My greatest apologies for those of you have been waiting for Part II of Amy’s story! Exciting things have been happening over here in sunny Southern California with the new practice and lots of amazing professional opportunities. If you can recall a couple of weeks ago I began a case study about a former patient named Amy*. Amy had a two year history of pelvic pain associated with some gastrointestinal issues and a stressful lifestyle. Check back to Mind-Body Case Story Part 1 if you haven’t yet read her history or my objective findings. Today we'll cover my assessment, treatment plan, goals for recovery, and most importantly, how a mindful approach to physical therapy helped to heal Amy's pelvic pain!
Based on objective findings during my initial evaluation of Amy, I concluded that her pelvic pain was multi-factorial. Our bodies have reflexes built into our nervous system which can often signal something gone awry- in this case I suspected the visceral-somatic reflex. It made sense that after prolonged GI problems, the connective tissues and muscles in the closest proximity (and shared nerve roots) started to become sensitized and painful. I also identified Amy’s pain as being sympathetically (think fight or flight) mediated following a highly stressful period in her life. I believed there were a series of myofascial and visceral causes involved in activating the hypertonic state and multiple trigger points throughout her pelvic floor and abdomen. There also appeared to be a strong hormonal link since Amy’s symptoms escalated around the same time asher cycle every month. Due to the chronicity of her pain I also considered that the central nervous system was involved in signaling her pain. I also suspected that pain worsened at night since there less distractions at night, and because of Amy’s chronic insomnia. I concluded that her prognosis for physical therapy was good since objective findings matched her complaints, and her motivation was very high.
I wanted to see Amy for physical therapy 1 time a week for 10 weeks. The treatment plan included:
Patient education regarding the anatomy of the tissues surrounding her pelvis, the pathophysiology of pain, down-training, and ways to stimulate the parasympathetic (think rest and digest) nervous system. (Stay tuned for future blogs detailing all of this education!)
Manual therapy to address the connective tissue restrictions and myofascial trigger points causing her pain.
Neuromuscular re-education to facilitate down-training and parasympathetic stimulation. We targeted diaphragmatic breathing to relax the tone in her pelvic floor and nervous system. We also focused on pelvic floor “dropping” which will be described in a future blog of it’s own.
Therapeutic exercise and a home program focused on down-training and relaxation. Important components of her home program included mediation, self soft tissue mobilization, and gentle cardiovascular and yoga-based activities to promote blood flow and sense of well-being.
Amy and I decided on the following goals for physical therapy:
Use the “drop” to manage pain throughout her day.
Decrease connective tissue and myofascial trigger point findings by 75% in order to decrease her pain.
Improved ability to sleep unlimited by pelvic pain.
0-1/10 pain at worst, with increased periods of periods of 0/10 pain.
Intercourse without pain and unlimited by fear.
I saw Amy for just 7 sessions. Manual therapy focused on her abdomen and adductors with fascial restrictions becoming hard to detect by the sixth session. She impressed me with her compliance of at home foam rolling, diaphragmatic breathing, meditation, and trigger point ball release. I recommended the book Explain Pain by Lorimer Moseley for further information about centrally mediated pain. Amy reported that reading this book was a major turning point in understanding her pelvic pain and in ultimately decreasing it.
Amy’s internal pelvic floor tone and trigger points were released after four sessions, so we shifted focus to external trigger point reduction. I evaluated posteriorly and found significant lumbosacral fascial restrictions which I suspected were also contributing to her pelvic pain. By visit five she reported no further need for lidocaine, an improved ability to sleep, and a decreased sensation of arousal. The remaining trigger points throughout her suprapubic region, adductors and abdomen reproduced her deep pelvic pain, so we continued focusing on releasing these as part of her home program. Amy periods of 0/10 more often.
Amy’s seventh consisted of a yoga- based session with no manual therapy. We were happy to find that this session actually reduced her pain from 6/10 to 3/10 within the hour by simply using breath, movement, and mindful meditation. This session was key in supporting my hypothesis; that a large portion of her pain was driven by the sympathetic nervous system. Yoga, meditation, and mindfulness practices helps to quiet this system. I encouraged Amy to continue with this type of program at home.
As of our last contact, Amy reported a 0/10 pain with an excellent compliance to her home program. She continues to work on her stress levels, nutrition, sleep habits, and on a progressive exercise program.
Amy is a great example of a highly motivated patient who responded well to a mindful physical therapy approach. In addition to the power of the mind-body connection I’d also like to applaud and give credit to Amy’s commitment to therapy. Her compliance with her home program and dedication to her holistic healing program played an essential role in her recovery. Whether you’re a PT or a patient, I hope you’ve been inspired by her story and perhaps you’ll remember to incorporate just a few extra moments of mindfulness into your next treatment sessions!
If you’d like to learn more about the yoga-based approach come see me for a one-on-one session or join me on retreat!
Casie Danenhauer, DPT
*Names have been changed for patient privacy.