By Guest Blogger Michael Yang

If you haven’t tried acupuncture/dry needling for your pain, you may be missing out on a safe and often effective treatment.

In this blog post, guest blogger, acupuncturist Michael Yang, answers some common questions about this alternative treatment approach to pelvic pain. Take it away Michael!

Where’d this whole needling thing start anyhow?

Well, we thought it was China. Thousands of years ago. And then archeologists got some new evidence that threw that theory up in the air. In 1991 they discovered Otzi the Copper Age frozen man in Austria, who is dated back to 5,300 years ago. Some scientists believed tattoos found on Otzi’s body marked acupuncture points, suggesting that the practice was around about 2,000 years earlier than was originally thought.

Nevertheless, the needle therapy that eventually became acupuncture was certainly best codified in China.

Let’s take a whirlwind tour through 3,000 years of medical history for a snapshot of how acupuncture as we know it today came to be:

Before needles existed, sharp rocks may have been the first tools used to treat patients back when evil spirits were likely considered the root cause of disease. It was around 200 BC that we see metal replace stone and bone needles, likely very much to the satisfaction of sore patients. Acupuncture caught the eye of Westerners in the 1600s and made it to the United States in the early 1800s,  and has been around ever since.

What does research tell us about how acupuncture works? 

As modern science matured, so did the research on acupuncture. As we started to understand pain better, we started to see where acupuncture fit into the picture. The body produces natural opioids and endorphins. For its part, acupuncture seems to affect endorphin response. According to the National Institutes of Health, evidence shows that acupuncture releases opioid peptides, and that the analgesic effects of acupuncture are at least partially explained by their actions. The finding that opioid antagonists, such as naloxone, actually reverse the analgesic effects of acupuncture has further strengthened this hypothesis.

In addition, stimulation by acupuncture may also activate the hypothalamus and the pituitary gland, resulting in a range of positive systemic effects. There is also evidence that there are alterations in immune functions produced by acupuncture.

What about safety?

The answer to this question is simple, and one of the great selling points of acupuncture. It won’t cause damage and make symptoms worse. When we look at the risks associated with medications and more so, surgery, conservative therapy starts to look like a good option. This is why patients are generally encouraged to go through conservative care first before looking to more invasive and potentially side effect ridden options.

Acupuncture is like pizza. There’s great pizza and there’s decent pizza, but rarely is it terrible. In fact, the big warning I give patients regarding side effects is “don’t be surprised if you sleep very deeply tonight.”

Which brings us to efficacy, does it work?

This is the question I always wish I had a more clear cut answer for, but like all interventions, it’s a question of percentages. That said, I have seen some remarkable improvements in patients that I honestly thought were real long shots. That is always a very happy day. Especially after all other options have been exhausted.

Some of the big benefits stem from the chance to treat multiple areas and issues simultaneously. For instance, I have yet to see a pelvic pain patient that was not also suffering from at least one of the following: neck pain, back pain, insomnia, anxiety, depression, headaches, digestive issues. Usually it’s a couple of these and then some. Being able to address multiple concerns during the same visit is a boon to patients, and as the saying goes, a rising tide raises all ships. If we can make progress in an area that may not even be the chief complaint, we can see a general improvement in other seemingly unrelated areas.

How much does it cost?

Of course there is a range of pricing based on region and experience, but the good news is that many more insurance plans are covering some or all of the treatment.

How about some pelvic floor specifics?

This is where a specialty level of understanding is helpful. Because of the precision needed to target the relatively thin muscles of the pelvic floor, finding a practitioner who is familiar with this are of the body is important. That way, targeting the trigger points in the muscles involved in a patient’s symptoms can be achieved with pinpoint accuracy (pun intended).

In addition, in my experience treating pelvic pain patients, I have found that using points that are not just at the point of discomfort, but in other parts of the body, adds to the efficacy of the treatment.

This amalgam style of therapy, which blends classic point selection with contemporary biomechanical understanding, is a strategy that yields the most bang for the buck and can be the difference in success or failure. Part of this stems from being able to tap into some of the more central effects that acupuncture has on the nervous system. In the realm of chronic pain, more and more attention is being given to what happens in the brain, as opposed to just what is happening at the site of pain.

So should you give acupuncture a try? Patients and doctors familiar with the benefits of well-performed acupuncture as part of interdisciplinary treatment plan will certainly tell you: “It’s worth a shot.” (Terrible almost pun intended).

If you have any further questions after reading this post, feel free to leave them in the comments section below!

All my best,

Michael

About the Author: Michael Yang DOM, L.Ac., has been practicing Integrative and Chinese Medicine since 2000. He studied at the University of California as Santa Cruz, Emperor’s College, and the PanAmerican School in Nevis.

He has been featured in various publications and on national television. He is the director of the Pacific Medical Group and past vice president of Vitality Healthcare. He is the author of The Lean Gene, due to published in 2015 and is the editor in chief for HealthInspiring.com.

Like so many of you, my new year’s resolutions include exercising more and eating healthy. As I embarked on my plan for doing both, I got to wondering where my pelvic floor health fell into the mix.

“Shouldn’t my exercise plan take my pelvic floor issues into consideration?” I wondered. I certainly didn’t want to start a fitness routine that would jeopardize all of the progress I’ve made in rehabbing my floor. “And was it possible to add some changes to my diet that would also benefit my pelvic floor health?”

To answer this questions, I decided to turn to, well, this blog! Turns out we’ve written posts on just these topics. In this blog post we’re going to rerun that advice. Because it’s advice worth repeating, and because reruns are awesome. I mean, there’s nothing better than catching one of your favorite episodes of Golden Girls as you’re drifting off to sleep after a long day, am I right?!

So here goes.

Pelvic Pain: Some General Exercise Tips

By Stephanie Prendergast

Exercising for fitness often poses a problem for those in the middle of the healing process for a pelvic pain issue. That’s because it can potentially cause their symptoms to flare. Often this occurs after patients have taken a break from their fitness routine because of their pelvic pain and/or fear of making themselves worse. After they return to exercise they oftentimes will start to become symptomatic again as a result.

Understandably this is very frustrating and people think they may never be able to exercise again.

It’s important for people to get daily exercise, so we work hard with patients to figure out the balance between staying fit and healthy and not exacerbating their symptoms. Therefore, exercise routines may need temporary modifications at first, with the goal being progression towards the patient’s desired activities.

So after years of conversations with my patients and a knowledge of exercise anatomy and physiology, we compiled a list of exercises that are reasonable starting places for people beginning to work out again as well as a list of activities that are often more provocative for pelvic pain patients.

The advice below is by no means and end-all be-all of “do’s and ‘don’ts”. I created it because I want people to know that they can exercise, and certain choices may be better than others when learning to manage pelvic pain.

A-List of Exercises for Pelvic Pain Patients

Slower, isometric, double-limb, lower impact exercises:

People that have been through any pain experience may have altered neuromuscular recruitment patterns. What this means is that they may use muscles other than the ones intended for the movement in question, which can result in injury and symptoms. Therefore, in general, slower, isometric, double-limb, lower impact exercises are a good place to start. With these types of exercises, the patient has a higher chance of performing the necessary motions with proper muscle recruitment as compared to faster moving, higher impact, and single-leg stance activities. Below is a list of examples of these types of exercises.

Shallow squats

Shallow squats are better because the deeper the squat, the greater the chance that hypertonic (too tight) muscles will change the motion and that the external rotators and hamstring muscles instead of the gluteal muscles will get involved, which are the muscles you want to be working in this type of exercise.

Progression: shallow squats on a foam pad

This movement creates an unstable surface and co-contraction of muscles, and is a safe and effective way to strengthen the gluteus muscles, thighs, and hips.

Balancing on the Bosu ball or foam roller

If using the Bosu Ball, first use the flat side down, then progress to flat side up for 30 seconds to two minutes.

Abdominal Exercises that are appropriate for pelvic pain patients

Abdominal muscles are often associated with pelvic pain; therefore, some abdominal exercise can exacerbate symptoms. Below are the abdominal exercises that we recommend for patients with pelvic pain. For a variety of reasons, these exercises do not negatively impact the pelvic floor.

Plank: these are great because they are a good way to recruitment trunk muscles.

Standing Triceps Extensions: these create a way to recruit the core without over-activating the rectus abdominus muscles.

Supine leg-lifts on a physio ball: again, these create a way to recruit the core without over-activating the rectus abdominus muscles.

Walking backwards on a treadmill at 5% incline, 2.0 miles per hour.

This will help to strengthen the lower extremities while also providing an aerobic activity, but it will do so in a way that doesn’t engage those muscles that are a problem like the pelvic floor and the rectus abdominus muscles.

The StepMill cardiovascular machine that most gyms have.

This machine is great because at slower speeds (less than level five), people can get great gluteal muscle recruitment while also getting cardiovascular benefits.

Exercises that are more provocative and may flare symptoms:

Activities that involve impact, such as single leg or double leg jumping

Squatting in single leg stance

Hamstring and quadriceps machines: I recommend free weights over gym machines. Many of my female patients report that these machines simply feel uncomfortable and exacerbate their symptoms.

Deep squats and lunges

When folks who have pelvic pain do squats or lunges, their hamstrings oftentimes fire instead of their gluteal muscles, which can be detrimental to a tight pelvic floor. Also, pelvic pain patients often have hip rotators that are too tight to be able to do the exercise properly.

Biking or spinning

Most people with pelvic pain have problems and pain in the muscles that are compressed on a bike seat, i.e. nearly the entire pelvic floor. So the pressure will aggravate the pelvic floor. In fact, some of our patients’ pain started as a result of biking in the first place. I’m not saying that if you’re a passionate cyclist and develop pelvic pain that you’ll never be able to ride again, but for those who are in treatment these exercises are not the best choices.

Sitting abduction/adduction machine (inner/outer thigh)

The sitting adduction and abduction machine is not a functional exercise, meaning that we do not use these muscles in our daily lives in the positions required on these machines, so unless you’re a competitive weightlifter, there really is no functional reason to do these exercises. On top of that, these machines can actually cause pelvic pain and, therefore, should be avoided.

Calf raises

Unless you are a professional body builder, most people do not need to strengthen their calf muscles. The general population tends to have tight calf muscles, which can change how a person walks and the muscles that they use daily. These muscles should be stretched versus strengthened, and daily.

Situps or crunches

Sit-ups directly involve the rectus abdominus muscles, one of the abdominal muscles, which have a high correlation with pelvic pain or a high tone pelvic floor as well as urinary urgency and frequency. In addition, this muscle is not a trunk stabilizer and does not need to be individually strengthened for musculoskeletal health.

Deep squats with heavy weights

Deep squats with heavy resistance are not a good choice due to a higher risk of injury and incorrect muscle recruitment. This position also causes a lengthening of the pudendal nerve and a tightening of the pelvic floor muscles. This combination can cause pudendal neuralgia.

May or May not be Appropriate for Pelvic Pain Patients

Running

Patients who have trigger points in their hips or if their gluteal muscles aren’t strong enough, running is going to bother their pelvic floor symptoms, but if they are clear in those areas they can usually slowly start to get back into running.

Swimming

Swimming is a great form of exercise. Certain strokes may be problematic for patients with trigger points. For example, the breaststroke activates the obturator internus muscle, patients with trigger points here should choose a different stroke, such as freestyle. Conversely, patients with psoas or hip flexor trigger points may get aggravated by the freestyle motion, but feel comfortable using the breaststroke.

But walking in water can be a fantastic cardiovascular exercise because it gets your heart rate up but because we’re practically weightless in water, muscles and joints are free of pressure.

Pilates and yoga

These exercises have a range of motions that can be therapeutic for pelvic pain, good for general fitness, and occasionally problematic. Therefore, pilates or yoga programs really need to be individualized per patient. To read more about yoga and pelvic pain, check out our blog on the topic here.

When it comes to exercise and pelvic pain it’s important for me as a PT to help my patients find that happy medium between continuing to exercise and stay fit and not exacerbating their pelvic pain symptoms. Not only because it adds to their quality of life and overall health, but because any exercise, and especially cardiovascular exercise will encourage blood flow and release endorphins, which is beneficial for patients in pain.

Eating to Manage your Pelvic Pain

By Melinda Fontaine

Can we eat to relieve our pain?

Actually, the answer is a resounding “Yes!” More and more research is finding a connection between what we eat and how our bodies experience pain.

That’s why I was so thrilled to attend a lecture on how nutrition can help us manage our pain at the IPPS Conference in Chicago last month. The lecture titled “Nutritional Considerations in Treating Patients with Pain,” was delivered by the brilliant Dr. Geeta Maker-Clark.

The nutrition advice that Dr. Maker-Clark gave focused mainly on tackling the body’s inflammatory responses. For many chronic pain patients, inflammation plays a major role in their pain.

Inflammation is the body’s natural response to acute injury, and chronic inflammation significantly contributes to persistent pain.  At the cellular level, pro-inflammatory cytokines produced at the site of injury increase the sensitivity to pain.  (“Cytokines” are proteins that interact with cells of the immune system to regulate the body’s response to disease and infection.)

The good news is that these pro-inflammatory cytokines can be reduced by proper diet. In fact, Dr. Maker-Clark is adamant that proper nutrition must be a part of our treatment for pain and is also an important part of the healing process.

So what sort of diet can help us manage our pain?

Well, the guidelines and rules of eating to help manage pain and promote healing or what I like to call an “anti-inflammatory diet” are not all complicated. In fact, there are only two basic rules of thumb to follow.

The first rule has to do with how quickly our bodies process sugar. You see, the slower your body processes sugar, the better it can tackle inflammation.

In fact, one important study found that inflammation markers were higher in women who ate foods with a high glycemic index.  (The glycemic index is a measurement of how quickly your body can process the glucose or sugars in a food.) The study showed that pain tends to follow the glycemic index, meaning that foods that are higher on the index are associated with more inflammation and more pain.

Examples of foods that are high on the glycemic index include: white bread, potatoes, beer, cereal, and rice, white flour, and processed foods.

So foods that are lower on the glycemic index are a better choice for folks dealing with pain. And conversely, foods that are higher on the index are not a good choice for pain management.

A little tip: foods that are higher in fiber are going to be lower on the glycemic index, so better for anti-inflammatory purposes.

Rule number two focuses on essential fatty acids–specifically how we balance our intake of omega-3 fatty acids and omega-6 fatty acids.

Essential fatty acids are called “essential” because we can’t make them on our own, but must get them from our diet. It turns out that when it comes to essential fatty acids, it’s not a matter of more is better, but a matter of balance is the key.

Let me explain: Nutritionists believe that in the past, humans ate just as much omega-3s as omega-6s, but since the advent of the modern diet, there has been a huge shift in the ratio. And for optimal health, it’s important for us to get a balanced amount of omega-3s to omega-6s.

In our modern diet there are actually not many sources of omega-3s. The main source is the fat of cold-water fish, other sources include walnuts and flaxseeds, olive oil, avocado, and enriched eggs.

On the flip side, our modern diet is full to overflowing with omega-6s. Omega-6s are found in seeds and nuts as well as the oils extracted from them. Most processed foods contain refined oils. On top of that, the majority of the protein we eat–even farmed fish–are fed grains. And not only are you what you eat, you are what you eat eats.

So because omega-3s are so hard to come by and omega-6s are all too easy to come by on the modern menu, there’s a huge imbalance between the omega-3s and omega-6s we eat.

Many researchers believe that it is this dietary imbalance that is behind the rise of such diseases as asthma, coronary heart disease, many forms of cancer, and the slew of autoimmunity and neurodegenerative diseases, all of which are believed to stem from inflammation in the body.

For our purposes, it is this imbalance that can cause problems when it comes to inflammation. That’s because, in general when it comes to inflammation, omega-6s and omega-3 have different effects. Omega-6s tend to increase inflammation (which isn’t necessarily a bad thing because inflammation plays an important role in the body’s immune response), while omega-3s decrease inflammation.

For the purposes of following an anti-inflammatory diet, what you’re striving to do is to get a healthy ratio of omega-3s and omega-6s. The best way to do that in today’s Western diet is to make it a point to eat more foods with omega-3 fatty acids and less with omega-6 fatty acids. One tip that Dr. Maker-Clark gave for upping your intake of omega-3s is to buy eggs that are fortified with omega-3.

In addition to the two hard and fast rules Dr. Maker-Clark gave she also listed a handful of specific foods that, according to research, have anti-inflammatory properties.

Here are a few:

Tart Cherry juice:

Mushrooms

Soy

Green Tea

Red Wine

Turmeric

So to summarize, a solid anti-inflammatory diet consists of:

Low glycemic index foods

Limited amount of processed foods

A reduction of hydrogenated fats

Plenty of omega 3-rich foods

Other tips include:

Less meat and dairy

More fresh fruits and vegetables

Fewer chemical additives

Not only will I be recommending Dr. Maker-Clark’s dietary tips to my patients, I’m going to be implementing a few of them into my own diet. If you would like more info on Dr. Maker-Clark’s pain management diet advice, just click here.

Do you have any pelvic floor-related new year’s resolutions? If so, share in the comments section below!

All our best,

Stephanie, and Melinda

If you’ve read any of my past blog contributions, you know I’m someone who has managed pelvic pain for the past decade, (if you haven’t read them, feel free to check them out here, here, and here) and while I was confident that in that time I had gamely faced and overcome all of the issues, big and small, that come with that, turns out I was wrong. Enter cold and cough season.

This year I got struck early on in the season by a nasty case of bronchitis (basically a fancy word for chest cold). A hacking cough ensued. After a couple of days of heavy coughing where I was sure any minute a lung would come flying out, something…er…interesting happened. During a fit of coughing, I completely lost my bladder. At first I thought it was just the result of a particularly wracking coughing spell, but for the next few days, every time I coughed, bam! I peed my pants.

I panicked. “So is this a new symptom that I’ll have to figure out?!” I wondered. “Are my ‘tight’ pelvic floor muscles now also ‘weak’ pelvic floor muscles?!” “And if so, wouldn’t any efforts to strengthen my tightish pelvic floor be a bad idea?!”

To put my fears to rest I did what I always do when my pelvic floor stumps me: I called Stephanie, my PT.

In this blog post, I’m going to share what I learned from Stephanie because turns out what happened to me is very common for folks with a pelvic floor that runs a little on the tight side or who have pelvic pain.

What I was experiencing is known as “stress urinary incontinence,” something that can happen when the pelvic floor muscles don’t work properly.

You see, when you urinate, urine flows from the bladder through the urethra to the outside, and the pelvic floor muscles are among the structures that support the bladder and urethra. And when the pelvic floor muscles are compromised, urine can escape when pressure is placed on the bladder.

And that’s exactly what was happening to me. When I would let out a real wallop of a cough it put a ton of pressure on my abdominal muscles, which then put pressure on my bladder.

But it wasn’t happening because my muscles were weak, which is what I assumed at the time.

“Your pelvic floor muscles are not necessarily weak, but they are tight. ” Stephanie explained. “Muscles function optimally–meaning they generate maximum force–at a certain length. When muscles are too tight they generate less force. In your case, because your muscles are too tight, the amount of force they were able to generate was not enough to keep your urethra closed against a powerful cough.”

So because my issue was tightness, not weakness, which is what I originally assumed when the leakage began, I didn’t have to strengthen, but needed to continue on the track of lengthening my too tight pelvic floor muscles. Which was a relief because I knew that efforts to strengthen pelvic floor muscles, such as doing Kegels, could have an adverse effect on too tight muscles, making them even tighter and causing pelvic pain.

“Lastly,” Stephanie said, “while leaking urine is a sign that something is not working properly, it’s important NOT to panic and to know that the problem is likely going to be transient. If anything, it’s indicative that you still have tight pelvic floor muscles.

Coughing is similar to doing repetitive Kegels. My patients with pelvic pain may feel an increase in their symptoms after being sick because their muscles could not relax after the forceful pelvic floor contractions that come with coughing. The good news is you can work on improving your pelvic floor muscle function through your continued PT and home exercises. ”

Stephanie advised that I manage the symptoms for as long as they lasted, which turned out to be about a week, which for me meant wearing pads and/or hanging out on the throne when I felt a particularly bad coughing spell coming on. And to counter the muscle tightness, she suggested that I get back into the habit of doing my pelvic floor drops.

However, there was one lingering question that my cough induced leakage brought up that I wanted to run past Stephanie: What happens in situations where someone has both a tight and a weak pelvic floor? Because if there’s one thing I’ve learned in the years I’ve dealt with pelvic floor issues, it’s that the pelvic floor is fixable; if it’s too tight, you can work to loosen it up, and if it’s weak you can strengthen it. But what if you are someone who has both a weak and a tight pelvic floor? What then?

Here’s what Stephanie had to say about this: “While tight pelvic floor muscles result in what appears to be weakness, the fact is that once they’re lengthened to a normal position, they are able to generate more force. So if a tight muscle is returned to its normal resting length, and is still unable to generate adequate force, it is in fact also a weak muscle and it’s time to strengthen it.

Generally speaking, however, women with a history of pelvic pain that are still menstruating and have not given birth likely have tight muscles. On the other hand, peri-menopausal, menopausal and/or women who have given birth may have muscles that are weak. Both groups may leak urine in situations where the abdominal pressure exceeds the capacity of their pelvic floor muscles. My suggestions are different for each group.

Women with weak muscles will benefit from an uptraining program to strengthen their pelvic floor and girdle muscles and improve their motor control. Additionally, this group may reduce episodes of stress urinary incontinence by performing a technique referred to as “the knack” prior to coughing or lifting. The knack is a learned motor skill that involves contracting your pelvic floor muscles when urine is likely to leak.

Conversely, women with tight muscles need to focus on lengthening their pelvic floor muscles, taking the steps mentioned above. The knack technique will not help them because contracting their muscles further just leads to more shortening, which generates even less force.

I hope this post has been helpful to anyone who, like me, thought they had seen it all when it comes to pelvic floor maintenance. If you have any questions about the issues covered in this post, or about incontinence in general, please leave them in the comment section below, and I’ll be sure to pass them along to Stephanie!

Take care,

 

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Are you unable to come see us in person? We offer virtual physical and occupational therapy appointments too!

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.