How do you explain pain to a patient? How do you reeducate the nervous system to be less sensitive? These are the questions that Tara Sullivan, PT, DPT, PRPC, WCS, IF, and Alyson N Lowrey, PT, DPT, OCS address in their new course Pain Science for the Chronic Pelvic Pain Population. The chronic pain population is often dismissed or misled that they have something drastically wrong with them, or worse, nothing wrong with them at all. Alyson and Tara share that “this population often has the most functional deficits and the worst clinical outcomes. We want to change that.”

Tara has specialized exclusively in pelvic floor dysfunction treating bowel, bladder, sexual dysfunctions, and pelvic pain since 2012. Alyson became involved with pelvic rehabilitation through working in a clinic with Tara Sullivan. She is a board-certified orthopedic specialist and primarily works with the ortho patient population. When Tara came into the clinic she brought along the pelvic floor population and they joined forces. Alyson, with her ortho perspective, is better able to recognize that in some of her orthopedic patients, a lot of their pain was coming from the pelvic floor. The pelvic pain patient population crosses over from physical therapy to the orthopedic and occupational therapy worlds. By treating their patients wholistically Tara and Alyson have been able to make a huge difference to both of their practices.

By focusing specifically on the topic of pain science in their new course, Tara and Alyson delve into the true physiology of pain including the topics of central and peripheral sensitization. Pelvic specialists that can benefit from this course are those whose patients have chronic pelvic pain including endometriosis, interstitial cystitis, irritable bowel syndrome, vaginismus, vestibulodynia, primary dysmenorrhea, and prostatitis. The biggest thing is to learn how to recognize if there is a sensitization component to your patient’s pain.

Alyson shares that being able to recognize chronic pain in the patient is huge, that this is “not your regular patient who has a peripheral injury and we just need to rehab them through that process. It’s a whole different ballgame when we’ve got our nervous system in a hypersensitive state.” She continues, “a huge part of the treatment is educating your patient about pain and trying to decrease the fear around movement…and how we use our words to decrease fear is huge.” This course also discusses how to desensitize the nervous system through dry needling, diaphragmatic breathing, sleep hygiene, and bowel and bladder retraining.

Pain Science for the Chronic Pelvic Pain Population is scheduled for February 19-20, May 21-22, and September 10-11. This course is targeted to physical therapists, occupational therapists, physical therapist assistants, occupational therapist assistants, registered nurses, nurse midwives, and other rehabilitation professionals. The full interview with Tara Sullivan and Alyson Lowery is available on the Herman & Wallace YouTube channel.

Pelvic rehab therapists and physiatrists both focus on the return to life and function. In a recent interview, Allyson Shrikhande shared, “Physiatrists are extensions of physical therapy. We analyze and treat the muscles, nerves, and joints of the pelvis non-operatively.” Physiatrists bring a holistic viewpoint and are trained to look at the interplay between the different organ systems with each other, as well as the muscles, nerves, and joints.

Dr. Shrikhande is joining H&W to bring in the New Year with her short format course, Working with Physiatry for Pelvic Pain, on January 11th. This 4-hour course delves into diagnosis and non-operative treatment options for Chronic Pelvic Pain (CPPS). Allyson believes in an interdisciplinary team approach to treating patients and spends time discussing the interplay between professions for the betterment of patients.

Physiatrists often work with an interdisciplinary team of rehabilitation experts to coordinate a treatment plan that is based on each patient’s personal needs, abilities, and goals. Members of this interdisciplinary team can include several practitioners:

• Rehabilitation nurses
• Physical therapists
• Occupational therapists
• Respiratory therapists
• Gynecologists
• Dieticians

You can find many clinics and healthcare systems that incorporate a variety of professionals and share a multidisciplinary approach. Multidisciplinary typically means that there are multiple providers but not working together in the same way as interdisciplinary teams. The interdisciplinary approach differs from the multidisciplinary approach by focusing on the common patient and team goals, compared with a discipline-specific focus. It emphasizes regular and effective communication, coordination, and integration of care. Interdisciplinary medical teams are able to work together for functional outcomes (1). 

Patients with Chronic Pelvic Pain Syndrome (CPPS) typically experience pain in the abdomen, lower back, and genitals. These patients often experience frequent urination, pain when sitting, and even pain during or after sexual intercourse and impair the function of organs such as the bladder and bowel. 

CPPS is a multifaceted disorder. It is a challenge to health care providers because of its unclear etiology and complex natural history. In this case, a pelvic physiatrist may lead an interdisciplinary team including a gynecologist, psychologist, and physical or occupational therapist. In her course, Dr. Shrikhande shares how important it is to understand the pathophysiology of pain. “Experiencing pain for a long period of time changes how the brain receives and processes pain signals. Essentially there is this amplification of pain. This really describes neuroplasticity. The rehab world is founded on neuroplasticity, meaning your peripheral and central nervous system can change in a positive direction or a negative direction.”

Dr. Shrikhande delves into the important role of the physiatrist and pelvic therapist in CPPS treatment in her course  Working with Physiatry for Pelvic Pain. Physical and occupational therapists are trained in the clinical features of common musculoskeletal pathology and musculoskeletal examination and develop treatment plans, exercise programs, and physical modalities (including heat, cold, TENS). As a pelvic therapist, an evaluation for CPPS is not just of the pelvic floor. It includes other structures including the abdomen, hip complex, diaphragm, ribcage, low back and looks for weakness, difficulty of coordination, and assessing breathing dysfunction. 

As stated by the American Academy of Physical Medicine and Rehabilitation, "Physiatrists, on the other hand, make and manage medical diagnoses and prescribe the therapies that physical and occupational therapists perform. Despite these differences, both therapists and psychiatrists collaborate and communicate to ensure patients are receiving appropriate treatment (2)."

If you have taken Pain Science for the Chronic Pelvic Pain Population, Pudendal Neuralgia and Nerve Entrapment, Yoga for Pelvic Pain, Nutrition Perspectives for the Pelvic Rehab Therapist, Biofeedback for Pelvic Muscle Dysfunction - Satellite Lab Course, or Male Pelvic Floor Function, Dysfunction, and Treatment - Satellite Lab Course you may be interested in attending this course (Working with Physiatry for Pelvic Pain).

Upcoming Working with Physiatry for Pelvic Pain Courses

January 11, 2022

April 5, 2022

September 25, 2022

November 15, 2022

References:

1. Poduri K. R., Vanushkina M. Epidemiology of Aging, Disability, Frailty and Overall Role of Physiatry. Geriatric Rehabilitation. 2018; Pages 1-17. https://doi.org/10.1016/B978-0-323-54454-2.00001-7
2. American Academy of Physical Medicine and Rehabilitation. The Medical Student's Guide to PM&R. https://www.aapmr.org/career-support/medical-student-resources/a-medical-students-guide-to-pm-r/what-is-the-difference-between-physical-therapy-and-physiatry

Allyson Shrikhande, a board-certified Physical Medicine and Rehabilitation specialist, is the Chair of the Medical Education Committee for the International Pelvic Pain Society. She is a leading expert on pelvic health and a respected researcher, author, and lecturer. Dr. Shrikhande is a recognized authority on pelvic pain diagnosis and treatment and is the author and instructor of the remote course Working with Physiatry for Pelvic Pain. Her course discusses the synergistic nature of pelvic physiatry with pelvic floor therapy.

Chronic Pelvic Pain Syndrome (CPPS) is a condition that causes pain or discomfort in the lower abdominal and pelvic region including the buttocks, lower back, hips, groin, perineum, and deep pelvic structures which last longer than six months. The symptoms of CPPS often affect the function of organs such as the bladder and bowel. It can cause difficulty sleeping and pain with sitting or sexual intercourse. It may also result in mobility issues which can impede your ability to manage basic daily tasks. The symptoms of CPPS should be taken seriously and deserve the attention of a healthcare professional.

What causes CPPS?

CPPS often has no singular root cause but is rather rooted in a combination of multiple different issues. Some of the many common risk factors are:

• Hormonal changes, which may occur naturally, throughout a woman’s lifetime (such as during menopause or pregnancy), or because of a glandular imbalance
• Gynecological disorders like fibroids, endometriosis, adenomyosis, polycystic ovarian syndrome, pelvic inflammatory disease, pelvic congestion syndrome, vulvodynia, and lichen sclerosus
• Infections, including yeast infections, urinary tract infections, and bacterial vaginosis
• Urological causes such as bladder pain syndrome or interstitial cystitis
• Musculoskeletal causes including hip, sacroiliac joint, or spine pathology, Myofascial Pain syndromes, and pelvic floor muscle tightness or spasticity
• Gastrointestinal causes like hemorrhoids, irritable bowel syndrome (IBS), Crohn’s disease, and ulcerative colitis
• Neurologic disorders such as herpes simplex or migraines
• Rheumatological disorders such as Ehlers Danlos Connective Tissue hypermobility disorders, rheumatoid arthritis

We also need to acknowledge how important mental factors like stress, anxiety, and emotional trauma often are in contributing to pelvic floor muscle tension. There also may be hereditary factors that cause an upregulated nervous system, which often contributes to increased pain sensitivity.

What makes CPPS so difficult to diagnose?

The causes of CPPS are complex. It’s a condition that often involves multiple organs as well as the nervous, myofascial, and skeletal systems. Some of the most common risk factors for CPPS, including endometriosis and neuromuscular dysfunction, are hard to accurately diagnose. These conditions may not appear on x-rays, ultrasounds, or other imaging tests. Proper identification of CPPS requires a pelvic pain specialist to make an informed analysis of the patient’s medical history and symptoms.

How would you describe a physiatrist's role in working with other specialists to treat CPPS?

Physiatrists are the “quarterback” of CPPS patient care. This is because physiatrists are not trained in just one organ system, we’re trained to examine the interplay of the different organ systems with each other, as well as with the muscles and nerves. This makes physiatrists uniquely qualified to “quarterback” a CPPS patient’s healthcare team. We take a holistic look at each patient, including mind-body connections. This helps us understand each individual person’s primary pain generators and predisposing factors to having pelvic pain.

To learn more about working with physiatry, join Allyson Shrikhande at her course, Working with Physiatry for Pelvic Pain, scheduled for January 11, 2022. Her course will review the core elements, including diagnosis and non-operative treatment options, for a successful pelvic floor therapy and pelvic physiatry relationship for non-operative management of Chronic Pelvic Pain (CPPS) patients.