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Physical Therapy Treatment for Interstitial Cystitis and Chronic Pelvic Pain Syndrome

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By Stephanie Prendergast

Urinary tract infections hurt. It hurts as your bladder fills, you constantly feel the need to pee and when you do it feels like knives are coming out of your body. You do not experience post-void relief and immediately feel like you need to pee again. Your doctor asks you to urinate urinate in a cup, you are (thankfully!) told you have a UTI, you are given medication and in a few days you are back to normal.

What happens when you have those horrendous symptoms and there is no infection?

November is Bladder Health Awareness Month and November 27th – 30th has been designated Interstitial Cystitis Awareness Week. We are dedicating this week’s blog post to Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS), Chronic Pelvic Pain Syndrome/Nonbacterial Chronic Prostatitis (CPPS) and the role physical therapy plays in treating these disorders.

These syndromes can cause debilitating pain, the type of pain that leaves patients actually HOPING to have an infection, because that means there is a fast treatment. Unfortunately in most cases of IC/PBS/CPPS cultures return negative and patients and their doctors are left wondering what is going on and what to do about it.

Did you know…..

  1. Hypertonic pelvic floor muscles cause symptoms that feel like a urinary tract infection?
  2. Hypertonis and/or myofascial trigger points in pelvic girdle muscles, such as the rectus abdominus muscles and adductors, can also cause urinary urgency, frequency, and burning with urination?
  3. Hormonal changes during menopause, breastfeeding, and oral contraceptive use can compromise the peri-urethral tissues and contribute to symptoms of urgency and frequency, dysuria, and urethral pain?
  4. The majority of men diagnosed with ‘Prostatitis’ never had an actual prostate infection?
  5. Skilled pelvic floor physical therapy can reduce these impairments and lead to a reduction in symptoms?

The Evidence

Multiple studies have been published on the association between pelvic floor/girdle muscle dysfunction and Interstitial Cystitis/Painful Bladder Syndrome and Chronic Pelvic Pain Syndrome. These studies show that dysfunction in the musculoskeletal system can mimic urologic dysfunction (1,2). This means patients with symptoms of urinary urgency, frequency, and burning in the absence of infection can benefit from a pelvic floor physical therapy evaluation to determine if pelvic floor dysfunction is a contributing factor to their symptoms. But how effective is physical therapy treatment for these symptoms? In 2009 a prospective, randomized, blinded, prospective multi-center study was initiated by Rhonda Kotarinos and Marypat Fitzgerald.3 This high-powered study was the first of its kind to be published on the role of myofascial physical therapy for the treatment of urologic chronic pelvic pain syndrome. The investigators compared two methods of manual therapy (myofascial physical therapy and global therapeutic massage) in patients with urologic pelvic pain symptoms.

In the study, 49 men and women enrolled and were divided into two groups. One group received skilled myofascial pelvic floor physical therapy and the control group received general massage, one hour per week, for 10 weeks. 94% of the participants completed the study, demonstrating that it is feasible to conduct a larger study on myofascial physical therapy treatment. Importantly, this trial also showed that 57% of the group that received skilled pelvic floor physical therapy demonstrated improvement, and this group showed statistically significant improvement over the group receiving massage.

These studies are important because they demonstrated the role the musculoskeletal system can play in what seems to be solely a bladder or prostate problem. Furthermore, they demonstrate that manual pelvic floor physical therapy treatment can play an important part of someone’s treatment plan. The role of a pelvic floor physical therapist does not stop manual therapy alone, however.

Recent studies have also shown that pain physiology education improves the health status of  people recovering from persisting pain syndromes. In a study initiated by J Van Ossterwick in a double-blind randomized controlled trial, 30 patients with fibromyalgia were assigned to receive pain physiology education or pacing self-management education.4 The results showed that the group receiving pain physiology education worried less about their pain, had long-term improvements in physical function, vitality, mental health, and general health perceptions. In addition and importantly, this group reported lower pain scores and showed improved endogenous pain inhibition compared with the control group.4

These quality studies show that physical therapy can help reduce or eliminate the symptoms of Interstitial Cystitis/Painful Bladder Syndrome and Chronic Pelvic Pain Syndrome as well as have a positive effect on pain, disability, and catastrophization in patients with these debilitating pain disorders. But the role of physical still does not end with manual therapy and pain physiology education.

Assessment, case management, goal setting and quality of life restoration

Physical therapists are often afforded the most one-on-one time with patients. Therefore, we are well-positioned to help the patient figure out how they developed their symptoms and link their history to their physical findings. This is called an assessment and it often includes components such as the differential diagnosis and development of an interdisciplinary treatment plan.

Specialists working with patients with IC/PBS/CPPS will tell you that no two patients are alike and therefore standard one-size-fits-all protocols are not effective. Each individual will have different levels and combinations of musculoskeletal, central and peripheral nervous system, and urologic impairments. Physical therapists can help patients identify why certain treatments have worked and why others have failed, and can use critical reasoning skills to help them set reasonable goals. Patients with these disorders often have multiple doctors and other healthcare providers involved in their care. Physical therapists can help them organize the treatment plan to make sure their goals are being met and they are improving. Individualized treatment plans may include various combinations of medications, medical interventions, physical therapy, cognitive behavioral therapy, hypnosis, diet management, yoga, etc. It is a lot to understand and manage, however, functional improvement and complete symptom resolution is totally possible. You can read more about this in our previous post “Why a ‘diagnosis’ is not the key to recovery”, and in our book, Pelvic Pain Explained.

As a physical therapist myself, I value the role we can play in helping patients organize their treatment plans, use education to reduce the understandable anxiety that comes from being diagnosed with IC/PBS/CPPS, reduce or eliminate the terrible symptoms with skilled manual techniques and home exercises, and help people put these problems behind them and move on with their lives. They can stop hoping for positive urine cultures because they understand the true causes of their symptoms and are equipped with the tools to treat them. 

In honor of Bladder Awareness Month and Interstitial Cystitis Awareness Week, we ask that everyone reading this share this post with at least one person who may not know about the role pelvic floor physical therapy can play to help people with IC/PBS/CPPS!

Burnaby Massage Therapy

Pain is in the Brain

PAIN IS IN THE BRAIN

By Krista Burns
 
 
Pain is a conscious experience, crucial for survival. Pain is perceived in the brain, not in your body. Understanding that the perception of pain in the brain and segmental dysfunction are not necessarily related, is an important clinical distinction.
 
PAIN IS PERCEIVED IN THE BRAIN, NOT YOUR BODY.

“We have traveled a long way from the psychophysical concept that seeks a simple one-to-one relationship between injury and pain” (Melzack, 1999).

DIFFERING BETWEEN PAIN AND SUFFERING

Although commonly used as synonymous terms, the words “Pain” and “Suffering” are not the same.

  • Pain is a perception of a noxious stimulus.
  • Suffering is the psychologic experience of the patient that prevents them from separating their physical pain with their ability to live and thrive.

The primary reason pain patterns are so commonly misdiagnosed and misunderstood is that practitioners view the patient segmentally. Pain is perceived in the brain, and should be treated that way.

NEUROMATRIX THEORY OF PAIN

The neuromatrix theory of pain proposes that pain is a multidimensional experience produced by “neurosignature” patterns of nerve impulses, generated by a widely distributed neural network in the brain. These neurosignature patterns may be triggered by sensory inputs, but they may also be generated independently of them (Melzack, 2001).

Advanced imaging studies identify neuroanatomical correlates of the “Pain matrix” that include:

Pain Is In The Brain

  • the anterior cingulate cortex,
  • the insular cortex,
  • the thalamus and
  • the sensorimotor cortex of the parietal lobe.

The pain neuromatrix is activated whenever the brain concludes that body tissue is in danger and action is required. That pain is allocated an anatomical reference in the virtual body of the sensory homonculus, upon which coherent motor output is also dependent in the motor homonculus.

Multiple inputs that act on the neuromatrix contributing to the output of pain: (Melzack, 1999)

  • Sensory inputs (cutaneous, visceral and other somatic receptors)
  • Visual and other sensory inputs that influence the cognitive interpretation of the situation
  • Phasic and tonic cognitive and emotional inputs from other areas of the brain
  • Intrinsic neural inhibitory modulation inherent in all brain function
  • The activity of the body’s stress-regulation systems, including cytokines as well as the endocrine, autonomic, immune and opioid systems

PAIN IS AN OUTPUT

The human experience of “Pain” as we know it, is an output and ultimately a conscious decision by the brain, based on the sum of all the inputs and past experience. From an evolutionary perspective, pain is for homeostasis of the organism and is produced whenever the brain concludes that body tissue is in danger and action is required.

When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms. This means that less input, both nociceptive and non-nociceptive, is required to produce pain (Moseley, 2003).

WE NEED TO CHANGE THE BRAIN TO REDUCE PAIN.

When new age healthcare professionals are working with chronic pain patients, they need to reduce the amount of threat, or risk to the body to reduce activation of pain pathways.

POSTURE AS PAIN PREVENTION

A great way to reduce threat to the system is to educate your patients on how to maintain proper posture. When the patient has proper posture their body is in a position of minimal load and threat associated with flexor dominance.

Poor posture increases stress, load, and threat to the body. Regardless of what you do in your office with the patient one-on-one, if you don’t help them reduce environment stress during their daily activities with proper posture, they will continue to present with postural distortion patterns and express pathways of chronic pain.

Neuroplastic changes of the Posture System allow the patient to hold themselves upright against gravity in an effective manner, and reduce excessive threat to the system.  Posture is fundamental for proper function, and for the reduction of threat leading to chronic pain.

North Burnaby Massage Therapy Clinic

Brain can be tricked into feeling pain relief

New research shows the brain can be tricked into feeling pain relief

Mind games: new research shows the brain can be tricked into feeling pain relief

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Shifting mindsets. shutterstock
Giuliana Mazzoni, University of Hull

Pain is never a nice things to experience, but it is one of the most useful bodily signals we have. It acts like an alarm system – sending an immediate message for highly harmful and potentially fatal conditions – so you know that when you touch that boiling hot pan, you should take your hand away very quickly.

Pain is also a highly subjective experience – people can experience different levels of pain in the same situation. So while some people tend to have a very low pain threshold – for example, needing anaesthetic when having dental cavities fixed – others seem to have no problem when they have teeth removed.

These individual differences seem to have a genetic basis, but there are also things that can help to “manipulate” the mind and change the way we feel pain – such as a sudden distraction. This could be as simple as making someone laugh, as this shifts attention away from the pain, helping to reduce its perceived intensity and unpleasantness.

And new research shows that as well as tricking the mind into feeling distracted from pain, the brain also seems to be able to be tricked into experiencing pain relief.

The power of pain

On a brain scan, the areas that light up when pain is felt are in the frontal brain regions. These are the areas of the brain that regulate the intensity and quality of the pain experience. They are also the brain areas that are responsible for setting expectations – which is no coincidence. Expectation plays a big part in how we perceive pain and the intensity with which it is felt.

So if you are waiting for an injection that you are told will be really painful, you are likely to experience it in this way. And on the flip side, if something painful happens unexpectedly – such as stubbing your toe – it might take a bit of time before you realise the actual intensity of the pain.

In this way, the now somewhat famous “rubber hand illusion” reveals the powerful connection between what we see and what we feel. Using a fake rubber hand, psychologists found they could convince people an artificial arm was part of their body. For this to happen, the participants had to hide their real arm from view (under a piece of cloth) and then both their real arm and fake arm were simultaneously stroked.

A few studies have also suggested that pain – not just touch – can be perceived by the rubber hand illusion. And there are countless YouTube videos of people cringing as the rubber hand is threatened by a hammer or pricked with a needle.

Mind over matter

New research now shows how as well as being tricked into experiencing pain, the brain can also be fooled into experiencing pain relief. The recent study involved researchers carrying out the rubber hand illusion, and then using a thermode to deliver intense pain stimulation on selected sites of the real arm. This was done while a visible mock thermode was attached to the exact same sites of the rubber arm, which then lit up during the stimulation.

It was discovered that a large number of participants reported experiencing the pain as if it was coming from the rubber arm. The researchers then used a fake pain relieving cream – in other words a placebo – on the “painful site” of the rubber arm. This time round, people who experienced the rubber hand illusion also reported a decrease in pain intensity.

‘Is this my hand I see before me?’ 

What this shows is that people’s minds can be tricked into experiencing both pain and pain relief on a fake hand, where of course no pain stimulation, or any pain relief, were applied.

But the rubber hand illusion is more than just a great party trick, it also reveals one of the most important ideas in brain science. It shows how multi-sensory perception can influence how we see our own body. It also reveals how what we know to be true can be overridden by the brain.

In the experiment, the brain is changing to accommodate the new rubber hand – which is called neuroplasticity. This is the idea that the brain can change in response to experience.

The ConversationAnd in practical terms, these findings could present viable treatment and pain relief in conditions for people with chronic pain – such as phantom limb syndrome, where pain is experienced as if coming from an nonexistent limb. It could even be used in other chronic pain conditions such as fibromyalgia or complex regional pain syndrome, potentially offering hope to thousands of people whose lives are blighted by real pain on a daily basis.

Giuliana Mazzoni, Professor of Psychology, University of Hull

This article was originally published on The Conversation. 

North Burnaby Massage Therapy Sept 2017

Massage Therapy for Plantar Heel Pain

Plantar heel pain (previously known as plantar fasciitis) is generally described as sharp or stabbing, and worse in the morning.

The pain can decrease with activity, but can return after long periods of standing or after getting up from a seated position. Massage therapy as a therapeutic intervention is being embraced by the medical community. This is in part because it is a non-pharmacological therapeutic intervention that is simple to carry out, economical, and has very few side effects. One area that is being explored is the use of massage therapy for patients who suffer from plantar heel pain.

Existing evidence suggests that massage therapy (joint mobilization and soft tissue massage) is helpful in improving function and reducing plantar heel pain (Fraser et al. 2017, Martin et al. 2014, Mischke et al. 2017, Piper et al. 2016, Sutton et al. 2016)

Why Does Massage Therapy Work for Heel Pain?

A biopsychosocial framework helps put into context the interconnected and multidirectional interaction between: physiology, thoughts, emotions, behaviors, culture, and beliefs. In terms of clinical responses to massage therapy there are a couple of proposed mechanisms of action, including but not limited to: neurodynamics, contextually aided recovery, neuromodulation, social grooming and mechanotherapy.

Structures to be aware of when treating plantar heel pain

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from plantar heel pain may include neurovascular structures and investing fascia of:

 
  • Plantar Fascia
  • Lumbricals
  • Adductor Halluscis
  • Flexor Hallucis Brevis
  • Tibialis Anterior
  • Metatarsals & Interossei
  • Peroneals
  • Tibialis Posterior
  • Triceps Surae 
  • Hamstrings 

Stretch Training for Plantar Heel Pain

Calf tightness and reduced dorsiflexion are a possible factor for plantar heel pain (Bolivar 2013, Pascual Huerta 2014, Patel & DiGiovanni 2011). Therapists may want to consider including calf stretches part of a rehabilitation program.

Preliminary findings suggest stretch training is a viable way to stimulate architectural adaptation in the lower limb. Changes in the passive elastic properties and ROM induced by stretch training is due to both increases in stretch tolerance AND changes in passive properties of muscle. For a more indepth looks at theses changes you may want to check out these recent studies:

  • 6 weeks of loaded stretch training of the plantar flexors resulted in hypertrophic like adaptations of the gastrocnemius (Simpson et al. 2017)
  • 3 weeks of twice daily stretch training (4 × 30 s) lead to an increase in dorsiflexion range of motion (ROM)  a 28% increase in passive joint moment (Blazevich et al. 2014). 
  • 4-week static stretch training program changes the flexibility of the gastrocnemius muscle tendon unit (Nakamura et al. 2012)

Intrinsic Foot Training

Intrinsic foot muscles play a crucial role in supporting the medial longitudinal arch, providing the foot stability and flexibility for shock absorption. There are a number of footcore exercises laided out by McKeon et al. 2015 that will help reconditinog foot muscles.

Burnaby Massage Therapy Clinic 2017

How to Avoid, Recognize and Treat Concussion in Sports

How to avoid, recognize and treat concussion in sports

There are benefits to sport participation, and it is important for parents to be aware of concussion risks, how to avoid them, and the signs when they may have occurred. 

Kathryn Schneider, University of Calgary

Recognize, remove, rest and recover before returning to sport. Those are key points about sport-related concussion stated in the 5th International Consensus Statement on Concussion in Sport.

The Canadian Guidelines on Concussion in Sport have been developed based on this statement and were recently released by Parachute Canada, a charitable organization focused on injury prevention, and its expert advisory group.

The good news is that most people who suffer a concussion will recover in the initial days and weeks following injury. However, some will have ongoing symptoms. While concussions may occur in sport, there are many benefits to physical activity and sport participation for both youth and adults.

I am a physiotherapist and researcher (assistant professor and clinician scientist) at the Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary. My research focuses on the prevention and treatment of sport-related concussion in children, youth and adults, with special emphasis on the role of the neck and balance systems.

A concussion is a type of a brain injury that occurs following a trauma to the head or body. Symptoms can come on immediately or may take hours to gradually evolve. The most common symptom following concussion is a headache. However, a number of other symptoms such as dizziness, nausea, fatigue, difficulty with concentration, neck pain and other complaints may also occur. Lying motionless, clutching the head, being slow to get up, wobbling and appearing dazed are some of the observable signs.

In the event that a concussion may have occurred, it is important that the player is removed from the activity and has follow-up medical evaluation as soon as possible. A tool called the Concussion Recognition Tool 5 (CRT5) has been developed by the Concussion in Sport Group and is meant to help coaches, officials, parents and players recognize the signs of concussion.

How are concussions treated?

All individuals with a suspected concussion should see a health care professional with knowledge of concussion. The typical treatment is a short period of rest (24 to 48 hours, both mental and physical) followed by a gradual return to the typical activities that are done throughout the day.

Following this, individuals may slowly increase their activity level using a graduated return-to-school strategy and return-to-sport strategy.

The return-to-school strategy includes steps to gradually increase the amount of mental activity prior to returning to school.

The return-to-sport strategy includes a series of steps that are performed sequentially, with each step taking a minimum of 24 hours. These include light aerobic exercise, sport-specific exercises, non-contact training drills and full practice prior to returning to play or sport.

These two strategies can be performed simultaneously under the supervision of a health care professional. They take approximately one week to complete as long as the person with the concussion does not have any recurrence of symptoms. It is recommended that individuals return to school prior to returning to sport. Medical clearance should be obtained prior to returning to sport.

Dr. Bennet Omalu, left, is calling for parents not to enrol their children in contact sports. He discovered cumulative brain trauma from concussions in football players. In this 2010 file photo, he talks with neurologist Dr. Ira Casson, former head of the NFL Mild Traumatic Brain Injury Committee.

Most people get better in the initial days to weeks following a concussion. However, for those who have ongoing symptoms and difficulties, there are some treatments that have been shown to help.

My research has found that people with ongoing headaches, neck pain and/or dizziness and balance problems who are treated with physiotherapy techniques aimed at treating the neck and balance systems are more likely to be medically cleared to return to sport in eight weeks.

There is also some research that low-level aerobic exercise may be beneficial following a concussion. Our research in this area is ongoing and we currently have a number of studies that are evaluating different types of treatments to help with recovery.

Is there any way to prevent a concussion?

The best way to minimize the impact of concussions is to prevent them. To do this, we first need to understand who is at the greatest risk.

Research has shown that individuals who have had a previous concussion, who play games (as opposed to practice) and engage in contact sports all increase the risk of concussion.

Many different sport associations are working to use research to inform rule changes to decrease the risk of concussion, including rules to disallow bodychecking in youth ice hockey nationally, in leagues for 11-to-12-year-olds (based on research led by Carolyn Emery).

Another focus of my research program is to evaluate different pre-training strategies that may be used to prevent concussions.

Concussions in sport are an area of much discussion. It is imperative that individuals with a suspected concussion are removed from play until they can be medically evaluated and do not return until they are cleared to do so.

At this time, the literature on the long-term consequences of exposure to head trauma is inconsistent. Thus, more research is required to answer these important questions.

The ConversationThe good news is that most people recover well following a concussion when managed appropriately. Awareness of the signs and symptoms of concussion, and appropriate initial management when a concussion may have occurred, are of utmost importance.

Kathryn Schneider, Assistant Professor, Clinician Scientist (Physiotherapist), Faculty of Kinesiology, University of Calgary

Burnaby Massage Therapy Clinic - September 2017

Massage therapy for neck pain

 Conservative Care Options for Neck Pain

Physicians, now more than ever are recommending conservative treatment including manual therapy, acupuncture, education and exercise as part of a multi-modal approach for patients suffering from neck pain (Busse et al. 2017, Kjaer et al. 2017)

Types of Neck Pain

Proper assessment help identify who is most likely to benefit from conservative treatments. Recent clinical guidelines published in the JOSPT suggest that patients with neck pain fall into 1 of 4 groups (Blandpied et al. 2017):
• neck pain with limited motion
• neck pain associated with whiplash
• headaches related to neck pain
• neck and nerve-related pain into the arm (also known as radicular pain).

Conservative Care Options for Neck Pain

Massage Therapy and Neck Pain - For those who suffer from neck pain, massage therapy has been shown to be a safe, effective non-pharmacological therapeutic intervention that is simple to carry out, economical, and has very few side effects (Brosseau et al. 2012, Bussières et al. 2016, Côté et al. 2016, Nahin et al. 2016, Sutton et al. 2016, Wong et al. 2016, van der Velde et al. 2016).

Acupuncture and Neck Pain - There is quite a bit of research suggesting that acupuncture/electro-acupuncture has therapeutic benefit for neck pain (Blanpied et al. 2017, Cerezo-Téllez et al. 2016, Gerber et al. 2017, Kjaer et al. 2017).

Talk to your local physicians about conservative treatment options

Massage therapists are uniquely suited to incorporate a number management strategies (exercise, education, acupuncture and manual therapy) to help decrease neck pain and increase function. Proper assessment and referrals are important to identify who is most likely to benefit from conservative treatments.

Burnaby Massage Therapy Clinic June 2017

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