Tuesday, September 30, 2014

Fibromyalgia and Interstitial Cystitis: Healthy Updates and Resources,
Integrative Medicine, September 2014
Maureen Mason-Cover MS PT, WCS, Comprehensive Therpy Services
September is Interstitial Cystitis (IC) Awareness Month, this is Part Two in a profile on IC, Part One last week featured information on Fibromyalgia and IC
Part Two: IC
How can PT help IC? A PT must decipher your primary “driver” for your overactive bladder. Anything that increases pain input to the nervous system, especially at the level of the bladder, can lead an to incresed sense of pain, urgency, urinary retention, dysuria, and pelvic muscle spasm. A PT investigates your “soft tissues; all the layers of skin, connective tissue, muscles, and nervous system structures, as a detective looking for “triggers” that create a sense of discomfort in the area of the hips, pelvis, low back, and legs. A NIH study in 2009, throughout the US, demonstrated significant reduction in pelvic pain, or painful bladder syndrome (PBS) symptoms, from PT soft tissue work.
Surgeries can create scar tissue that can limit the mobility of the bladder, and visceral mobilization, the expert assessment and gliding tissues into restorative ranges of motion and function, can improve bladder function. PT’s working with pelvic problems use visceral and scar mobilization as part of the treatment. Tight Ceserean scars are often problematic. Men with hernia repairs, and also surgery for Low Back Pain, seem to have an increased predominance of IC.
Tailbone sprains, injuring the tip, or coccyx, and or larger bone, sacrum, can lead to pelvic pain, muscle spasm, and associated bladder symptoms. The pelvis is a ring, and
any malalignment in one area can transmit force and uneven muscle and fascial tension across ligaments, causing pelvic pain.Montlhy cycles, childbirth, and menopause can also contribute to Pelvic alignemnt problems, causing pain and spasm, and feeding into IC.
Hormone imbalances that disrupt the estrogenation of tissues can cause thinning of support tissue around the urethra, and the development of urethral pain, feeding into IC.
A PT may recognize muscle thinning and recommend you discuss hormone levels with your MD. Non-restorative sleep, and chronic stress, can both affect hormone levels so that metabolic growth and repair do not take place.
 The pelvic muscles, also called Kegels, or PC muscles, can develop tender points and trigger points that sustain a sense of bladder urgency and frequency, by continuously activating the nervous system at the bladder level. Home trigger point relase can involve the use of vaginal dilators, wands, or vibrators, selected for the need of each client for pain relief. (Specialty training is needed for most individuals to use safely and effectively, and it is releiving for most, but potentially aggravating for some people).Myofascial pain sites, such as the urethral sphincter,and obturator internus, can be palpated and identified as holding extra tension, leading to a diagnosis of overactive pelvic floor. Also the larger associated muscles such as the hamstrings, adductors, quadriceps, hip flexors, and abdominals can have tender and trigger points that contribute to pain syndromes.All these areas are accessable to conservative treatment with PT.
Vulvar pain may develop after a bladder infection, or associated with hormone changes or scarring as above. Multifacted treatment for female vulvar pain, or male pelvic-or prostate related pain, can involve PT. Vulvar or male pelvic pain can exacerbate bladder symptoms.
Postural problems, neck and back pain, and pelvic organ prolapse are some other conditions that can aggravate IC. I often have clients who sit slumped and compress their pelvic organs with prolonged or frequent bearing down-from straning with voiding, defecation, power lifting, occupational heavy lifting strains, and /or child care. The bladder can signal a false sense of fullness and urgency, when it is in a position of prolapse, as our brain poorly localizes senations from the pelvic area .Pelvic organ prolapse, when mild, can be helped by PT specialists.
Thoracic or Lumbar or spinal cord problems can mimic a painful bladder; Thoracic nerves 11 and 12 wrap around the front of the pelvis, and if irritated in the back, may cause pain in the front regions near the bladder. Also surface nerves to the skin can become entrapped or compresesed after trauma or surgery; the Iliohypogastric, genitofemoral, and ilioinguinal nerve can all cause aching near the bladder and genital area, leading to a false sense of urgency and frequency.
Specific to deep in the pelvis, pudendal nerve symptoms may need exploration and treatment for a comprehensive approach. IC may be associated with a compression of the pudendal nerve. This nerve wraps between 2 ligaments in the buttocks and if compressed, can cause urethral and other discomfort. The pudendal nerve has branches to the anus, vaginal or scrotal area, urethra, and clitorus and / or penile shaft. Aching, pressure, sharp fleeting pains, senses of itching or cramping in these areas can all come from pudendal compression. Soft tissue mobilization, posture, and exercises may help reduce pudendal copression.
Bladder histories are essentail to understanding urinary patterns. Children that are humiliated in front of an elementary school class for wetting their pants, or adults that experience medium to large leaks, may lead to a fear/anxiety reaction with bladder filling. A partially full bladder may eventually trigger a sense of anxiety and panic to avoid a leak, leading to an  increased frequency of progressively smaller voids.
Inflammation, and a tendency to a greator sensitivity to PH of foods, environmental allergens, and emotional triggers of stress reactions are also items that can increase IC symptoms. This requires investiogation of food/beverage triggers, environmental allergens, and emotional stressors. Any factor that increases a sense of fear, anxiety, or worry can increase the “dangometer” processing in the brain and allow nerve flow to areas so that pain signals are magnified. Stress can increase pain. Any factor that causes peace and contentment, or relaxation and comfortable body sensations, can dial down the “dangometer” to the brain, and reduce pain signal perception. Therefore it is critical with IC that individuals perform self care with nutrition, healthy homes and work sites, and stress management.
Soaps, detergents, and tight clothing can irritate genital tissues. Hypoallergenic soaps,
And loose fitting clothing is imperitive in reducing skin inflammation and irritation.
Vaginal douches can disrupt the PH of the genital area, and are to be avoided.
Finally, breathing exercises can be accessable and developed to a skill level to calm and restore nervous system balance and health. As hormone imbalances can be an underlying component of FMS, and IC, living in a high stress “fight or flight” state can involve hormone imbalances and increased muscel tension and pain. Cortisol is released in response to stress, and it alters hormone levels and nervous system actitivity such that increased pain may be perceived The pelvic muscels should relax when we inhale, and this is opposite to how most have been trained to “take a breath”. We erroneously puff out our upper chest and tense the pelvic muscels, which may increase baldder urgency . We can develop the ability to recruit upper, mid, or lower rib cage motions, as well as to allow the diaphragm to desend fully with inhalation. We can learn to relax, and sense the pelvic muscles.This use of brathing exercises to relax the pelvic muscles can take PT training, as well as spine, rib, and visceral mobilization. Breathing exercises, combined with stress management, prayer, or meditation, can promote health and wellness, and for IC sufferers, lead to a path of improved function in life.
In summary, PT specialty tratment can help IC and may involve soft tissue, visceral, postural, body mechanics, modalities, and stress management training, in conjunction with fluid and fiber and medication management with a medical team.
1. http://www.auanet.org/content/guidelines-and-quality- care/clinical-guidelines.cfm?sub=ic-bps
2.Interstital Cystitis, Diagnosis and Treatment, An Overview, Jane M Meijlink, International Painful bladder foundation, www.painful-bladder.org
4.http://www,pubmed/Rev Urol. 2004; 6(Suppl 5): S2–S10. Female Pelvic Floor Anatomy
Manual Therapy
1.Barral, Jean Pierre, Visceral Manipulation, Eastwood press, Seattle, 1988
2. Travel, Janet, Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 2, The Pelvic Floor, Williams and Wilkins
3. National Institute of Diabetes and Digestive and Kidney Diseases, 2010
Urological Pelvic Pain Collaborative Research Network
Interstitial Cystitis Collaborative Research Network, Clinical notes with Rhonda Katarinos, PT
            “A Single-Blinded Randomized Multi-Center Trial to Evaluate the Efficacy and Durability of   Myofascial Tissue Manipulation in Women with Interstitial Cystitis/Painful Bladder Syndrome”
( Maureen Mason-Cover MS PT and Cindy Furey PT were research therapists with UCSD on the San Diego arm of this study).
Relaxation, Mind Body Therapies
1.Kraftsow, Gary, Yoga for Transformation, Penguin Compass, 2002
2. Franklin, Eric, Pelvic Power, Mind/body exercises for strength, flexibility, posture and balance, Elysian 2003

Thursday, September 18, 2014

Fibromyalgia and Interstitial Cystitis: Healthy Updates and Resources,
Integrative Medicine Sept 2014
Maureen Mason-Cover MS PT ,WCS, Comprehensive Therapy Services

September is Interstitial Cystitis Awareness Month!
If you have a diagnosis of IC, you may also have associated symptoms in other areas,
and you may have a diagnosis of Fibrymyalgia Syndrome, FMS. Conditions that aggravate your IC would potentially aggravate other symptoms that you have as well, symptoms that are part of your FMS. This is because the entire immune system, nervous system, muscular system, and metabolism are interconnected. In Part I, I will explain FMS in more detail, and then in Part II next week, how Interstitial Cystitis, IC, and it’s profile of problems, can be treated with physical therapy (PT).
Part One: FMS
FMS is a chronic pain disorder, with multiple areas of dysfunction throughout the body. Typical problems include symptoms such as sleep disturbances, widespread pain, fatigue, and possible associated headaches, digestion problems such as ulcers and irritable bowel disease (IBS), bowel and bladder disorders, numbness and tingling in arms and legs, and other ailments. The key musculoskeletal signs are the presence of pain and tender points in 11 of 18 regions throughout the body. (Reference 1). The American College of Rheumatology established the “tender/painful point” criteria for diagnosing FMS in 1990. Recently researchers have identified vascular and sensory changes in the hands of patients with FMS, and you can view the links at the end of this article for more information. If you have FMS, you may have felt overwhelmed at the diagnosis, and felt your future was bleak. Read on!
Medically, health practitioners have to investigate the causes of symptoms, and a combination of physical trauma (strains, sprains, falls, car accidents), hormone imbalances (hypothyroidism, endometriosis), stress, and nutritional deficiencies can all contribute to FMS. Emotional trauma can trigger FMS, as well as infections such as Mononucleosis, and Lyme disease. Cases I have seen have had an onset after military deployment, a car accident, pelvic surgery for endometriosis, and thyroid cancer treatment. Most cases have a few triggers from the preceding list, so that the illness can seem to come up with no real cause for the individual suffering with symptoms.The bodies systems for recharge and energy production can dwindle, with a decline in work performance and mood. Ultimately, an individual with FMS may end up feeling weak, not sleeping, and losing function for basic activities of daily living (ADL’s) such as stair climbing, lifting groceries, and general fitness decline. Due to the myriad of causes for FMS, a multifaceted treatment approach can help reduce pain and increase function and quality of life. Whereas individuals with FMS have been “written off” as simply “depressed” in the past, now there are clinics and programs that offer resources and solutions for healing.
Your MD can screen hormones and blood values, and nutritional deficiencies such as anemia, low vitamin D, and thyroid imbalances can be addressed. SLEEP DISORDERS must be addressed, and a program for “restorative sleep” created, so that an individual with FMS “charges their battery” during sleep. You cannot work, and work out with fitness, if your own personal energy level is like a battery without a charge.Medications, stress and relationship management with counseling, and changing nighttime routines (reduce TV, warm bath, earlier bed time, block light at night) can all help improve restorative sleep.
Conservative treatment of bowel, bladder, and musculoskeletal pain problems is offered by Physical Therapists for FMS. Elimination of dietary irritants, healthy food choices with nutritional class support, and honoring posture and optimal body mechanics can reduce symptoms. Manual therapy, massage, and visceral (organ, fascial and muscular) treatments can help you to rebalance and lighten your physical pain. Hypnosis, counseling, acupuncture and massage therapy are often helpful as well, and can be part of your FMS therapeutic tools. A local military MD tells her patients they have to “have fun” regularly, so play time with art class or similar relaxing adventures can create good moods and alter your outlook and enjoyment of life.
Medical studies have been performed with analysis of the benefits of strength exercise and aerobic exercise for FMS, and it is a fact that these treatments can help reduce pain and improve function. The key is to gradually increase health exercise performance and to stay with it so it becomes a part of your healthy lifestyle.
What is the best type of aerobic exercise? That which you perform consistently that suits your lifestyle, such as bicycling, treadmill or outdoor walking or running, elliptical trainer, or hiking. Pool fitness, including aerobic activities, is also recommended. Ottawa panel guidelines (reference 2) identified positive benefits of aerobic exercise programs from two times up to three times a week, from 20 to 60 minutes, for 8 weeks, up to 24 weeks. Participant benefits ranged from pain relief, improved psychological well-being, reduced depression and anxiety, improved quality of life and sense of self-efficacy, improved sleep, muscle strength, cardio respiratory fitness, balance, coordination, and mobility.
What about strength exercises? Can individuals with FMS lift weights and reduce, rather than aggravate, their FMS symptoms? The Ottawa Panel of researchers performed a comprehensive analysis of the studies on strength training with FMS, and they universally recommended weight lifting for helping FMS patients (reference 3).
The exercise ideally should be individually tailored to each person, be provided near the persons home, and include feedback and social encouragement. Intensity can be moderate to strong resistance without aggravation of the FMS, depending on the individual. Expected improvements from strength training can be found in an improved quality of life, decreased sense of depression and of course increased strength. A PT or restorative-fitness professional can train you in progressive fitness as part of functional training, so you can walk, climb, lift, push and pull with more power. The BenchFit strength training DVD and Book (Mason Home Fitness) are 20 minute workkouts and contain progressive fitness protocols that can be performed at home, and are joint and spine-safety oriented as designed by this author for healthy fitness for beginning to intermediate level exercises (Reference 4). Key ingredients for a fitness recipe for you include assessment of interests, measurements of starting aerobic and strength levels, goal setting, and creating an action plan with weekly and monthly adjustments.

As you look for resources to help your FMS, please recognize that each person FMS is unique, and avoid anyone selling a “#1 cure” product, as success comes a multifaceted approach. One person’s FMS may have evolved from physical trauma and infections, another from genetics, digestive problems, and nutritional deficiencies, and your MD can help you decipher the causes of your condition. As you go through treatment, try to add one new healthy habit a week, rather than change your whole life suddenly. Consult the Web MD and National Fibromyalgia Association websites (references 1, 5). There are FMS support groups both locally and nationally, and  Janet Lawler, massage therapist, helps with a local chapter and can refer you to a local support group as needed (reference 6). You can keep a “healthy habits tracker” that you can pick use to log your progress. Keeping a written record, having specific goals, and medical and peer support are all ingredients for success.


2. Brosseau, Wells, Tugwell et al, Ottawa Panel
Evidence-Based Clinical Practice Guidelines for Aerobic Fitness Exercises in the Management of Fibromyalgia: Part 1, Physical therapy Journal, Volume 88, Number 7, 857-871, July 2008

3.Brosseau, Wells, Tugwell et al, Ottawa Panel
Evidence-Based Clinical Practice Guidelines for Strengthening Exercises in the Management of Fibromyalgia: Part2, Physical therapy Journal, Volume 88, Number 7, 873-885, July 2008

4. Mason-Cover, Maureen, BenchFit I 20 Exercises, Book and
DVD, Mason Home Fitness, 2004, www.BenchFit.com

Wednesday, September 3, 2014

Breast Cancer, Part 2: Risk Factors and Prevention
Natasha Ratajczak, PT, DPT
In the last post, I discussed the risk factors and role of genetics with breast cancer. The factors that mainstream lets us hear about include gender, age and family history. However, did you know that there are several other things that could potentially increase the risk of breast cancer? Let’s take a look at a few of these and see if there are some manageable steps to decrease personal risk of breast cancer.
1.   Being overweight: Women that have a BMI (Body Mass Index) greater than 25 are more likely to be at risk for breast cancer than women who maintain a healthier body weight, especially after menopause. The reason for this is because fat cells produce estrogen; therefore, extra fat cells in the body mean more estrogen in the body. However, this risk factor is complex because the area of where the extra fat is stored is important – extra fat around your middle section may increase risk more than having the same amount of fat around the thighs and hips. So, how can you take step to manage or prevent this? Create a healthy eating and exercise plan, after consulting with your physician. For helpful tips, please look here. For more information on healthy eating, dietary supplements, and nutrition resources, visit the Breastcancer.org Nutrition section.

2. Pregnancy history: Women who delivered before full term, or had their first child after the age of 30 have a higher incidence of breast cancer. According to breastcancer.org, “when breast cells are made in adolescence, they are immature and very active until your first full-term pregnancy. The immature breast cells respond to the hormone estrogen as well as hormone-disrupting chemicals in products. Your first full-term pregnancy makes the breast cells fully mature and grow in a more regular way. This is the main reason why pregnancy helps protect against breast cancer. Being pregnant also reduces your total number of lifetime menstrual cycles -- which may be another reason why earlier pregnancy seems to offer a protective effect.” Regardless of this fact, you can manage any increased risk by looking at lifestyle choices to keep your breast cancer risk as low as it can be: maintain a healthy weight, exercise regularly, limit alcohol, eat nutritiously, and never smoke, or quit smoking if you do so currently.
3. Going along with pregnancy histo is breastfeeding history: breastfeeding, especially for a year or more, can decrease your risk of breast cancer for several reasons. First, making milk 24/7 limits breast cells' ability to overgrow and misbehave. Also, most women have fewer menstrual cycles when they're breastfeeding (added to the 9 missed periods during pregnancy) resulting in lower estrogen levels. And of course, many women tend to eat more nutritious foods and follow healthier lifestyles (limit smoking and alcohol use) while breastfeeding. Whether or not you breastfeed, following the same lifestyle habits listed above can keep your breast cancer risk at bay.
4. Drinking alcohol: Research shows that drinking any type of alcohol excessively can increase risk by increasing estrogen and other hormones associated with hormone-receptor-positive breast cancer. Alcohol also may increase breast cancer risk by damaging DNA in cells. Minimize drinks per week to 3 or less in order to reduce the risk maximally.
5. Lack of exercise: Exercising regularly at moderate intensity (60-70% of your max heart rate) for 4-7 hours per week helps reduce breast cancer risk, according to research.

For more information on risk factors and more tips for prevention, please visit breastcancer.org/risk/factors.