By Kim Buonomo, PT, DPT, PHRC Lexington
Here at PHRC we often write our blogs weeks in advance. Kim wrote this post shortly after #IPPS2019 in October. Little did we know when she wrote it how relevant it could be for the current times here in 2020. Back in October we did not see this pandemic coming and we hope her informative posts help whatever challenges you may be facing today. We will all get through this, together. From Kim:
“Thinking back to when I wrote this article in November, I realized how much has changed in the world in only a few months. It can be really overwhelming to think about how our day to day lives are so different since COVID-19 started. We have all been spending more time at home, and I admit that I’ve been struggling to find the motivation even to do tasks that I love. It’s hard for us all to be away from our friends, family, and hobbies.
Today, I took another look at this article and re-imagined self-efficacy in the post-COVID world. How do we change self-efficacy? Educate ourselves, observe others with similar experiences, and use our own experiences. This seems pretty similar to the advice I’ve heard on the news for strategies to manage stress and mental health in this time. By educating myself about COVID-19 (in small doses to avoid media overload), staying connected to my friends and family on the phone and on zoom, and using some graded exposure by forcing myself to do “small” things like shower, put on real clothes, and keeping my routines as normal as possible, I’m getting back to myself and building self-efficacy that I can do everything in my control to stay safe, even if that means staying home unless it’s absolutely necessary to go out (which is very hard for an extrovert like me!). These are hard times for us all, but we will get through them together. We may be apart, but we are not alone, and we got this! Stay safe and healthy, my friends!”
Today’s blog article is about what I learned at the International Pelvic Pain Society 2019 conference in Toronto. Between exploring the Great White North and getting to network with my amazing colleagues after lectures, I left IPPS feeling like I could do anything… which ties in perfectly with my blog post today!
At Sunday’s post-conference, Alison Sim and Carolyn Vandyken presented about the role of physical activity in improving self efficacy. What’s self efficacy, you ask? It’s the confidence that a person has in their own ability to achieve a desired outcome. Studies have shown an association between higher self efficacy and lower levels of pain and disability in patients with chronic pain.
The basic concept is that if I’m confident that I can accomplish a task, I’m generally more likely to be successful at it. This is huge for our patients with chronic pain.
How do we change self efficacy? There are three strategies we discussed.
- Education- Look no farther than our amazing website and the book Pelvic Pain Explained for a ton of information! I am always educating my patients on what I think is contributing to their symtpoms and how PT can help. Knowledge is power!
- Observing others with similar experiences- There are countless support groups online for various conditions, and here at the Pelvic Health and Rehabilitation Center we share success stories from some of our patients to show that no one dealing with pelvic pain is alone and people recover!
- Experience- I’m going to talk about how to improve self efficacy through experience by applying graded exposure techniques.
Graded exposure training is when you take a large goal and break it into smaller, more manageable tasks. This allows you to participate in the goal activity in a way that you can control and is less likely to become overwhelming. Taking small, successful steps helps improve confidence about the task and sets you up to achieve bigger goals.
Personal story: I used graded exposure to help me start running and I finished my first 5K this Thanksgiving! I made a plan and used small steps to help me achieve my goal and feel successful. Mini-goal one wasn’t even physical… It was buying my workout clothes (a very important step!). Mini-goal two was walking a mile. Mini-goal three was walking a 5K. Mini-goal four was alternating jogging 30 seconds for every five minutes that I walked. I kept increasing my run time and decreasing my walk time to build up my tolerance slowly. Months after my training started, here is a picture of my sister and me at the end of the race!
Feeling Accomplished!
Two things that I did well in this example were 1) my use of graded exposure, and 2) setting attainable goals. If I had tried to run a 5K without stopping on day one of my training, or if my goal was to run a marathon next week, I wouldn’t be setting myself up for success and my self efficacy would have definitely taken a hit when I wasn’t able to meet my goals!
So let’s give an example for pelvic pain. (I hear this one a lot!)
Let’s say that your pelvic pain acts up after you sit for five minutes. If you went to sit for eight hours at work tomorrow, you would be in a ton of pain! You wouldn’t be able to pay attention. You wouldn’t be productive. You might feel like you need to quit your job because sitting for eight hours is such a big goal that there’s no way you could ever achieve it. I mean, you can’t even sit for five minutes! You can’t go out to dinner with your friends because sitting in the restaurant is too much to tolerate. (Don’t even get me started on those hard restaurant chairs that provide no support!) So suddenly you have no job, no friends, and no quality of life.
Slow down, there… Take a deep breath… Reframe those goals and try graded exposure.
Five minutes is your maximum sitting time without any help/support/cushions. Okay. So, mini goal one is to try to sit for four minutes, and use a cushion to improve your chances of success… That ends up being successful, achievable, and not painful. Great! So let’s try sitting for four and a half minutes. Now try for five… five and a half… six… Another mini-goal might be trying to sit for a few minutes without the cushion. See how you can build your way up by using those smaller steps? I’m not saying that there will not be discomfort through this process, and I can’t promise that you’ll have no pain after sitting through the work day, but the point is to use small goals, to move slowly, to progress when you’re ready, and to build your confidence in your own ability to function. If sitting for a work day is too much, make mini goal one be sitting for a coffee with a friend. Maybe mini goal two is sitting 30 minutes for a TV program. Maybe mini goal three is sitting for dinner. Before you know it, sitting to watch that two hour movie or trying to survive the work day won’t seem so intimidating!
For the record, self efficacy is about how you feel about what you can do. So while these strategies are helpful in improving your confidence, it’s not designed to do much about your pain. There’s no guarantee that you’ll be completely without pain at the end of the day (just like my example is no guarantee that I’ll be able to run a marathon). But self efficacy does have significant associations with impairment, affective distress, and pain severity within chronic pain samples. This means that patients with higher self efficacy can typically function better despite their pain and limitations. And as a PT, function is what I’m all about! If you’re struggling with low self efficacy and anxiety around movement, it may also be a good idea to work with a pain psychologist. Your PT will suggest a referral for you if they think it is appropriate.
All the best, and know that you got this!
Additional Resources:
Check out Morgan Conner’s blog Tips on Reducing Stress During COVID19
Check out Elizabeth Akincilar’s blog on Mindful Meditation
And Meditation for Pelvic Pain Relief
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.