female pelvic floor has

  • no pelvic pain or pain/tingling/feeling of pressure in the sexual organs,
  • painless intercourse and insertion of tampons,
  • the ability to stay relaxed and soft, not to be chronically tense, which leads to pelvic/back/hip pain,
  • ease of voiding (of pee and poop) with no issues of frequency, bladder pain, nor straining during every BM due to constipation
  • no leaking when lifting weights, laughing , sprinting for a bu

If you experience any symptoms, consult an experienced pelvic floor physical therapist for evaluation and guidance.

Multi-Disciplinary Approach is best for relieving Chronic Pelvic Pain

Evelyn and her DPT staff traveled to Chicago for the International Pelvic Pain Society conference to learn about the evolving sciences and evidence based treatment for pelvic pain.

Pelvic pain is typically located in the lower part of your abdomen & pelvis and can stem from the reproductive, urinary or musculoskeletal systems. The cause of pelvic pain can be complicated, involving interactions between gastro-intestinal, genito-urinary, musculoskeletal, nervous, endocrine systems and can include socio-cultural factors.

So it’s important to have a medical team working with you. Your team can include a urologist, pelvic physical therapist, gynecologist, gastroenterologist, psychologist, radiologist acupuncturist and sex therapist.

In our experience we find that patients just need 2-3 team members such as a medical doctor well versed in pelvic pain to guide on medications and general health, an experienced pelvic physical therapist who provides education, manual and movement therapy, and a talk therapist to address underlying emotional traumas. 

UPOINT  helps MD’s find best treatments for Male pelvic pain

Most men with symptoms of chronic pelvic pain syndrome (CPPS), such as penile pain or discomfort, urinary urgency/frequency, inability to sit, testicular pain and/or ED, have been given a diagnosis of “Non Bacterial Prostatitis” and prescribed antibiotics. I often hear from my patients that the medicine didn’t help, as their prostate gland was not infected, which is what antibiotics target. Many men were not getting pain/symptom relief from antibiotics and doctors needed a better system to determine the cause of CPPS.  UPOINT was developed to help.

 

UPOINT is a classification system to determine the specific diagnosis and treatment for male CPPS. The white boxes below represent the cause of symptoms, which in the case of CPPS, can be multiple. The higher the number of causes, the more severe the symptoms.  The gray boxes show the appropriate treatment options depending on the cause(s).1

 

 

A study of 100 men assessed and treated with the UPOINT system saw an 84% reduction in pain and disability. 2 CPPS can have multiple classifications including Psychosocial, Neurologic/Systemic and Tenderness of Skeletal Muscles.  These men healed with a combination of pelvic floor physical therapy, medication that targets nerves and talk therapy. By using the UPOINT system doctors can prevent the natural increased anxiety and pain escalation that these patients experience the longer they experience pain.  

Women with Endometriosis benefit by a team of providers

The BC Women’s Centre for Pelvic Pain and Endometriosis utilizes an interdisciplinary approach to treat women with endometriosis which resulted in 45% of their patients feeling “much better” in regards to pain and quality of life. Twenty three percent (23%) reported feeing “somewhat better” and only 20% reported feeling the “same”. These results were seen at the completion and at the 1 year follow up of the program.3

 

What does this interdisciplinary approach look like?

BC’s approach included education in the recent science of pain – how the brain is involved in sending pain signals as a form of protecting the body and how the brain can be retrained to lower or stop sending those signals. BC clients received pelvic physical therapy which involved manual therapy to release adhesions of muscles, fascia & intestines and movement/exercise prescription. They were also assessed by a gynecologist, received counseling (stress management), nursing care management and  BC’s team would meet to discuss their patients to ensure great outcome.

Create Your Medical Team

Women may not have access to nor can afford an extensive program like BC’s, however they can use the same approach with their own care. An experienced pelvic physical therapist can be the liaison between the medical doctor and all other healthcare providers as we tend to spend dedicated 45 minutes to an hour of interrupted time with our patients.  Being open to explore other treatment options such as cognitive behavioral therapy, acupuncture and nutritional guidance as this can also lower symptoms of endometriosis.

 

 

Pelvic Physical Therapy helps Cervical Cancer Survivors

 After being diagnosed and successfully completing cervical cancer treatment, we learned that 66% of cervical cancer survivors suffer from urinary issues such as leaking. Thirty three (33)% percent have a “storage dysfunction” which means the bladder sends the “Gotta Go” signal when it is only a quarter or half full, making women go to the bathroom too many times a day. Fifty (50) % have voiding dysfunction, which means there is left over urine in the bladder or the time it takes to pee is markedly increased.4

Pelvic physical therapy is an accepted treatment option for these women. Gentle manual release of the lower abdominal, inner thigh and pelvic floor/perineal regions and pelvic floor muscle training using biofeedback can significantly improve urinary incontinence, sexual function and quality of life for women who survived cervical cancer. Progressive use of vaginal dilators can help promote optimal healing of vaginal tissues after radiation.5

We want all women to feel good and confident about their body after cancer treatments and are thrilled to see this research.

  1. Nickel JC. C. Paul Perry Memorial Lecture “Clinical Approach to Male CPPS”. 2016.
  2. Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. J Urol. 2010;75(6).
  3. Allaire C. Innovations in the Evaluation and Care of Women with Endometriosis. 2016.
  4. Katepratoom C, Manchana T, Amornwichet N. Lower urinary tract dysfunction and quality of life in cervical cancer survivors after concurrent chemoradiation versus radical hysterectomy. Int Urogyn J. 2014;5(1).
  5. Lyons M. Women, Cancer and Pelvic Pain. 2016.

 

 

 

Online Educational & Empowerment Course for Women Suffering with PGAD &/or Vulvodynia

therapy

A unique program designed for a small group of women (15) who suffer with PGAD and chronic vulvar pain.  From the comfort of your home, you’ll have the opportunity to connect with each other in a safe environment, using private encrypted meeting platform (Zoom.us) while learning evidence-based therapeutic solutions for both your physical and emotional healing process. Each class is 2 hours held every 2 weeks for a total of eight(8) classes over a four month time period.

Health care experts from the fields of physical therapy and social work will be teaching this one of a kind program: Evelyn Hecht, PT, ATC and Eva Margot Kant LCSW-R . Their combined 35 years of experience will help you learn effective self-help tools for your mind and body while connecting and supporting each other on your journey to health.

Evelyn Hecht, PT, ATC owner of EMH Physical Therapy has been treating women with pelvic pain and sexual dysfunction for 20 years. She and her team of Doctor of Physical Therapists will be teaching self-care techniques and exercises that can be easily implemented into your healing routine.   The DPT’s will will answer questions about physical symptoms and exercises to the best of their virtual ability.

Physical therapy topics will include

  • Breathing and Meditation
  • Symptom Tracking to identify triggers and solutions
  • Pelvic Floor stretching exercises
  • Neuroplasticity – break the pain cycle

Eva Margot Kant, LCSW-R is a compassionate sex/psychotherapist in private practice with 15 years counseling patients with chronic and sexual pain. She helps clients navigate life’s transitions, address fears and questions about chronic illness/pain.  As a group therapy facilitator, she has worked with organizations including the American Cancer Society and National Multiple Sclerosis Society. Eva teaches courses on sexuality at Columbia University Graduate School of Social Work.

Talk therapy topics will include:

  • Fear
  • Avoidance
  • Mindfulness Based Stress Reduction (MBSR)
  • Educating the Clinician
  • Sharing Information to Loved Ones
  • Dating/Love Relationships

Additional Experts may be incorporated into the separate groups to share information and resources.

Course Details

Length of Online Group Class: 7PM to 9PM Eastern Standard Time

Start Date: Thursday January 19, 2017

2017 Class schedule:  1/19, 2/2, 2/16, 3/2, 3/16, 3/30, 4/13, 4/27

Number of Classes:  Eight (8) classes over a 4 month period January thru April 2017

Cost: Each two hour class is $40.00 per person.  You must register and pre pay for  all 8 classes, at a cost of $320 per person one week prior to the first class.  The price of attending one personal session with a counselor or physical therapist can range between $80 to $250 per hour, depending on where you live. This program offers you access to speak to and learn from a pelvic physical therapy professional with experience treating PGAD, vulvodynia and a clinical social worker seasoned in treating sexual issues and chronic pain for a total of 16 hours at a reduced rate of $320.

While Online Educational & Empowerment Course for Women with PGAD &/or Vulvodynia  does not substitute for individualized therapy, the evidence-based strategies, techniques and support you will gain without leaving the comfort of your home is a one of kind opportunity.

Online Educational & Empowerment Course for Women with PGAD &/or Vulvodynia welcomes a maximum of 15 attendees.

To Register: contact Cindy or Star at (212) 288-2242. Payment is accepted by check, no credit cards. Write check to “Evelyn Hecht, PT” in the amount of $320 and mail to following address:

Evelyn Hecht, PT,1317 Third Avenue,9th Floor, New York, NY 10021

Payment in full is due by January 12, 2017.

Space is limited, so please Sign Up Today

This course will only be conducted with a registration of 15 women.  If the course is cancelled, all monies will be refunded.

For additional questions, please email: info@emhphysicaltherapy.com or call  (212) 288-2242

 

 

A Pregnant Physical Therapist’s Top Tips for Your Healthy Pregnancy

Navigating the pregnancy literature on proper posture, exercise and sleeping alignment can be overwhelming and the guidelines presented are often not a “one size fits all”. Afterall, everyone’s pregnancy is unique. Below you will find some quick and easy tips that I utilized and found helpful throughout my pregnancy that kept me fit, aligned and pain free throughout my work day as a physical therapist at EMH.

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Chronic Pain and sexuality: How Eva Margot Kant, LCSW-R helps people navigate these issues

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(Image courtesy of Eva Margo Kant, LCSW-R)

The National Institute of Health (NIH) defines chronic pain as pain lasting more than 3 months and it affects more than 100 million Americans today.  As a pelvic floor physical therapist, I help patients with both acute and chronic pain, more specifically pelvic pain, on a daily basis. Due to the private nature of pelvic floor issues, sexual dysfunction, or bowel and bladder complaints it can be difficult for patients to feel comfortable talking about their symptoms.

The famous quote, “no man is an island,” rings true for healthcare providers who treat chronic pain as multiple specialists working together is more effective than one. I recently met with Eva Margot Kant, LCSW-R  with 12+ years of experience helping people deepen their self-esteem, navigate life’s transitions, and address fears and questions about chronic illness/pain which includes topics of sexuality and sensuality. Eva taught me some great perspectives on how she helps people heal their emotional/sexual wounds and how they can be a source of chronic pain.

Eva runs workshops about sex and disability, sex and aging and trains medical students how to talk about sex with their patients. Her goal is to help people “unpack their feelings” that are attached to physical pain and anxiety. Anxiety increases the output of the limbic system, the emotional flight or fight, and memory areas of our brain which results in pain.

Eva believes that “understanding how the body works is the key to understanding you”.  Her job is to help people understand what their sexuality is to them and to own how they view and understand it.  Eva believes that “the body always remembers.” She likened the reflexive blink of an eye that’s about to be poked to the feeling a woman with sexual pain feels if her partner demonstrates affection. The woman may fear that any show of affection may lead to sex which is painful for her, so she avoids this.

Eva’s goal is to help patients learn if some physical reflexive tightening may be due to thoughts involving shame, guilt, or embarrassment.  She helps clients decide when to disclose to a new partner about their chronic condition. She stressed the importance of self-care with their partner and to feel emotionally safe. People who have chronic pain/illness may go thru life as if they are “holding their breath.” Often times Eva finds that partners want to help, they just don’t know how. Demystifying chronic pain/illness allows partners to be supportive and an active participant in healing.

Eva’s upcoming book and course work, called “The Holy Trilogy of Sex (c),” guides patients and their partners in sensuality, sexuality, and intimacy; none of which are possible without communication, sensation, and connection. She encourages partners to engage in body mapping: offering each other a “menu” of intimate ideas that can promote togetherness without causing more pain.

As a Pelvic Physical Therapist, I invite my patient’s partner to a session to observe, learn, and understand what my patient is experiencing and teach the partner ways they can help. I work on the physical aspect of pain with my manual, movement and exercise therapies while Eva addresses on the mental and emotional aspects of chronic pain which leads to a more efficient outcome.

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EMH Team; Jennifer Jurewicz, Tova Laufer & Charissa Morrisroe with Eva Margot Kant, LCSW-R

If you have chronic pelvic pain consider receiving both physical and talk therapy to get your life back on track.  Consider visiting us at EMH Physical Therapy and Eva Margot Kant, LCSW-R if you are in the NYC area. Your pelvic floor with thank you!

Resources:
http://evamkantlcsw.com/
http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm

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EMH Physical Therapy Goes To Chicago for The International Pelvic Pain Society (IPPS) Conference on Chronic Pelvic Pain

                                     

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screen-shot-2016-10-07-at-11-40-39-amAt EMH Physical Therapy, we support an interdisciplinary approach to treating our patients. We are in constant communication with primary care physicians, urologists, psychologists, gynecologists and other healthcare providers to make sure all our patients have a strong team working for them

A team based approach to medical care has been shown to prevent medical errors (1), improve patient-centered outcomes and chronic disease management (2-4). 

This week the EMH team are packing our bags and headed to Chicago to attend the International Pain Societys annual fall meeting on chronic pelvic pain where well hear practitioners of various disciplines discuss advances and techniques in treating pelvic pain. Some topics were excited about exploring include the mind-body” connection, psychosocial aspects of pelvic pain, cancer and pelvic pain, cystitis, hormone treatments, vulvodynia and more. 

The International Pelvic Pain Society (IPPS) was established in 1996 with the goals of educating health professionals on how to diagnose and manage chronic pelvic pain and to bring hope to men and women who suffer from this pain by raising public awareness (5). 

Their website, pelvicpain.org, contains articles which can help to educate patients on a wide variety of conditions and find healthcare providersWe are excited to share the information we learn at IPPS conference with all of you when we return to New York City next week! Stay tuned.

P.S. Well be active on Instagram, @emhpysicaltherapy, and Twitter, @EMHPH, while were away, so keep up with us there!

Resources:

1. IOM (Institute of Medicine) To err is human. Washington, DC: National Academy Press; 1999.

2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: The chronic care model, part 2. Journal of the American Medical Association.2002;288(15):19091914.

3. Ponte P, Conlin G, Conway J, et al. Making patient-centered care come alive: Achieving full integration of the patients perspective. Journal of Nursing Administration. 2003;33(2):8290.

4. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Affairs. 2001;20(6):6478.

5. International Pelvic Pain Society. Pelvicpain.org

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A Pelvic Physical Therapist’s Approach to PGAD: Persistent Genital Arousal Disorder

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What’s your first reaction to this image? Laugh? Sigh and Roll your eyes at the tasteless joke?  Did you think: “How can anyone REALLY have this?”

What if you were experiencing sexual arousal or multiple orgasms on a daily basis, for hours at a time, day or night, with no one medication or method to relieve symptoms on a consistent basis?

What if you had the guts to talk to your doctor about the embarrassing (or what may even feel like devastating) symptoms and find out that your doctor either never heard about PGAD, or worse was a medical professional that did not believe you?

This is the suffering that people with PGAD or PSAS, Persistent Genital Arousal Disorder or Persistent Sexual Arousal Syndrome, experience and continue to endure. Sadly, the condition has even led some patients end their own lives as recently as a few months ago in 2016.

What  is PGAD?

Persistant Genital Arousal Disorder, a “monster sexual dysfunction”, as coined by Irwin Goldstein, MD (1) is a condition characterized by 6+ months symptoms of high levels of genital sexual arousal in the absence of desire (2). Genital arousal does not dissipate, with orgasm nor by medication alone.

PGAD sufferers describe their symptoms as intrusive, unwelcome, unpleasant and sometimes painful. Multiple, frequent disturbing orgasms (not pleasurable) occur spontaneously, at work, home, school and create tremendous embarrassment and anxiety, which eventually can lead to depression, frustration, and social withdrawal. It causes major stress for personal relationships. Seventy five percent (75%) of women with PGAD report moderate to high distress levels and report feelings of shame, isolation and suicidal thoughts (3).

PGAD: Subset of Chronic Pelvic/Abdominal Pain

PGAD has similar qualities, fluctuations, flares like and is starting to be viewed as a subset of chronic pelvic/abdominal pain.

Chronic pelvic/abdominal pain diagnosis is also made after 6 months of pain, burning, stabbing, cramping  + other symptoms involving 1 or more “private “areas: bladder (urinary frequency and bladder pain) bowel, (IBS) reproductive organs (endometriosis, vulvodynia), groin, buttocks and pelvic floor muscle pain.

As chronic pain takes 6 months to develop, the tissues that were involved at the initial onset of insult or trauma  may not be the main or only source currently producing chronic symptoms.  Rather, a highly sensitive brain/nervous system that is persistently on High Alert, “Danger-Danger!” mode perpetuates the symptoms.

PGAD Research

PGAD alone has not been researched extensively. We do not know the cause, the amount of women and men with symptoms, nor do we have effective, evidence based treatment – yet. With the push of some PGAD “warriors” and a relatively young organization, International Society of the Study of Women’s Sexual Health (ISSWSH), www.isswsh.org, research on PGAD is now being conducted. ISSWSH will have their annual conference in February 2017 where the PGAD Significant Interest Group will present state of the art research as well as testimonials from sufferers.

PAIN comes from the BRAIN

Chronic pain research has made amazing strides in the last 10 years due to the ability to incorporate MRI studies of the brain in all sorts of pain research. Our brain’s main job is to protect us. For example, we don’t keep our hand on the hot stove, or step down further onto the nail under our foot as the brain instantly weighs information coming from sensory nerves and makes a decision on how to react – i.e. PROTECT.  Pain is the brain’s response to incoming nerve reports.

Research shows hundreds of areas in our brain “light up,” or simultaneously become active when experiencing pain, including areas in the brain that process Sensation, Movement, Emotions and Memory. This knowledge helps us understand how a certain movement, emotion or even noise & light can lead to a pain reaction, especially if the brain is persistently on the faulty “Danger-Danger!” mode.

“Neuroplascity” is the ability for the brain to make new neural connections throughout our whole lifetime, to adjust, to change.

How can we help our brain change from being on a highly sensitive “Danger Danger!” mode to a more functional mode?

PGAD TREATMENT Step 1: EDUCATE yourself about Pain & Know your Triggers

Once medical diseases have been ruled out, the first step of effective treatment of PGAD is to change the brain from high alert to a healthy functional mode, by educating yourself on the science of pain (stay with me!)  and to write down all of your possible triggers for symptoms. Lorimer Moseley’s and David Butler’s Explain Pain (www.noigroup.com) and pain educational website www.retrainpain.org are great resources for pain/PGAD sufferers and their loved ones.

Write down all the actions (riding in a car, walking up stairs, showing affection to partner, etc.) and write down what fears/thoughts (not knowing the “cause” of pain, not being able to work, loss of partner, inability to care for children etc.) that stimulates PGAD symptoms (4).

Describe each symptom related to the trigger and rate the intensity of symptom on scale of 0-10. This will give you and your medical team a baseline to measure and monitor progress.  You have to be an active participant in your healing because each person’s cause of symptoms and how your brain reacts with pain/PGAD symptoms is unique.

PGAD TREATMENT Step 2: Find your T-E-A-M

Find your team of practitioners who understand PGAD and who will work with you. A Medical Doctor and a Pelvic Physical Therapist is a good start.

  1. MD/DO – for prescription medicine, trigger point injections, superficial nerve blocks, botox – treatments to  give the faulty nerves/brain activity a break
  2. Pelvic Physical Therapist – who is up-to-date with the recent pain research information, provides manual treatment and offers paced, gradual movement/exercise therapies to pelvic floor, abdomen, pudendal nerve and viscera – see below for more details
  3. Psychotherapist – to  address any possible childhood traumas/abuse issues that over 50% of PGAD sufferers experienced, as these experiences may be held (remembered) in their genital region  (see EMH Physical Therapy’s blog on Somatic Experiencing (http://www.emhphysicaltherapy.com/what-is-somatic-experiencing-and-how-does-it-heal-traumachronic-pain/1450/). Therapy can help manage the depression and anxiety that accompanies PGAD.
  4. Acupuncturist – to help lower the “high alert” brain/nervous system, releasing the “fight or flight” pattern or stimulating the sluggish, depressed pattern

PGAD TREATMENT Step 3:  Pelvic Physical Therapy

Physical therapy treatments are individualized as no patient is alike in their presentation – their symptoms of PGAD /pain may be similar, but the causes are different. Education about brain/nervous system and motivating patients to become active partners in their healing process has the best outcome.

There is no one “magic bullet,” no 1 medication or 1 technique for symptom relief. Receiving regular pelvic PT treatments plus doing a daily exercise/movement program (the brain loves movement!) is part of PGAD therapy. Treatments can include:

Manual Therapy – incorporating movement and awareness for both the external & internal muscles of the pelvis, abdominals, hips, fascia and skin; calming  the “fight or flight” reaction allows for improved blood flow, oxygenation and balances the nervous system.

  • strain / counterstain
  • myofascial release
  • connective tissue massage (aka skin rolling)
  • trigger point release
  • pudendal nerve glides
  • visceral mobilization

Biofeedback – to promote awareness of pelvic floor muscle tension and teach coordination training.

Breath and Meditation – deep diaphragmatic breath expands the front, sides, back of the ribs & abdominal cavity, relaxes the pelvic floor muscles, massages the internal organs and improves oxygenation to tissues. A simple 5 minute meditation where one focuses on the sensation of slow inhalation and exhalation calms the brain.

Desensitization Techniques:  Strategies to lower the high alert nervous system as used in treating Complex Regional Pain Syndrome, is applied to our PGAD patients with promising results.

Stretching and Stabilization Exercises to lengthen and strengthen, stimulate the core stabilizers, soften the pelvic floor. Cardiovascular exercises to improve general blood flow are performed daily at home. Exercises are paced and applied gradually as the patient reports responses in their symptoms.

Modalities such as TENS, Low Level Laser and use of dilators can also be used as part of our treatment.

Final Thoughts

PGAD, like chronic pelvic pain is complex and requires patience by both the patient and the practitioner. Results are best if patient and practitioner work consistently together and the patient performs daily home/self care exercises, paying attention to responses and slowly increasing the pace and challenge of the new movement. Neuroplasticity takes persistence and develops over time.

Further research in measuring the efficacy of all the treatment techniques mentioned above and the importance of a concurrent multi-specialty approach to PGAD still needs to be done. My team and I at EMH Physical Therapy will continue to help patients heal from PGAD.

References

1 Goldstein I. Persistent genital arousal disorder- update on the monster sexual dysfunction. J Sex Med 2013;10:2357-2358

2 Jackowich R, Pink L,Gordon A, Pukall  C. Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact and Treatment. Sex Med Rev 2016;1-14

3 Leiblum SR, Brown C, Wan J, et al. Persistent sexual arousal  syndrome: a descriptive study. J Sex Med 2005; 2:331-337

4 Butler D,Moseley L, Explain Pain, Noigroup Publications Adelaide, Australia 2013

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