This week guest blogger and esteemed LA colleague, Julie Weibe, PT talks about her conversation the brilliant Lorimer Moseley, Ph.D., B.App.Sc. Her posts sums up one of the reasons Steph and Liz asked Dr. Moseley to write the forward for their book, Pelvic Pain Explained.

Here’s what Julie has to say:

November 17th 2014

Well, we didn’t actually have coffee. But I think I may have been drinking coffee and done a spit-take when I opened my inbox to find that Lorimer Moseley had responded to an insanely long, and question laden email I sent him about a year and a half ago. Tweets had stirred up confusion in my mind over our new understanding of pain developed through the work of he and David Butler. Together, they have guided us into a new world where pain is now understood as a product or output of the brain. The brain is the decision maker as to whether or not a particular signal or input is dangerous enough to warrant a pain response or output. The brain evaluates and estimates the threat based on multiple areas of input: history, emotion, experience, etc., not simply how hard did you fall or how hard were you hit.

Moseley has pioneered the use of motor imagery to address chronic pain states. Providing new inputs through imagery to influence the brains output. In his book, Painful Yarns, he highlighted the story of a man injured in a bread factory accident that had a severe increase in his CRPS (Chronic Regional Pain Syndrome) every Saturday morning. They finally figured out the trigger for his routine Saturday symptom increase was the scent of his neighbor baking bread. Scent input triggered a perceived threat by his brain, which then ramped up and produced the pain output. Chronic pain, not to oversimplify, is an overprotective brain, misinterpreting input and using pain signals as a warning.

I attended a conference in which Lorimer and Paul Hodges team taught these concepts and others regarding the changes in the brain that occur with muscular training. I left with a loose grasp on the concepts, but was still working out the application of it clinically in my primarily non-chronic pain patient population, when the tweets began….

So I wrote Lorimer a note. Excerpts are below, Lorimer’s responses are bolded:

(JW) At the Fall conference, you talked about output, and Hodges about the influence and changes we see in the brain due to input, it seemed a perfect pairing of information. Input and output intermingled. Creating clinical models around that intermingling in multiple populations is the key and at the heart of why I am writing. So if you have a moment…I have some questions to help me communicate to my patients, and myself how this all gets translated into practice. The messaging in social media and blogs out there is getting a bit confusing, and lack practical steps for application.

People are tweeting stuff like this:

” Pain has never been shown to be caused by the length and strength of muscles. Lets stop telling patients otherwise. #solvePT #PainPT“

So if we follow the logic of this statement, then why do we bother to strengthen? Is that what we should be telling people instead, don’t bother, b/c the evidence shows strength has nothing to do with resolution of your pain? That doesn’t fit with my interpretation of the blend of your work with Hodges work. But perhaps I am missing something, which is why I am writing. In terms of the all important emotional piece, is the capacity to take action in your pain through say exercise an empowering positive emotional input?

(LM) I would say it is, but that does not stand in contradiction to the statement from twitter above.

If for example, the injured tissue involved is say a nail hammered into the back of a patients hand, and the patient hits the hammer over and over again throughout the day….shouldn’t we do something about that, get the patient to stop that? And of course call for a psyche consult. A tongue and cheek way of asking do we run the risk of throwing the baby out with the bath water by not appreciating neuromuscular and mechanical inputs, too (repeated through movement patterning or faulty alignments or bad habits)?

Well, of course we should do something about that. I think you are not thinking of an actual patient here, BUT, you might be thinking of a patient you consider to be continually provoking a nociceptor in the tissues. Then of course you should fix this. The tricky thing is that it can be difficult to demonstrate the nail in the hand effect and many of our tests are not quite as specific as we thought. Still, your argument stands I reckon.

Poor motor control, alignment, shearing forces, weakness, etc all of our previous theories about why we experience pain, do they still hold some merit if essentially they are metaphorically hammering the nail in a little bit deeper each day? If graded motor imagery is a way to change input to the somatosensory cortex to create a change in the brains output, can form, movement, alignment, muscle recruitment strategies, ANS involvement, etc also be inputs to change the brain’s outputs? If not, then why do peripheral treatments seem to improve pain (or reduce the brains interpretation of threat)? Hodges work leads me to believe we can actually change the brain with some of our training ideas.

I think there is very, very good evidence that we can change the brain by training. Paul’s work adds to a very large body of evidence in this regard. But what has really changed is Paul’s interpretation of that work, which I think is a sensible change, is that the training might be having its main effect in the brain, rather than in the forward shift, by 20ms, of contraction of a particular – not very high impact biomechanically – muscle. The thing that is difficult is interpreting it all – motor control training is not simply that – it is also a conceptual package, graded exposure, cognitive therapy, behavioural therapy. That M1 (Primary Motor Cortex) changes is lovely and interesting, why it changes is PROBABLY due to the contraction, why it changes functionally is very difficult to know, and whether it relates to pain relief is impossible at the moment to work out.

Is there a distinction between how the brain produces “regular” old pain (like a nail driven into your hand) vs phantom pain in that same hand after the nail hammering behavior has stopped? Should their clinical programs be different?

Yes. In the former the clinician should reason honestly and in an informed way and end up removing the nail, but the latter, the clinicians should also reason, there is no nail to remove so the treatment should be different. Both treatments might contain common elements of course.

Isn’t there a way of communicating this so that both inputs and outputs are considered and have some value (input and output intermingled)? Is it just how we are communicating causality? Or am I just lost??

You are clearly searching and I LOVE this. I hear myself in some of this. The questions that I found most difficult to answer without learning more, and then more etc., etc. (the old the more I know the more I realise I don’t know etc. thing) – are questions like ‘did I ONLY change form? Recruitment? Alignment? Etc? or did I inadvertently do many things.

Again, my questions in part are born out of a lot of the social media trickle down from your work, particularly a lot of statements that I think communicate throwing the baby out with the bath water as we try to create clinical programs. I am not trying to create the message, but came to the source to clarify for those of us in the trenches trying to integrate the info in multiple patient populations. I think (hope?) I am not alone trying to decipher it.

I don’t reckon you would be. I am also trying to work it out. A common misinterpretation of my work is that I think that there is no point thinking about primary nociceptive input in people with pain. I do not think this and I do not think I would ever have said this. What I do think is that there is compelling evidence that the relationship between pain and tissue damage is seldom simple and is sometimes very tenuous indeed.

Thank you for your time, I really appreciate it.

and I yours.

Awesome…right?

I was so grateful for all of Lorimer’s insight, and his continued kindness in HOW he delivers his message. Please take note bloggers, and social media users, think WWLD before you tweet or blog. I had some great takeaway’s that have guided my own practice and teaching since this conversation a year and a half ago. First, I really liked that we can earnestly say, that we aren’t really sure why a lot of what we do works, but we are trying to figure it out! And just because we don’t understand the why, it doesn’t negate that our interventions can bring change and help. I can live in that uncomfortable unknown…how about you?

Also, when we change a piece of the puzzle through a peripheral intervention, we likely change multiple inputs at once. It is hard to point to the one thing that ultimately caused the change in pain…that is what our old idea of pain as input promoted and what we can no longer support in the new pain paradigm.

Lorimer’s final point has provided the greatest clarification for me as I slog through the social media pontification and pundits. More importantly as I apply these ideas clinically. “A common misinterpretation of my work is that I think that there is no point thinking about primary nociceptive input in people with pain. I do not think this and I do not think I would ever have said this.”

And how comforting is it that he is “still trying to work it out”, too.

Thanks again to Lorimer. He is a great communicator and teacher, moving us all forward!

To learn more about the new pain science paradigm, check out: Lorimer’s Ted Talk Explain Pain and Painful Yarns.

And if you haven’t already, SUBSCRIBE to this blog (up top, to the right, under Stephanie’s photo!), so you can get the weekly blog update in your email inbox, and follow us on Facebook and Twitter where the conversation on pelvic health is ongoing!

educator :: advocate :: clinician

Julie Wiebe, PT has over eighteen years of clinical experience in both Sports Medicine and Women’s Health. Her passion is to revolutionize the mainstream perception of the pelvic floor. She pursues this through innovative education, rehabilitation and return to fitness/sport programs that promote pelvic floor/diaphragm integration into exercise and manual therapy programs. Julie shares her evidence-based approach through one-on-one care, community seminars, professional continuing education programs worldwide, online professional mentoring and webinars. Course participants have successfully integrated the pelvic floor into programming for a variety of patient populations including sports medicine, orthopedics, women’s health, pediatrics and adult neuro.

For more information on Julie, please visit her website.

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.