You have been treating a highly motivated 24-year-old woman with a diagnosis of Interstitial Cystitis/Painful Bladder Syndrome (IC/BPS). The plan of care includes all styles of manual therapy, including joint mobilization, soft tissue mobilization, visceral mobilization, and strain counterstrain. You utilize neuromuscular reeducation techniques like postural training, breath work, PNF patterns, and body mechanics. Your therapeutic exercise prescription includes mobilizing what needs to move and strengthening what needs to stabilize. Your patient is feeling somewhat better, but you know she has the ability to feel even more at ease in their day to day. Is there anything else left in the rehab tool box to use?
Kanter et al. set out to discover if mindfulness-based stress reduction (MBSR) was a helpful treatment modality for (IC/BPS). The authors were interested in both the efficacy of a treatment centered on stress reduction and the feasibility of women adopting this holistic option.
The American Urological Association defined first-line treatments for IC/PBS to include relaxation/stress management, pain management and self-care/behavioral modification. Second-line treatment is pelvic health rehab and medications. The recruited patients had to be concurrently receiving first- and second-line treatments, and not further down the treatment cascade like cystoscopies and Botox.
The control group (N=11) received the usual care (as described above in first- and second-line treatments). The intervention group (N=9) received the usual care plus enrollment in an 8-week MBSR course based on the work of Jon Kabat- Zinn. The weekly course was two hours in the classroom supplemented with a 4-CD guide and book for home meditation practice carryover. The course content included meditation, yoga postures, and additional relaxation techniques.
The patients who participated in the MBSR program reported improved symptoms post-treatment, and perhaps more notably, their pain self-efficacy score (PSEQ) significantly improved. All but one of the participants reported feeling “more empowered” to control their bladder symptoms.
As clinicians working so intimately with our patients, we are often given the privilege of bearing witness to the emotional pain of healing chronic, persistent pelvic pain. We understand how terribly frightening it is for our patients to feel like they will never get better and we see this come out sometimes as fear-avoidance, which has the potential to cascade further into other areas of the social sphere.
If we are able to encourage holistic methods of building strategies to handle the challenges of IC/BPS, our patients will be set up for success in ways beyond the treatment room. While we hope for immediate results in the form of pain relief (which five patients in the study did), we also can appreciate the strategy building for resiliency in the face of persistent pain. As a very strong woman said, “hope serves us best when we do not attach specific outcomes to it”.
Dustienne Miller is the author and instructor of Yoga for Pelvic Pain. Join her in Kansas City, MO on April 7, 2018 - April 8, 2018 to learn about treating interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia with a yoga approach.
Kanter G, Kommest YM, Qaeda F, Jeppson PC, Dunivan GC, Cichowski, SB, and Rogers RG. Mindfulness-Based Stress Reduction as a Novel Treatment for Interstitial Cystitis/Bladder Pain Syndrome: A Randomized Controlled Trial. Int Urogynecol J. 2016 Nov; 27(11): 1705–1711.
If you area clinic owner, are in a management or leadership position, one of your jobs is making sure your therapists are using best practices. This can be a challenge when best practices are continually being researched and discussed, and when systematic reviews continue to tell us that pelvic rehabilitation research lacks homogeneity and enough high-level evidence to make convincing arguments about interventions. In the absence of this, we can still integrate recommendations from clinical practice guidelines and from best practice statements. The American Physical Therapy Association's (APTA) Section on Women's Health (SOWH) is participating in the APTA's initiative to develop clinical practice guidelines. For current guidelines, check out their page here. To see which guidelines are in development at the APTA, click here.
The American Urological Association (AUA) has also developed practice guidelines, including the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (IC/PBS). Within this guideline, the first line treatments are listed as general relaxation/stress management, pain management, patient education, and self-care/behavioral modification. Second-line treatments include "appropriate manual physical therapy techniques", oral medications, bladder medications (administered inside the bladder), and pain management. What is very interesting about this guideline is that the authors define what types of manual therapy approaches are appropriate, and these include techniques that resolve muscle tenderness, lengthen shortened muscles, release painful scars or other connective tissue restrictions. The guidelines also define who should be working with patients who have IC/PBS and pelvic muscle tenderness: "appropriately trained clinicians". Very importantly, the authors state that pelvic floor strengthening exercises should be avoided.
How can these guidelines be used to assess best practices? Find out if your therapists who work with patients who have IC/PBS are indeed instructing in relaxation strategies, using pain education and pain management techniques (for pain-brain education specific to pelvic pain, check out the book "Why Pelvic Pain Hurts". Find out if your therapist is instructing in pelvic muscle strengthening as a first-line of treatment, since this would not be in line with the AUA guidelines. (Having said this, teaching pelvic muscle strengthening can be very appropriate when done with consideration of pelvic muscle pain.) Lastly, ask your therapist if she feels that her skill set and training is sufficient to treat the condition. Even in our comprehensive pelvic floor series, there is so much to learn at the initial course that IC/PBS is not discussed in great detail until PF2B. Maybe a little more knowledge and training would help your therapist feel that she is providing the "appropriate manual physical therapy techniques" recommended in the guidelines.
To find out when the next intermediate or advanced course in the series is happening, or to find other specialty courses, check our course listings to see if there is a course happening near you!