Can physical therapy help a "bladder problem?" Highlights from my presentation at the Atlanta Interstitial Cystitis Support Group

Yesterday, I was fortunate to speak with the Atlanta area Interstitial Cystitis (IC)Support Group regarding physical therapy interventions for men and women with IC/PBS (Painful Bladder Syndrome).  I love working with men and women with IC for so many reasons. First, IC can be a fairly scary diagnosis for a lot of people as there is not one specific known "cause", nor is there a "cure" that works for everyone. Dr. Google can also cause quite a bit of fear as the newly diagnosed read "horror stories" of people who have suffered for years and years with debilitating pain.

The amazing thing is that often times, bladder pain can actually have strong musculoskeletal components and neuromuscular components that are easily addressed with a skilled physical therapist--but in order to understand that fully, we will have to dive in a little deeper. So, here are some of the highlights from the presentation I gave to this wonderful group last night. (Sidenote: IC/PBS is different in everyone, meaning that some treatments work great for some and not so well for others. This blog highlights physical therapy interventions for IC, but please know that each person with IC will have a different journey toward recovery. I strongly recommend building a network of health care providers and finding the treatment that works the best for you.)

First, we started with a little pop quiz--and we'll start you with the same, to test your knowledge on physical therapy for people with IC :). 

1. True or False.  It is common for men and women with IC/PBS to have tenderness and banding of the pelvic floor muscles as well as other soft tissues structures around the pelvis.

True. A study by Peters and colleagues in 2007 estimated that 87% of people with IC/PBS also have pelvic floor muscle tenderness.

2. True or False.   Traditional pelvic floor strengthening (Kegels) are helpful in reducing pain for men or women with IC/PBS.

False. For people with tender pelvic floor muscles, traditional kegel exercises are actually contraindicated. The American Urological Association's Guidelines for the Evaluation and Treatment of IC states that people who are receiving physical therapy with kegel exercises should stop treatment and seek out care from someone with advanced training in working with this population.

3. True or False.  The most recent American Urological Association’s Guidelines for the Evaluation and Treatment of IC/PBS strongly recommends physical therapy for men and women diagnosed with IC/PBS.

True. I know, I sort of gave it away in my answer up above. But physical therapy interventions such as education on IC and dietary modifications, use of cold/hot packs, stress management strategies, managing tender points in muscles, pelvic floor relaxation exercises and managing constipation/sexual pain are considered first-line treatments in the most recent guidelines. Of note, manual physical therapy including connective tissue mobilization is a second-line treatment.

In order to better understand how physical therapy can help someone with IC, we need to look a little deeper into why the muscles around the pelvis become tender in the first place. At my presentation last night, we spent some time discussing the muscles of the hips and abdomen as well as the pelvic floor muscles. If you aren't familiar with these muscles already, you can take a quick course by reading Tracy Sher's article here.

We then spent some time discussing some of the reasons the muscles and the soft tissues of the pelvis become tender when someone has IC. Specifically, we discussed the following mechanisms:

1) Tension response to pain: Basically, if the bladder is hurting, I will likely contract the muscles around it to "protect" the painful area. Over time, those muscles can become fatigued and tender.

2) Viscerosomatic reflex: When the brain is receiving a "danger" message from the bladder for a long period of time, there will often be an increase in sympathetic nerve activity (fight or flight response) which can lead to increased inflammation and decreased blood flow in the muscles and the connective tissue around the organ. Over time, this can contribute to tender muscles around the organ. We also often will see that muscles which are innervated by nerves at the same spinal cord level will also have some increased sensitivity and tenderness.

3) Somatovisceral reflex: This is basically the reflex above, but in reverse. Tendernesss in the muscles or a "danger" message from the muscles can also create that same sequelae of events which may lead to increased sensitivity at an organ near those muscles. The cool thing is that we can use this to our advantage because treating the muscles and tender soft tissues can actually help to decrease the bladder irritation!

Typically, for people with IC, we see connective tissue restrictions in the suprapubic area, abdomen, thighs, buttock and perineal area. We also will see tender and sensitive muscles including the pelvic floor muscles, adductor muscles, hip flexors, hamstrings, piriformis and gluteal muscles. Treating these muscles with manual therapy and connective tissue mobilization can help to improve blood flow, decrease inflammatory chemicals and improve the sensitivity in these structures. You can read more about connective tissue mobilization in this blog post by my colleagues over at the Pelvic Health and Rehabilitation Center.

This all ties in very nicely with our current understanding of the neuroscience of pain, which of course, is where we went next.  Much of what we discussed last night can be found in greater detail in the book, Why pelvic pain hurts which I summarized for you a few weeks ago here. The key thing to recognize is that pain is our body's alarm system-- it's meant to tell us when there is "danger" and to help us protect ourselves. For someone who has had pain for a long time, this system can become sensitized meaning that previous non-painful activities or areas of the body can start to become perceived as painful. This is also influenced by a strong "fight or flight" response which basically can make your body respond like it is constantly under attack. Our brain integrates all of this with our previous experiences, emotions, fears, etc. All of this contributes to a worsening pain experience.  The great thing is that we now know that there is so much we can do to help re-train a brain that is constantly "protecting!" 

So, next we moved to the most important piece...what can a skilled physical therapist do for someone with IC/PBS? 

 1. Education- knowledge is power and this is such an important component for someone with pelvic pain! We typically will discuss the following:

• Dietary education

• Bladder/Bowel habits

• Sexual function

• Sleep habits

• Stress Management

• Relaxation training/downtraining

• Neuroanatomy of pelvic pain

2. Desensitizing and retraining the nervous system 

• Manual therapy techniques (discussed more below)

• Specific stretches to lengthen muscles

• Graded motor imagery

• Posture/alignment training

• Breathing/Relaxation

• Setting of appropriate goals, pacing and graded exposure to movements

3. Manual therapy techniques to reduce muscle soreness, improve blood flow,  and desensitize the nervous system

• Connective tissue mobilization

• Internal soft tissue treatment to the pelvic floor muscles

• External soft tissue treatment to the muscles around the abdomen and pelvis

• Dry needling

• Scar tissue management

Recent research has shown that manual therapy for someone with IC is very effective in reducing pain. In fact, a multicenter study by Fitzgerald and colleagues in 2012 showed that 60% of women with IC who were treated with soft tissue treatments and connective tissue mobilization saw moderate-marked reductions in pain and improved urinary urgency and frequency.

We closed our discussion last night with a plan of action-- reviewing some basic recommendations to get started on improving pain for people with IC.  It was wonderful to meet with this awesome support group! For those of you with IC or bladder pain, the IC Association has a list of support groups that are registered in cities in the US and internationally. They also have great options for online support groups.

If you live in Atlanta or the surrounding area, Judy Eichner is the group coordinator. She can be e-mailed at: icatlanta@live.com.

As always, I would love to hear from you! What have been your experiences with physical therapy IC? Is there anything you would like me to add for future presentations? Let me know in the comments!

Have a great weekend!

~ Jessica