The Women on Fire chat with Michelle Lyons – all the references you’ll need!

I‘ve just had a fab chat with Michelle Lyons about my Bladder Pain Syndrome (BPS) talk at the upcoming Woman On Fire conference in Brighton in April 2018.

The conference has a great premise, bringing together health and fitness professionals who want to collaborate to best serve women throughout life. I missed it last year and I’m super excited that I’m going to the next one, let alone presenting. Fiona Rogers is coming over from Australia to talk about electrotherapy and tech, Jessica Drummond is back over from the USA and talking about nutrition, pain, fatigue and professional burnout (we all need this talk!), and Michelle will be discussing a variety of specialist women’s health topics, amongst lots of other interesting talks over 3 days. Then there’s the huge Fitpro side of things – as a physio we often don’t get exposed to fitness training that’s truly transferable from the clinic to the gym, which is often the most important for our sporting patients. I’m sure I’ll be exhausted by the end of the 3 days!

I know a lot of you will want the references I mentioned in our chat, so here they are. I thought I’d give you a summary if you haven’t had chance to watch it yet.

Bladder pain isn’t normal.

If you have a client or patient who has the following, start considering BPS:

  • A 6 month history of pain in the pelvis (it doesn’t necessarily have to be over the bladder region, but is usually suprapubic or perineal)
  • Pain that worsens with bladder filling
  • Pain relief with bladder emptying
  • A constant desire to pass urine

If you’re a pelvic health physio and vaginal examination is in your scope, then you can positively diagnose BPS with the symptoms above and pain on palpation of the pelvic floor.

But remember – it rarely comes in isolation. They may also be sleeping poorly, depressed or anxious, have Fibromyalgia or chronic fatigue and be dyspareunic. As my #BladderHeroes know, you’ve got to think about it all.

You can find the European guidelines for chronic pelvic pain management (and nice big chapter on BPS) here.

Engeler, D., Baranowski, A. P., Elneil, S. et al. (2012) Guidelines on Chronic Pelvic Pain.  European Association of Urology.

When treating Bladder Pain Syndrome you need to address the Whole person.

Spend the time to get a good idea of their bladder and bowel habits and any pain associated with them. Not just that they have pain, but the nature, variations in their pain and their responses to normal visceral proprioception like bowel or bladder loading, urethral opening. Find out about their vulva/genitals and perineal area responses to normal and abnormal situations and what their pelvic floor is doing. Not just what it’s doing in a lying position on a couch, but get a good idea of how it may be functioning throughout their day.

The Brain is Key

Then the most important thing is to make sure you have a good appreciation of their mental state, fears and anxieties, previous experiences of treatment and expectations of your treatment, and their goals. It’s often easy to get into the habit of using pattern recognition and a treatment formula – we all do it because we know certain combinations of treatment tend to work. But make sure you’re addressing your patient’s needs – there’s no point suggesting going through the full Sensate Focus protocol to someone who actually isn’t concerned by a lack of intercourse or dyspareunia.

 

Exercise is really important.

It does a fantastic job of calming the system – not only through serotonin production but also by reducing the overall level of threat in the body. Less threat + more natural movement = happier body = reduction in symptom flares.

There’s no “Safe” or “Unsafe” exercise for these patients, just safer ways to approach it. In the exact same way that squatting isn’t safe for all women with prolapses, nor is it dangerous if they manage their intra-abdominal forces well.

Try to stay away from nocebo language like “I really wouldn’t run/do crossfit, it’ll just make everything tighter and hurt more” – so since that run you did 8 years ago have your quads been in spasm? No. Have a healthy discussion about what your patient wants to achieve with their fitness and then guide them into healthy habits of activity, respecting their body’s responses to it and encouraging Happy Pelvic Floor time afterwards (releasing, breathing for down training, mindfulness, resting postures and stretching are my favourites).

 

Empower your patients!

There’s a wealth of research looking at health empowerment, and that when treatment/rehabilitation is instigated by the patient themselves they Get Even More Better And Faster.

Educate Educate Educate. I send patients these links to get up to speed with pain science and the things I want them to know about:

Tame the Beast

Lorimer Moseley “Why Things Hurt”

The Microbiome

Stop abdominal gripping

Relax your pelvic floor

My research looked at using a therapeutic wand (the PelviWand, previously called the TheraWand) to get a manual release of the pelvic floor. When this was done by patients a few times a week symptoms improved much faster than with my input alone. And even better than that, they kept getting better after active treatment had finished. Empowering them to be the masters of their own rehabilitation also appeared to improve how bothered they were by their symptoms and their overall coping skills. It’s a win-win, especially within our current NHS limitations, where you’d be more likely to see a unicorn than someone weekly for 6 weeks.

You can find a free copy here.

Bond J, Pape H and Ayre C (2017) Efficacy of a therapeutic wand in addition to physiotherapy for treating bladder pain syndrome in women: a pilot randomized controlled trial. Journal of Pelvic, Obstetric and Gynaecological Physiotherapy. 120: 12-27.

If you’ve trained in therapeutic wand use and feel confidently able to teach your patients safe use it can be a great tool for those who are comfortable with self-touch. Make sure you check for contraindications (listed in my article). If your manager wants some evidence that they’re safe, have a look at this paper:

Anderson, R., Wise, D., Sawyer, T. and Nathanson, B. H. (2011) Safety and effectiveness of an internal pelvic myofascial trigger point wand for urologic chronic pelvic pain syndrome. Clinical Journal of Pain 27(9), 764-768.

 

Treating the bladder alone is Ineffective

If any other dysfunctions remain untreated (bowel, abdominal, visceral hyperalgesia, vulvodynia, fear, anxiety and depression) then specific bladder treatments such as botox, GAG layer replacements and hydrodistension will not work.

Best of all, if the pelvic floor remains painful on palpation then bladder treatment will be ineffective! This is the reference I use with my consultants. It’s an odd paper, but one that most clearly states that pelvic floor treatment is necessary in BPS:

Peters, K. M., Carrico, D. J., Kalinowski, S. E., Ibrahim, I. A. and Diokno, A. C. (2007) Prevalence of pelvic floor dysfunction in patients with interstitial cystitis. Urology 70 (1), 16-18.

Treat the pelvic floor to help with urinary symptoms

Pelvic floor overactivity is associated with BPS symptoms, and a reduction in it’s overactivity is associated with symptom improvement. There are a handful of papers that show this, these are some of the better ones:

Anderson, R. U., Wise, D., Sawyer, T., Glowe, P. and Orenberg, E. K. (2011) 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training. The Journal Of Urology 185 (4), 1294-1299.

Anderson, R. U., Wise, D., Sawyer, T., Nathanson, B. H. and Nevin Smith, J. (2015) Equal Improvement in Men and Women in the Treatment of Urologic Chronic Pelvic Pain Syndrome Using a Multi-modal Protocol with an Internal Myofascial Trigger Point Wand. Applied Psychophysiology And Biofeedback 41 (2), 215-24

FitzGerald, M. P., Payne, C. K., Lukacz, E. S., et al (2012) Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. The Journal Of Urology 187 (6), 2113-2118.

Oyama, I. A., Rejba, A., Lukban, J. C., Fletcher, E., Kellogg-Spadt, S., Holzberg, A. S. and Whitmore, K. E. (2004) Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology 64 (5), 862-865.

Weiss, J. M. (2001) Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. The Journal Of Urology 166 (6), 2226-2231.

I hope that’s covered everything. It was a fun chat! If there’s any other references you’d like or queries just let me know.