Friday, December 19, 2014

Functional Medicine for Digestive and Pain Disorders
Maureen Mason, MS, PT, WCS
Many patients receiving specialty Pelvic and Pain Rehab care at CTS have been diagnosed as having a Functional Gastro-Intestinal (GI) disorder. This means that medical testing has revealed that the problem presenting with pain or indigestion or other complaint is in the functioning of the system, but the condition does not represent an emergency condition, nor does it require surgery. More specifically, reference 1 states” A functional gastrointestinal disorder comprises symptoms arising in the mid or lower gastrointestinal tract that are not attributable to anatomic or biochemical defects.” It is estimated that 25 million Americans suffer from Functional GI disorders.
Medical screening by your MD is vital to review your history, signs and symptoms, and to diagnose a Functional GI disorder. Your MD may perform specialty lab tests such as scoping the tissue by viewing it directly with a camera (i.e. endoscopy, colonoscopy), potential X rays, MRI, and lab tests. If you have a Functional GI disorder, it is likely to feel frustrating as “help” may entail medication, supplements, dietary and behavioral changes, and even referral to Physical Therapy (PT). The PT referral may be to help with pain from musculoskeletal and connective tissue (fascial) restrictions, and for specialty habit and coordination training of the pelvic floor muscles (PFM). It is not unusual for patients to be surprised that they were referred to PT for a symptom such as constipation, so we provide education at the first session into the role of specialty PT for your condition. This typically involves anatomy and function training with muscle charts for the abdomen and pelvis, bladder, bowel, and genital regions.
The most common conditions presenting to MDs include irritable bowel syndrome (IBS), dyspepsia, and constipation. Functional medical disorders are quite common and range from one end of the digestive tract to the other. Upper GI problems include swallowing disorders, Gastro-Esophageal reflux (GERD), and stomach problems such as gastroparesis. Swallowing problems, reflux, and any other GI symptom may have a serious medical problem causing it, such as infection, tumor, bleeding, or restricted blood flow from a vascular problem such as a blood clot, therefore, never assume you can figure it out yourself, see your MD for assessment.
Under the heading of functional GI problems we see often, are constipation, and urinary incontinence. Constipation can include bloating, gas, and cramping, and pain. Lower GI and colon problems may be labeled as functional GI disorders, including some types of constipation, as well as the opposite problem, bowel or bladder leakage, labeled as incontinence.  Stress can be a trigger for some functional GI disorders, and the references listed explain the connection with the nervous system and the stress response in potentially aggravating a functional GI condition.
As part of helping our specialty patients, we may explore fluid and fiber management, mind-body awareness training, bladder and bowel diaries, and a physical exam of skin, scars, fascia-connective tissue-and muscle tone and strength. and respiratory patterns. Visceral mobility and motility tests may be performed, and manual therapy may be applied to balance and release tension across connective tissue planes. Spinal and local muscles may be involved in a pain, spasm, pain syndrome that has an individual “locked up” in a region surrounding an area or viscera that has a history of pain, such as upper back spasm associated with GERD, and low back and pelvic spasm associated with constipation.
Medical paperwork completion for specialty pelvic PT takes 15 minutes, up to even 30 minutes, as insurance companies and medical standards of practice dictate that we thoroughly screen for details regarding pelvic and abdominal and other pain sites, and minutia of detail regarding bladder and bowel functioning. Typically patients gain confidence and a sense of comfort from the evaluation as they learn to clarify the PT components of their problem, and set functional, measurable goals with their PT. The treatment plan will typically include exercise, respiratory and pelvic muscle coordination, manual therapy, habit training, bladder or bowel diaries, massage, mind-body skills practice, and biofeedback.
Biofeedback is a standard PT tool to help profile and understand muscle function including those in the pelvic region. Many patients are unknowingly clenching or tensing their pelvic muscles during attempted elimination, and pelvic coordination and relaxation training may be required to restore function. Weak, or slow to respond pelvic muscles may be involved in leakage. Surprisingly, pelvic muscles that are too tight are also often involved in leakage. Constipation, or incontinence, which has been diagnosed as “functional” by an MD, therefore can be referred for conservative treatment with PT.
Infections are often a trigger for starting GI symptoms, yet after an infective agent is discovered and “eradicated”, symptoms may persist. Genetic testing is demonstrating patterns to levels of susceptibility for things like celiac disease (gluten intolerance), chrons disease (ulcerative colitis), and other conditions.
The GI microbiome, or “gut health”, is a growing area of medical interest, as our gut bacteria composes a critical part of our immune system. The national institute of health recently analyzed the microbiomes of 200 healthy people, and mapped out over 80% of the organisms present in health individuals. The human microbiome is an acquired system based on birth type, and environment.
The human biome changes somewhat day to day, depending on what we ingest, and are exposed to via our airways, and skin. A common change agent in the microbiome results from antibiotics. Many doctors now advise that following a course of antibiotics, individuals take probiotics, to re-establish the “healthy bacteria” of our gut. There does not appear to be a current consensus on which probiotics are best to restore health gut bacteria. Medical research is currently expanding rapidly into the field of nutrition, gut health, and probiotics, as pharmaceutical management certainly does not resolve all problems, but may help reduce symptoms. A functional MD who practices “holistic and integrative medicine” will strive to discern the root cause of the GI symptom, and this may involve extensive dietary and lifestyle analysis. Adopting positive lifestyle habits, and the optimum use of medication and/or supplements, can help to turn down, or even turn off functional GI problems. However the field of integrative, holistic medicine has it’s critics, who look for more research and studies to back up and support the use of the toolkit of supplements, mind body approaches, and other non-traditional medical approaches.
Reference 4 reviews many areas where the writer critiques holistic medicine and it’s practitioners. When one delves further into the writer critiquing holistic practitioners, one sees he indirectly receives funding from the pharmaceutical industry for his research. Any person touting a holistic approach, or a pharmaceutical approach, or a specific dietary or exercise approach, may receive financial benefit from your use of the products sold. Consumers have to be careful to not fall under the care of someone who is promoting unsound or even dangerous supplements, herbs, or pharmaceuticals. The best method is to work with a medical practitioner who uses a research base for prescribing your treatment.
GI symptoms from the use of over the counter items such as non-steroidal anti inflammatories (NSAIDS) can cause GI bleeding, and Tylenol has been in the news recently for being found to irritate the liver at lower levels than had been prescribed in the recent years. Alcohol consumption can exacerbate the effects of GI irritation associated with NSAID or Tylenol use. Be sure to discuss your med and supplement use with your MD, as things like an ulcer from NSAIDS may appear to be back or abdominal region pain that is not appropriate for PT treatment. Reference 5 includes information on liver toxicity from Tylenol.
There is an increasing incidence of auto-immune disorders, many of which include functional GI symptoms. Identifying lifestyle triggers including stress, dietary habits, as well as having a complete medical workup is the safest and most logical process. Reference 6 describes the common autoimmune GI disorders, and provides an example of a combined medical approach of diet, lifestyle, and medication management of a medical condition.
In summary, if you have GI symptoms, discuss these with your MD, and look to your diet and stress level and antibiotic use as potential aggravators. Perhaps you have had genetic testing and know you are susceptible to specific problems, yet it often requires a trigger to turn on a GI disorder, and functional GI disorders are often improved with medical care and healthy habits. Most of our patients significantly reduce constipation and incontinence while receiving comprehensive PT. Listen to the signals or symptoms you are receiving from your body, and take care.