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Three Big Facts About Chronic Lower Back Pain

If you or anyone you know has chronic low back pain (LBP) lasting several months or recurring multiple times, then this blog is for you. That means most people should read this, since up to 58% of people at any point in time experience LBP.1

Your perception of your pain will shape your recovery. Let’s break this down for you into 3 concrete concepts:

1. Pain is not harm.

“Pain is the perception by the brain of an unpleasant sensation that is due to actual or potential tissue damage.”2

Actual tissue damage in this sense is acute pain – for example, when you suffer a hard fall on your bum or you deadlift beyond your capacity at the gym. This acute, protective LBP is due to traumatic incidents.

Chronic LBP is typically associated with the brain perceiving potential tissue damage. Long after your fall or your back strain at the gym, you feel this pain 6 months or even 5 years later. Physiologically, the tissue has long passed its phase of healing. But you STILL feel pain. Why is this?

To begin with, we often believe that the pain in our back is always causing physical damage. Has someone told you that if you cough, sneeze, or bend in a weird way, your disc will slip out of place? Or has someone told you your back looks like a 90-year-old’s? Because of this, have you been fearful of certain movements or avoided moving as much? Well, the spine is a strong and stable structure. It would take a lot more than a cough to cause any serious destruction.

Anytime we actually injure our body (e.g., muscle strain, fracture, etc.), our brain creates a strong memory about this pain. Following the incident, even the smallest discomfort in that area is interpreted as intense pain. The lasting memory of the accident, the location in which

the injury was sustained, the position of the body, or the time of the incident can all resurface the feeling of pain. But pain is not always harm!

There is enough research out there to show that only a small portion of LBP is due to fracture, tumors, infection, aneurism, or more. For example, less than 1% of patients coming into a primary care office have a tumor, 4% have a spinal fracture, and <.01% have a spinal infection.1,3 Therefore, it is crucial to first understand that, most likely, your back pain is not due to a serious medical condition. When you feel pain, your back is not increasingly being harmed.

Red Flag Disclaimer: This is not to say that your back pain is definitely not a serious problem! If you have unexpected weight loss, pain at night that does not change with altering position, rapid fatigue, fever, reduced appetite, any trauma (accident or fall), bowel or bladder changes, or pain radiating down both legs, please see a medical doctor.1

2. Negative emotions and Pain are Interconnected

Have you ever noticed that if you are really busy at work or school, you “forget” your pain for a little while or you feel it less intensely? Or have you noticed that if you are relaxed and calm, sipping a corona on the beach, you have less LBP? This tells us that much of our pain comes from emotional regulation. This does not mean that your back pain is not real! However, you cannot feel pain without your brain because your emotional state at any moment in time can influence how you perceive pain. Being unhappy, negative, stressed, or anxious can be linked to your pain. In fact, there is a higher occurrence of LBP with reports of decreased job satisfaction and social support and increased workplace demands and stress.1

If you feel less pain when distracted, then focusing on symptoms may actually increase pain. If you were to shift your focus away from constantly thinking about it and, instead, believe that you are strong and healthy, you may not experience pain as intensely. Similarly, if you feel pain less when you are relaxed, then decreasing your stress can play an important role in your path to pain relief. See our Chronic Pain blogs 1 and 2 (hyperlinks) to understand how this works!

In general, while LBP can cause unhappiness, stress, and anxiety, the reverse is also true. With continued negative emotions, pain is perceived more intensely and frequently and this becomes a cyclical process. If you can connect your pain to your emotions, then you are one step closer to controlling your pain. It’s all a matter of shifting your perception of how pain works.

3. An aging back is just like your gray hairs. It’s normal.

Spinal degeneration is part of the normal aging process. As we spend more time on this earth, our spine is subject to the same effects of gravity as the wrinkles on our skin. It is clear through research that age is a risk factor for LBP, particularly increasing between ages 30 to 60.1,4 Your perception of a naturally aging spine can change how you feel about your lower back.

Just because your MRI says you have a disc herniation or your x-ray shows arthritis in your spine does not mean you will be doomed for life. Join the club – you are getting older! In one study, researchers took MRIs of two groups of patients with sciatica (intense nerve pain in the leg). Firstly, only 68% of those who reported disabling LBP had presence of disc herniation whereas a striking 88% of those who didn’t report disabling LBP had a herniation. This shows that disabling LBP did not correlate to a worse MRI result. Secondly, they found that reports of disabling LBP WITHOUT a disc herniation on MRI caused WORSE perception of recovery 1 year later than an ACTUAL herniation without disabling LBP.

What an interesting finding! Just being preoccupied about your MRI can be linked to more pain later on! It all boils down to perception.

The Take Away…

If you can understand that pain is not harm, that emotions can affect pain, and that an aging back is a normal human phenomenon, then you can gradually alter your perception of your back pain and be one step closer to finding a solution for it. Without the brain, you wouldn’t feel the pain because the mind and the body are not separate entities. Pain IS real… but this real physical pain comes from your brain. The brain can also send pain-relieving signals just as it induces pain-producing signals. Changing your perception of your pain can change the physical

feeling of pain. Understanding this is Step 1. Step 2 is taking massive action! If you continued to live the way you did, if you did not change a thing about your mindset or the way your body moves, then there is little to no chance that you will see improvement.

But there is hope! While back pain has been a massive enigma for centuries, with the advent of modern pain science, we understand it at a higher level. At EMH Physical Therapy, we have devised an evidence-based approach called re.lieve Solutions for Chronic Pain (hyperlink) that treats pain by targeting the brain and the body. If you or your loved one has been suffering from chronic LBP and want solutions NOW, then take a look at what re.lieve Solutions for Chronic Pain (hyperlink) has to offer for you. Visit our website or give us a call to learn more!

References:

  1. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Practice & Research Clinical Rheumatology, 2010; 24:769–781.
  2. Tanenbaum, D.R., & Roistacher, S.L. (2012). Docto, Why Does My Face Still Ache?: Getting Relief from Persistent Jaw, Ear, Tooth, and Headache Pain. New York: Richard Altschuler & Associates, Inc.
  3. Verhagen AP, Downie A, Popali N, Maher C, Koesi BW. Red flags presented in current low back pain guidelines: a review. Eur Spine J, 2016; 25:2788-2802.
  4. Meucci RD, Fassa AG, Faria NMX. Prevalence of Chronic Low Back Pain: Systematic Review. Rev Saúde Pública, 2015; 49:73.

http://emhphysicaltherapy.com/2104-2/2104/

re.lieve Solutions for Chronic Pain Wellness Roundtable

Please join us for a series of 4 online live lectures that can help anyone, family or friend, suffering with chronic migraines, neck pain, back pain, hip pain, abdominal pain, pelvic pain, IC, IBS, fibro myalgia and more.

Learn about the empowering modern science of pain and self help techniques that, with practice and time, can retrain the brain, lower a hypersensitive nervous system resulting in decreased pain.

Lectures take place Sunday evenings, April 15th • April 22nd • April 29th • May 6th @ 8PM EST

Admission: $20 per lecture

Register here ——>www.wellnessroundtable.com/browse-lectures

Improving Orgasm in Men and Women

The ability to achieve a healthy, strong, satisfying orgasm is a gift. When we have low libido, inability to orgasm or our quality of orgasm is not as strong as it used to be, can anything be done?  Plenty! For women and in some cases, men, their low libido may be due to hormone imbalances. Levels of testosterone and other sex hormones can be checked by a doctor specializing in sexual medicine and you may be prescribed hormone replacement therapies. To find a doctor with this knowledge, go to www.isswsh.org.  For most men and women, it’s a simple matter of becoming aware and retraining their pelvic floor muscles – the ability to be strong, have good endurance like any other muscle in the body, as well as the ability to relax.

 

WHERE TO GET ASSESSED for your Pelvic Floor

Consult a physical therapist who has been trained and is practicing in the field of pelvic physical therapy;

To find one:

The Section of Women’s Health of the APTA – American Physical Therapy Association, www.womenshealthapta.org.

Herman and Wallace Pelvic Rehabilitation Institute, hermanwallace.com

Both organizations have lists of Practitioners that have attended and received certifications in the field.

 

ASSESSING PELVIC MUSCLES

In pelvic physical therapy, we assess your core, hip, external pelvic and internal pelvic floor muscles – how relaxed, tense and strong they are using manual and biofeedback methods.  We check your ability to breathe using your diaphragm.  The breath and core/pelvic muscles work together in unison.  The pelvic floor aka “Kegel” muscles are located inside your pelvis, running from the front of the pubic bone, attaching to your tailbone and to the sides on the deep hip external rotator muscles.

Pelvic floor muscles have two types of fibers: The slow twitch or the endurance fibers – they are the ones that hold against gravity if you jump, run, sneeze, laugh or cough.  Fast twitch muscle fibers – these rhythmically contract during orgasm -10 – 15 contractions during an orgasm. We focus on strengthening the core muscles and the fast twitch muscle fibers for the pelvic floor. We find that 50-60% of our patients do not know how to recruit these muscles without holding their breath or using other muscles.

 

RELAXING THE PELVIC MUSCLES

To have a really good orgasm, your pelvic floor muscles need to be relaxed during the day – not in a high tense state, always on guard. Breathing properly and being mindful your pelvic floor can prevent automatic tension that occurs in the pelvic floor during a stressful situation (work, home, relationship, life stresses).  Most people don’t realize they are holding tension in their pelvic floor, like a tight fist.  If the pelvic floor muscles are constantly tense, it can lead pain to with sexual intercourse in women, difficulty in achieving/maintaining erection in men and for both, the ability to have a satisfying orgasm.   Plus chronic PF tension can show up as difficulty in going to the bathroom, urinary urgency, frequency, bladder pain, abdominal bloating and bowel issues  – chronic pelvic floor tension is a major contributor to Constipation.

 

EXERCISES FOR RELAXING PELVIC FLOOR

 

Child’s Pose

Start on all 4’s.  Sit back onto your heels. If your buttocks cannot reach your heels, place a pillow so you can fully rest. Lower your head to the floor, resting on a pillow if needed.

Slightly widen your knees apart to provide space for your stomach to expand as you inhale. As you inhale, your stomach expands and very subtly, your pelvic floor muscle expands as well.  As you exhale, your stomach deflates and the pelvic floor return to the rest position. Do slow, deep diaphragmatic breaths, inhaling for a count of 4 seconds, exhaling for a count of 6 seconds. Do 3 times. Once a day.

 

Happy Baby Pose

Lie on your back, bring both knees to your chest. Grasp underneath your knees and bring your thighs wider to each side and slightly down to open your groin/pelvic floor.  For more advanced, grasp both feet and gently pull the feet and knees toward the floor. You are stretching and opening your pelvic floor.  Inhale for count of 4, Exhale for count of 6. Do 3 times. Once a day.

 

 

Inner thigh groin stretch

Sit on the floor. Straighten both legs and comfortably widen to either side. You may need to place a small folded towel under your seat if you’re rounding hunching forward too much.   Place both hands on the floor behind you as this will help you keep an upright posture. Hinge your body slightly forward from the hips.  The inner thigh muscles attach to the pubic bone. If they are tight and restricted, it will affect how the pelvic floor works. Hold for 30 seconds to 1 minute. Do 2’x. Once a day

 

 

 

EXERCISES THAT STABILIZE AND STRENGTHEN

PF Slow twitch exercise

In lying or sitting position, Inhale.  As you exhale, Squeeze your anal and vaginal/penile region tight for five seconds (“one-one thousand, two one thousand”, to five). Breathe as needed versus holding your breath.   Avoid contracting your larger gluteal or abdominal muscles. Work up to ten seconds. Release slowly and relax fully for ten seconds before trying again. If you can contract for ten seconds, rest for 20 seconds. Do 2 sets of 10 repetitions twice a day.

 

PF Fast twitch exercise

Squeeze your anal, vaginal/penile area strong, quickly holding one second (“one one-thousand”) Fully relax for about 2 seconds.

Exhale in a faster pace during the squeeze, inhaling during the relaxation

Do two sets of 10 reps twice a day.

 

 

CORE EXERCISES

 

Plank

Lie on your stomach. Elbows bent on the ground, Bent toes on the floor. Exhale as you tighten your abdominals and lift your

body off the floor keeping shoulders, hips, knees is in a straight line.

Hold for 10 seconds, up to 30 seconds. Do 2 sets of 10 reps. Once a day

 

 

Bridge

Lie on your back, knees bent, feet hip width apart, arms by your sides, palms down.

Inhale. Exhale as you first think of bringing your pubic bone upwards towards your navel (recruiting the Transverse Abdominals) then squeeze your gluteals (buttocks muscles) together, raising your hips off the floor. Hold end position for 5 seconds.  Lower your hips to the floor, fully releasing the abdominal and gluteal contraction as you inhale. Exhale and repeat.  Do 2 sets of 20 reps. Once a day

 

At EMH Physical Therapy, we offer a PelviCorFit Program http://emhphysicaltherapy.com/pelvicorfit-program/ that teaches you how recruit and relax your pelvic floor muscles in 1-3 sessions.

 

My app PelvicTrack , free on iTunes store has a compilation of pelvic and core exercises.

If anyone in NYC needs to see pelvic floor physical therapist please visit us  http://emhphysicaltherapy.com/pelvic-floor-dysfunction-therapy

 

 

 

Let’s talk about sex-things I learned at the ‘International Society for the Study of Women’s Sexual Health’ annual conference

At the recent ISSWSH www.isswsh.org conference in San Diego there was a lot of talk about sex. Psychologists, physical therapists, researchers, sexual medicine doctors and a spine surgeon presented on insights and medical advances to improve women’s sex drive (hypoarousal no more!); reducing pain during/following sex; balancing hormones (estrogen is good!); post menopause in the bedroom (women in their 60-70’s have sex!) transgender information (3% of highschool students in a major US city say they are transgender). Today’s blog is about the big insights in treating vaginal pain.

Many women still think that it’s normal to have vaginal pain during and following intercourse.  Some experience vaginal burning, itching, pain and feel raw in this area 24/7 and sex increases their pain.

Women may be embarrassed, think this experience is normal, some even feel guilty so they don’t tell their doctors. Unfortunately, many doctors do not ask 3 important questions:

  1. Do you feel pain during/after intercourse?
  2. Are you happy with your sex drive?
  3. Can you achieve orgasm and if yes, are you satisfied with the quality?

 

 

Women with persistent pain can get stuck in a cycle of pain. Vaginal pain causes tension of the pelvic floor/abdominal muscles which can lead to depression, anxiety and catastrophizing behavior. If not treated effectively, they can develop a hypersensitive central nervous system and overprotective brain which worsens pain.  To break this cycle, it’s crucial to find out what type of vaginal pain she has, as each requires a completely different medical approach.

 

The following is a general information guide – see your doctor to get your specific diagnosis!

 

After taking a good history and listening to your symptoms, your doctor that specializes in sexual medicine will do a physical exam, using a Q-tip to gently press against each point of the Vestibule (see image below)

The vestibule is divided like a clock, the top portion, 9 to 3 o’clock is considered the “anterior vestibule” and contains Skenes glands.  The lower 4 to 8 o’clock are considered the “posterior vestibule” contains Bartholin glands and reflect how tense or relaxed are the pelvic floor muscles. Redness of the vestibule is not always an easy way to determine pain because it’s naturally red due to lots of blood vessels.

Complete Vestibulodynia

The whole vestibule, anterior and posterior portions are super sensitive to the Q-tip touch.

This is due to a dominance of estrogen (the pill, acne medicine, facial hair medicine all contains estrogen). These women are not getting enough androgen and testosterone, male hormones that the vestibule needs to be balanced.  Treating this type of vaginal pain is challenging because the woman on the pill has to discontinue and find alternate birth control methods. Teenagers being treated for acne will have it return, so coming off estrogen is a challenge yet once done, this type of vaginal pain will completely heal.  The time it takes to heal – in 6 months she is 50% better and in a year, she is  100% better.  While waiting for the body to balance, doing some healthy mental and physical exercises from the relieve program (link) can also help.

Inflammatory Vestibulitis.

If a woman has a history of chronic infections or if she is one of the 3-4% of American woman who is allergic to propylene glycol which is found in all vaginal gels, yeast creams, steroid creams such as the over the counter Monistat.  Woman may have been incorrectly diagnosed with a yeast infection and given creams (that contains propylene glycol) which causes more sensation of rawness, burning and cutting. What’s happening is that the inflammatory cells, called Mast cells, actually signal nerve endings to grow into the vaginal tissue which makes women feel more pain.

How to treat? If women can be seen within 6 months of symptom onset, they’ll be started on Interferon, a medicine which stops the production of mast cells.

If the woman is seen after 6 months, then treatment is more challenging. Either they use of a capsaicin crème (hot pepper component which removes “Substance P” of the nerve ending or desensitizes the nerve). Treatment is for 12 weeks of use of nightly cream – doable, but painful. Other option is surgery (vestibulectomy) to remove the affected tissue.

Congenital Neuroproliferation.

There is an increased amount of nerve fibers in the vestibule since birth.  These women could never use a tampon. A quick test is to touch your inner belly button and gently press inward. If you feel increase pain/sensitivity in your vagina, then this may be the cause for your pain. How can this be? The umbilicus shares the same embryonic tissue as the vestibule – so they are connected and have the same increased nerve fiber growth.

Treatment is surgical removal of the vestibular tissue (which healthily heals without the extra dense nerve fibers) resulting in no pain.

Overactive Pelvic Floor

Women who experience vaginal pain and have pain with the Q-tip test at the 4-8o’clock region, the posterior vestibule, with no sensitivity in the anterior vestibule. These women have overly tense pelvic floor muscles and this is the most common cause for vaginal pain.  Women can also experience symptoms of urinary frequency, urgency, sensation of incomplete emptying, constipation, rectal fissures, hemorrhoids.

This condition can be effectively treated by pelvic physical therapy. Pelvic PT includes releasing tension in the muscles of the lower back, sacrum, inner thighs, pelvic floor, teaching breathing techniques to relax the pelvic floor muscle, biofeedback, use of dilators and bladder and bowel retraining exercises.

Biopsychosocial Approach for Chronic Pain

Over the last 10 years, we also are now understanding why people stay in chronic pain for months, years, even decades.  Once an injured or chronically inflamed tissue has healed, why is there pain?

 

The answer is that they have developed an overprotective brain and hypersensitive nervous system. Without being aware of their habits developed due to social norms, family history, past experiences with pain, some people learn to be in a pattern of pain. Once the tissue issue has been healed, yet there is still pain, pain is the brain’s way to protect your body.   Ongoing negative experiences like a fight with your partner, stress at work, abuse at home, loss of a pet, saying non-loving, fear-based statements to yourself all day, not having or doing something that gives you joy  (even for a few minutes) can make the brain feel you are always in danger and send pain to protect you.

 

The Doctors of Physical Therapy at EMH are well versed in helping women heal from chronic pain using the biopsychosocial approach as well as our pelvic floor physical therapy for vaginal tissue based pain.  Our e-Book, re.lieve Solutions for Chronic Pain can help you learn self-help techniques to lower chronic pain.  Here’s the link: http://emhphysicaltherapy.com/product/re-lieve-solutions/

 

In summary, women can have a healthy fulfilling sex life – to find a provider, go to isswsh.org.

 

Don’t miss your chance to listen to Evelyn Hecht, PT, ATC speak about modern pain science and how she’s been using it to help heal chronic pain

 

Follow this link to listen to Evelyn’s episode of the Healing Pain Podcast: listen to podcast here

Chronic Pain: New Science provides Solutions for Complete Recovery (Part 1)

Chronic pain is a worldwide epidemic, affecting 1.5 billion people1.   In the USA we spend over $635 BILLION dollars treating chronic pain, visiting multiple medical practitioners, getting  tests, injections, prescription medications, and surgeries2.     With all the amazing advances made in treating cancer, diabetes and heart conditions, the numbers of people suffering with chronic pain has not lowered; in fact it’s increasing.

The good news is that we have learned more about pain in the past 10 years than ever before. The fields of neuroscience, physical therapy, psychology and nutrition have unearthed a treasure trove of knowledge to help people truly heal from chronic pain. There are a number of non-invasive, low risk self-help treatments that people with chronic pain can do simultaneously while they receive treatments by their doctors, physical therapists and other health practitioners to achieve total chronic pain relief.

Chronic Pain Defined

Chronic pain is pain that lasts longer than the normal tissue healing time of 3-6 months. Note: this blog does not include the pain caused by active cancers nor end of life pain issues. So, by the end of 6 months all tissues (skin, muscles, fascia, tendons, ligaments, nerves and bones) should be completely healed barring no major complications such as infections, disease processes or re-injuries.

3 Phases of Healing

Below is what our body does after getting a physical injury:

Inflammatory phase 3-7 days from original injury: when you feel most pain or see redness and swelling. Swelling shows that your body is doing an excellent job of healing and prevents further injury to the area.

Repair (Proliferation) phase 2-6 weeks from original injury: depending on the tissue (skin heals faster than bone). New collagen is laid down, like weaving a basket or sewing up a hole in your socks. Collagen replaces the torn, strained, or fractured tissue.

Remodeling phase 3-6 months from original injury: this phase starts when production of new collagen stops. New collagen is usually stiff, inflexible and needs to be remodeled, lengthened, and strengthened to your pre injury state and function. This is best achieved by going to physical therapy and doing your exercises.

Acute Pain Process

If the normal healing timeline takes 6 months at most, why do so many people experience chronic pain for years, sometimes decades past the original injury? Before we can understand how pain becomes chronic, here’s how our nervous system and brain works when we are experiencing acute injury pain.

When we first sprain our ankle, specialized sensors in our skin called “nociceptors” are activated (see red “Nociceptive Information” ).  Nociceptors are not pain sensors- rather pressure sensors, chemical sensors and stretch sensors. In fact, we don’t have actual “pain sensors” in our bodies. Nociceptors sense that your ankle ligament is overstretched or your muscle fibers are torn and sends this information to the brain.

 

Brain is our Protector

Your brain’s main role is to protect your body, so when your brain receives the nociceptive signals about the overstretched/torn tissues, it also checks your surrounding environment and assesses the situation to decide how best to protect.

Let’s say you twisted your ankle in a pothole while crossing a busy NYC street. You need to run quickly or you may be hit by oncoming cars. The brain decides that you need to get to safety first so it allows you to run on your injured ankle WITHOUT PAIN by sending pain reducing chemicals to the area. Once you are safely on the sidewalk, the brain sends pain signals to your ankle so you immediately take your weight off your foot. Your brain has effectively protected you from harm both by decreasing and increasing pain. This whole process happens in milliseconds.

 Brain is the Boss of Pain

Our brains are capable of learning and creating new nerve pathways throughout our whole lifetime. This is called “neuroplasticity”3.  Areas of the brain that are used very frequently show high levels of activity (as seen in brain MRI scans) and may actually increase in size4.  Before iPhones and Google Maps, London cab drivers had to memorize the whole intricate street map of the city before they could get their licenses. Studies show that they actually have enlarged areas in the brain associated with memory. The brain changes based on how we use it.

The brain is the center where the actual sensation of physical pain originates from and gets relief. People who experience chronic pain have a brain and nervous system that has learned to be in a heightened state, always on guard awaiting the next danger signal. What leads to this “faulty wiring” of our brain and nervous system?  Some factors include:

  1. Childhood and early social experiences – did you suffer loss/lack of love or did you feel safe and supported? These experiences affect how we respond to both physical and emotional pain.
  2. Daily thoughts and self-talk – are they positive or tend to be negative/fear based?
  3. Current social interactions – are they mostly supportive, like seeing a good friend, petting your cat or stressful, like fighting with your spouse/children?
  4. Your Expectations- are you afraid of bending forward because years ago a doctor said it could flare up your back pain? 5,6

Nutrition, exercise, restful sleep plays just an important role in total healing which we will discuss in the next few blogs. While we can’t change what happened to us in the past, the good news is that our brains can relearn healthy patterns to lower/stop chronic pain.

While receiving medical care from your doctor, you can simultaneously  retrain your brain to learn healthy processes, decrease fear based movement patterns, use mindfulness to stop negative catastrophizing thoughts, breathing techniques to lower fear/anxiety and much more.

At EMH Physical Therapy, we offer a chronic pain recovery program, called re·lieve, which educates patients in the new science of pain and teaches them a scientifically proven self-help program along with providing any needed manual and movement therapies.

Stay tuned for Part 2 of  “Solutions for Complete Recovery of Chronic Pain”.

References

1.Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: Institute of Medicine of the National Academies; 2011.

2.Darrell J. Gaskin, Patrick Richard. The economic costs of pain in the United StatesThe Journal of Pain 2012;13(8):715

3.Draganski B, May A. Training-induced structural changes in the adult human brain. Behav Brain Res 2008;192:137-42

4.Johansson BB. Brain plasticity in health and disease. Keio J Med 2004;53:231-46.

5.Seifert F, Maihofner C. Functional and structural imaging of pain-induced neuroplasticity. Curr Opin Anaesthesiol 2011; 24: 515-523

6.Sandkühler J. Learning and memory in pain pathways. Pain 2000; 88: 113-118

7.Jensen M. Magnetic resonance imaging of the lumbar spine in people without low back pain. New Eng J Med. 1994;331: 69-73.

8.Katharina A. Schwarz, Roland Pfister, Christian Büchel. Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends in Cognitive Sciences, 2016

 

 

 

Online Educational & Empowerment Course for Women Suffering with PGAD &/or Vulvodynia

therapy

A unique program designed for a small group of women (15) who suffer with PGAD and chronic vulvar pain.  From the comfort of your home, you’ll have the opportunity to connect with each other in a safe environment, using private encrypted meeting platform (Zoom.us) while learning evidence-based therapeutic solutions for both your physical and emotional healing process. Each class is 2 hours held every 2 weeks for a total of eight(8) classes over a four month time period.

Health care experts from the fields of physical therapy and social work will be teaching this one of a kind program: Evelyn Hecht, PT, ATC and Eva Margot Kant LCSW-R . Their combined 35 years of experience will help you learn effective self-help tools for your mind and body while connecting and supporting each other on your journey to health.

Evelyn Hecht, PT, ATC owner of EMH Physical Therapy has been treating women with pelvic pain and sexual dysfunction for 20 years. She and her team of Doctor of Physical Therapists will be teaching self-care techniques and exercises that can be easily implemented into your healing routine.   The DPT’s will will answer questions about physical symptoms and exercises to the best of their virtual ability.

Physical therapy topics will include

  • Breathing and Meditation
  • Symptom Tracking to identify triggers and solutions
  • Pelvic Floor stretching exercises
  • Neuroplasticity – break the pain cycle

Eva Margot Kant, LCSW-R is a compassionate sex/psychotherapist in private practice with 15 years counseling patients with chronic and sexual pain. She helps clients navigate life’s transitions, address fears and questions about chronic illness/pain.  As a group therapy facilitator, she has worked with organizations including the American Cancer Society and National Multiple Sclerosis Society. Eva teaches courses on sexuality at Columbia University Graduate School of Social Work.

Talk therapy topics will include:

  • Fear
  • Avoidance
  • Mindfulness Based Stress Reduction (MBSR)
  • Educating the Clinician
  • Sharing Information to Loved Ones
  • Dating/Love Relationships

Additional Experts may be incorporated into the separate groups to share information and resources.

Course Details

Length of Online Group Class: 7PM to 9PM Eastern Standard Time

Start Date: Thursday January 19, 2017

2017 Class schedule:  1/19, 2/2, 2/16, 3/2, 3/16, 3/30, 4/13, 4/27

Number of Classes:  Eight (8) classes over a 4 month period January thru April 2017

Cost: Each two hour class is $40.00 per person.  You must register and pre pay for  all 8 classes, at a cost of $320 per person one week prior to the first class.  The price of attending one personal session with a counselor or physical therapist can range between $80 to $250 per hour, depending on where you live. This program offers you access to speak to and learn from a pelvic physical therapy professional with experience treating PGAD, vulvodynia and a clinical social worker seasoned in treating sexual issues and chronic pain for a total of 16 hours at a reduced rate of $320.

While Online Educational & Empowerment Course for Women with PGAD &/or Vulvodynia  does not substitute for individualized therapy, the evidence-based strategies, techniques and support you will gain without leaving the comfort of your home is a one of kind opportunity.

Online Educational & Empowerment Course for Women with PGAD &/or Vulvodynia welcomes a maximum of 15 attendees.

To Register: contact Cindy or Star at (212) 288-2242. Payment is accepted by check, no credit cards. Write check to “Evelyn Hecht, PT” in the amount of $320 and mail to following address:

Evelyn Hecht, PT,1317 Third Avenue,9th Floor, New York, NY 10021

Payment in full is due by January 12, 2017.

Space is limited, so please Sign Up Today

This course will only be conducted with a registration of 15 women.  If the course is cancelled, all monies will be refunded.

For additional questions, please email: info@emhphysicaltherapy.com or call  (212) 288-2242

 

 

“Rewire Me” The Source for Your Healing Journey

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I am fascinated by how the body and mind work together to heal from pain and injury.  To learn more about healing and how physical therapists can help patients be committed to their healing process, I interviewed my good friend Rose Caiola, founder of Rewire Me, a company with a wealth of resources, writings and teachers in fields of physical, spiritual and emotional health, all thoroughly researched and curated by Rose and her team at Rewire Me.

Here are some of the gems I gleaned from our interview:

Evelyn: Why did you start Rewire Me?

Rose: Rewire Me evolved from life lessons I’ve learned from age 13 onward, meeting various teachers and mentors who helped me on my life’s healing journey. Connecting with these teachers proved more beneficial than trying to “fix things on my own.”

Many people feel alone when dealing with life’s challenges and don’t know how to ask for help or even where to look for guidance. One method or teacher may not resonate for every person, so I thought “Wouldn’t it be wonderful to have a site with a range of authentic experts, teachers, and healers?” People can seek and access these teachers’ wisdom through writings, books and classes to help them on their healing journey”.

Rewire Me’s website includes a range of experts on topics such as relationships, parenting, physical health, spiritual growth,  dealing with illness and loss –  incorporating all aspects of life.

E: How can people with physical pain start their healing process?

R: The first step is to acknowledge that there is something wrong. Many people don’t want to acknowledge that they are feeling pain, so they bury it or pretend it is not there. Once you acknowledge there is a problem, then you can reach out to a friend, call a medical professional, research on professional medical websites like WebMD and go on to Rewire Me to find teachers who may inspire them.
People may reject acknowledging pain or injury due to fear of the unknown.  Others may feel that asking for help is a sign of weakness, especially if they are used to being in charge or control.  Pain can make a person feel out of control. In essence what this really translates into is, ‘I don’t feel worthy enough to have somebody help me. I don’t love myself enough to get the help I need.’

E: How can one rewire fear-based thinking that stumps taking positive action?

R: Set a little time in the morning before you have to start your day. Sit up, feet on the floor to ground yourself and spend 5 minutes focusing on your breath, feeling and focusing your attention to the breath moving in and out, at whatever pace. This centers you to the present.

After the 5 minutes of quiet breath, ask “What do I want to happen today so I can achieve good health, or be successful as a parent or attain a work goal”

Envision your hero, or person of history who inspires you, for example, Amelia Earhart. What would it feel to be like her? Envision and embody the emotion of Amelia‘s courage, risk taking, forward thinking. How do you think she felt when she was flying solo in the starry night sky?

E: How can we help patients stay motivated and the course of treatment; to understand that their home program as physical therapy is not a “quick fix?”

R: Well, one I think is to have faith in the healing process. So that might become their mantra. ‘Today I’m going to do what I can to heal myself.’ ‘Today I’m going to take that first step.’ ‘Today I’m going to do my physical therapy exercises.’ Not worrying about tomorrow, not thinking about anything else, but having faith that they can overcome. When and if they come up to a crossroad or a flare up, don’t give up. Tell yourself “It’s okay.” Acknowledge that it’s painful and that you’ve hit a rock or a wall. Figure out how you can go around the wall instead of letting yourself get stuck. Avoid the “Oh poor me.’ ‘This always happens to me.’ ‘This is my life.’ If you keep repeating that story, you’re never going to get anywhere. Replace them with positive statements. The brain and body are listening!

The second thing to do is Practice. Practice your home exercises, self care techniques, say your positive affirmations out loud.  With practice different parts of our brain light up and those neural networks become bonded over time, overriding faulty pain patterns. If you play a sport you have to practice to compete well.  But, if you don’t practice, you won’t play as well. My kids are on sports teams and if they don’t practice, they get benched. They’ll say: “Why did the coach do that? I’m so angry…the coach hasn’t put me in play for the last 3 games!” Well, if you don’t practice, why would that coach put you in the game? It’s the same with committing and doing your home program, practice allows your body to change for the better.

Third, Schedule the 2-3 times a day in your calendar where you know you can do your physical therapy exercises. They don’t take long, right?

E: No. People wouldn’t do them otherwise, so we keep them short and manageable.

R: That’s great, so patients start to feel better, get stronger and over time they’ll see the many benefits of committing to their treatment.

E: Yes!  You’ve used the term “healing journey.” What does that means to you?

R: A healing journey means learning to love myself. Learning to forgive myself, including what happened in my past.  Incorporating growth and love from others and building this Rewire Me community is all about healing. Healing your heart. Healing your physical, emotional and spiritual well-being

Check out Rewireme.com to be inspired and continue on your healing journey!

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A Pelvic Physical Therapist’s Approach to PGAD: Persistent Genital Arousal Disorder

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What’s your first reaction to this image? Laugh? Sigh and Roll your eyes at the tasteless joke?  Did you think: “How can anyone REALLY have this?”

What if you were experiencing sexual arousal or multiple orgasms on a daily basis, for hours at a time, day or night, with no one medication or method to relieve symptoms on a consistent basis?

What if you had the guts to talk to your doctor about the embarrassing (or what may even feel like devastating) symptoms and find out that your doctor either never heard about PGAD, or worse was a medical professional that did not believe you?

This is the suffering that people with PGAD or PSAS, Persistent Genital Arousal Disorder or Persistent Sexual Arousal Syndrome, experience and continue to endure. Sadly, the condition has even led some patients end their own lives as recently as a few months ago in 2016.

What  is PGAD?

Persistant Genital Arousal Disorder, a “monster sexual dysfunction”, as coined by Irwin Goldstein, MD (1) is a condition characterized by 6+ months symptoms of high levels of genital sexual arousal in the absence of desire (2). Genital arousal does not dissipate, with orgasm nor by medication alone.

PGAD sufferers describe their symptoms as intrusive, unwelcome, unpleasant and sometimes painful. Multiple, frequent disturbing orgasms (not pleasurable) occur spontaneously, at work, home, school and create tremendous embarrassment and anxiety, which eventually can lead to depression, frustration, and social withdrawal. It causes major stress for personal relationships. Seventy five percent (75%) of women with PGAD report moderate to high distress levels and report feelings of shame, isolation and suicidal thoughts (3).

PGAD: Subset of Chronic Pelvic/Abdominal Pain

PGAD has similar qualities, fluctuations, flares like and is starting to be viewed as a subset of chronic pelvic/abdominal pain.

Chronic pelvic/abdominal pain diagnosis is also made after 6 months of pain, burning, stabbing, cramping  + other symptoms involving 1 or more “private “areas: bladder (urinary frequency and bladder pain) bowel, (IBS) reproductive organs (endometriosis, vulvodynia), groin, buttocks and pelvic floor muscle pain.

As chronic pain takes 6 months to develop, the tissues that were involved at the initial onset of insult or trauma  may not be the main or only source currently producing chronic symptoms.  Rather, a highly sensitive brain/nervous system that is persistently on High Alert, “Danger-Danger!” mode perpetuates the symptoms.

PGAD Research

PGAD alone has not been researched extensively. We do not know the cause, the amount of women and men with symptoms, nor do we have effective, evidence based treatment – yet. With the push of some PGAD “warriors” and a relatively young organization, International Society of the Study of Women’s Sexual Health (ISSWSH), www.isswsh.org, research on PGAD is now being conducted. ISSWSH will have their annual conference in February 2017 where the PGAD Significant Interest Group will present state of the art research as well as testimonials from sufferers.

PAIN comes from the BRAIN

Chronic pain research has made amazing strides in the last 10 years due to the ability to incorporate MRI studies of the brain in all sorts of pain research. Our brain’s main job is to protect us. For example, we don’t keep our hand on the hot stove, or step down further onto the nail under our foot as the brain instantly weighs information coming from sensory nerves and makes a decision on how to react – i.e. PROTECT.  Pain is the brain’s response to incoming nerve reports.

Research shows hundreds of areas in our brain “light up,” or simultaneously become active when experiencing pain, including areas in the brain that process Sensation, Movement, Emotions and Memory. This knowledge helps us understand how a certain movement, emotion or even noise & light can lead to a pain reaction, especially if the brain is persistently on the faulty “Danger-Danger!” mode.

“Neuroplascity” is the ability for the brain to make new neural connections throughout our whole lifetime, to adjust, to change.

How can we help our brain change from being on a highly sensitive “Danger Danger!” mode to a more functional mode?

PGAD TREATMENT Step 1: EDUCATE yourself about Pain & Know your Triggers

Once medical diseases have been ruled out, the first step of effective treatment of PGAD is to change the brain from high alert to a healthy functional mode, by educating yourself on the science of pain (stay with me!)  and to write down all of your possible triggers for symptoms. Lorimer Moseley’s and David Butler’s Explain Pain (www.noigroup.com) and pain educational website www.retrainpain.org are great resources for pain/PGAD sufferers and their loved ones.

Write down all the actions (riding in a car, walking up stairs, showing affection to partner, etc.) and write down what fears/thoughts (not knowing the “cause” of pain, not being able to work, loss of partner, inability to care for children etc.) that stimulates PGAD symptoms (4).

Describe each symptom related to the trigger and rate the intensity of symptom on scale of 0-10. This will give you and your medical team a baseline to measure and monitor progress.  You have to be an active participant in your healing because each person’s cause of symptoms and how your brain reacts with pain/PGAD symptoms is unique.

PGAD TREATMENT Step 2: Find your T-E-A-M

Find your team of practitioners who understand PGAD and who will work with you. A Medical Doctor and a Pelvic Physical Therapist is a good start.

  1. MD/DO – for prescription medicine, trigger point injections, superficial nerve blocks, botox – treatments to  give the faulty nerves/brain activity a break
  2. Pelvic Physical Therapist – who is up-to-date with the recent pain research information, provides manual treatment and offers paced, gradual movement/exercise therapies to pelvic floor, abdomen, pudendal nerve and viscera – see below for more details
  3. Psychotherapist – to  address any possible childhood traumas/abuse issues that over 50% of PGAD sufferers experienced, as these experiences may be held (remembered) in their genital region  (see EMH Physical Therapy’s blog on Somatic Experiencing (http://www.emhphysicaltherapy.com/what-is-somatic-experiencing-and-how-does-it-heal-traumachronic-pain/1450/). Therapy can help manage the depression and anxiety that accompanies PGAD.
  4. Acupuncturist – to help lower the “high alert” brain/nervous system, releasing the “fight or flight” pattern or stimulating the sluggish, depressed pattern

PGAD TREATMENT Step 3:  Pelvic Physical Therapy

Physical therapy treatments are individualized as no patient is alike in their presentation – their symptoms of PGAD /pain may be similar, but the causes are different. Education about brain/nervous system and motivating patients to become active partners in their healing process has the best outcome.

There is no one “magic bullet,” no 1 medication or 1 technique for symptom relief. Receiving regular pelvic PT treatments plus doing a daily exercise/movement program (the brain loves movement!) is part of PGAD therapy. Treatments can include:

Manual Therapy – incorporating movement and awareness for both the external & internal muscles of the pelvis, abdominals, hips, fascia and skin; calming  the “fight or flight” reaction allows for improved blood flow, oxygenation and balances the nervous system.

  • strain / counterstain
  • myofascial release
  • connective tissue massage (aka skin rolling)
  • trigger point release
  • pudendal nerve glides
  • visceral mobilization

Biofeedback – to promote awareness of pelvic floor muscle tension and teach coordination training.

Breath and Meditation – deep diaphragmatic breath expands the front, sides, back of the ribs & abdominal cavity, relaxes the pelvic floor muscles, massages the internal organs and improves oxygenation to tissues. A simple 5 minute meditation where one focuses on the sensation of slow inhalation and exhalation calms the brain.

Desensitization Techniques:  Strategies to lower the high alert nervous system as used in treating Complex Regional Pain Syndrome, is applied to our PGAD patients with promising results.

Stretching and Stabilization Exercises to lengthen and strengthen, stimulate the core stabilizers, soften the pelvic floor. Cardiovascular exercises to improve general blood flow are performed daily at home. Exercises are paced and applied gradually as the patient reports responses in their symptoms.

Modalities such as TENS, Low Level Laser and use of dilators can also be used as part of our treatment.

Final Thoughts

PGAD, like chronic pelvic pain is complex and requires patience by both the patient and the practitioner. Results are best if patient and practitioner work consistently together and the patient performs daily home/self care exercises, paying attention to responses and slowly increasing the pace and challenge of the new movement. Neuroplasticity takes persistence and develops over time.

Further research in measuring the efficacy of all the treatment techniques mentioned above and the importance of a concurrent multi-specialty approach to PGAD still needs to be done. My team and I at EMH Physical Therapy will continue to help patients heal from PGAD.

References

1 Goldstein I. Persistent genital arousal disorder- update on the monster sexual dysfunction. J Sex Med 2013;10:2357-2358

2 Jackowich R, Pink L,Gordon A, Pukall  C. Persistent Genital Arousal Disorder: A Review of Its Conceptualizations, Potential Origins, Impact and Treatment. Sex Med Rev 2016;1-14

3 Leiblum SR, Brown C, Wan J, et al. Persistent sexual arousal  syndrome: a descriptive study. J Sex Med 2005; 2:331-337

4 Butler D,Moseley L, Explain Pain, Noigroup Publications Adelaide, Australia 2013

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