“Functional Medicine is a systems biology–based approach that focuses on identifying and addressing the root cause of disease. Each symptom or differential diagnosis may be one of many contributing to an individual’s illness.”
In non-scientific terms, functional medicine is the practice of figuring out the cause of disease and treating it rather than managing symptoms through medications aka bandaids that often cause further harm.
How I see it is this: every disease or condition is simply a name given to a cluster of signs and symptoms. In the traditional western medical model, treatment of such diseases and conditions involve medications and/or surgeries that only address the symptoms rather than getting to any underlying cause and in the process, often lead to additional symptoms aka side effects. Let’s pick cancer as an example; the uncontrolled division of abnormal cells in the body. Treatment can be monitoring, chemo, radiation or a combo of it all. But what does that actually treat? It attempts to kill the group of abnormal cells but does it actually address why those cells are uncontrollably dividing in the first place? No it doesn’t. And what does it do in the process? It kills a ton of good stuff in the body that may ultimately be the reason someone dies from cancer rather than the cancer itself. Don’t get me wrong, there is a place for traditional western medicine. Someone with aggressive cancer needs to be treated. But what if we didn’t stop with the chemo? What if we went further to figure out why the cells divided in the first place and treat that? My hypothesis would be that the cancer would never come back.
“The precise manifestation of each cause depends on the individual’s genes, environment, and lifestyle, and only treatments that address the right cause will have lasting benefit beyond symptom suppression.”
Functional medicine asks the question “why?” and with that answer, actually treats the cause of disease. In this light, you can look at every diagnosis as the same. It is simply a sign of the system functioning at a suboptimal level. Sometimes a diagnosis can be the result of more than one cause or sometimes a cause can be the reason for multiple diagnoses. For example, depression can be caused by vitamin insufficiencies, decreased thyroid function or over-growth of bad bacteria in the gut. On the flip side, an overgrowth of bad bacteria in the gut can be the cause of depression, arthritis, cancer, heart disease and more.
In some respects, this simplifies the entire study of disease states. There is almost no need for an emphasis on the diagnosis of a condition. Instead the microscope needs to be on the root cause of systemic breakdown. Let’s go back to the cancer example. If the genetic marker for cancer is present, it explains why an individual ended up with cancer versus having heart disease, diabetes or depression BUT that’s still not the actual cause. The true cause could be an ineffective immune system due to chronic systemic inflammation from a leaky gut caused by poor diet, a history of viral infections and excessive stress hormone release that then enabled that genetic mutation for cancer to be expressed. This might sound daunting because most everyone is stressed, has been treated with antibiotics for an infection and doesn’t have the best diet BUT it can also be empowering. Could we actually stop the expression of the cancer gene by optimizing the environment it lives in?I believe the answer is yes, we can. And that is pretty freaking cool. Welcome to functional medicine.
“Functional Medicine is true healthcare. Conventional medicine is really disease management: its doctors focus on controlling illness once it has already occurred, usually by suppressing symptoms with prescription drugs.”
– Chris Kresser
There is one thing I have left out up to this point and it happens to be the single most important factor when it comes to my experience of pain; perceived threat. At the time of the accident, my entire being was under a large amount of stress and to the nervous system, stress equals threat.
I was in a high stress residency, a stagnant romantic relationship and a job that brought me no joy. I was putting my head down and getting through it but my body was likely experiencing the equivalent of running away from tigers with a headwind. Then the accident happened. It came out of no where. There was no time to react, no time to prepare and barely time to comprehend what had happened. When something so unlikely happens, you start living life on the edge, afraid the odds will be against you again any second of any day.
Then there were the doctors. They made sure I remained fearful for the rest of my life. There was the doctor that told me I would never be able to lift my eyebrow again and would need botox to even out the wrinkles on my forehead; the doctor that said I would never be able to smell or taste food ever again; and the one who told me to never ride a bike because I would immediately die if I suffered another head injury. Even my mom got into the mix. She told me I should have a cesarean birth for my theoretical baby because the pushing involved with natural labor would burst the “weak” blood vessels in my brain leaving my theoretical husband a single parent. Looking back on it, its painstakingly obvious I would be the 1 in 4 that would have chronic pain. RESEARCH has listed psycho-social yellow flags that predict who the 1 in 4 will be but the common theme is simple: threat perception. If you perceive threat, your nervous system will remain on high alert and you will have a heightened and prolonged experience of pain.
What I didn’t know then but I know now is this: once your injuries have healed, the first and only way to treat persistent pain is to eliminate the perception of threat. For five years I did physical therapy, acupuncture, massage, chiropractic, functional medicine, rolfing, cortisone shots, herbal and dietary changes. Sure, I got better in some respects. I returned to work and returned to some physical exercise but I was still in pain. I was functioning but I was functioning with pain. In some way, these treatments fed my perception of a threat. All of the tests, examinations and diagnoses made me think my pain was a sign something was still very wrong. The fact that even I couldn’t change my pain had to mean it was serious and beyond repair. I even went to a neurosurgeon. Yes, you read that right. I, Jenny Putt the physical therapist, went to a neurosurgeon. Thats how threatened I felt.
Then there was a shift. The first significant improvement in my pain came after I attended a lecture on neuroscience at a physical therapy conference. Remember how I have been saying that simply reading these blog posts and increasing your knowledge of how pain works decreases your pain? I’m a real life example of this but just incase you don’t want to take my word, RESEARCH shows it too. Why? How? Well once you know that your pain does not mean something is seriously wrong, once you learn that your physical injuries are healed and once you understand that it’s just your nervous system that is still on alert, the threat decreases. With a decrease in perceived threat, the nervous system starts to calm down and poof! your pain disappears.
Aside from pain neuroscience education, we have many other tools that have been shown to decrease the perception of threat, decrease the sensitivity of our nervous system and decrease pain. RESEARCH backs up the use of aerobic exercise, graded activity exposure, manual therapies, meditation, relaxation, diaphragmatic breathing, sleep, social interactions and humor as strategies to eliminate pain. This looks a lot different than our typical model of tests, medication and surgeries but thank goodness! Because the old model isn’t working all that great. The current narcotic epidemic is proof of it! Here are a few pointers from research so you can bulk up your tool box:
AEROBIC EXERCISE has been shown to improve sleep, improve motor function, improve memory, improve cortisol changes, aide the immune system, decrease chronic inflammation, decrease anxiety, decrease depression, improve mood and decrease nerve sensitivity. Aerobic activity is defined as working out at an intensity of 60-70% your age-predicted max heart rate (220 minus your age) but that can be intimidating when you have pain. The point is to get moving and the strategy of “kissing the pain” is best when it comes to returning to activity. Gradually increasing the distance and intensity while nudging the pain has been shown to have great results. The motto here is “hurt does not equal harm”. Start with 3-5 minutes at 50% of your max heart rate. Add 1-2 minutes every other day until you have worked up to 30 minutes. Then slowly start increasing the intensity to the goal of 60-70% your max heart rate.
GRADED ACTIVITY EXPOSURE has been shown to be just as effective as aerobic exercise in decreasing pain intensity and disability. So if you’re not much of an exerciser, pick an activity you want to return to and apply the same principle of starting slow, kissing the pain and gradually increasing amount and intensity.
SLEEP has so many benefits to our whole being and we just don’t get enough of it! Here are some strategies to help develop a more healthy sleep pattern: set a time to go to bed (before 11pm), stop using all screens (computer, TV, phone, iPad etc) at least an hour before bedtime, reduce fluid intake (especially alcohol and coffee) in the evening, darken and cool your bedroom, remove kids and pets from your bed, relax, meditate or read a book before bed, stay in bed even if you can’t fall asleep right away, eliminate naps or restrict naps to <20 min during the day and exercise during the day so you are more tired come night.
RELAXATION whether it be through meditation, diaphragmatic breathing or a trip to the spa, is key to calming the nervous system. The goal is to live more in the parasympathetic state (rest and digest) than the sympathetic state (fight or flight). This will look different for each individual. I am not a person that finds tranquility in meditation or yoga but being with family and friends or working on a puzzle puts me in a state of ease. Find whatever does this for you and do more of it.
OTHER THERAPIES including mobilization, manipulation, soft tissue massage and trigger point dry needling have been shown to be the most effective in decreasing chronic pain when used in combination with pain neuroscience education. So all of the time and money I spent seeing physical therapists, chiropractors and acupuncturists would have been more effective if education regarding my pain had been included.
The happy ending to this story and this series of blog posts is that most likely, some of your pain is coming from your brain and you can 100% change that. I still have pain when I’m stressed, sleep deprived, over committed, eating poorly and not moving. BUT that’s my fault. I can chose to not do these things. I can chose to be pain free. Thats some powerful sh*t.
Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long term disability and work loss. Wellington: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee; 1997. Full text.
Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056. Full text.
Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302. Full text.
Van Oosterwijck J, Meeus M, Paul L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. The Clinical journal of pain. Oct 2013;29(10):873-882. Abstract.
Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy Theory and Practice. Jul 2016;32(5):385- 395. Full text.
George S, Wittmer V, Fillingim R, Robinson M. Comparison of Graded Exercise and Graded Exposure Clinical Outcomes for Patients With Chronic Low Back Pain Journal of Orthopedic and Sports Physical Therapy. 2010; 40(11):694-704. Full text.
Fulcher KY, White PD. Randomized controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ. Jun 7 1997;314(7095):1647-1652. Full text.
Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice. Jul 2016;32(5):332-355. Full text.
Aure O, Nilsen J, Vasseljen O. Manual Therapy and Exercise Therapy in Patients with Chronic Low Back Pain: A Randomized, Controlled Trial with 1-Year Follow-up. Spine. March 2013: 28(6):5250531. Full text.
It was June 12, 2011. I was out on an evening walk when a very fast car decided to join my friend and I on the sidewalk. I will spare both you and myself the details of the accident and instead, focus on my nervous system and it’s interpretation of pain over the years…yes, years.
At the time of the accident there was significant tissue damage. Significant enough to warrant a large amount of pain however, I felt nothing. My brain had decided that the threat of my injuries did not outweigh the threat of the car that was still present and trying to reverse to flee the scene. So I quickly got up and ran out of harm’s way kind of like a super human.
Once out of harm’s way, my super human powers disappeared and I started to experience pain. Bummer. Simplified for teaching purposes, there are three nerves that pass a message from the injured tissue to the brain for interpretation. Peripheral nerves go from the body to spinal cord, in the spinal cord there is a small interneuron that acts as a gateway to the third nerve which is ironically called a second order neuron because medical terminology likes to be confusing. This second order neuron travels up the spinal cord to the brain where multiple areas go into the processing of the signal to determine what meaning the message has.
Upon impact, my injured tissues started sending signals through peripheral nerves to my spinal cord. At first, they were either stopped by the interneuron or my brain decided they weren’t a threat because a bigger threat (the car) was present. Once I was removed from danger, the messages were allowed to pass through and my brain interpreted them as the next most immediate threat so I started to perceived pain. At first, the pain experienced directly correlated to the extent of my injuries but over time, my pain became disproportionate to the tissue damage.
At first, my body’s top priority was to heal and in order to heal, the body must rest. Even as tissues started to repair, my nerves remained extra sensitive and my brain continued to interpret everything as a threat (pain) so I would minimize my movement and allow for further healing. Makes sense right? Now typically this protective pain will go away once the tissues have healed because it is no longer needed but 1 in 4 people will experience persistent pain long after the injury has resolved. I am one of those lucky people. Yay me! At first I thought this was just due to chance but knowing what I now know about pain, I believe this has nothing to do with chance and everything to do with the adaptations of my nervous system.
Let’s start with the peripheral nerves: the ones going from the body to the spinal cord. Nerves have a level of charge that must be met in order to send a message. If the threshold is met, the nerve will fire. Nerves reach their firing charge by allowing ions from the outside to the inside through ion channels. There are many types of ion channels that open or close in response to different stimuli. Some respond to chemicals (stress, immune, inflammatory) while others respond to mechanical stimuli like tension and pressure. Temperature also opens and closes ion channels. The more ion channels that are open, the more likely the nerve is to fire. With my original injury, the mechanical impact and the inflammatory response opened more than enough ion channels for nerve firing. Ion channels are only present where there isn’t myelin (a sheath that improves the speed of signaling). Over time, inflammatory chemicals can demyelinate nerves allowing an increase in ion channels and a perpetually more sensitive nerve long after the inflammation is gone. So fast forward a few months and even a few years, my nerves still have increased ion channels and still reach their firing threshold more easily. I experience pain when I’m sick, when I’m stressed and even when I’m cold all because there are more ion channels.
Moving on to the spinal cord where the peripheral nerves meet interneurons before going to the brain for interpretation. If this interneuron is bombarded by messages, it will die off. This eliminates the gate keeper of messages and allows all of them to get to the brain easier. I’m pretty sure my interneurons were obliterated. My injuries took a really long time to heal on a tissue level which meant a lot of messages were sent for a long time. The brain can also ease the passing of messages from the body through the spinal cord if it believes there is a threat. The brain becomes more interested in the danger signals and will therefore increase nerve sensitivity by keeping ion channels open longer so it can receive more information more often. For good reason, my brain perceived threat for a long time so it likely made it as easy as possible for messages to pass through.
Another thing to note is that the nervous system is messy in its organization and adaptations. These changes occurred at the nerves corresponding to the areas that were injured but there is crossover in representation of an area as the nerves enter the spinal cord and within the brain. As a consequence, the area of my perceived pain spread over time. Not because of further tissue damage but because the adaptations of my nervous system and the interpretation of where the signals were coming from are not precise.
Just like the rest of the nervous system, the brain is also adaptable. When an area of the body is used more or generates a disproportionate amount of signals, the representation of that area in the brain will grow and borders of it will become less defined. This is another reason why pain can go from being isolated to the injured tissues, to being more diffuse.
All of the magic really happens in the brain. Up to this point, all messages are just an electrical signal traveling down a nerve. It’s the brain that gives meaning to this electrical charge. It’s the brain that decides whether the message is pain, a different sensation or not worthy of any feeling at all. Many areas of the brain participate in this decision making process. The areas for sensation, emotions, memory, cognition, movement planning and stress response have all been shown to be activated during the experience of pain. This complex interaction varies for each individual and each pain experience. The specific pattern of activation is called a neurotag. Other experiences and memories also have their own neurotag. The more often a neurotag is used, the more it becomes reinforced and the easier it will be accessed. This is where the phrase “its like riding a bike” comes from. The more we practice something, the easier it is to do automatically and this can occur with a movement, a memory or the experience of pain. Specific movements and activities had become so strongly associated with the experience of pain within my neurotag that even after my body healed, these movements still generated pain.
So with all of these adaptations, am I destined to be in pain for the rest of my life because I am literally wired to experience more pain? For years, the answer was yes but once I started learning about pain neuroscience, the answer became heck no. If the nervous system can adapt in one direction, it is also capable of reverse adaptations and the key to this switch is actually quite simple. It all lies in the perception of threat.
Stay tuned for the final post of this series: How to Decrease Pain by Decreasing the Perception of Threat.
Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; 2013. Textbook.
Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, 2003. 8(3): p. 130-40. Full text.
Melzack, R., Pain and the neuromatrix in the brain Journal of Dental Education, 2001. 65: p. 1378-1382. Full text.
Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. Apr 2007;106(4):864-867. Full text.
Moseley GL. Reconceptualising pain acording to modern pain sciences. Physical Therapy Reviews. 2007;12:169-178. Full text.
Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84:27-33. Full text.
Woolf CJ, Salter MW. Neuronal plasticity: increasing End the gain in pain. Science. Jun 9, 2000;288(5472):1765-1769. Full text.
Simply put, the nervous system is an alarm system. But it’s not entirely that clear cut. Let’s say you were crossing the street and sprained your ankle. Ordinarily this would hurt but let’s also say a large bus is coming toward you. Would your ankle still hurt? The answer is of course not! In this situation, it would not be smart for the brain to produce pain because it would hinder your ability to get out of the way of the bus. The brain would decide that the bus was a bigger threat than the ankle sprain and would therefore not send the signal of pain. This is how people with a broken leg can escape a burning car. This is also why some people don’t feel their pain until after they have stopped working, gardening, playing etc.
The brain evaluates all threats, not just tissue damage. Nerves have receptors for temperature, stress, blood flow, movement, pressure and immune responses. A change in any of these can be interpreted as a threat and thus cause pain in the body. This is why people experience more pain in colder temperatures, with stagnant postures, during times of high stress and when you are fighting off the common cold.
Have you wondered why you are the one that ended up with chronic pain while your friend Sally who was in the same car accident with the same injuries walked away pain free? Every brain is different and processes pain differently. It has been shown that multiple areas of the brain are involved in a pain experience. These areas include those responsible for sensation, movement, focus, concentration, fear, memory, motivation and stress. Each of these areas communicate with each other to discuss and determine the appropriate action. Its like a board meeting takes place to discuss the danger messages. If it is decided that there is a threat and an action is required, pain will be produced to protect you. The members of the board and the decision made will be different for each individual.
Aside from the brain, people experience injury in very different life environments. Someone who is in a car crash during a happy time in life will have a lesser pain experience than someone going through a divorce and layoff. Stressful life environments produce stress chemicals throughout the body that will cause the nervous system to wake up quickly, be extra-sensitive and take a long time to calm down. This is why people who get injured at work (especially at stressful jobs) have slower recoveries than someone injured at a soccer game or a destruction derby driver who crashes cars for fun.
My point here is that it is complicated. Pain is not as simple as you have an injury, it causes pain, the injury heals, the pain goes away. Confused yet? Don’t worry, you’re not alone! This very fact makes my job a million times more difficult! But the great news is this: research has proven that simply knowing pain is complicated, can and likely will reduce your pain if you are experiencing pain for reasons other than damaged tissues. Thank goodness!
Louw A, Puentedura E. Therapeutic Neuroscience Education: Teaching patients about pain. Minneapolis, MN: OPTP; 2013. Textbook.
Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, 2003. 8(3): p. 130-40. Web. FULL TEXT
Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84:27-33. Web. FULL TEXT
Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy Theory and Practice. Jul 2016;32(5):385-395. Web. FULL TEXT
There are 400 individual nerves (about 45 miles worth) in the human body that act as an alarm system. At all times there is a little bit of electricity traveling through each of them. Various factors including stress, movement and temperature can make this level of electricity go up or down.
Each nerve has a threshold. When a nerve gets excited enough to reach this threshold, a message will be sent to the brain for analysis and possible action. So let’s say you lift something way too heavy with horrible form. The alarm system will go off and you will react by dropping the box…maybe even hire someone else to do the moving. Once the message has been sent and you have responded, the nervous system should return to its normal resting state. However, in 1 out of 4 people, the alarm system gets activated and then rests just below the threshold rather than returning to its original resting state. This is an extra sensitive nerve.
Having extra sensitive nerves is quite common but not normal. It can significantly impede activity and function. When the nervous system is at its normal resting level, there is a lot of room for activity before reaching the threshold. For example, you can sit in a car for hours before your nerves send the signal to stop, get out of the car and stretch. Then they return to normal and you can drive for a few more hours before another signal would be sent.
After hurting your back lifting, the nerves have become extra sensitive so now there is very little room for activity before the alarm system goes off. You find that you can only sit for 5 minutes before you need to get up. And this occurs even after the tissues in your back have healed from your original injury all because the nervous system hasn’t returned to its normal resting level.
If you look at your own story it will become clear. Perhaps all diagnostic tests have come back negative but you’re still in pain. Maybe doctors keep telling you everything looks fine but you still can’t do nearly the amount of activities you used to do without consequences. Parts of your body not originally involved may all of a sudden start hurting as well. Small activities, movements and even light touch have become painful. These are all signs that your nervous system is on high alert. If you have been prescribed anti-depressants or nerve inhibitors, your physician agrees!
Two people with the same injury can end up in entirely different situations. One may be fine a week later while the other suffers from chronic pain for the rest of their life. How come? The sensitivity of your nervous system depends on many factors going on in your life. These include but are not limited to failed treatments, family issues, levels of fear, concerns about your job and even being given different explanations of your pain. Someone who has job satisfaction, healthy relationships, good sleep, a balanced diet and a clear treatment plan given by passionate health care providers will have a better chance of being pain free when compared to an individual who is sleep deprived, stressed, jacked up on sugar and worried about their prognosis.
The short answer: A LOT! The coolest part is that just by understanding the concept of nerve sensitivity, you are already on your way to decreasing it. Research shows that if people understand more about their pain, the alarm system immediately starts turning down its sensitivity. This makes complete sense don’t you think? The alarm system is kept on high alert for good reason when there are more questions and concerns than answers and reassurances. By understanding that your pain is likely due to sensitive nerves rather than damaged tissues, fear is reduced and in turn, nerves are calmed. Research also shows that oxygen and blood flow, through aerobic activity, can help calm the nervous system. This includes a brisk walk, swim, bike ride or pretty much anything that gets you breathing a little hard and sweating a little bit. So nothing too crazy! But the easiest strategy of them all is something we do all day long: breathing. Diaphragmatic excursion has been shown to calm the whole nervous system down. The only trick is learning how to breath the right way. Don’t know how to breath right? No worries, that’s what I’m here for. Stay tuned.
Adriaan Louw, Ina Diener, David S. Butler, and Emilio J. Puentedura. “The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain.” Archives of Physical Medicine and Rehabilitation 92.12 (2011): 2041-056. Web. FULL TEXT
Kirsten R. Ambrose, and Yvonne M. Golightly. “Physical Exercise as Non-pharmacological Treatment of Chronic Pain: Why and When.” Best Practice & Research Clinical Rheumatology 29.1 (2015): 120-30. Web. FULL TEXT
Daniela Roditi and Michael E Robinson. “The Role of Psychological Interventions in the Management of Patients with Chronic Pain.” Psychology Research and Behavior Management 4 (2011): 41–49. Web. FULL TEXT
Pain neuroscience education can be a sensitive topic. The big underlying message of it all is that our brains determine whether or not we feel pain. This statement pretty much takes everything we thought we knew and throws it out the window. For years I have treated musculoskeletal tissues under the notion that they were responsible for causing pain but maybe this isn’t always true. Pain neuroscience theorizes that the experience of pain is not caused by the injured tissue but rather by how our brain interprets messages sent from the nervous system. Mind. Blown. And yes, pun intended.
Where this topic can become a little offensive is how this new information is perceived. I am by no means saying that people make up their pain and I don’t think pain is all in people’s heads. Pain is real, no matter where it is coming from. Pain neuroscience is not discrediting people’s experience of pain BUT it does provide an explanation for why pain sometimes doesn’t go away even after the original cause has been resolved.
I want to start with a personal story so that no one feels alone with the idea that your brain might be playing more of a role in your pain than your muscles or bones. It will also explain why I have become so interested in the topic.
I have chronic pain.
It’s hard for me to admit to that. Its like going to a marriage counselor and finding out they have been divorced 10 times. But I think its time for me to look at my pain in a different light. It allows me to relate to all of my patients and for that, I believe I am a better physical therapist. So lets just agree that no one will ask me about my pain during their treatment time. Agreed? Cool.
For many years I was at a plateau and I had tried EVERYTHING. Or so I thought. On many occasions I viewed myself as a failure in that I couldn’t fix my own pain. But then I went to a lecture on neuroscience and my entire perspective changed. Could my brain be the reason that I couldn’t change my pain? I started being more aware of my flare ups as they related to my emotional state. It soon became obvious that fatigue and stress definitely made my pain worse. My entire approach to my pain needed to change. Things like sleep, nutrition, exercise, meditation and even trauma counseling became my focus and my home exercise program. Today, I am by no means pain free but each time I have a flare up, I can always come up with an explanation for why I am in pain. This alone helps the flare up be shorter in duration and less intense (I will support this with research in a later post).
I am not sure how many parts there will be to this series, nor do I know how long it will take me to completely cover the topic, but here is a little preview of whats to come: how does the brain contribute to pain, how pain neuroscience education can actually decrease pain, other ways of managing pain when the brain is contributing, and lots of research articles to support all of it. If you have any questions along the way, feel free to contact me here.
I think it’s probably best to start with “what the heck is the pelvic floor?” Just like the rotator cuff, the pelvic floor is a group of muscles that work together for a common purpose. The pelvic floor spans the bottoms of the pelvis from the pubic bone to the tail bone like a hammock. There are three layers to the pelvic floor. The first and second layer (most superficial layers) contain the sphincter muscles that are responsible for urinary and bowel continence. The third (most deep) layer acts as support for the pelvic organs. As a whole, the pelvic floor works in conjunction with the diaphragm and abdominal muscles to stabilize the trunk. Sounds like a pretty important part of the body right? It is!
So what does pelvic floor dysfunction look like? Some people might not know they have pelvic floor dysfunction while others may have symptoms coming directly from their pelvic floor making it more obvious. Dysfunction of the pelvic floor can cause or contribute to low back pain, hip pain and sacroiliac pain. Symptoms related directly to the pelvic floor can include vulvar, testicular or scrotal pain; tailbone, pubic bone or sacroiliac pain; pain generated by scar tissue related to episiotomies, tearing during vaginal birth, cesarian surgery, or any other surgery involving sex organs; prolapse or the feeling of vaginal heaviness; urinary leakage or retention, pain with urination, excessive urination frequency or urge; fecal incontinence, pain with bowel movements, inability to hold farts in or hemorrhoids; pain with penetration, inability to orgasm and erectile dysfunction. What a long list! And I’m sure I have missed a few.
Some common diagnoses treated by pelvic physical therapists are: abdominal pain, anal spasm, bladder pain, coccygodynia, constipation, cystocele, diarrhea, diastasis recti, dysmenorrhea, dyspareunia, enterocele, fecal incontinence, fecal urgency, feeling of incomplete defecation or urination, flatulence, frequency of micturition (urination), hesitancy of micturition, interstitial cystitis, irritable bowel syndrome, low back pain, mixed incontinence (urge and stress), nocturia, nocturnal enuresis, overactive bladder, overflow incontinence, pain in hip, pelvic and perineal pain, poor/weak stream, piriformis syndrome, post-void dribbling, prostatitis, prostatodynia, pudendal neuralgia, radiculopathy, rectocele, sacrococcygeal disorders, sacroiliac disorders, scar conditions and fibrosis of skin, sciatica, splitting of stream, straining to void, stress fracture of pelvis, stress incontinence, symphysis pubis dysfunction, urethritis, urethrocele, urge incontinence, uterovaginal prolapse, vaginismus, vulvar vestibulitis, and vulvodynia.
Many people will look at this list and ask, can these issues really be fixed? Or worst, most people won’t feel comfortable asking. The answer is ABSOLUTELY YES! For most of these symptoms and diagnoses, the first step is seeing a pelvic physical therapist to see what conservative treatment can do to help improve your pain and/or function. Just like any other muscle in the body, the pelvic floor can be strengthened and stretched which can dramatically improve the quality of life of an individual with pelvic floor dysfunction. For some of these diagnoses it will be important to have a health care team to fully treat the problem. This might include an OBGYN, urologist, gastroenterologist, acupuncturist, psychologist, and/or general medicine doctor to ensure the dysfunction is treated from a lifestyle, anatomical, physiological and psychological perspective. No matter what the game changing intervention might end up being, its important to know there is something you can do about it!
Still weary? I understand that for most, talking about poop, pee and sex is awkward and uncomfortable but for a pelvic physical therapist, its like talking about the weather or what’s for dinner. Afraid of farting during your evaluation? It’s totally normal to feel that way but it’s also just as normal to fart a little. I’m serious! I recognize coming to pelvic physical therapy is inherently intimidating for many so to help ease any hesitations, here is what to expect at your first appointment: it starts with lots of talking and yes, clothes are still on at this point. In fact, clothes never need to come off if you don’t feel comfortable with it! There are plenty of external techniques to both diagnose and treat effectively. Discussion includes past medical history, current complaints and your individual goals. Then we move on to testing through functional movements, joint range of motion and muscle strength assessments. Since the pelvic floor is very connected to the low back, hip and sacroiliac joint, I start with an orthopedic screen of each of these first. I also look at management of pressure through breath and activation of the “core” because the pelvic floor is integrated with the diaphragm and abdominal muscles. If you feel comfortable, the internal evaluation of the pelvic floor is next. For this, you undress from the waist down but will have a sheet draped over you. I describe exactly what I am going to do before doing it and at any point, you can say “I’m done with this” or say “no thanks” to any of the techniques described. Internal assessment is best for measuring the strength of the pelvic floor, giving cues to increase coordination of the pelvic floor, assessing position of the coccyx, releasing trigger points within muscles of the pelvic floor and mobilizing scar tissue. But as I said before, external techniques are always an option if you just don’t want the internal stuff. As with every physical therapy evaluation, a musculoskeletal diagnosis is given, a plan of care is discussed and you will be given a home exercise program to get started on reaching your goals. At the end of your visit, I’m sure you will feel silly for being so nervous about going to one! It’s 100% worth your time, energy and a brief moment of feeling uncomfortable to improve your quality of life.
Are you wondering who I am and what I do? What my qualifications are and what I specialize in? What services I offer and how much they cost?
Are you in chronic pain that no one has been able to help? Have you been in a car accident and are worried your life will never be the same? Did you injure yourself doing the activity you love and you can’t wait to get back to it?
Are you wanting to get to the gym regularly but you don’t know what to do when you get there? Are you having difficulty getting motivated when no one is holding you accountable? Do you have a history of injury or are you in chronic pain and worried you are just going to injure yourself in the gym? Are you wanting to cross-train or improve your performance in your sport of choice? Are you getting older and afraid of injuring yourself doing what you love to do?
Are you pregnant or planning on getting pregnant? Do you want to know how to optimize your physical health throughout pregnancy? Do you have questions regarding what physical activities you can or cannot do? Can you no longer do your normal activities and you need some direction on how to stay strong and fit? Do you want to know how to prepare for the physically demanding task of labor? Do you want to prevent postpartum conditions such as diastasis recti, hemorrhoids, prolapse and perineal tearing?
Are you a new mom? Are you finding that things just aren’t the same down there? Do you still have pain? Are you still leaking pee and is it effecting your daily life? Do you still have difficulty or pain with pooping? Are you unable to hold in gas? Are you wondering how to return to physical activity safely and without injuring yourself? Do you want to work toward being even stronger than you were before pregnancy?
Are you wondering what pelvic physical therapy is? Do you have pelvic pain unrelated to pregnancy or childbirth? Do you have pain with penetration or bowel and bladder issues even though you have never had a kid?
Still lost? No problem!
The first step toward change is recognizing that there is a problem and I believe we are there when it comes to peripartum care in the United States. Research is showing that as a first world country, the US is falling short especially when it comes to postpartum care for mothers (article).
I have experienced this first hand even with the best insurance, the most amazing OB and my own medical background. I can only imagine how poor the level of care is for mothers that are not as privileged as I have been. But today is an exciting time. In May 2018, the ACOG (American College of Obstetricians and Gynecologists) released new recommendations for peripartum care (article). It includes a visit for mom within 3 weeks of baby’s arrival versus the standard 6 weeks. FINALLY! They also state that “postpartum care should become an ongoing process” and include a “comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being, including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance.” Pelvic physical therapy even got a shout out! We are on our way toward bettering peripartum care and I am excited to be a part of it. So here is my contribution…tell your friends and family. And any stranger that might listen.
Peripartum care should start with a preconception visit to you OBGYN. It provides a space to ask questions, voice concerns, talk about fears, understand what to expect and get some basic tests to confirm your body is fit to grow a baby. This is also where difficult but ever so common occurrences like miscarriage and infertility should be discussed. By knowing about all of these things BEFORE they happen, women can be better equipped to deal with it when it is happening.
Once pregnant, the education should shift toward what to expect during pregnancy. It’s actually quite simple, expect anything and everything. But knowing this before the skin rash, insomnia, discharge, dizziness, shortness of breath etc. comes on would again be helpful. Pregnancy can be scary and it’s important for expecting mothers to know what constitutes a reason to call the nurse or head to urgent care. All of this should be covered in prenatal visits to a nurse, midwife or OB but sometimes it won’t be volunteered information. So ask questions mamas! No question is dumb. In fact you are likely wondering the exact same thing as that pregnant person sitting next to you in the waiting room. This is why I absolutely love prenatal yoga, prenatal fitness classes and group prenatal care. It’s so important to know and feel that you are not alone throughout all of this. If you are in Santa Cruz, check out Luma, Fit4Mom and BirthFit. We are so fortunate to have such amazing programs in our backyard. Go take advantage of it!
I have to refer to doctors, midwives and doulas for most prenatal education but when it comes to the musculoskeletal system, a pelvic physical therapist is the expert to consult. One day I hope pelvic PT will be part of routine prenatal and postnatal care but until then, it’s important you seek it out on your own. You don’t need to wait until you have pain or incontinence to see a pelvic physical therapist. Even before you’re showing, you can learn about how to engage your core, how to contract and relax your pelvic floor and how to stand properly so that when the belly is big and the system is challenged, you are better equipped to manage it and prevent pain, incontinence and prolapse. Sound like a good plan? I think so! During the later stages of pregnancy modification of exercises, sleeping positioning and preparation for delivery can be addressed. Doing so can minimize tearing, hemorrhoids, prolapse and diastasic recti. What an opportunity that is so often missed!
Ok so you have the baby. Chances are good labor and delivery aren’t going to go as planned but its a good lesson in letting go of control and expectations. All attention is turned toward baby and let me tell you, the baby always wins. But what about you? Your body has just performed a miracle! It grew a baby and now that baby is out either through what used to be a small hole or through a cut in your abdomen. In my opinion, neither are great options. If prenatal care didn’t fall short, postpartum care definitely will and this is why I am spending the time to write all of this and get it out there for anyone who wants it. Very little time goes into preparing a mama for what to expect physically after delivery. Again, I have to leave most of this up to doctors but ask the questions! If something isn’t working or feeling right, if you’re depressed and nothing brings you joy, or if you’re just wondering if something is normal, go see your doctor and ask questions! You are just as important as that baby you just made. In fact you are more important because a healthy and happy mom is going to nurture a healthy and happy baby.
What I can tell you is this, everything is going to hurt at first and pooping is going to be very painful so take your stool softeners! Rest is the most important thing at first which is hard because you have a baby to keep alive and likely feel like you don’t know what you are doing when it comes to parenting. But rest. Please rest. As tissues heal and hormones level a little, a new version of your physical self will emerge. The most important thing I can tell you is this, you DO NOT have to live with pelvic pain or incontinence! Fancy diapers that look like panties or avoidance of sex does not have to be the answer! Go see a pelvic physical therapist. A pelvic PT can help guide you through low or mid back pain from lifting and nursing a baby, return to exercise safely so you can avoid injury, scar tissue release so you have less pain or so your c-section mark becomes invisible, and pelvic floor strengthening so panty liners are no longer needed.
It’s also never too late to get the care you might have missed. Sure the “fourth trimester” is a very important time but technically, every mama is postpartum for the rest of their life. It’s never too late to work on scar tissue or strengthen the pelvic floor. We can wallow in what should have happened or what peripartum care should have looked like but instead, its best to look ahead. Spread the knowledge and know that postpartum care today was better than yesterday and will be even better tomorrow.