This is part two of a three-part series on self-care and preventing practitioner burnout from faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC. Part One is available here. Jennafer is the co-author and co-instructor of the along with Nari Clemons, PT, PRPC.
Augh, I was so frustrated with myself. I fell for it again. Here’s the scenario: a patient came in suffering excruciating pain. She had been to see a pelvic health professional as well as various medical professionals and was unable to get relief and answers for her rectal pain. She was desperate and called me “her last hope.” Phrases used included, “I need you! Fix me! I hear you are a miracle worker! If you can’t help me no one can!” And just like that I took on the role of Rescuer.
In 1968 a psychiatrist named Stephen Karpman developed a model of personal interaction that he called the Conflict Triangle. It has also become known as the Karpman Triangle, The Drama triangle or the Victim triangle. Per Wikipedia:
The Victim: The Victim's stance is "Poor me!" The Victim feels oppressed, helpless, hopeless, powerless and ashamed. They seem unable to make decisions, solve problems, take pleasure in life or achieve insight. The Victim, if not being persecuted, will seek out a Persecutor and also a Rescuer who may save the day, but may also perpetuate the Victim's negative feelings.
The Rescuer: The Rescuer's line is "Let me help you." A classic enabler, the Rescuer feels guilty if they don't rush to the rescue. Yet their rescuing has negative effects: It keeps the Victim dependent and gives the Victim permission to fail. The rewards derived from this rescue role are that the focus is taken off of the Rescuer. When they focus their energy on someone else, it enables them to ignore their own anxiety and issues. This rescue role is also pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs.
The Persecutor: (a.k.a. Villain) The Persecutor insists, "It's your fault." The Persecutor is controlling, blaming, critical, oppressive, angry, authoritative, rigid, and superior.
What is interesting about this triangle is that the roles are constantly shifting. In full rescuer mode, I gladly took on this patient, intent on solving her problems. Over time, I saw that my consistent coaching for lifestyle change and self-care was falling on deaf ears. My patient was not following through with anything I asked of her; therefore my treatment plan was not working. The patient began to get frustrated with me. I then cast myself as the victim. She became my persecutor! While perhaps in her mind, I had failed as the rescuer, she was still the victim and I had become her persecutor. At the time, I did not have the skills to know how to navigate this situation in a positive or helpful way. Finally I sought the advice of my supervisor and my therapist to draw up a contract with this patient. The contract outlined each of our responsibilities. If either of us didn’t fulfill our responsibilities, the consequence would be ending our professional relationship. When she persisted, unwilling to do her part, I discharged her per our agreement.
I learned so much from this experience. Here are some things that I have implemented and may be helpful in your practice if you have similar challenges.
- In an initial visit with a new patient I explain that the patient and I make a team and we each have a role to play in reaching the patient’s goals.
- If someone says, “Fix me!” I say, “Think of me as your coach, I can show you how to help your body heal, but it’s your job to do the work.”
- When I hear, “Everyone says you are a miracle worker.” I say, “That is so kind, but it doesn’t work that way. Healing is complicated and everyone has their own journey.”
- In this way, with baby steps, we can get OUT of the drama triangle and into healthy relationships with our patients and the people in our lives.
- Consider the Winner's Triangle published by Acey Choy in 1990.
In her blog NextMeCoaching, Jessica Vader coaches on turning Drama and Control into a Winning situation.
The three roles in the Winner’s Triangle.
Vulnerable – a victim should be encouraged to accept their vulnerability, problem solve, and be more self-aware.
Assertive – a persecutor should be encouraged to ask for what they want, be assertive, but not punishing.
Caring – a rescuer should be encouraged to show concern and be caring, but not over reach and problem solve for others.
If you struggle with professional and personal boundaries, you are not alone, and you can get support. Consider talking with your supervisor, a counselor, reading a good book on the subject, and or taking Boundaries, Mediation and Self Care, a course offering through Herman and Wallace that was designed to help pelvic health professionals stay healthy and inspired while equipping therapists with new tools to share with their patients.
We hope you will join us for Boundaries, Mediation and Self Care this November 9-11, 2019 in San Diego, CA.
Look forward to my next blog where saying no takes an unexpected turn.
The following is the first in a series on self-care and preventing practitioner burnout from faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC. Jennafer is the co-author and co-instructor of the Boundaries, Self-Care, and Meditation course along with Nari Clemons, PT, PRPC.
“I just want you to fix me.” How many times have we heard this statement from our patients? And how do we respond? In my former life as a “rescuer” this statement would be a personal challenge. I wanted to be the fixer, find the solution and identify the thing that no one else had seen yet. Then, if I am being completely honest, bask in the glory of being the “miracle worker” and “never giving up” on my patient.
If you recognize that this attitude was going to run me into some problems, kudos to you. If you are thinking, “well of course, isn’t that your job as a pelvic floor physical therapist?” Please read on.
On my very first job performance review, when it came time to discuss my problem areas my supervisor relayed I was “too nice” and cited some examples: giving a patient a ride home after therapy (it was raining and she would have had to wait for the bus), coming in on Saturdays to care for patients (he was sick and couldn’t make it in during the week but was making really good progress). You get the picture. At the time, I didn’t understand how this could be something I needed to work on. I was going above and beyond and I got so much satisfaction from taking care of others!
Fast forward 10 years and add to my life a husband, two daughters, a teaching job, part time homeschooling, and writing course material. I was an emotional mess. Anxiety was my permanent state of mind. I gave my best to my patients while my family got my meager emotional leftovers. Something had to change and luckily it did. I got help and learned exactly what boundaries are and how to develop as well as enforce them.
There are several resources that discuss professional boundaries in health care, like this from Nursing Made Incredibly Easy. In this particular article, health care professionals are exhorted to stay in the “zone of helpfulness” and avoid becoming under involved or over involved with patients. Health care professionals are also urged to examine their own motivation. Am I using my relationship with my patient to fulfill my own needs? Am I over involved so that I can justify my own worth?
Here are some warning signs that you are straying away from healthy boundaries with patients and becoming over involved:
For some people, certain patients who push professional boundaries will cause the therapist to feel threatened and under activity is the result. This might result in talking badly about the patient to other staff, distancing ourselves, showing disinterest in their case, or failing to utilize best care practices for the patient.
Per Remshard 2012, “When you begin to feel a bit detached, stand back and evaluate your interactions. If you sense that boundaries are becoming blurred in any patient care situation, seek guidance from your supervisor. A sentinel question to ask is: ‘Will this intervention benefit the patient or does it satisfy some need in me?’”
Healthy professional boundaries are imperative for us and for our patients. Boundaries also help prevent burnout. Remshard delineates what healthy boundaries look like:
If you struggle with professional and personal boundaries, you are not alone and you can get support. Consider talking with your supervisor, a counselor, reading a good book on the subject or taking Boundaries, Self-Care, and Meditation, a course offering through Herman and Wallace that was designed to help pelvic health professionals stay healthy and inspired while equipping therapists with new tools to share with their patients.
We hope you will join us for Boundaries, Self-Care, and Meditation this November 9-11, 2019 in San Diego, CA.
Look forward to my next blog where The Rescuer (me) needs Rescuing and learn about the Drama Triangle.
Remshardt, Mary Ann EdD, MSN, RN "Do you know your professional boundaries?" Nursing Made Incredibly Easy!: January/February 2012 - Volume 10 - Issue 1 - p 5–6 doi: 10.1097/01.NME.0000406039.61410.a5
While my dad was visiting Michigan, we had the day to ourselves as my kids were in school. I was so excited to have quality time with my dad. Unfortunately it was pouring down rain. We decided on a leisurely brunch and then a movie. Dad chose the movie, “Wind River.” While not a movie I would normally pick, I was happy to go along. A little more than half way through…there was a horribly violent scene against a young women. I panicked, plugged my ears and closed my eyes. Unfortunately some images were burned into the back of my mind. When the movie was over, I remained seated and tears just came. My dad held me while I cried. I was able to calm down and leave the theater, but the images continued to bother me. During the next few days, I made it a priority to care for myself and allow my nervous system to process and heal.
What happened to me? I have never had any traumatic personal experience. Why did I react so strongly? I talked with my therapist about it and she suggested I might have experienced secondary traumatic stress. We know, as pelvic health therapists, we need extra time to hear the “stories” of new patients. We do our best to create a safe space for them so they can trust us and we can help them discover pathways to healing. Yet no one has taught us what we are supposed to do with the traumatic stories our patients share. How are we to cope with holding space for their pain? How do we put on a happy face as we exit the room to get the next patient?
Teaching Capstone over the last few years, Nari Clemons and I have talked with many of you who were feeling emotionally overloaded especially when treating chronic pelvic pain and trauma survivors. Some of you were experiencing job burnout, others were deciding maybe it was time for a career shift, away from the pelvis. We realized something needed to be done as our field was losing talented pelvic health therapists. We have also struggled ourselves with various aspects of our profession.
There are no studies that directly look at job burn out, secondary traumatic stress, and compassion fatigue among pelvic health physical therapists. Yet these problems are common among social workers, physicians and other people groups in health care. There are individual as well as institutional risk factors that lead to the development of each. The solution, as one self-help module puts it, is developing resilience. A large part of this skill is making self-care a priority. The basics such as adequate sleep, nutrition, and exercise are foundational. Meditation, mindfulness, therapy, and spiritual practices, as well as supportive friends/groups are also imperative.
Nari and I realized that training to develop resilience in therapists was missing. Initially we equipped ourselves to have better boundaries, ground ourselves with meditation, mindfulness and exercise, which enhanced our skills in dealing with complex, chronic patients. We compiled what we have learned and want to share it with you. We would like to invite you to attend Holistic Interventions and Meditation: Boundaries, Self-Care, and Dialogue. We have designed this 3 day course to be partially educational and absolutely experiential. We are going to dig deeper into ways to calm our patient’s and our own nervous systems, explore and practice the latest recommendations on treatment of persistent pain, we will mediate and learn about mediation, play with essential oils, learn some new hands on techniques, and support and encourage one another as we build communication skills. We want you to leave feeling refreshed and equipped to continue to treat patients without losing yourself in the process. We want to invest in you so you can continue the investment you have made in your career and avoid job burnout, compassion fatigue and secondary trauma. We invite you to develop the resilience you need for a rewarding career in pelvic health physical therapy by joining us in Tampa this January.
Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C. C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological services, 11(1), 75.
Meadors, P., Lamson, A., Swanson, M., White, M., & Sira, N. (2010). Secondary traumatization in pediatric healthcare providers: Compassion fatigue, burnout, and secondary traumatic stress. OMEGA-Journal of Death and Dying, 60(2), 103-128.
Sodeke-Gregson, E. A., Holttum, S., & Billings, J. (2013). Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with adult trauma clients. European journal of psychotraumatology, 4(1), 21869.
Stearns, S., & Benight, C. C. (2016). Organizational Factors in Burnout and Secondary Traumatic Stress. In Secondary Trauma and Burnout in Military Behavioral Health Providers (pp. 85-113). Palgrave Macmillan US.
Today we pick up on Jennafer Vande Vegte's interview with her patient, "Ben", about his experience overcoming chronic pelvic pain syndrome. Ben's quality of life improved so much that he has returned to school in order to become a PTA, with a focus on pelvic rehabilitation!
Describe your physical therapy experience. Talk about your recovery process. Include the physical, mental and emotional components.
For my initial visit, my therapist questioned and assessed my pain, then explained pelvic floor dysfunction. She made sure I understood that the evaluation and treatment process involved internal rectal work. After developing the condition and months of seeing doctors who didn’t listen, finally I found a physical therapist who was actually listening to me and determined to get to the bottom of what was going on. I could tell she already knew much about the mechanics (if not the exact cause) because she had treated other patients with the same issues. I immediately sensed a difference from any other health care professional in attitude, compassion, and knowledge. Of course, how do you know for sure? Well, you don’t. But after repeated visits and excellent results, you experience the difference. An important realization while going to Physical Therapy is learning to see the mind-body connection. In the back of my mind I sensed that my pain was being perpetuated by emotional trauma. This is not an intuitive way of thinking when you are in constant high-level, 5-alarm pain. I was obsessed with finding the cause of my pain, but chronic pain is extremely elusive and complicated.
Over the course of many months of PT though we couldn’t pinpoint what started the pain, we knew my nervous system was keeping it going. Sensory signals had somehow been rerouted through pain centers in the delicate and complicated highway interstate of the nervous system. It was as if the Fed Ex truck that was supposed to carry a package from Miami to Denver got rerouted to New York, stuck in traffic in Manhattan, flipped off by cab drivers, beaten up by gang members, contents of the truck shaken up by the driver trying to flee the city, and then finally finding the way out of New York to the true destination of Denver – with damaged goods, and shaking with anxiety. As to who the idiot dispatcher was who re-routed the truck to New York, well, he’s really good at keeping himself secret and innocent-looking. Jerk!
Physical therapy, over time, began to work for me. It released trigger points which are the first step in the long process of recovery. As we know, chronic tension must be addressed in tissues and nerves, and the mind must relearn how to remain in neutral. I found that as I gained periods of relief I could see that there truly was a mind-body connection beyond what I could imagine. My physical therapist and I both knew that nerves are the slowest recovering tissue in the body, and when you combine that with an anxious mind, you have a complicated puzzle to solve. There is definitely a closed circuit that develops with chronic pelvic pain. Pain causes anxiety, anxiety causes pain and circularly they feed one another.
During my physical therapy I joined a male pelvic pain message board online. I began understanding that most men who develop pelvic pain also have experienced traumatic emotional stress. And a large part of chronic pelvic pain is rooted in a mind-body dysfunction. I had to learn how to stop thinking catastrophically, especially during flare ups. I had to trust that my body would heal and think positively. I had to learn how to relax, take care of myself, eat well, stretch and exercise daily.
When I started physical therapy, I hoped to escape the pain. My first 5 month phase of physical therapy helped to loosen the chronically tightened pelvic sphincter muscles. However, I still had allodynia. In my second phase of physical therapy I began experiencing reduction of pain for a longer duration of time. After about a year of therapy, I finally got to a point where I could see there was significant improvement, even though some intermittent pain and anxious symptoms stubbornly persisted. In late spring of 2017, I finally felt like I had conquered the pain by 98%. Occasionally flares would still come, but they were brief and nothing like before physical therapy.
How has your experience with chronic pelvic pain changed you?
CPPS has profoundly changed me. I don’t take the little things for granted or sweat them anymore. I am grateful for not feeling that horrible, hellish sensation any longer. I appreciate having my mind pain and panic free. I speak my mind while respecting my own desires instead of belittling them. I am currently in school to become a Physical Therapy Assistant as through this process I learned that I’m actually much smarter than my middle school guidance counselor thought. I understand the mind is incredibly powerful, and fear rarely has the same power over me.
How do you handle flare ups?
I now handle brief flare ups with deep breaths, meditation, and/or just taking a step back and trying to zero in on what is really bothering me. At least now I can clearly think without debilitating pain and am able to function.
What would you like to say to other people who are struggling with chronic pelvic pain?
Oh, man. For the initial duration, I would say find a safe place where you can feel as comfortable as possible until the pain lessens. When it is bad, you sort of have to give in to it. However, part of this recovery is the physical mechanics of muscle and fascia. Physical Therapy is essential in the process of recovery to release this tension. I would tell them not to give up hope. You will not find many health professionals or websites that will tell you that you can beat this and recover 100%. But I will tell you, you can recover, 100%. You can. But for now, your full-time job is to work on recovery, and that includes lots of self-care, facing possible emotional pain, and physical therapy.
If you would like to learn more about addressing the mind body connection with patients please join us for Holistic Intervention and Meditation: Boundaries, Self-Care and Dialog in January. We will be exploring ways to help our patients heal to their fullest potential as well as keeping ourselves emotionally healthy in the process. Treating patients with persistent pain can be challenging for the best of us. Please come for this three-day course where you will leave feeling refreshed, renewed and reinvigorated to treat even your most complex patient.
Recently my coworkers and I celebrated a male patient’s recovery from a long and difficult journey with persistent pelvic pain. “Ben’s” case had many elements of what we normally see in our patients: chronic muscle holding, restricted fascia, allodynia, hyperalgesia, castrophizing and kenisiophobia. Ben was also very upfront about how his pain impacted his emotional well-being and vice versa. His healing process taught us a lot about the biopsychosocial aspects of treating persistent pain. Along his journey we dreamed of the day we could write a blog together and help other people learn from the experience. Ben also decided to make a career change entering school to become a PTA so that he could help others in pain. Here is my interview with this brave patient.
1. Tell us about how your pain started
My pain started with urethral burning. Tests showed there was no infection. In retrospect, the cause of pain could have been the beginning of tension on pudendal nerve branches from extreme stress and a series of traumatic incidents that happened within weeks of each other. They included a very embarrassing and stressful summer of unemployment, a father who had heart failure and triple bypass in the fall, and a girlfriend who gave me an ultimatum when I was too stressed to get an erection.
2. What medical tests or treatments were done?
When the pain started, I first thought it was a basic urinary tract infection. I went to the med center and was prescribed an antibiotic. After 3 days without change, I went back in and although they still found no sign of infection, they prescribed an additional antibiotic. The urethral pain never stopped and seemed to get worse. Following a series of visits to numerous doctors and urologists, I repeated tests on the prostate fluid, blood tests, and more bacterial tests. No infection. My PCP also made a fairly large overture of testing me repeatedly for HIV. For five months I had a blood test every month, all came back negative. This was damaging to my psyche. For those months I was terrified my life was over. In retrospect, that doctor was out of line, I changed doctors.
3. What were your thoughts when your doctor suggested physical therapy?
When the doctor suggested pelvic floor physical therapy, I was a little skeptical because I was still convinced that something was wrong in a chemical or infectious way (as is typical for most men with pelvic floor dysfunction). However, desperate to take away the constant pain, I followed the advice.
Stay tuned for part two of our conversation with Ben, coming up in our next post on the Pelvic Rehab Report!
Recently I had a patient referred to me for fecal incontinence. She looked so familiar to me and we realized she had seen me before, years ago, for bladder issues. She was a sweet 60 something single woman who had raised 6 kids on her own after her husband left her. We laughed as she remembered something funny I had said back then. Then we got down to business. In recent years my patient “Inez” had been diagnosed with both diabetes and Crohn’s disease. She was managing the Crohn’s very well but her sugars were much harder for her to get under control. When I asked her about her current complaints and symptoms she reported that most days her bowels were perfect. She reported one or two soft easy to pass stools per day. But when she had to leave the house for a doctor appointment, she would have explosive diarrhea. This didn’t happen if she went to the grocery store or to visit a friend. Upon further questioning she realized she was really anxious about her diabetes and her interactions with her medical provider regarding her diabetes had not been positive. She felt frustrated, scared, and powerless.
As a pelvic health PT I could have treated Inez in a variety of ways. With my initial exam I did not see any glaring musculoskeletal issues. I suggested to Inez the possibility that her nervous system was sending the wrong kind of signals to her bowels when she got anxious and that we could address this in PT. Inez agreed that she would like to try this approach. We decided that we would reevaluate after four visits to see if we needed to change the plan. Over four visits I used craniosacral therapy protocols to address nervous system upregulation and tension. I taught Inez relaxation techniques and encouraged 10 or 15 minutes of daily relaxation practice. Inez opened up about her relationship with her kids and how they tended to be takers but not givers. She would get frustrated and feel a bit used at times. We had conversations about boundaries and saying “no” and I shared some of my own experiences and struggles as well. Lastly we talked about how what we think can affect how we feel and what we do. Inez’s faith was important to her. She found a few bible verses that were meaningful to her about fear and anxiety and would repeat those during her daily relaxation time. On her fourth visit, Inez was all smiles. She brought me a jar of her homemade salsa as a graduation present. As we sat down to talk she reported to me that she saw her doctor yesterday. She had no bowel issues. And more than that, as her doctor began to talk over her she said to him, “No. Stop. You are always talking and never listening. I need you to listen to me today.” She went on to explain to him how it worried her that she was not able to control her diabetes well and she didn’t think he was doing enough to help her. Her physician did stop and listen and asked Inez, “what would you like me to do for you?” She asked for a referral to a specialist and he obliged. Inez was thrilled that she was able to manage her anxiety in a way that helped her bowels and to find the courage to confront her doctor to get the care she felt she needed.
As we grow in the knowledge of how the human body works it seems like all roads lead back to the nervous system. All of our treatments and interactions with patients affect the nervous system in one way or another. In our fast paced, stressed out world, finding ways to be intentional in addressing the nervous system can be a game changer for patients (as well as for ourselves). If this is an area you would like to grow in, please consider a new course being offered this January in Tampa, Florida. Participants taking Holistic Interventions and Meditation will experience and explore evidence-based information on strategies to address the nervous system. Topics covered include practical meditation, use of essential oils, supplements, yoga, calming and centering manual techniques and instruction in how to best dialogue with patients struggling with pain, anxiety and the effects of trauma. Nari Clemons and I hope to see you there.
Faurot, K. K. R., Gaylord, S., Palsson, O. S., Garland, E. L., Mann, J. D., & Whitehead, W. E. (2014). 715 Mindfulness Meditation Has Long-Term Therapeutic Benefits in Women With Irritable Bowel Syndrome (IBS): Follow-Up Results From a Randomized Controlled Trial. Gastroenterology, 146(5), S-124.
Kearney, D. J. (2012). Mindfulness meditation for women with irritable bowel syndrome–evidence of benefit from a randomised controlled trial. Evidence-based nursing, 15(3), 80-81.
Keefer, L., & Blanchard, E. B. (2001). The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study. Behaviour research and therapy, 39(7), 801-811.
The first time I experienced the effects of Post-Traumatic Stress Disorder (PTSD) was when my patient dissociated during a treatment session and relived the rape that had occurred when she was ten years old. It was devastating. I didn’t know what to do. She was unresponsive to my intervention. Her eyes didn’t see me, alternating between wide-eyed, horrified panic and clenched-closed, lip biting excruciating pain. It was my late night and I was alone in the clinic. I sat helplessly next to my sweet patient hoping and praying that her torture would end quickly. When she finally stopped writhing, she slept. Deep and hard. Finally she woke up disoriented and scared. She grabbed her things and left. For me, this experience was my initiation into the world of trauma.
Approximately 5-6 % of men and 10-12% of women will suffer from PTSD at some point in their lives. Researchers believe that 10% of people exposed to trauma will go on to develop PTSD. The expression of PTSD symptoms can present differently in men and women. Men may have more externalizing disorders progressing along a scale that includes vigilance, resistance, defiance, aggression and homicidal thoughts. Women tend to present with internalizing disorders such as depression, anxiety, exaggerated startle responses, dissociation, and suicidal thoughts. The research is clear that both men and women with PTSD display changes in brain function. The mid brain (amygdala, basal ganglia and hippocampus) tends to be overactive in sounding alarm signals while the prefrontal cortex fails to turn off the mid brain when a threat is no longer present. Since the prefrontal cortex is not always functioning correctly, traditional talk therapy may not be as effective for treating PTSD. Instead, say many researchers, breath and movement exercises may help regulate brain functioning. Yoga, Tai Chi, and meditation have been shown to have a positive impact on down regulating the mid brain and improving cerebral output. As pelvic floor therapists we deal with trauma on a daily basis, whether we know it or not. Although we are not trained in psychology, understanding PTSD and equipping ourselves with tools to support our patients is imperative for both our patients and ourselves.
You might be wondering what happened after that frightful night in the clinic? My patient was determined to get better. She had a non-relaxing pelvic floor. She was a teacher and was plagued by urinary distress. She either had terrible urgency or would go for hours and not be able to empty her bladder. So we met with her therapist to learn strategies to help us to be able to work together without triggering dissociation. It was a slow road, but the three of us working together helped my patient not only reach her goals but to be able to be skillful enough to maintain her gains using a dilator for self-treatment.
If you would like to learn more about PTSD, meditation, yoga, chronic pain, psychologically informed practice and self-care for patients and providers please join Nari Clemons and I in Tampa in January as we present a new offering for Herman and Wallace, “Holistic Intervention and Meditation.” We would love to see you there.
Bremner, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in clinical neuroscience, 8(4), 445-461.
Kerr, C. E., Jones, S. R., Wan, Q., Pritchett, D. L., Wasserman, R. H., Wexler, A., ... & Littenberg, R. (2011). Effects of mindfulness meditation training on anticipatory alpha modulation in primary somatosensory cortex. Brain research bulletin, 85(3), 96-103.
Morasco, B. J., Lovejoy, T. I., Lu, M., Turk, D. C., Lewis, L., & Dobscha, S. K. (2013). The relationship between PTSD and chronic pain: mediating role of coping strategies and depression. Pain, 154(4), 609-616.
Olff, M., Langeland, W., & Gersons, B. P. (2005). The psychobiology of PTSD: coping with trauma. Psychoneuroendocrinology, 30(10), 974-982.
The Role Of Yoga In Healing Trauma
One of my dear patients was recently diagnosed with Ehlers-Danlos sydrome (EDS). The diagnosis brought a sense of relief for sweet Katie who for years struggled with numerous health problems and was often misunderstood and under cared for by the medical community. Katie was referred to me 2 years ago at 28 for pelvic pain, endometriosis and IC. Upon exam we also discovered a significant elimination disorder and paradoxical elimination. Katie regularly timed her elimination and was spending at times up to 2 hours trying to empty her bowels. As we worked together we uncovered bilateral hip dysplasia, left hip labral tear, ilioinguinal and pudendal neruralgia and POTS (Postural Orthostatic Hypotension Syndrome). Katie already had a history of anxiety and depression but managed well with good family and friend support. When the diagnosis of EDS came, she finally felt like she had an explanation for why her body is like it is. This brought great relief as well as the knowledge that her condition was genetic and her conditions needed to be managed as best as possible to give her the most function, but would likely never be fully resolved.
In her book "A Guide to Living with Ehler's Danlos Syndrome" Isobel Knight does a beautiful job outlining the various genetic subtypes of Ehlers Danlos but also highlighting the fact that EDS hypermobility type (Type III) does not just affect the connective tissue in the musculoskeletal sytem leading to joint instability and hypermoblity, muscle tears, dislocations, subluxations, hip dysplasia and flat feet. EDS can also affect the body's systemic collagen leading to increased risk for endometriosis, POTS, Renauds, bladder problems, fibromyalgia, headaches, restless legs, ashtma, consitpation, bloatedness, prolapse, IBS symptoms, anxiety, depression and learning difficulties. She notes that some people have only a few of these systemic symptoms while others may be more affected. Per Isobel: "it is important that all symptoms are treated seriously and not ridiculed and that the appropriate medical support is given to them when necessary."
It seems that EDS is becoming more widely recognized. As rehabilitation specialists we should be alert to problems stemming from joint hypermobility when we notice how our patients position themselves. Often legs are curled up or double crossed. Upon questioning we might find that the patient has a history of being "double jointed" or was able to do "party tricks" with their bodies. The Bighton scale is a test of joint hypermobility which we should all be familiar with. It is also important to note that a patient may have hypermobility without having EDS, and that EDS is usually associated with pain. A rheumatologist, or in Katie's case a geneticist, can help confirm a suspected EDS diagnosis.
If you have a patient with hypermobliiy or with EDS, know that their ability to know where their body is in space is limited as their joints have much more range of motion than normal. The proprioceptors do not fire well at mid range and the patient will have to be trained to become accustomed to neutral joint positions. This was really painful for Katie and it took a huge mental and physical effort. She is getting stronger now and it is becoming easier to achieve. Stretching and soft tissue massage can feel really good when your muscles have to work so hard to maintain your joints in healthy positions. Patients should be instructed to not stretch into end range and also not "hang out" on their ligaments. Some patients may have to begin just with isometrics. I used Sara Meeks' program for safe and effective floor exercise with Katie. The floor gave her support while she strengthened her core muscles. Then she was able to progress to seated and seated on a ball as well as standing exercises. She loves the body blade! Yoga, Pilates, exercise in water can be effective for strength, propriception and movement reeducation. Mirrors are helpful for increasing position sense.
It is also helpful to note that even patients with EDS may be hypermobile in some joints and hypomobile in others. Isobel reports that her SI joints were extremely unstable while her thoracic spine was very rigid to the point that her lung capacity was affected. Having her therapist work on the hypomobility and doing breath work was life changing.
As pelvic health therapists and rehabilitation providers we may be the first professional to suspect EDS in a patient. There is a great deal that we and the greater medical and holistic community can do to help patients with EDS lead lives with less pain and dysfunction.
Faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC has written in to encourage us all to practice kindness and patience. A positive attitude can affect more than just your friends and family; your patients will benefit in so many ways as well!
First a little personal story. Several years ago my daughter was going through a tough time and we worked with a child psychologist. He was a wonderful man who taught my husband and I so much about how to raise a challenging kiddo. The foundation of what we needed to learn was the power of positive. People need nine (or so) positive interactions to override a negative one. Poor kid was definitely at a deficit! So if she did something that needed correcting, we were to give her a chance at a "do over" where sometimes we had to coach her to choose a better action. After she got it right, we lavished praise on our little pumpkin. And would you believe, not only did all that positiveness make a difference for her, it made a difference for her parents too!
Now back to the clinical. Just about two years ago I had the privilege of teaching with Nari Clemons. We taught PF2B together. Nari said something during one of her lectures that revolutionized my PT practice. She challenged us in lab to find three positive things about our lab partner and share those things before recognizing any deficits. How many times do we get finished with an evaluation and sit down with a patient and list all the things we found that need correction or help, perhaps drawing on our Netter images to fully illustrate the parts of their body that are broken or need fixing.
So I changed things up a bit and started remarking about the positive things I found on exam. "Wow, your hips are really strong and stable." "You've got a really coordinated breathing pattern, that is going to work in your favor." "You're pelvic muscles are really strong." and then later drawing on those positives outline how we could use the patient's strengths to help them overcome their challenges. "Because you have a great breathing strategy we are going to use that to help your whole nervous system to relax which with help your pelvic floor relax," for example.
The results were shocking. Person after person told me how much it meant to them to leave feeling positive and hopeful. One delightful woman who I saw for a diastasis had amazing leg muscles and I told her so. When she returned she said, "I've felt so self conscious about my flabby belly, but this week all I could think about were my strong leg muscles. Thanks for telling me that."
We do know is that our attitudes and beliefs as providers influence not only our clinical management but patient outcomes as well. Darlow et. al. performed a comprehensive literature review looking at how attitudes and beliefs among health care providers affected outcomes in patients with low back pain and discovered, "There is strong evidence that health care provider beliefs about back pain are associated with the beliefs of their patients."
Why not use that truth to our advantage and be positive? Would love to hear about your experiences!
Join Jennafer at one of her upcoming courses, Pelvic Floor Level 2B - Trenton, NJ - February 24-26, 2017, Pelvic Floor Series Capstone - Arlington, VA - May 5-7, 2017, Pelvic Floor Series Capstone - Columbus, OH - August 18-20, 2017, and Pelvic Floor Series Capstone - Tampa, FL - December 2-4, 2016.
My job as a pelvic floor therapist is rewarding and challenging in so many ways. I have to say that one of my favorite "job duties" is differential diagnosis. Some days I feel like a detective, hunting down and piecing together important clues that join like the pieces of a puzzle and reveal the mystery of the root of a particular patient's problem. When I can accurately pinpoint the cause of someone's pain, then I can both offer hope and plan a road to healing.
Recently a lovely young woman came into my office with the diagnosis of dyspareunia. As you may know dyspareunia means painful penetration and is somewhat akin to getting a script that says "lower back pain." As a therapist you still have to use your skills to determine the cause of the pain and develop an appropriate treatment plan.
My patient relayed that she was 6 months post partum with her first child. She was nursing. Her labor and delivery were unremarkable but she tore a bit during the delivery. She had tried to have intercourse with her husband a few times. It was painful and she thought she needed more time to heal but the pain was not changing. She was a 0 on the Marinoff scare. She was convinced that her scar was restricted. "Oh Goodie," I thought. "I love working with scars!" But I said to her, "Well, we will certainly check your scar mobility but we will also look at the nerves and muscles and skin in that area and test each as a potential pain source, while also completing a musculoskeletal assessment of the rest of you."
Her "external" exam was unremarkable except for adductor and abdominal muscle overactivity. Her internal exam actually revealed excellent scar healing and mobility. There was significant erythemia around the vestibule and a cotton swab test was positive for pain in several areas. There was also significant muscle overactivity in the bulbospongiosis, urethrovaginal sphincter and pubococcygeus muscles. Also her vaginal pH was a 7 (it should normally be a 4, this could indicate low vaginal estrogen). I gave her the diagnosis of provoked vestibulodynia with vaginismus. Her scar was not the problem after all.
Initially for homework she removed all vulvar irritants, talked to her doctor about trying a small amount of vaginal estrogen cream, and worked on awareness of her tendency to clench her abdominal, adductor, and pelvic floor muscles followed by focused relaxation and deep breathing. In the clinic I performed biofeedback for down training, manual therapy to the involved muscles, and instructed her in a dilator program for home. This particular patient did beautifully and her symptoms resolved quite quickly. She sent me a very satisfied email from a weekend holiday with her husband and daughter.
Although this case was fairly straightforward, it is a great example of how differential diagnosis is imperative to deciding and implementing an effective treatment plan for our patients. In Herman & Wallace courses you will gain confidence in your evaluation skills and learn evidence based treatment processes that will enable you to be more confident in your care of both straightforward and complex pelvic pain cases. Hope to see you in class!