“Keep Calm and Treat Pain” is perhaps an affirmation for therapists when encountering patients suffering from pain, whether acute or chronic. The reality is this: treating pain is complicated. Treating pain has brought many a health care provider to his or her proverbial knees. It has also led us as a nation into the depths of the opioid epidemic which claimed over 165,000 lives between the years of 1999 and 2014 (Dowell & Haegerich, 2016). That number has swollen to over 200,000 in up-to-date calculations and according to the CDC, 42,000 human beings, not statistics, were killed by opioids in 2016 - a record.
So why has treating pain eluded us as a nation? The answers are as complicated as treating pain itself. Which is why we as health care providers must seek out not simply alternatives, but the truth in the matter. Why are so many suffering? Why has chronic pain become the enormous beast that it has become? What might we do differently, collectively, and how might we examine this issue through a holistic mindset?
In just a few weeks, I have the privilege of teaching amongst 10 physical therapy professionals and one physician from around the nation who with coordinated efforts created a landmark pre-conference course at CSM in New Orleans through the Orthopaedic Section of the APTA. Included in the 11 are myself and another Herman & Wallace instructor Carolyn McManus, PT, MS, MA who teaches “Mindfulness Based Pain Treatment” through the Institute.
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.
The new year is here and with it, lots of motivational posting about exercise and weight loss…but how is this desire for ‘new year, new you’ affecting peri-menopausal women with urinary dysfunction? It has been established that the lower urinary tract is sensitive to the effects of estrogen, sharing a common embryological origin with the female genital tract, the urogenital sinus. Urge urinary incontinence is more prevalent after the menopause, and the peak prevalence of stress incontinence occurs around the time of the menopause (Quinn et al 2009). Zhu et al looked at the risk factors for urinary incontinence in women and found that some of the main contributors include peri/post-menopausal status, constipation and central obesity (women's waist circumference, >/=80 cm) along with vaginal delivery/multiparity.
Could weight loss directly impact urinary incontinence in menopausal women? In a word – yes. ‘Weight reduction is an effective treatment for overweight and obese women with UI. Weight loss of 5% to 10% has an efficacy similar to that of other nonsurgical treatments and should be considered a first line therapy for incontinence’ (Subak et al 2005) But do these benefits last? Again – yes! ‘Weight loss intervention reduced the frequency of stress incontinence episodes through 12 months and improved patient satisfaction with changes in incontinence through 18 months. Improving weight loss maintenance may provide longer term benefits for urinary incontinence.’ (Wing et al 2010)
The other major health issues facing women at midlife include an increased risk for cardiovascular disease, Type 2 Diabetes and Bone Health problems – all of which are responsive to lifestyle interventions, particularly exercise and stress management. In their paper looking at lifestyle weight loss interventions, Franz et al found that ‘…a weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals’. 5% weight loss is the same amount of weight loss necessary to provide significant benefits for urinary incontinence at midlife.
When I work prn in inpatient rehabilitation, I have access to each patient’s chart and can really focus on the systems review and past medical history, which often gives me ample reasons to ask about pelvic floor dysfunction. So, of course, I do. I have yet to find a gynecological cancer survivor who does not report an ongoing struggle with urinary incontinence. And sadly, they all report that they just deal with it.
Bretschneider et al.2016 researched the presence of pelvic floor disorders in females with presumed gynecological malignancy prior to surgical intervention. Baseline assessments were completed by 152 of the 186 women scheduled for surgery. The rate of urinary incontinence (UI) at baseline was 40.9% for the subjects, all of whom had uterine, ovarian, or cervical cancer. Stress urinary incontinence (SUI) was reported by 33.3% of the women, urge incontinence (UI) by 25%, fecal incontinence (FI) by 3.9%, abdominal pain by 47.4%, constipation by 37.7%, and diarrhea by 20.1%. The authors concluded pelvic floor disorders are prevalent among women with suspected gynecologic cancer and should be noted prior to surgery in order to provide more thorough rehabilitation for these women post-operatively.
Ramaseshan et al.2017 performed a systematic review of 31 articles to study pelvic floor disorder prevalence among women with gynecologic malignant cancers. Before treatment of cervical cancer, the prevalence of SUI was 24-29% (4-76% post-treatment), UI was 8-18% (4-59% post-treatment), and FI was 6% (2-34% post- treatment). Cervical cancer treatment also caused urinary retention (0.4-39%), fecal urge (3-49%), dyspareunia (12-58%), and vaginal dryness (15-47%). Uterine cancer showed a pre-treatment prevalence of SUI (29-36%), UUI (15-25%), and FI (3%) and post-treatment prevalence of UI (2-44%) and dyspareunia (7-39%). Vulvar cancer survivors had post-treatment prevalence of UI (4-32%), SUI (6-20%), and FI (1-20%). Ovarian cancer survivors had prevalence of SUI (32-42%), UUI (15-39%), prolapse (17%) and sexual dysfunction (62-75%). The authors concluded pelvic floor dysfunction is prevalent among gynecologic cancer survivors and needs to be addressed.
Perimenopausal pelvic health issues are, for many of us, some of the most common issues that we see in the women that we work with. Urinary incontinence is one of the most important issues for peri- and postmenopausal women. In Melville’s study1 of U.S. women, half of the participants between the ages of 50 and 90 experienced urine leakage every month. Zhu’s 2008 study2 looked at the risk factors for SUI - Multiple vaginal deliveries, Age/postmenopausal status, Chronic pelvic pain, Obesity, lack of exercise, constipation, and hypertension. But what is not often (enough) looked at in the research, is the link between urinary dysfunction and sexual dysfunction – usually because questions aren’t asked or assumptions are made. In Mestre et al’s 2015 paper3, they write ‘…Integrating sexual health in clinical practice is important. In women with pelvic floor disorders, the evaluation of the anatomical defects, lower urinary tract function and the anorectal function often receives more attention than sexual function.’
But are they linked?
In Moller’s exploration of this topic, they report that lower urinary tract symptoms (LUTS) have a profound impact on women’s physical, social, and sexual wellbeing. Unsurprisingly (to pelvic rehab specialists at least!), they found that the LUTS are likely to affect sexual activity. Conversely, sexual activity may affect the occurrence of LUTS. The aims of the Moller study were to elucidate to which extent LUTS affect sexual function and to which extent sexual function affect LUTS in an unselected population of middle-aged women in 1 year. A questionnaire was sent to 4,000 unselected women aged 40–60 years. Compared to women having sexual relationship, a statistically significant 3 to 6 fold higher prevalence of LUTS was observed in women with no sexual relationship. In women who ceased sexual relationship an increase in the de novo occurrence of most LUTS was observed. In women who resumed sexual relationship a decrease in LUTS was observed. In women whose sexual activity was unchanged no change in the occurrence of LUTS. So they rightfully concluded ‘…sexual inactivity may lead to LUTS and vice versa.’
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.
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.
As someone who has spent nearly two decades marketing myself, my practice, or practices for employers, I have learned a lot of skills by trial and error. One of my favorite strategies to expand my professional network is to “Follow the Patient.” By this I mean to follow the patient to a specialist consult, to a procedure, or to a referral that you helped to coordinate. This must be done with the patient in mind, first and foremost, and then also the provider and their practice environment, so as not to have that practice shut the door on you in the future. Of course, this process can look different if you are in a health network because as an insider, you will likely be more welcome and have all the right credentials in order to simply attend a patient’s provider visit. If you are in a private practice, there are sometimes more hoops and permissions to negotiate. Following are some tips I have learned about this strategy of nurturing referral sources.
Offer the idea to the patient and see if they are open to it. It might sound like this: “If you are interested, I may be able to accompany you to your upcoming appointment. Does that interest you?” It’s very important that the patient is consenting to you being in attendance at their appointment, as the visit is for them. It may be best to not promise that you can clear your schedule, or coordinate the visit, but finding out if the patient is open to the idea is the first step.
2. Check in with the provider’s office. This can be accomplished by you or by the patient. This might sound like this: “I’d like to be sure that your provider would welcome me at your appointment. Would you prefer to contact the provider’s office or shall I?” In my experience, the provider’s office will say “if it’s ok with the patient, it’s fine with us!” Typically, a patient can bring whomever they like to an appointment, so that’s not much of an issue, unless there is close quarters or some other limiting scenario. The good thing about giving a heads up is it allows the provider’s office the opportunity to know that you may be joining your patient. I was able to follow a patient into a hernia repair surgery, and the nurses were so surprised that a physical therapist was in the prep room, they asked me “does the doctor know you are here?” in which case I was able to affirm that I indeed had permission from the surgeon.
When reading published research on a subject matter directly relating to what we do in our career, we may need to remember the expression, “Don’t throw the baby out with the bathwater.” Sometimes the test results for a promising hypothesis are not statistically significant, and we can close our minds to the concept entirely. If we skim the abstract and hone in on the “results” or “conclusion” rather than reading the whole article, particularly a study’s limitations, we may drop a sound clinical pearl down the drain.
A research article published in May 2017 by Amorim et al., looked at the force generation and maintenance of the pelvic floor muscles when combined with hip adduction or abduction contractions. They hypothesized that pelvic floor muscle (PFM) contraction combined with hip abduction contraction (rather than adduction) should produce a greater PFM contraction because of the myofascial connection of the obturator internus to the levator ani muscle. The study included 20 nulliparous women without pelvic floor dysfunction. The pelvic floor muscle contraction was measured in isolation, with 30% and 50% maximum hip adduction contraction, and with 30% and 50% maximum hip abduction contraction. The forces were measured with a cylindrical, intravaginal strain-gauge for PFM and another strain-gauge around the hips for adduction/abduction force generation. The women were given visual feedback to help them obtain the required hip contraction force. An average of 3 contractions (10 seconds each with a 1 minute rest) was used for each condition. This was all performed again 4 weeks later.
The results of this study by Amorim et al.2017 did not support the hypothesis. No statistically significant difference was found among any of the conditions measured. The intravaginal PFM force generation was not different when combined with hip abduction versus hip adduction contraction. Neither hip adduction nor abduction made a significant change in force of the PFM contraction compared to isolated PFM contraction. The authors had to conclude there is no evidence to support the efficacy of combining PFM training with contraction of the hip abductors or adductors.
One of my greatest nemeses when I was racing at 30 years of age was a woman in her 50’s. Although I hated losing to her, I was always inspired by her speed at her age. She motivated me to continue training hard, realizing my fastest days could be yet to come. As I now race in the “master’s” category in my 40’s, I still find myself crossing the line behind an older competitor occasionally. Research shows I should take heart and keep in step with females who continue to move their bodies beyond menopause.
Mazurek et al., (2017) studied how organized physical activity among post-menopausal women could reduce cardiovascular risk. The study included 35 sedentary women aged 64.7 ± 7.7 years who had no serious health issues. They all participated in the Active Leisure Time Programme (ALTP) 3 times per day for 40–75 minute sessions for 2 weeks, including 39 physical activities. Exercise intensity stayed within 40–60% of maximal HR, and ratings of perceived exertion (RPE) on the Borg scale stayed between 8 and 15 points. This exercise training was followed by 3 months of the Prevent Falls in the Elderly Programme (PFEP), which is a general fitness exercise program to prevent falls in the elderly. Health status was measured at baseline, 2 weeks into the program, and after 3 months. The results showed significant reductions in central obesity, which increased the exercise and aerobic capacity of the subjects and improved lipid profiles. A significant reduction also occurred in the absolute 10-year risk of death from cardiac complications. The authors concluded these exercise programs could be effective in preventing primary and secondary cardiovascular disease in the >55 years old female population.
Nyberg et al., (2016) took a physiological look at exercise training on the vascular function of pre- and postmenopausal women, studying the prostanoid system. Prostanoids are vasoconstrictors, and prostacyclins are vasodilators. The loss of estrogen in menopause affects the ability of the vasodilators to function properly or even be produced, thus contributing to vascular decline. The authors checked the vasodilator response to an intra-arterial fusion of a prostacyclin analog epoprostenol as well as acetylocholine in 20 premenopausal and 16 early postmenopausal women before and after a 12-week exercise program. Pre-exercise, the postmenopausal women had a reduced vasodilator response. The women also received infusion of ketorolac (an inhibitor of cyclooxygenase) along with acetylcholine, creating a vasoconstriction effect, and the vascular response was reduced in both groups. The infusions and analyses were performed again after 12 weeks of exercise training, and the exercise training increased the vasodilator response to epoprostenol and acetylcholine in the postmenopausal group. The reduced vasodilator response to epoprostenol prior to exercise in early postmenopausal women suggests hormonal changes affect the capacity of prostacyclin signaling; however, the prostanoid balance for pre and postmenopausal women was unchanged. Ultimately, the study showed exercise training can still have a positive effect on the vascularity of newly postmenopausal women.