By Sara Stuart

     Pelvic pain can present itself in a number of ways. For Amanda* (name has been changed for anonymity), her symptoms began with her first menses. “I remember being on a cruise to Mexico with my mom and trying to learn how to put a tampon in for the first time. I spent the time either crying or laughing in 5 minute intervals until after an hour I gave up altogether.” Despite the frustration she felt, Amanda was able to successfully insert a tampon three years later, a huge milestone for her. Unfortunately, as is the case for a large amount of people suffering from pelvic pain, Amanda’s symptoms changed over time- and for the worse. “However, it wasn’t until I was a senior in high school that I developed chronic pelvic pain that wasn’t associated with my cycle. I had developed a very specific hot, bloated, localized, shaped like a ball, pain in my lower right abdomen. The pain was constant and things like stretching, coughing, and sneezing made it worse. Then I noticed that the pain started showing up on the other side of my abdomen and the cramps that accompanied my menstrual cycle were now present 3 out of the 4 weeks of my cycle.“ Amanda’s new onset of symptoms stayed with her for quite some time and she began to seek treatment to alleviate her symptoms.

 

     As can often be the case, Amanda had difficulty getting onto the right care plan. “It unfortunately took me several years, several doctors, and several misdiagnoses before I was accurately diagnosed.” Amanda wasn’t put on the right track until one of her friends pointed her in the right direction, to a gynecologist with knowledge of pelvic pain and treatment options. Within the first minute of Amanda’s gynecological exam, she received a diagnosis and options to help her pain! Amanda was ecstatic that she had finally found someone who understood her pain and, more importantly, had a plan to help her alleviate her pain.  it wasn’t until Amanda relocated to the San Francisco bay area that she found PHRC. Amanda’s doctor referred her to a colleague who knew that Amanda’s symptoms could be alleviated through pelvic floor physical and occupational therapy; the colleague quickly referred Amanda to PHRC.

 

     Amanda knew that PHRC was the right place to help her from the beginning. “I loved my first phone call with PHRC. I was really excited that I was speaking with an agency who knew what I needed, because I sure as hell didn’t. The woman I spoke with was really helpful and super friendly. I had a lot of silly questions that she answered without judgment. “ Often, new patients to PHRC are confused, hurt, and misguided from navigating the healthcare industry themselves. These prospective patients often have a wide variety of questions, mostly aimed at making sure that they have found somewhere that can help them to find the treatment best for their pelvic pain or dysfunction. The path to recovery for pelvic pain and pelvic dysfunction patients is hardly ever easy to find. To help those suffering from pelvic pain and dysfunction, Stephanie and Liz have written a book about treatment options for pelvic pain and dysfunction to help others find the care that they need (click here for a sneak peak at the book, “Pelvic Pain Explained”, which will be released early 2016).  Before her first appointment, Amanda’s treating therapist, Malinda Wright, MPT, emailed Amanda to introduce herself and to invite her to ask any questions that she might have. When the day came for Amanda’s first appointment, she recalls that,  “… (Malinda) was very warm and inviting”, Amanda recalls of Malinda during her first appointment. Peace of mind came almost immediately as Amanda quickly realized that “… Malinda knew exactly what the cause of my pain was and it’s such a relief that after so many years of trying without success to figure out my problem that Malinda knew how to help me from day one.”

 

With a stressful full-time job and a full calendar as a graduate student, Amanda has high stress levels in her life. “I’ve learned that, like most people, when I’m stressed I tense up my muscles and I find that by the time I get home and I’ve processed my day my pain can be pretty bad.” Using the tools and techniques that she has learned from Malinda Wright, MPT at PHRC, Amanda is able to take time out of her day to relax and de-stress before going back to work.

 

     As with any journey, recovery from pelvic pain often isn’t a straight line, flare-ups can occur (read here to learn about what to do during a flare). “I definitely have flare-ups”, Amanda recalls.  Despite the occasional set back from a flare, Amanda’s quality of life has vastly improved“That being said, my life is actually functional now! Before my weekly visits with Malinda I would never have been able to physically sustain this level of stress at my job so I am happy to have the occasional flare up instead of the constant debilitating pain.”  Amanda has some wise words for anyone suffering from pelvic pain or pelvic dysfunction:  manage stress wisely. Amanda advises, “…that you take care of yourself by eliminating as much as stress as you can. Hopefully you’ll notice a difference in your pain level.“ 

 

Thanks Amanda! Wishing you the best on your journey to recovery from your pelvic pain.

 

Kind Regards,

Sara

 

Sara Stuart graduated from UCLA in June 2013. With a life-long passion for helping others, she assists the Los Angeles office with all of their administrative needs. Sara is also an avid writer and reader and contributes to various online publications in her free time.

 

 

 

Earlier this year Liz and I completed our manuscript for our book, Pelvic Pain Explained. Writing it was a challenging process, to say the least. We are hopeful that this book will raise awareness about and help to demystify pelvic pain. By sharing our combined clinical experience we want to help people with pelvic pain and their providers develop the skills to better understand each individual case. After treating thousands of patients, we know thorough clinical reasoning, ongoing communication, and persistence works. In this week’s blog, we are excited to share the introduction to Pelvic Pain Explained. The book is scheduled to be released in January 2016. Stay tuned to PHRC’s social media for pre-sale information!

 INTRODUCTION

Anyone with persistent pelvic pain knows that getting on the right treatment path is often half the battle. The main reason for this is that persistent pain in general is a poorly understood medical condition compared to other diagnoses. So at the end of the day, many people with pelvic pain—while in the throes of dealing with symptoms that often wreak havoc on their daily lives—are struggling to find answers. They’re not alone in their frustration. Medical providers are often equally at a loss as they find themselves up against a lack of available research and education. The good news is that in recent years, a growing group of physicians, pelvic floor physical and occupational therapistss, and psychologists are becoming actively involved in the research and management of pelvic pain syndromes. But while the landscape for treatment is improving, for many people dealing with pelvic pain getting a correct diagnosis and the appropriate treatment continues to be an uphill battle. We wrote this book to address that challenge. The purpose of this book is to act as a guide for patients and providers as they navigate the many complexities associated with the pelvic pain treatment process. As clinicians, we have a combined 30 years of experience both treating patients and educating providers. Over the years we’ve treated thousands of patients from one end of the pelvic pain spectrum to the other. As a result, we’ve learned what works (and what doesn’t) when it comes to successfully treating pelvic pain. In the pages of this book we share that knowledge.

What is this book about?

At its heart, Pelvic Pain Explained is an exploration of pelvic pain from how patients get it to the challenges both patients and providers face throughout the treatment process to a discussion of the impact that an “invisible” condition has on a patient’s life and relationships, and much more. Patients will walk away from this book with a complete understanding of pelvic pain, from how it occurs to the variety of symptoms associated with it to how the impairments and contributing factors that are causing their symptoms are uncovered and treated.

In addition, the book will provide patients with an understanding of all of the current treatment options available to them. Those who develop pelvic pain can find the path to treatment frustrating and unsuccessful, oftentimes because they’re attempting to work within the framework of recovery that they’re used to; one in which they go to the doctor, maybe have some diagnostic testing done, then get a very specific diagnosis that dictates a very specific mode of treatment. This simply is not the path to recovery from pelvic pain. Pelvic pain is a health issue that often crosses the borders between medical disciplines because of the many different systems that can be involved. Gynecologists, urologists, gastroenterologists, orthopedists, pain management specialists, psychologists, acupuncturists, among others, all have a role to play in treating the pelvic floor. In addition, for recovery to occur, the patient must be an active participant in the treatment process. This book provides patients with the guidance they need to navigate this unfamiliar treatment framework thus placing them on the right path to recovery. For providers, the book demystifies pelvic pain. In addition, it contains information that will help them troubleshoot in situations where patients either cannot tolerate or are unresponsive to a particular treatment approach. As the information in these pages will prove, when a particular treatment doesn’t work, another option exists.

The book is organized into three parts. The goal of the first part of the book is to give readers an overview of pelvic pain. Toward that end, the chapters in this section discuss the symptoms, causes, and factors that contribute to pelvic pain as well as explain the role of the neuromusculoskeletal system in the condition. Part two of the book lays out the path to recovery from pelvic pain. This part of the book provides guidance on how patients can assemble the best team of providers, takes readers through the pelvic pain PT process, and provides a complete overview of the many different treatment options available for the condition. In addition, part two covers pelvic pain related issues concerning pregnancy and sexual health. Part three places patients in the driver seat of their recovery by giving them actionable information. At-home self-treatment strategies, tips on communicating with providers and staying fit while in recovery as well as practical tips for day-to-day living are among the topics covered in this section.

How will this book help me through treatment?

This book aims to provide a stepping off point for those with pelvic pain to begin to navigate the treatment process. Toward that end, it provides answers to the many questions they have as they stand on the threshold of their treatment journey, such as: How did I get pelvic pain? What is the best way to treat pelvic pain? What are my treatment options? How do I find qualified and knowledgeable providers? How do I navigate day-to-day life with pelvic pain? In addition, it guides patients through the many complexities that arise during the treatment and recovery process such as what to do when treatments don’t work; how to improve communication with medical providers; how to remain calm during a flare; and how to cope with the many emotional issues that crop up during the recovery process, among many others.

Our main intention in writing this book is to streamline the treatment process for both patients and providers. Oftentimes, patients fall into treatment traps, such as wasting time and money on unnecessary procedures that may make their condition worse. Just as often, they don’t fully understand the treatment modalities they sign up for, so they’re not compliant, and for that reason, they don’t get better. For all of these reasons, in this book we don’t just present information about pelvic pain; we combine it with the comprehensive assessment skills we’ve gained from our own experience as clinicians and educators. So by reading it, both patients and providers are not just informing themselves about pelvic pain, they’re also beginning to think critically about the issues that surround the treatment process thus better arming themselves for decision-making along the way.

Can reading this book help me get better?

Yes. For one thing, research shows that educating patients about the physiology behind their symptoms reduces stress and in return that reduces pain.The information in this book will demystify pelvic pain for readers allowing for reduced stress and anxiety surrounding their pain. Also, the book will help patients get better by helping them to navigate the pelvic pain treatment process. It will help direct them to the right providers, allow them to make educated treatment choices, alert them to the right questions to ask, and in general, enable them to be unintimidated by the treatment process. At the end of the day, all of this will help patients get better.

Why did PTs write this book?

Physical therapy, specifically, is becoming the standout of the new interdisciplinary treatment approach to persistent pain in general. In fact, in her best-selling book on persistent pain, The Pain Chronicles, author, Melanie Thernstrom advises readers to commit to giving PT a try. “Truly, if you take any advice from this book, take this one,” she writes. And New York Times author, Barry Meier, in his controversial article “The Problem with Pain Pills,” passes along similar advice. PT, along with an interdisciplinary treatment plan, is the way to go, he writes. And to further validate the central role that PT now plays in the treatment of persistent pain, lawmakers in all 50 states and the District of Columbia, have some form of “direct access” law in place allowing patients to have direct access to PTs without a physician referral or prescription. This emphasis on PT is especially relevant when it comes to the treatment of pelvic pain. That’s because PT is a main line of treatment for the majority of pelvic pain patients. Therefore, it makes sense for THE definitive book on navigating pelvic pain to be written by PTs…

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When Liz and I met each other a decade ago we instantly bonded over our shared passion for helping people dealing with pelvic pain. Spurred on by our desire to improve the standard of care for this patient population, we ultimately partnered up and opened our physical and occupational therapy practice, the Pelvic Health and Rehabilitation Center (PHRC). From the outset, our goal with PHRC was to improve the standard of care for pelvic pain treatment. At this point, we believe we have developed a successful treatment model, one that stresses an interdisciplinary approach to treatment, and we’re looking forward to sharing it in these pages.

 

All our best,

Liz and Stephanie

 

By Melinda Fontaine, DPT, PHRC Walnut Creek

I recall being eight months pregnant treating other pregnant women or new moms.  I would always hear, “How are you still working full time on your feet?” I still think the most honest answer is, “Pure luck”.  Every pregnancy is different, and there are a lot of things that are out of your control.  We all do the best we can to take care of ourselves, which means staying informed and making healthy choices.  The other common response I gave to people was, “I work with a great group of women who specialize in caring for pregnant women, so I am very well taken care of.”  I wouldn’t undervalue the importance of having a support group during pregnancy.  My colleagues were there to listen to my musings and complaints about pregnancy, give me advice, and treat my aches and pains.  I am very lucky to have such vast experience with pregnancy professionally because I knew what to expect and how to prepare myself physically and mentally.  I am also very unlucky to have such vast experience with pregnancy professionally because I know about all the worst case scenarios!  The possibilities of what can happen during pregnancy are endless, but I’d like to share some of the knowledge that helped get me through my pregnancy with minimal freak-outs and discomfort.

Build Core Strength

When I first found out I was pregnant, I did two things for myself: I signed up for prenatal Pilates and I bought compression stockings.  The Pilates classes were to strengthen my core in a safe, effective, and fun way. I knew that a strong core would support me while I carry a baby. The deep core muscle, transverse abdominus, wraps around one’s midsection like a corset.  It is responsible for supporting the low back and hips, which becomes increasingly important as the hormone relaxin starts to make joints looser and the belly starts to pull forward.  Pelvic girdle pain or low back pain affects 72% of all pregnant women¹, and a strong transverse abdominus is the first defense.  There are many exercises to strengthen this muscle, but I chose Pilates because I thought it would be fun and safe.  My instructor was very knowledgeable about the special needs of a pregnant body and knew how to modify exercises and teach perfect form.  My biggest fear about starting a new exercise regimen, especially when pregnant, was trying to keep up with the group, doing something wrong, not being corrected, and ending up injured.  I also kept up my old exercise routine at the same intensity as before I was pregnant until my body started to tell me to take it easy.  In healthy women with uncomplicated pregnancies, it is generally safe to do so², but always listen to your body and your doctor.  The American College of Obstetrics and Gynecology recommend moderately intense exercise for 30 minutes a day on most or all days of the week.  Exercise during pregnancy has been associated with lower risk for diabetes, depression, hypertension and preterm birth³. In some cases, the increasing weight of the pregnant belly, the hormone relaxin, and underlying pathology will overpower the core muscles, and external support may be needed to alleviate pregnancy related low back pain.  A sacroiliac joint belt hugs the bones of the pelvis and supports the pelvic girdle and sacroiliac joints. A maternity support belt lifts and hugs the belly to reduce abdominal and back discomfort.

Wear Compression Stockings

The compression stockings help minimize swelling and circulate blood from the feet back to the heart.  During pregnancy, the volume of blood increases and the walls of the veins soften and expand.  This leads to fluid collecting in the feet and legs, especially in women who spend a lot of time on their feet.  For all people, pregnant or not, who spend a lot of time standing during the day, such as myself, compression stockings with light to moderate compression can help to counteract the effects of gravity and help legs feel more energized.  Maternity compression stockings exert about 15 mmHg of pressure and are comfortable (although sometimes hot in California in the summer).  Try different brands of knee highs or full length stockings to see what you find comfortable. I wore Juzo.

Avoid Constipation and Hemorrhoids

As pregnancy progresses, different signs will appear such as morning sickness or that dark line in the middle of your abdomen.  So many changes could possibly happen that I can’t list them all. One guarantee is that the pregnant body produces more progesterone. Progesterone is the hormone responsible for relaxation of smooth muscle, such as that in your digestive system, and decreased motility in your stomach and intestines.  This means that food travels through your system slower and can lead to constipation.  Too much straining with constipation can lead to hemorrhoids.  I recommend drinking plenty of water and eating a high fiber diet.  I put my feet up on a stool when I sit on the toilet to have a bowel movement because this is the most natural way to poop.  After all, most of the world poops and has babies in the squatting position to put the pelvic muscles on slack and allow the pelvis to open. I can’t tell you how many people are in love with their poop stools after they try it.  Put one in your house, and everyone, young and old, male and female, will benefit.  Here is a link to the one we have in our clinic in Berkeley. I also avoid holding my breath and bearing down to poop.  All that pushing puts a lot of downward pressure on the pelvis and can lead to hemorrhoids, prolapse, or nerve injuries. This is such a common problem that some prenatal vitamins even have stool softeners in them.  If you still struggle with constipation and/or hemorrhoids, talk to your physical and occupational therapists or doctor about other ideas.

Beware of Incontinence

Instead of, or in addition to, struggling to get waste out, some pregnant women struggle to keep waste in. I’m referring to incontinence (or leaking) of urine, feces, or gas.  In pregnancy, this is most common due to the pelvic floor being asked to do too much work.  (There are other possible causes as well, so talk to your physical and occupational therapists.)  Besides doing its usual tasks of supporting the pelvic organs and pelvic girdle and maintaining sexual function and continence, the pelvic floor is asked to hold up an extra 7 lbs of baby, 1 ½ lbs of placenta, 2 lbs of enlarged uterus, and 2 lbs of amniotic fluid.  Something’s gotta give, and when it’s your pelvic floor, you end up leaking. Often this improves after delivery, but it is not a normal part of pregnancy or being a mom.  It is an indication that something is not working right, and it should be evaluated.  The pelvic floor may be too weak or too strong, which brings me to my next point…

To kegel or not to kegel

Another guarantee while you are pregnant is that you will undoubtedly hear from someone, “Do your kegels”. To be honest, this kind of makes my skin crawl because you can’t blindly prescribe any one exercise to every woman. Kegels are a strengthening exercise.  I wouldn’t tell a person with a strong pelvic floor to do kegels any more than I would tell a competitive weight lifter to run a marathon.  Not only is it not necessary, but it may also be harmful.  A pelvic floor that is too tight could lead to incontinence, retention, urgency, frequency, or pain.  Doing kegels could make these symptoms worse, your pelvic floor may need to be lengthened before it is strengthened.  On the other hand, a weak pelvic floor could really benefit from kegels to decrease incontinence and prolapse and improve ease of delivery.  It is impossible to tell which kind of pelvic floor someone has without a manual exam from a physical and occupational therapists, so take the advice to “do your kegels” with a grain of salt.

Expect Changes

Another common pregnancy tip for the 2nd and 3rd trimesters is to avoid lying on your back.  This is sound advice, especially as the baby gets larger.  The weight of the baby can press on the vena cava (a large vein in your abdomen responsible for returning blood to your heart). This can make mom start to feel lightheaded and can be serious if it is not corrected quickly by changing positions. The increasing size of a pregnant belly also stretches the muscles of the abdomen.  Sometimes, the recti abdominis (or 6-pack muscles) can separate creating a soft part in the middle of your belly above or below your belly button called a diastasis.  I avoid doing sit-up type exercises that would further stress and pull apart these muscles.  Diastasis is very common during pregnancy and is more likely if your belly grows quickly or if you have had multiple pregnancies.  It can go away on its own after delivery, or you may need a physical and occupational therapists to teach you how to correct it.  Lastly, carrying around extra weight in the front of your body means that the muscles in the back of the body have to work overtime to keep you standing upright.  The gluteals (buttocks) are one such group of muscles.  If these muscles feel tight, painful, or uncomfortable, getting a massage or rolling them out on a foam roller can feel really good. Wearing sneakers with good arch support will also support muscles further up the leg by creating good alignment, and they give added compression at the foot, in addition to the compression stockings discussed above.

Take a Class

At the end of about 40 weeks, the baby will be born.  Sometime before then, I recommend taking some sort of childbirth class.  There is no one right way to birth a baby.  As a mom, you have many choices to make.  It is hard to make decisions during delivery because you are physically and emotionally exhausted.  Learn as much as you can about what to expect before, during, and after delivery, and think about your preferences.  That being said, you cannot control what is going to happen and you may make changes to your preferences in the moment.  Some things to think about include: where will you deliver, vaginal or cesarean, who will be with you, what are your pain management options, who will cut the umbilical cord, will you vaccinate, who will be your Baby’s pediatrician, will you circumcise, will you try to breastfeed. I also find it comforting to know a little about labor and delivery including how to know when you are in labor, what does labor consist of, when will you start pushing, what will happen after the birth, what tests will be provided to the baby after birth, etc.  If you are birthing at a facility, take a tour.

Practice

Something that might not be covered in a typical birth class is practicing pushing and finding good positions for you during labor.  I do this with all of my patients who are preparing for delivery. A large number of women don’t know how to push a baby out on their first attempt.  Good pushing involves a soft relaxed pelvic floor to allow for easy passage of the baby and a strong abdominal contraction to increase the pressure in the abdomen above the baby and help push baby down and out. The most effective pushing position for each woman is different and some positions will not be possible after an epidural.  Curling up as if doing a sit- up could help increase abdominal pressure to bear down. Being in an upright position such as squatting uses gravity to help the baby come out.  Hands and knees can also be a nice way to labor without the weight of the baby on your back.  Use a chair, bed, or partner to lean on as well. Try multiple positions ahead of time and see which ones feel comfortable to you, so you will have some ideas to try during labor. For more information on labor and delivery, stay tuned for future blog posts.

Veteran Moms: Do you have any other tips you would like to add to this list?
Warmly,

Melinda Fontaine, DPT

Melinda is a native of Concord, California and is part of our Berkeley team. Melinda earned her bachelor’s degree in exercise biology from UC Davis and her doctorate in physical and occupational therapy from Simmons College in Boston. When she’s not at PHRC, you’ll find her either dashing around in her running shoes or cooking up delectable meals in her kitchen. She’s famous for her killer baked chimichangas and her inability to stick to a recipe.

 

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Are you unable to come see us in person? We offer virtual appointments!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical and occupational therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical and occupational therapistss committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical and occupational therapistss via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical and occupational therapistss, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical and occupational therapists who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.

 

References:

Bergström C et al. (2014). Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation. BMC Pregnancy and Childbirth,14, 48. doi:10.1186/1471-2393-14-48

American College of Obstetrics and Gynecology (ACOG). (2002, reaffirmed 2009). ACOG Committee opinion number 267: Exercise during pregnancy and the postpartum period. Accessed July 2015 via the web at: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Exercise-During-Pregnancy-and-the-Postpartum-Period

Domingues M R, et al. (2015). Physical activity during pregnancy and maternal-child health (PAMELA): study protocol for a randomized controlled trial. Trials, 16, 227. doi:10.1186/s13063-015-0749-3

Pregnancy weight gain: What’s healthy? Mayo Clinic. Accessed July 2015 via the web at http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy-weight-gain/art-20044360?pg=2