Before we talk about yoga, let’s do a quick overview of interstitial cystitis/bladder pain syndrome.
In 2022, the American Urological Association updated the clinical guidelines on the treatment of interstitial cystitis/bladder pain syndrome. Prior to this revision, pelvic physical (and occupational) therapy was considered first-line treatment with evidence strength grade A. After this revision, the AUA recommends looking at the phenotype of the patient to determine which treatment categories would best serve the individual patient.
Three phenotypes have been identified: a bladder-centric phenotype, a pelvic floor phenotype, and a phenotype that experiences widespread symptoms with chronic overlapping pain conditions.
Treatment categories include behavioral/non-pharmacologic, oral medicines, bladder instillations, procedures, and major surgery.
There are three guideline statements that are within our scope of practice as rehab professionals.
Guideline Statement 10: “Self-care practices and behavioral modifications that can improve symptoms should be discussed and implemented as feasible. Clinical Principle”
This is the space that pelvic PTs and OTs live in every day. The recommended treatments within our scope of practice include:
- evaluating the concentration and/or volume of urine
- limiting bladder irritants
- an elimination diet to determine which foods or fluids are triggering
- thermal modalities (eg, suprapubic or perineal heat or cold)
- strategies to manage IC/BPS flare-ups (eg, meditation, imagery)
- pelvic floor muscle relaxation
- bladder retraining
- avoiding pain-provoking exercise
- managing constipation
Guideline Statement 12: “Appropriate manual physical therapy techniques (eg, maneuvers that resolve pelvic, abdominal, and/or hip muscular trigger points, lengthen muscle contractures, and release painful scars and other connective tissue restrictions), if appropriately trained clinicians are available, should be offered to patients who present with pelvic floor tenderness. Pelvic floor strengthening exercises (eg, Kegel exercises) should be avoided. Standard (Evidence Strength: Grade A)”
As therapists, we will often also evaluate the spine and perhaps further up and down the chain to look for potential contributing factors. While this was not mentioned in the guideline paper, it is often how we holistically treat each individual who walks into our office.
But wait! There’s more! We can also help coach our patients on one more clinical principle….
Guideline Statement 11: “Patients should be encouraged to implement stress management practices to improve coping techniques and manage stress-induced symptom exacerbations. Clinical Principle”
Remember back in guideline 10 when it listed “strategies to manage IC/BPS flare-ups (eg, meditation, imagery) and pelvic floor muscle relaxation”? Clinically we use breathwork, pain neuroscience, and gentle stretching. Some practitioners use yoga as an adjunct modality in the clinic and for home programs.
Khandwala et al looked at 8 patients during 3 months of integrated yoga therapy. There was a statistically significant improvement in two areas of the SF-36 (social function and pain). There was a non-statistically significant trend towards improved voiding volumes.
Dao et al looked at 97 patients assigned to the control group (usual care) or intervention group (usual care plus yoga and meditation). The intervention group showed faster improvement during the clinical trial. Additionally, there were decreases in anxiety, depression, pain interference, and pain scores.
I (Dustienne) created the two flows for the Dao study, and I’m absolutely thrilled to see echoed in the research what we see clinically - downregulation of the nervous system, breathwork, visualization, and mindful movement support our patients and offer additional strategies for resilience.
For free access to the two videos used in the study, visit: https://www.yourpaceyoga.com/interstitial-cystitis-yoga
Dustienne Miller developed her course Yoga For Pelvic Pain in 2012. She enjoys seeing the research grow and supports how she and her colleagues have been practicing in pelvic health over the years. Remote course offerings for 2025 are: February 22-23, May 3-4, and September 13-14.
References:
- Clemens, J. Q., Erickson, D. R., Varela, N. P., & Lai, H. H. (2022). Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome. Journal of Urology, 208(1), 34–42. https://doi.org/10.1097/JU.0000000000002756 (Original work published July 1, 2022)
- Dau, A., Meriwether, K.V., Petersen, T., Jansen, S. & Komesu, Y. Mindfulness and Yoga for Pain with Interstitial Cystitis Evaluation: An RCT
- FitzGerald, M. P., Anderson, R. U., Potts, J., Payne, C. K., Peters, K. M., Clemens, J. Q., ... & Nyberg, L. M. (2009). Urological Pelvic Pain Collaborative Research Network Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J. urol, 182(2), 570-580.
- Khandwala, S., & Cruff, J. (2020). The Role of Yoga in the Management of Bladder Pain Syndrome: A Single-Arm Pilot Study. Advances in mind-body medicine, 34(4), 4–9.
- Rovner, E., Propert, K. J., Brensinger, C., Wein, A. J., Foy, M., Kirkemo, A., ... & Interstitial Cystitis Data Base Study Group. (2000). Treatments used in women with interstitial cystitis: the interstitial cystitis database (ICDB) study experience. Urology, 56(6), 940-945.
Author Bio:
Dustienne Miller PT, MS, WCS, CYT
Dustienne Miller is the creator of the two-day course Yoga for Pelvic Pain and an instructor for Pelvic Function Level 1. Born out of an interest in creating yoga home programs for her patients, she developed a pelvic health yoga video series called Your Pace Yoga in 2012. She is a contributing author in two books about the integration of pelvic health and yoga, Yoga Mama: The Practitioner’s Guide to Prenatal Yoga (Shambhala Publications, 2016) and Healing in Urology (World Scientific). Prior conference and workshop engagements include APTA's CSM, International Pelvic Pain Society, Woman on Fire, Wound Ostomy and Continence Society, and the American Academy of Physical Medicine and Rehabilitation Annual Assembly.
Her clinical practice, Flourish Physical Therapy, is located in Boston's Back Bay. She is a board-certified women's health clinical specialist recognized by the American Board of Physical Therapy Specialties. Dustienne weaves yoga, mindfulness, and breathwork into her clinical practice, having received her yoga teacher certification through the Kripalu Center for Yoga and Health in 2005.
Dustienne's love of movement carried over into her physical therapy and yoga practice, stemming from her previous career as a professional dancer. She danced professionally in New York City for several years, most notably with the national tour of Fosse. She bridged her dance and physical therapy backgrounds working for Physioarts, who contracted her to work backstage at various Broadway shows and for Radio City Christmas Spectacular. She is an assistant professor of musical theater and jazz dance at the Boston Conservatory at Berklee.
Dustienne passionately believes in the integration of physical therapy and yoga within a holistic model of care. Her course aims to provide therapists and patients with an additional resource centered on supporting the nervous system and enhancing patient self-efficacy.