As you may have noticed, IPPS is a pretty big deal around here. Every year, our PHRC physical therapists attend the International Pelvic Pain Society’s annual scientific conference. Additionally, Stephanie Prendergast has been on the IPPS Board of Directors since 2003, and was the first physical therapist to serve as president in 2013. Since our staff commits so much of their time to continued education, and as the field of pelvic pain advances, we wanted to recap what our clinicians took away from this year’s IPPS conference.
First, some background information…
The meeting is broken down into four sections. The first day is a “Basics” course, intended for the general medical professional who is interested in pelvic pain, but not regularly treating it. The topics span how the general gynecologist, urologist, psychologist, primary care physician, and pain management specialist can identify pelvic pain syndromes and direct the patient towards a solution.
Following the basics course, the next two days consist of the “Scientific” session, where the latest management strategies are presented for medical professionals who regularly manage people with pelvic pain and want to learn about the latest medical advances. It is during this time that our clinicians are able to attend lectures ranging from various topics and areas of expertise.
On the final day, IPPS hosts a post-conference course. The topic this year was a panel, their topic titled “Talking about sexual health and function with your patients: a healthcare professional’s guide”. The expert speaker panel consisted of Hollis Herman, DPT, OCS, WCS BCB-PMD, CSC, IF, PRPC Alexandra Milspaw, PhD, LPC, and Tracy Sher, MPT, CSCS. The speakers did an excellent job helping providers increase their competency discussing sexual challenges with their patients.
Alright, now on to our clinician’s summaries:
Liz Akinicilar- Rummer, MSPT, PHRC Waltham:
Liz gave a lecture at the basic’s course titled “Evaluation and treatment of musculoskeletal causes of pelvic pain”. Click here to view her presentation.
Shayna Reid, PHRC Los Angeles:
The basics day at IPPS provided a comprehensive review of the many factors, physiological, psychological and musculoskeletal, that are components of pelvic pain. I enjoyed the flow of the sessions and found that they built nicely upon each other. Starting the day with a reminder of how pain messages are transmitted in the body, then bringing in the psychology behind pain and next seeing specific diagnoses and musculoskeletal treatment provided a good foundation for understanding and treating pelvic pain. What I learned at the basics day at IPPS will translate into patient education on the science behind pain.
Stephanie Prendergast, MPT PHRC Los Angeles:
Stephanie lectured with Drs. Conway and Jordan on Interdisciplinary Management Pudendal Neuralgia. Click here to view her presentation.
From Malinda Wright, DPT, PHRC Los Gatos:
Alexandra Milspaw, PhD, M.Ed., LPC gave a wonderful lecture Saturday morning titled Training the Brain to Heal Painful Habits. Alexandra started her presentation off with an imagery to demonstrate the power of the brain. She had us close our eyes and imagine ourselves driving. How does the body feel as an aggressive car speeds by? Now, imagine in the speeding car is a father rushing his child off to the hospital due to a severe asthma attack. How does the body respond to that knowledge? Alexandra stated, “Not only can we change our brains just by thinking differently, but when are truly focused and single-minded, the brain does not know the difference between the internal world of the mind and what we experience in the external environment. Our thoughts can become our experience.”
Cognitive behavioral therapy (CBT) and mindfulness therapy are treatments aimed at retraining the brain. Alexandra defines CBT as, “Changing the thoughts we entertain throughout the day via behavioural interventions.” It is altering our thought patterns and beliefs. Mindfulness is, “The skill of training the brain to be aware of our experience in the present moment.”It is being aware of the cognitive response within the moment. Both therapies are helpful in treating pelvic pain, however Alexandra states there is a greater effect and a decreased rate of relapse when the two therapies are used together.
In her presentation, Alexandra stated chronic stress, pain, and trauma can actually change the brain’s physiology. It can decrease the size of the hippocampus, contribute towards a hypervigilant amygdala, and create a thinning of the cerebral cortex. These changes can create memory loss, exacerbate the flight-or-fight mode, and create slower processing. Neurotherapy interventions, such as CBT and mindfulness based therapy, can help resolve these changes by creating new neural pathways. This is done through habit modification. Alexandra defines a habit as, “An unusual way of behaving; something that a person does in a regular and repeated way. Habits are behavioral, emotional, or cognitive.” Some habits are helpful and some are painful. Examples of painful habits given by Alexandra are: negative self-talk, i.e. “I have a bad back.” “I can’t handle this.”; future based language, i.e. “My body will heal when…”; and guarded movements or lack of movement that is fear-based. Changing a painful habit includes being mindful to the cue/trigger for that habit. Triggers of a habit may include environment, social reinforcement, smells, sounds, and lights. Once the trigger has been identified, an intervention is needed. Alexandra stated, “It takes a habit to alter a habit.” Having the willpower to change a habit is not enough. She reported we need to have a reward system. Rewards influence our emotions and outcomes via neurotransmitters and neuropeptides. Neurotransmitters influence our emotions and neuropeptides influence our hormones, for example endorphins. Endorphins help to inhibit the transmission of pain signals and they help us to feel good. Alexandra stated the emotional state we are in can shift our outcome. The Prefrontal Cortex in the brain is also involved in the formation of new habits. Creating vision boards, reviewing one’s successes, and creating a daily to-do list are examples given by Alexandra to help access the Prefrontal Cortex and create a new habit. She reported it takes approximately 21 days to grow neural nets to change a habit. Practicing mindful awareness leads to cognitive and behavioral interventions, which leads to developing new habits.
I now have a better understanding of the importance of CBT and Mindfulness therapy, especially with treating pelvic pain. Her lecture has inspired me to research more into this field and to refer appropriate patients when necessary.
From Allison Romero, DPT, PHRC Berkeley:
Summary of Function Nutrition for Chronic Pelvic Pain: Evidence- Based Treatments for Success by Jessica Drummond, MPT, CCN, CHC Founder, The Integrative Pelvic Health Institute
I was lucky enough to get to hear Jessica Drummond the Founder and CEO of the Integrative Women’s Health Institute Fall 2015 talk about functional nutrition. She brought up some great tips for managing some issues that could be contributing to persistent pelvic pain.
-She laid out evidence to support increasing dietary omega-3 fatty acids, reducing sugar, and including supplements such as lycopene and zinc.
-If the gut is a problem including fermented foods, such as sauerkraut can actually be beneficial. I also wanted to include that there is some research suggesting that eating pistachios (who doesn’t love pistachios?) can improve good bacteria in the gut. Some probiotic strains may be helpful-however this is something that should be discussed with a dietician/physician before starting.
This was a great topic to bring light to at IPPS this year and already I have been able to make some suggestions to patients that have helped to improve their symptoms!
From Melinda Fontaine, DPT, PHRC Berkeley:
Richard E. Harris, PhD of The University of Michigan spoke on The Impact of Acupressure on Cancer Symptom Cluster: Molecular Mechanisms of Management. Patients with cancer and patients with chronic pelvic pain have a similar cluster of symptoms which include fatigue, disturbed sleep, depression, anxiety, altered cognition, and pain. Of these symptoms, fatigue is the most bothersome according to patients. Increased glutamate and creatine in the insula of the brain facilitate higher levels of fatigue by opening calcium channels and participating in the citric acid cycle and ATP production respectively. Glutamate can also enter the system through one’s diet in the form of monosodium glutamate, or MSG. Patients with pelvic pain or endometriosis were found to have higher levels of insular glutamate. Self-administered acupressure decreases insular glutamate and creatine and improve symptoms. Acupressure was well-tolerated, brief (15-20 minutes), low cost, easy to learn, low risk for side effects, and can be performed as frequently as needed. This makes acupressure a feasible and effective treatment option for patients with chronic pelvic pain and fatigue or cancer related fatigue.” My take home message was that patients can learn to do acupressure techniques on themselves to relieve chronic pelvic pain and fatigue.
On Friday and Saturday, expert roundtable lunch discussions covered 20 topics. Stephanie and Irwin Goldstein, MD led a table on Persistent Genitall Arousal Disorder.
On Saturday morning, Casie Danenhauer, DPT led a course teaching medical professionals how to integrate yoga into their clinical practice. 
“My most accomplished moment of IPPS 2015 was getting a room full 40 physicians, PTs, and other allied health professionals to “OM” with me. The best part was that I supported it with research! A couple weekends ago I had the great pleasure of sharing my yoga practice and yoga for pelvic pain class with a group of very special practitioners at the IPPS meeting. I was excited (and a little nervous) to see the room fill with early birds unrolling their yoga mats at 6:15am on a Saturday morning! After sharing a little bit about my background (pelvic floor PT/ orthopedic PT background/ 6 years of yoga teaching experience) I set forth on sharing my intention for the class: First, I wanted to share and teach the physical postures and specific verbal/tactile cues that I have found to be most beneficial for pain management and which facilitate the most relaxation of a hypertonic pelvic floor. See my yoga blog for examples of these poses. Second, I aimed to share breathing techniques (including “OMing”) that have been shown to facilitate parasympathetic activation and calming of the nervous system. Third, I wanted take the class through a guided meditation specifically targeting the pelvic floor.
Based on the excellent feedback after class, I’m happy to say that my intentions were fulfilled and there is now a group of dedicated practitioners who walked back into their clinics on Monday with some new “yoga tools” to share with their patients!
From Rachel, PHRC San Francisco:
Dr. Jane Leserman discussed the impact of abuse/trauma on gastrointestinal(GI)and chronic pelvic pain. Individuals with a history of abuse or trauma are more likely to develop GI dysfunction or pelvic pain. Many individuals develop both a GI condition and pelvic pain as Leserman reported that 35% of people with IBS have pelvic pain and vice versa. Leserman explained that people with a history of abuse were shown via functional MRI to have altered brain activation in areas that are involved in pain sensitivity and pain processing. These patients also demonstrated decreased activation in areas of the brain associated with pain inhibition and down regulation of emotional arousal. This date may explain why patients with a history of trauma are prone to pain syndromes. Although, many patients have pelvic pain or GI dysfunction without a history of sexual abuse or trauma, Dr. Leserman’s lecture brings up the point that pain syndromes involve more than just the area the pain is located and the importance of looking at the brains impact on a patient’s presentation.
All in all, IPPS was very informative. Next year, the conference will be in Chicago, October 13 -16, 2016. Additonally in 2017, IPPS is hosting the Third World Congress on Abdominal and Pelvic Pain in Washington, DC, October 12 -15. We hope to see you there!
Be Well,
Gabriella
Gabriella originally hails from Monterey, California and attended San Francisco State College where she majored in International Relations. With four years of experience, Gabriella ensures the wheels go round at PHRC as the Senior Administrator, and Social Media Strategist. When she doesn’t have her nose in a book, Gabby enjoys writing, community outreach, and a good run with her office dog Neziah.
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.