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The Chronic Stress of Chronic Pain: Clinical Implications

For many of our patients, chronic pain is a chronic stress. Unfortunately, the resulting ongoing physiological stress reaction can have neurotoxic influences in key brain regions, including the prefrontal cortex, amygdala and hippocampus, and drive maladaptive neuroplastic changes that may further fuel a chronic pain condition.1 For example, chronic stress generates extensive dendritic spine loss in the prefrontal cortex, hyperactivity in the amygdala, and neurogenesis suppression in the hippocampus.2,3,4 In parallel, patients with chronic pain have been shown to exhibit reduced gray matter in the prefrontal cortex, increased neuronal excitability in the amygdala and reduced hippocampal neurogenesis.5,6,7

These three brain areas have been identified to play an important role in fear learning and memory.8 Modulated by stress hormones and stress-induced neuroplastic changes, stress may:
(a) enhance the memory of the initial pain experience at pain onset
(b) promote the later persistence of the pain memory
(c) impair the memory extinction process and the ability to establish a new memory trace.9

Sections of the brainIn other words, an ongoing stress reaction, triggered by distressing cognitions and emotions in response to pain or other life circumstances, could reinforce and strengthen the memory of pain. The experience of pain could be generated not by nociceptive activity, but by a well-established memory of pain and inability of the brain to create new associations. Leading researchers in the cortical dynamics of pain at Northwestern University suggest this learning process and persistence of pain memory could be a major influencing mechanism driving chronic pain.9,10

In addition, neurogenesis suppression in the hippocampus is associated with depression, while increased amygdala excitability is associated with anxiety, two mood disorders that frequently accompany and complicate chronic pain conditions.11,12

Why is this important? Appreciating the complex factors that contribute to chronic pain conditions can point to treatment strategies that address these factors.13 For example, strategies that help reduce a patient’s stress reaction, mitigate the experience of fear and anxiety, and/or promote relaxation, positive mood and self-efficacy could conceivably reduce the stress reaction and reverse maladaptive neuroplasticity. While chronic pain is a multifaceted and highly complex condition with no simple answers or one-size-fits-all successful treatment strategy, initial research suggests promise for this approach to modulate cortical structure. In a study of cognitive-behavioral therapy (CBT) in the treatment of chronic pain, an 11-week CBT treatment course increased gray matter in the prefrontal cortex and hippocampus.14

In addition, a systematic review of brain changes in adults who participated in Mindfulness-Based Stress Reduction identified increased activity, connectivity and volume in the prefrontal cortex and hippocampus in stressed, anxious and healthy adults.15 Also, the amygdala demonstrated decreased activity and improved functional connectivity with the prefrontal cortex. Although yet to be studied in patients with chronic pain, these neuroplastic changes could potentially promote improved cortical dynamics in our patients.

I am excited to share this model of chronic stress and chronic pain and evidence-based applications of mindfulness to pain treatment in my upcoming course Mindfulness-Based Pain Treatment in Arlington, VA August 4 and 5, 2018 and in Seattle, WA November 3 and 4, 2018. Course participants will learn about mindfulness and pain research, practice mindful breathing, body scan and movement and expand their pain treatment tool box with practical strategies to improve pain treatment outcomes. Research examining the application of mindfulness in the treatment of patients at risk of opioid misuse will be included. I hope you will join me!


Vachon-Presseau E. Effects of stress on the corticolimbic system: implications for chronic pain. Prog Neuropsychopharmacol Biol Psychiatry. 2017; Oct 25. pii: S0278-5846(17)30598-5.
Arnsten AF. Stress signaling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci 2009:10(6):410-422.
Zhang X, Tong G, Guanghao Y, et al. Stress-induced functional alterations in amygdala: implications for neuropsychiatric diseases. Front Neurosci. 2018 May 29;12:367.
Kim EJ, Pellman B, Kim JJ. Stress effects on the hippocampus: a critical review. Learn Mem. 2015;22(9):411-6.
Fritz HC, McAuley JH, Whittfeld K, et al. Chronic back pain is associated with decreased prefrontal and anterior insular gray matter: results from a population-based cohort study. J Pain. 2016;17(1):111-8.
Veinante P, Yalcin I, Barrot M. The amygdala between sensation and affect: a role in pain. J Mol Psychiatry. 2013;1(1):9.
Vachon-Presseau E. Roy M, Martel MO, et al. The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function. Brain. 2013;136(Pt 3):815-27.
Greco JA, Liberzon I. Neuroimaging of fear-associated learning. Neuropsychopharmacology. 2016;41(1):320-334.
Mansour AR, Farmer MA, Baliki. Chronic pain: role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32(1):129.
Baliki MN, Apkarian AV. Nociception, pain, negative moods and behavior. Neuron. 2015;87(3):474-491.
Schmaal L, Veltman DJ, van Erp TG, et al. Subcortical brain alterations in major depressive disorder: findings from ENIGMA major depressive disorder working group. Mol Psychiatry. 2016;21(6):806-12.
Shin LM, Liberzon I. The neurocircuitry of fear, stress and anxiety disorders. Neuropsychopharmacology. 2010;35(1):169-91.
Greenwald J, Shafritz KM. An integrative neuroscience framework for the treatment of chronic pain: from cellular alterations to behavior. Front Int Neurosci. 2018 May 23;12:18.
Seminowicz DA, Shpaner M, Keaser ML, et al. Cognitive-behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. J Pain. 2013;14(2):1573-84.
Gotink RA, Meijboom R, Vernooij, et al. 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice – A systematic review. Brain Cogn. 2016;108:32-41.

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Multiple Sclerosis: Dealing with Bowel Dysfunction

The British author, John Donne, wrote, “No man is an island, entire of itself; every man is a piece of the continent.” In a similar idea, no neurological symptom is independent and isolated; every system has potential to impact the whole body. Neurogenic bladder should cue a clinician to check for neurogenic bowel and to assess the pelvic floor in order to get a complete map of what to address in treatment.

Multiple SclerosisMartinez, Neshatian, & Khavari (2016) reviewed literature on neurogenic bowel dysfunction (NBD) and neurogenic bladder in patients with neurological conditions such as multiple sclerosis (MS). Constipation and fecal incontinence can coexist with NBD, and a multifactorial bowel regimen is vital to conservative management in patients with neurological disorders. Nonpharmacological, pharmacological, and surgical approaches were reviewed in the article. Specific results for MS were reported only for transanal irrigation (TAI) and biofeedback. In TAI, fluid is used to stimulate the bowel and clean out stool from the rectum. A study showed 53% of the 30 patients with MS demonstrated a 50% or better improvement in bowel symptoms with TAI. In anorectal biofeedback, operant conditioning retrains motor and sensory responses via exercises guided by manometry. With biofeedback, a study showed 38% of patients had a beneficial impact with the intervention. The list of treatment approaches not specifically researched for MS patients in this review includes: dietary modifications, perianal/anorectal stimulation, abdominal massage, suppositories, oral medications such as stool softeners or prokinetic agents, sacral neuromodulation, antegrade continence enema, and colostomy.

Miletta, Bogliatto, & Bacchio (2017) presented a case study about management of sexual dysfunction, perineal pain, and elimination dysfunction in a 40 year old female with multiple sclerosis. She had been experiencing perineal pain for 5 months and had chronic MS symptoms of lower anourogenital dysfunction, including bladder retention and obstructed defecation syndrome. Physical therapy treatment included pelvic floor muscle training (primarily decreasing overactivity of pelvic muscles in this case), perineal massage, biofeedback, postural correction, global relaxation techniques, and a home self-training program. After 5 months of physical therapy, the woman had improved pelvic floor muscle contraction strength, resolution of pelvic floor muscle overactivity, increased sexual satisfaction (according to the Female Sexual Function Index score), a visual analog scale improvement of vulvar and perineal pain by 4 points, normalization of obstructed defecation syndrome, and decreased bladder retention symptoms. The authors concluded the variety of symptoms in MS require a multimodal approach for treatment, considering all the motor, autonomic, and cognitive impairments as well as side effects of medications that try to improve those symptoms. The quality of life of women with MS has potential to be improved significantly if pelvic floor disorders related to MS are addressed appropriately.

Ultimately, treating urinary dysfunction but avoiding bowel dysfunction does neurological patients a disservice. Systems are intertwined in a series of cause and effects throughout the body. The “Neurologic Conditions and the Pelvic Floor” course can expand your knowledge and understanding of how the symptoms of conditions such as multiple sclerosis can impact pelvic health and how we can better address the whole patient for optimal outcomes.


Martinez, L., Neshatian, L., & Khavari, R. (2016). Neurogenic Bowel Dysfunction in Patients with Neurogenic Bladder. Current Bladder Dysfunction Reports, 11(4), 334–340. http://doi.org/10.1007/s11884-016-0390-3
Miletta, M., Bogliatto, F., & Bacchio, L. (2017). Multidisciplinary Management of Sexual Dysfunction, Perineal Pain, and Elimination Dysfunction in a Woman with Multiple Sclerosis. International Journal of MS Care, 19(1), 25–28. http://doi.org/10.7224/1537-2073.2015-082

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Hypopressive Exercise for Post-prostatectomy Incontinence

Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of “Low Pressure Fitness and abdominal massage for pelvic care” in Princeton, New Jersey in July, 2018. Tamara is internationally recognized for her work with hypopressive exercise and Low Pressure Fitness. In this article she presents the novel topic of hypopressives as a complementary pelvic floor muscle training tool for incontinence after prostate cancer surgery.

Urinary Incontinence is the most common side effect men suffer after prostate cancer surgery along with erectile dysfunction. Although it is not life threatening, urinary incontinence definitely has a negative impact on the patient’s quality of life Sountoulides et al., 2013. Beyond the frustration and embarrassment associated with pelvic floor dysfunction, many patients describe it as depressing, disheartening and devastating.

The first line of conservative treatment - and most often recommended - is pelvic floor muscle training Andersen et al., 2015. Over the past few years, some researchers have also recommended alternative exercise programs with a holistic approach such as Pilates and hypopressives to improve the patient’s quality of life and urinary incontinence symptoms (Santa Mina et al., 2015). These alternative pelvic floor muscle training programs draw upon the connection between the pelvic floor, it’s synergistic muscles (abdominal, pelvic, lumbar) and their interrelated role in posture and breathing Hodges, 2007; Sapsford, 2004; Madill and McLean, 2008; Talasz et al., 2010. Among these complementary exercise programs, hypopressives have gained increasing attention for the recovery of post-prostatectomy urinary incontinence Santa Mina et al., 2015; Mallol-Badellino, et al. 2015.

What is known about hypopressives for post-prostatectomy incontinence?

Although hypopressive exercise has become popular for women, some researchers, clinicians and practitioners have begun to apply these exercises for specific male issues such as urinary incontinence following a prostatectomy. Recently, a case-study I co-authored about an adapted program of hypopressive exercise for urinary incontinence following a radical prostatectomy surgery was published in the Journal of the Spanish physiotherapy association Chulvi-Medrano & Rial, 2018. We describe the case of a 46-year-old male with severe stress urinary incontinence six months after surgery. We used a pelvic floor exercise program consisting of hypopressive exercises as described in the Low Pressure Fitness level 1 practical manual Rial & Pinsach, 2017 combined with contraction of the pelvic floor muscles. Satisfactory results were obtained after the rehabilitation protocol as evidenced by a reduction from 3 daily pads to none. Of note, clinical trails have demonstrated the benefits of initiating a rehabilitation program to strengthen the pelvic floor as soon as possible after prostatectomy. Previously, I’ve studied hypopressive exercise for female urinary incontinence Rial et al., 2015 and for the improvement of female athletes pelvic floor function Álvarez et al., 2016. However, this was the first time we’ve studied hypopressives in the context of male urinary leakage.

In the same light, other researchers have also included hypopressives in their pelvic floor training protocol for post-prostatectomy urinary incontinence. For example, Serda et al (2010) and Mallol-Badellino (2015) used protocols that combined pelvic floor contractions with postural re-education and hypopressives. Both studies found improvements in the severity of involuntary leakages and improvements in the patients’ quality of life. Similar results are also described in the clinical case by Scarpelini et al. (2014) who used hypopressives and psoas stretching exercises to reduce urinary incontinence after prostatectomy.

But how do hypopressives work?

The hypothesis underlying the use of hypopressives as a complementary pelvic floor and core exercise program is that it retrains the core system with specific postural and breathing strategies while reducing pressure on the pelvic organs and structures. The most striking part of hypopressives breathing technique is the abdominal vacuum. This breathing maneuver involves a low pulmonary volume exhale-hold technique followed by a rib-cage expansion involving the activation of the inspiratory muscles. The rib-cage expansion during the breath-holding phase leads to a noticeable draw-in of the abdominal wall and simultaneously to the rise of the thoracic diaphragm. Recent observational studies have shown how the hypopressive technique was able to elevate the pelvic viscera and to activate the pelvic floor and deep core muscles in women trained with hypopressives Navarro et al., 2017. From an historical point of view, this characteristic breathing maneuver was first described and practiced as a yoga pranayama called Uddiyanha Bandha Omkar & Vishwas, 2009.

Figure 1 shows the anatomical behavior of the rib cage and the abdominal wall when performing the hypopressive breathing maneuver, which should not be confused with an abdominal hollowing, or a bracing maneuver. Anatomical observation of the thoracic and abdominal behavior during the breathing maneuver of the hypopressive exercise. Figure elaborated by the author.

In addition to breath control, the hypopressive technique involves a series of static and dynamic poses which operate on the hypothesis of training the stabilizing muscles of the spine, such as the core and pelvic muscles. In this sense, hypopressives are not exclusively a breathing technique, but rather they are an integrated whole-body technique. The practice of hypopressives involves body control, body awareness, postural correction and mindfulness throughout its different poses and postural techniques. The introduction of holistic exercise programs to train the synergist pelvic floor muscles and breathing patterns can be viewed as complementary tools for the restoration of a patient’s body awareness and functionality.

Another hypothesis of the effects of the hypopressive-breathing in the pelvic floor is the ability to move the pelvic viscera cranially as a consequence of the ribcage opening up after the breath-hold. This vacuum lifts the diaphragm and consequently creates an upward tension on the transversalis fascia, the peritoneum and other related fascial structures. In addition to the diaphragmatic suction effect, a correct alignment of the rib cage and pelvis during the exercise contributes to an improved suspension and position of the viscera in the pelvis. The mobility achieved with the breathing and its body sensations may be one of the reasons why hypopressives have also been recommended as a proprioceptive facilitator for those with low ability to “find their pelvic floor” Latorre et al., 2011.

It’s crucial to highlight that a complete surgical resection of the prostate will cause - in most of the cases - post-operative fibrosis and neurovascular damage Hoy-Land et al., 2014. Both, the neurovascular and musculoskeletal injuries are contributing factors for urinary incontinence post-prostatectomy. Subsequently, exercises focusing on increasing local vascular irrigation and re-activating the damaged musculature have been highlighted as the main goals to help patients recover continence. In this sense, breathing movements, fascia manipulation and decreased pelvic pressure can result in increased vascular supply. A previous study has shown an improvement in venous return of the femoral artery during the hypopressive-breathing maneuver Thyl et al., 2009. Collectively, all these factors may favor microcirculation in the pelvic area. Finally, the muscle activation of the pelvic floor and core muscles observed during the practice of hypopressives (Ithamar et al., 2017) and the changes of puborectalis and iliococcygeus muscles after an intensive pelvic floor muscle training (Dierick et al., 2018) are other factors that could have impact on urge incontinence, stress incontinence and overflow incontinence symptoms common after prostatectomy surgeries.

To date, the results from these investigations and clinical reports open new complementary pelvic floor training strategies for the treatment of post-prostatectomy incontinence. Hypopressives and pelvic floor muscle exercises are non-invasive, don’t require expensive material, and provide an exercise-based approach as part of a healthy lifestyle. However, qualified instruction, technique-driven progression and adherence to the intervention are critical components of any pelvic floor and hypopressive training protocol.


Álvarez M, Rial T, Chulvi-Medrano I, García-Soidán JL, Cortell JM. 2016. Can an eight-week program based on the hypopressive technique produce changes in pelvic floor function and body composition in female rugby players? Retos nuevas Tendencias en Educación Física, Deporte y Recreación, 30(2): 26-29.
Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CM. 2015. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev, 1:CD001843.
Chulvi-Medrano I, Rial T. 2018. A case study of hypopressive exercise adapted for urinary incontinence following radical prostactetomy surgery. Fisioterapia, 40, 101-4. Doi: DOI: 10.1016/j.ft.2018.01.004
Dierick F, Galrsova E, Laura C, Buisseret F, Bouché FB, Martin L. 2018. Clinical and MRI changes of puborectalis and iliococcygeus after a short period of intensive pelvic floor muscles training with or without instrumentation. European Journal of Applied Physiology, doi:10.1007/s00421-018-3899-7
Ithamar, L., de Moura Filho, A.G., Benedetti-Rodrigues, M.A., Duque-Cortez, K.C., Machado, V.G., de Paiva-Lima, C.R.O., et al. 2017. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. J. Bodywork. Mov. Ther. doi: 10.1016/j.jbmt.2017.06.011.
Latorre G, Seleme M, Resende AP, Stüpp L, Berghmans B. Hypopressive gymnastics: evidences for an alternative training for women with local proprioceptive deficit of the pelvic floor muscles. Fisioterapia Brasil 2011; 12(6): 463-6.
Hodges P. 2007. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn, 26(3): 362-371.
Hoyland K, Vasdev N, Abrof A, Boustead G. 2014. Post-radical prostatectomy incontinence: etiology and prevention. Rev Urol. 16(4), 181-8.
Madill, S., McLean, L. 2008. Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle ontractions. J. Electromyogr. Kinesiol. 18, 955-64. doi: 10.1016/j.jelekin.2007.05.001.
Mallol-Badellino J., et al. 2015. Resultados en la calidad de vida y la severidad de la incontinencia urinaria en varones prostatectomizados por neoplasia de próstata. Rehabilitación, 49(4); 210-215.
Navarro, B., Torres, M., Arranz, B. Sánchez, O. 2017. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia. 39, 187-194. doi:10.1016/j.ft.2017.04.003.
Omkar, S., Vishwas, B. 2009. Yoga techniques as a means of core stability training. J. Bodywork Mov. Thep. 13, 98-103. doi: 10.1016/j.jbmt.2007.10.004.
Rial T, Chulvi-Medrano I, Cortell-Tormo JM, Álvarez M. 2015. Can an exercise program based on hypopressive technique improve the impact of urinary incontinence on women´s quality of life? Suelo Pélvico, 11:27-32.
Rial, T., Pinsach, P. 2017. Low Pressure Fitness practical manual level 1. International Hypopressive and Physical Therapy Institute, Vigo.
Santa Mina D, Au D, Alibhai S, Jamnicky L, Faghani N, Hilton W, Stefanky L, et al. 2015. A pilot randomized trial of conventional versus advanced pelvic floor exercises on treat urinary incontinence after radical prostatectomy: a study protocol. BMC Urology, 15. DOI 10.1186/s12894-015-0088-4
Sapsford R. 2004. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther, 9(1): 3-12.
Serdá B, Vesa, A. del Valle, y Monreal P. 2010. La incontinencia urinaria en el cáncer de próstata: diseño de un programa de rehabilitación. Actas Urológicas Españolas, 34(6): 522-30.
Scarpelini P, Andressa Oliveira F, Gabriela Cabrinha S, Cinira H. 2014. Protocolo de ginástica hipopressiva no tratamento da incontinência urinária pós-prostatectomia: relato de caso. UNILUS Ensino e Pesquisa, 11(23): 90-95
Talasz, H., Kofler, M., Kalchschmid, E., Pretterklieber, M., Lechleitner, M. 2010. Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women. Int. Urogynecol. J. 21, 475-81. doi: 10.1007/s00192-009-1060-1.
Thyl S., Aude P, Caufriez M, Balestra C. 2009. Incidence de l'aspiration diaphragmatique associée à une apnée expiratoire sur la circulation de retour veineuse fémorale: étude par échographie-doppler. Kinésithérapie scientifique, 502; 27-30.

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Carolyn McManus Presentating at the World Congress on Pain!

Exciting news! Carolyn McManus, Herman & Wallace instructor of Mindfulness-Based Pain Treatment, will be a presenter in programming at the International Association for the Study of Pain (IASP) World Congress on Pain in to be held in Boston, September 11 - 16. This conference brings together experts from around the globe practicing in multiple disciplines to share new developments in pain research, treatment and education. Participants from over 130 countries are expected to attend. The last time it was held in the U.S. was 2002, so it presents an especially exciting opportunity for those interested in pain to have this international program taking place in the U.S. Carolyn will present a workshop on mindfulness in a Satellite Symposia, Pain, Mind and Movement: Applying Science to the Clinic.

Carolyn has been a leader in bringing mindfulness into healthcare throughout her over-30 year career. She recognized early on in her practice how stress amplified patients’ symptoms and, as she had seen the benefits of mindfulness in her own life, it was a natural progression to integrate mindful principles and practices into her patient care. An instructor for Herman and Wallace since 2014, she has developed two popular courses, Mindfulness-Based Pain Treatment and Mindfulness for Rehabilitation Professionals, enabling her to share her clinical and research experiences with her colleagues.

For many patients, pain is not linearly related to tissue damage and interventions based on structural impairment alone are inadequate to provide full symptom relief. Mindfulness training can offer a key ingredient necessary for a patient to make additional progress in treatment. By learning therapeutic strategies to build body awareness and calm an over-active sympathetic nervous system, patients can mitigate or prevent stress-induced symptom escalation. They can learn to move with trust and confidence rather than fear and hesitation.

A growing body of research in mindfulness-based therapies demonstrates multiples benefits for patients suffering with pain conditions. Research suggests that mindfulness training can be helpful to women preparing for childbirth and patients suffering from fibromyalgia, pelvic pain, IBS and low back pain. In addition, for patients with anxiety, mindfulness training may contribute to reductions in anxiety and in adrenocorticopropic hormone and proinflammatory cytokine release in response to stress. Authors of this study conclude that these large reductions in stress biomarkers provide evidence that mindfulness training may enhance resilience to stress in patients with anxiety disorders.

In addition to her presentation at the IASP World Congress Satellite Symposia, Carolyn will be sharing a more in-depth examination and practice of mindfulness in her upcoming course Mindfulness-Based Pain Treatment, August 4 and 5 at Virginia Hospital Center, Arlington VA, and again November 3 and 4 at Pacific Medical Center in Seattle, WA. Please join an internationally-recognized expert for 2 days of innovative training in mindfulness that will both improve your patient outcomes and enhance your own well-being!


Duncan LG, Cohn MA, Chao MT, et al. Benefits of preparing for childbirth with mindfulness training: A randomized controlled trial. BMC Pregnancy Childbirth 2017 May 12;17(1):140.
Fox SD, Flynn E, Allen RH. Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med.2011;56(3-4):158-62.
Garland EL, Gaylord SA, Paisson O. Therapeutic mechanisms of a mindfulness-based treatment for IBS: effects on visceral sensitivity, catastrophizing and affective processing of pain sensations. J Behav Med. 2012;35(6):591-602.
Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized Clinical Trial. JAMA. 2016;315(12):1240-9.
Hoge EA, Bui E, Palitz SA, et al. The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Res. 2018;262:328-332.

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People with Parkinson disease can MOVE!

Akinesia is a term typically used to describe the movement dysfunction observed in people with Parkinson disease. It is defined as a poverty of movement, an impairment or loss of the power to move, and a slowness in movement initiation. There is an observable loss of facial expression, loss of associated nonverbal communicative movements, loss of arm swing with gait, and overall small amplitude movements throughout all skeletal muscles in the body. The cause of this characteristic profile of movement is due to loss of dopamine production in the brain which causes a lack of cortical stimulation for movement.

If the loss of dopamine production in the brain causes this poverty of movement in all skeletal muscles the body, how does the pelvic floor function in the person with Parkinson disease and what should the pelvic floor rehabilitation professional know about treating the pelvic floor in this population of patients?

Let’s take a closer look referencing a very telling article about Parkinson disease and skeletal muscle function. In the Italian town of L’Aquila, a major devastating 6-point Richter scale earthquake occurred on April 6, 2009. 309 people died and there was destruction and collapse of many historical structures, some greater than 100 years old. The nearby movement disorder clinic had been following 31 Parkinson disease patients in the area, 17 of them higher functioning and the other 14 much lower functioning. In fact, of those 14, 10 of them were affected by severe freezing episodes with severe nighttime akinesia requiring assistance with bed mobility tasks, 1 was completely bedridden and the others with major fluctuations in motor performance. 13 of the 14 patients also had fluctuating cognitive functioning.

This devastating earthquake occurred at 3:30 am. All 14 of these patients were able to escape from their homes during or immediately following the event. Caregivers reported that in the majority of the cases, the person with Parkinson’s disease was the first one to be alerted to the earthquake, the first one to get out of the house, ability to alert relatives to run for safety, physically assisting relatives out of the collapsing buildings, and in some cases independently escaping down 1-2 flights of stairs.

Paradoxical kinesia is thought to be the reason for this all but sudden ability to move normally within the presence of an immediate threat to their life and lives of loved ones. Paradoxical kinesia is defined as “a sudden and brief period of mobility typically seen in response to emotional and physical stress in patient’s with advanced idiopathic Parkinson’s disease.” There are a few mechanisms hypothesized to play a role, such as, adrenaline, dopaminergic reserves activating the flight reaction, and compensatory nearby cerebellar circuitry.

There is no pathological evidence that in Parkinson disease there is any break in the continuity of the motor system. The neurologic pathways are all intact and the ability to produce muscle power is retained however requires a strong base of clinic knowledge of the disease to help these patients activate these intact motor pathways. I look forward to sharing the neurologic basis of these deficits in Parkinson disease and strategies in pelvic floor rehab to do just that!

Erica Vitek, a specialist in treating patients with neurologic dysfunction, is the author and instructor of Neurologic Conditions and Pelvic Floor Rehab, taking place September 14-16, 2018 in Grand Rapids, MI.


Bonanni, L., Thomas, A., Anzellotti, F., Monaco, D., Ciccocioppo, F., Varanese, S., Bifolchetti, S., D’Amico, M.C., Di Iorio, A. & Onofrj, M. (2010). Protracted benefit from paradoxical kinesia in typical and atypical parkinsonisms. Neurological sciences, 31(6), 751-756.

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Improving Sexual Function in Women with Cognitive Behavioral Therapy

In a previous post on The Pelvic Rehab Report, Sagira Vora, PT, MPT, WCS, PRPC explored the impact that pelvic floor exercises can have on arousal and orgasm in women. Today we hear part two of the conversation, and learn what factors can impact a woman's ability to achieve orgasm.

Mindfulness“An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.”

Wow, that sounds like paradise! The question is--how to get there? Many of our cohorts and many our female patients have not experienced this or orgasm happens for them rarely. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Some of the reasons cited for lack of orgasm are orgasm importance, sexual desire, sexual self-esteem, and openness of sexual communication with partner by Kontula el. al. in 2016. Rowland found that most commonly-endorsed reasons were stress/anxiety, insufficient arousal, and lack of time during sex, body image, pain, inadequate lubrication.

One factor that comes up consistently, is the ability of women to focus on sexual stimuli. This point has been brought up by various studies and presented in different ways. Chambless talks about mindfulness training and improvements in orgasm ability noted equally in women who practiced mindfulness vs. women who engaged in Kegels and mindfulness. Rosenbaum and Padua note in their book, The Overactive Pelvic Floor, “women who do not have a low-tone pelvic floor and who seek to enhance sexual arousal and more frequent orgasms have not much to gain from pelvic floor muscle training. Actually, a relaxed pelvic floor and mindful attention to sexual stimuli and bodily sensations seem a more effective means of enhancing sexual arousal and orgasm.” Various studies specifically studying the effect of mindfulness training have demonstrated both improved arousal and orgasm ability in women who practiced mindfulness. Brotto and Basson found their treatment group, which consisted of 68 otherwise healthy women, who underwent mindful meditation, cognitive behavioral training and education, improved in sexual desire, sexual arousal, lubrication, sexual satisfaction, and overall sexual functioning.

Cognitive-behavioral therapy appears to play a significant role in improving sexual function in women. Meston et. al. notes, “cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.”

Alas, there are no magic pills to create the above described “state of altered consciousness,” allowing women a sense of “well-being and contentment.” However, mindfulness training and cognitive behavioral therapy are both accessible and attainable for women who want to improve their ability to enjoy this much desired state. Many Pelvic floor therapist incorporate cognitive behavioral and mindfulness approaches in their practice.

The studies above mention pain as one of the factors for inability to experience arousal and orgasm. Hucker and Mccabe even noted that their mindfulness treatment group demonstrated significant improvements in all domains of female sexual response except for sexual pain. Dealing with sexual pain is a daily battle pelvic floor therapist face each day. So, how do women with sexual pain dysfunction differ from women who are experiencing sexual dysfunction but not pain? Let’s explore this in our next blog…


Chambless DL, Sultan FE, Stern TE, O’Neill C, Garrison S. Jackson A. Effect of pubococcygeal exercise on coital orgasm in women. J Consult CLin Psychol. 1984; 52:114-8
Bratto LA, Basson R. Group mindfulness-based therapy significantly improves sexual desire in women Behav Res Ther. 2014 Jun; 57:43-5
Hucker A. Mccabe MP. Incorporating Mindfulness and Chat Groups Into an Online Cognitive Behavioral Therapy for Mixed Female Sexual Problems. J Sex Res. 2015;52(6):627-33
Kontula O., Mettienen A. Determinants of female sexual orgasms. Socioaffect Neurosci Psychol. 2016 Oct 25;6:31624. doi: 10.3402/snp.v6.31624. eCollection 2016
Meston CM1, Levin RJ, Sipski ML, Hull EM, Heiman JR. Women’s orgasm. Annu Rev Sex Res. 2004;15:173-257. Review
Rosenbaum, Talli Y., Padoa, Anna. The overactive Pelvic floor. 1st ed. 2016
Roland DL, Cempel LM, Tempel AR. Women’s attributions on why they have difficulty reaching orgasm. J. Marital Therapy. 2018 Jan 3:0

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Pregnancy Associated Ligamentous Laxity

Kelly Feddema, PT, PRPC returns in a guest post on Pregnancy Associated Ligamentous Laxity. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. See her post on diastasis recti abdominis on the pelvic rehab report, and learn more about evaluating and treating pregnant patients by attending Care of the Pregnant Patient!

Ligament Laxity Indicated with Finger StretchingPregnancy associated ligamentous laxity is something that we, as therapists, are fairly well aware of and see the ramifications of quite often in the clinic. We know the female body is changing to allow the mother to prepare for the growth and birth of the tiny (or sometimes not so tiny) human she is carrying. We also know that the body continues to evolve after the birth to eventually return to a post-partum state of hormonal balance. Do we think much about what this ligamentous laxity can mean during the actual delivery? Does laxity predispose women to other obstetric injury?

A recent study in the International Urogynecology Journal assessed ligamentous laxity from the 36th week of pregnancy to the onset of labor by measuring the passive extension of the non-dominant index finger with a torque applied to the second metacarpal phalangeal joint. They collected the occurrence and classification of perineal tears in 272 out of 300 women who ended up with vaginal deliveries and looked for a predictive level of second metacarpophalangeal joint (MCP) laxity for obstetric anal sphincter injury (OASI). They concluded that the increased ligamentous laxity did seem associated with OASI occurrence which was opposite of their initial idea that more lax ligaments would be at less of a risk of OASI.

In another study from the same journal published in 2017, researchers studied if levator hiatus distension was associated with peripheral ligamentous laxity during pregnancy. This was a small study but they concluded that levator hiatus distension and ligamentous laxity were significantly associated during pregnancy. They did admit the relationship was weak and results would have to be confirmed with a larger study and more specific study methods. However, the likelihood of major levator trauma more than triples during the reproductive years from under 15% at age 20 to over 50% at age 40(University of Sydney) so it seems that these issues warrant continued study with the continued trend toward delayed child bearing in Western cultures.


Gachon, B., Desgranges, M., Fradet, L. et al. Int Urogynecol J (2018). https://doi.org/10.1007/s00192-018-3598-2
Gachon, B., Fritel, X., Fradet, L. et al. Int Urogynecol J (2017) 28: 1223. https://doi.org/10.1007/s00192-016-3252-9
University of Sydney. "Levator Trauma" sydney.edu.au. Accessed 25 April 2018.

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Positive Activities

Coaching Patients to Engage in Positive Activities to Improve Outcomes

Substantial attention has been given to the impact of negative emotional states on persistent pain conditions. The adverse effects of anger, fear, anxiety and depression on pain are well-documented. Complementing this emphasis on negative emotions, Hanssen and colleagues suggest that interventions aimed at cultivating positive emotional states may have a role to play in pain reduction and/or improved well-being in patients, despite pain. They suggest positive affect may promote adaptive function and buffer the adversities of a chronic pain condition.

Hanssen and colleagues propose positive psychology interventions could contribute to improved pain, mood and behavioral measures through various mechanisms. These include the modulation of spinal and supraspinal nociceptive pathways, buffering the stress reaction and reducing stress-induced hyperalgesia, broadening attention, decreasing negative pain-related cognitions, diminishing rigid behavioral responses and promoting behavioral flexibility.

In a feasibility trial, 96 patients were randomized to a computer-based positive activity intervention or control condition. The intervention required participants perform at least one positive activity for at least 15 minutes at least 1 day/week for 8 weeks. The positive activity included such tasks as performing good deeds for others, counting blessings, taking delight in life’s momentary wonders and pleasures, writing about best possible future selves, exercising or devoting time to pursuing a meaningful goal. The control group was instructed to be attentive to their surroundings and write about events or activities for at least 15 minutes at least 1 day/week for 8 weeks. Those in the positive activity intervention demonstrated significant improvements in pain intensity, pain interference, pain control, life satisfaction, and depression, and at program completion and 2-month follow-up. Based on these promising results, authors suggest that a full trial of the intervention is warranted.

Rehabilitation professionals often encourage patients with persistent pain conditions to participate in activities they enjoy. This research highlights the importance of this instruction and patient guidelines can include the activities identified in the Muller article. In addition, mindful awareness training may further enhance a patient’s experience as he or she learns to pay close attention to the physical sensations, emotions and thoughts that accompany positive experiences. I look forward to discussing this article as well as sharing the principles and practices of mindfulness in my upcoming course, Mindfulness-Based Pain Treatment at Samuel Merritt University, Oakland, CA. Course participants will learn about mindfulness and pain research, practice mindful breathing, body scan and movement and expand their pain treatment tool box with practical strategies to improve pain treatment outcomes. I hope you will join me!


Hanssen MM, Peters ML, Boselie JJ, Meulders A. Can positive affect attenuate (persistent) pain? Curr Rheumatol Rep. 2017;19(12):80.
Muller R, Gertz KJ, Molton IR, et al. Effects of a tailored positive psychology intervention on well-being and pain in individuals with chronic pain and physical disability: a feasibility trial. Clin J Pain.2016;32(1):32-44.

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Multifidus size and prevalence of concussion

A couple of years ago, I wrote a blog about an interesting article by Hides and Stanton that related size and strength of the multifidus to the risk for lower extremity injury in Australian professional football players.

Now some of the same researchers are looking above. A prospective cohort study has recently been published that examined factors and their effects on concussions. Physical measurements of risk factors were taken in pre-season among Australian football players. These measurements included balance, vestibular function, and spinal control. To measure these outcomes the following tests were included: for balance the amount of sway across six test conditions were performed; vestibular function was tested with assessments of ocular-motor and vestibular ocular reflex; and for spinal control cervical joint position error, multifidus size, and contraction ability was tested. The objective measure was concussion injury obtained during the season diagnosed by the medical staff.

The findings were so interesting! Age, height, weight, and number of years playing football were not associated with concussion. Cross-sectional area of the multifidus at L5 was 10% smaller in players who went on to sustain a concussion compared to players that did not receive a concussion. There were no significant differences observed between the players that received concussion and those who did not with respect to the other physical measures that were obtained.

With all the recent evidence about the harmful effects of concussions amongst our athletes, I find this information amazing and am excited to see where the researchers take this in the future. The next question for the physical therapist is how do we train the multifidus? The multifidus can be difficult to retrain in some individuals. It is a hard muscle for some patients to learn to recruit. Biofeedback using ultrasound imaging can make this daunting task easier for many patients. With the cost of ultrasound units coming down, it is also a very reasonable tool for clinics to look at investing in.

Join me to learn more about the multifidus and how to use ultrasound imaging in the retraining process. Future course offerings include August in New Jersey, and November in San Diego. I look forward to seeing you there!


Hides, Stanton. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exerc. 2014; 46(4): 762-8.
Leung, Hides, Franettovich Smith, et al. Spinal control is related to concussion in professional footballers. Brit J of Sports Med. 2017; 51(11).

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Using Yoga for Post-traumatic Stress Disorder

When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.

Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).

This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.

Cushing et al., (2018) recently published online a study testing the impact of yoga on post-9/11 veterans diagnosed with PTSD. The participants were >18 years old and scored at least 30 on the PTSD Checklist-Military version (PCL-M). They participated in weekly 60-minute yoga sessions for 6 weeks including Vinyasa-style yoga and a trauma-sensitive, military-culture based approach taught by a yoga instructor and post-9/11 veteran. Pre- and post-intervention scores were obtained by 18 veterans. Their PTSD symptoms decreased, and statistical and clinical improvements in the PCL-M scores were noted. They also had improved mindfulness scores and decreased insomnia, depression, and anxiety. The authors concluded a trauma-sensitive yoga intervention may be effective for veterans with PTSD symptoms.

Domestic violence, sexual assault, and unimaginable military experiences can all result in PTSD. People in our profession and even more likely, the patients we treat, may live with these horrors in the deepest recesses of their minds. Yoga is gaining acceptance as an adjunctive therapy to improving the symptoms of PTSD. The Trauma Awareness for the Physical Therapist course may assist in shedding light on a dark subject.


Walker, J., & Pacik, D. (2017). Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Medical Acupuncture, 29(4), 232–238.
Cushing, RE, Braun, KL, Alden C-Iayt, SW, Katz ,AR. (2018). Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Military Medicine. doi:org/10.1093/milmed/usx071

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