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