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By Bryn Zolty, PT

​Planks are one of the most well-known core exercises. Doing a plank incorporates many muscles to make us strong and support our joints. Typically an individual starting off with planks would try a modified plank and build up to a full plank. A modified plank means less difficulty when you are starting out so you can maintain a nice neutral spine, avoid holding your breath, and build strength. Two common modifications would be starting on your knees or placing your elbows on a higher surface than your feet as seen below in the Common Progression. After this position becomes easier, you can hold longer or perform more repetitions. Next you could try a full plank. Planks can continue to be progressed to have your feet above your elbows, your elbows on exercise balls, use exercise bands and more.  
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Now let's add prolapse to the situation. Pelvic organ prolapse can feel like heaviness in the vagina and even progress to the organs (bladder, uterus, vagina, rectum) coming out of the body. These symptoms increase with gravity. The more upright you are, the more symptoms you may have. So with a prolapse, we may consider reversing the progression. We may start with your body inverted - check out the picture with the feet on a chair and elbows on the ground in step 1 of the Prolapse Progression. We also encourage you to monitor your breathing. Holding your breath can increase symptoms. Consider what happens when you breathe in and fill your system with air, and then hold your breath and strain in a position. This can push these organs down. In addition, you could consider adding a kegel, or pelvic floor squeeze, to help support the organs. Your progression might look like the reverse of the Common Progression! As you gain better control of the pelvic muscles and breathing, you may be able to progress to being more upright with less symptoms. Good Luck! Contact us if you need help modifying your exercises, breathing, or help with pelvic muscle strengthening so you can exercise with confidence.

By Karen Bruno, PT

Can self-compassion really help when you are in pain?
Let’s explore this. First, what is self-compassion? Self-compassion is giving yourself kindness, forgiveness and understanding when confronted with personal failures or discomfort. Basically, it means giving yourself the care and gentleness that you would give to a beloved friend or a child who is in need of support. In the words of Dr. Kristen Neff, a self -compassion expert and teacher, "Instead of mercilessly judging yourself for various inadequacies or shortcomings, self-compassion means you are kind and understanding when confronted with personal failings – after all, who ever said you were supposed to be perfect?" (1)  It is an acceptance of your humanness even when things don’t go your way.
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So, what does self- compassion have to do with chronic pain? Recent research suggests that self-compassion is associated with better outcomes, such as lower levels of depression, pain-anxiety, physical and psychosocial disability, and higher levels of pain acceptance. Higher levels of self-compassion supports engagement in meaningful activities and use of pain coping strategies. (2)

What does that mean for you?

• Lower levels of depression, sadness and anxiety.
• Less physical and psychological stress.
• Higher levels of pain acceptance and engagement.
• Improved ability to perform meaningful activities and use pain coping skills.
• Better overall outcomes, function and quality of life.

Self-compassion has been found to be beneficial in situations related to the ineffective way we respond to things, how we talk to ourselves and the behaviors we engage in. So, when you notice yourself  worrying, thinking or talking negatively, isolating yourself, or beating  yourself up, choose to use a better approach of treating yourself with care, gentleness and kindness. (3)
 
What can you do?

• Meditate. Practices such as mindfulness, breath meditation or any other physiological quieting methods help us to reduce tension and train us to tune into our needs to better take care of ourselves. Here is a link to some guided meditations: https://self-compassion.org/category/exercises/
• Consider treating yourself the way you would treat a close friend or a small child. How might you respond to them with kindness and gentleness?
• Remind yourself that you are worthy of kindness and compassion.
•  Take a self-compassion break. What do you need to hear? What do you need to give yourself? How can you encourage yourself and be patient, kind and forgiving to yourself?
• Explore self-compassion through writing. Start by writing about your concerns.  Next, write yourself a letter from the perspective of a loving friend. The last step is to let yourself receive those kind words, allowing love and compassion to soothe and comfort you.
• Practice supportive touch.
  1. Putting your hands on your body and taking some conscious breaths can be relaxing. 
  2. Place your hands over your heart and breathe comfortably. Notice the rise and fall of your chest as you breathe. Do this for as long as needed to calm your nervous system. 
  3. If it is convenient, put your hands over the area of pain and breathe love and nourishing oxygen into the region. 
  4. Place one hand over your heart and one hand over the abdomen. Breathe gently and consciously- 4 seconds in and 4 seconds out. This is a great way to relax as you drift off to sleep.   

 
This PDF download summarizes the relationship between self-compassion and pain.
 
Self-care is also an integral component of self-compassion.
We have heard it before from the airlines, "“put your own mask on first, then help someone else." Remember that you are your own best advocate and as you care for yourself, you model for others how to care for themselves, you teach others how you want to be treated, and you harness the resources to be of service to others. Just do it! You are worth it.
 
"Life is full of disappointments, failures and setbacks. None of those things can permanently stop you. You have the power within you to overcome anything that life throws at you. There is nothing more powerful than a made up mind. Surround yourself with people who remind you that you matter, and support you in ways that matter most to you. No person, situation or circumstance can define who you are. Don't give up, cave in or stop believing that it's possible. It's not over until you win."
-Unknown

Notes 

1. Website: selfcompassion.org
2. Paper: The relation of self-compassion to functioning among adults with chronic pain. Eur J Pain. 2019 Sep;23(8):1538-1547. doi: 10.1002/ejp.1429. Epub 2019 Jun 11.
3. Audio: Integrative Pain Science Institute podcast

​We get a ton of questions every day about breathing and spend a lot of time teaching different breathing techniques, which can help with both exercise and meditation/prayer.

Learn about what we usually see and also what we're looking for, as we breathe with Marzena Bard, PTA, CYT.

​April through May 2020

​Marzena Bard, PTA, CYT brought yoga to our homes over Zoom twice a week, offering Chair Yoga and Relieve Stress & Rebuild Strength Yoga to help the community stay active and connected despite sheltering at home.

Answer from Becca: Juan, I feel your pain. This is a tough condition, but fortunately for you, you are alive at a time where pelvic floor physical therapy for men is becoming more widely available. The reason that you have rectal spasms is likely because the muscles of your saddle region are too tight. Just like having neck spasms and having difficulty turning your head, spasms in the pelvic floor or saddle region will make it so you cannot open up your rectum to get poop out without discomfort. It is often that simple.

The fact that you are constipated is consistent with the rectal spasms. This is because the human brain is very clever. It wants to protect the body from pain, so your intestines will hold onto that fecal matter to prevent the rectal spasms from overwhelming your nervous system. This contributes to the cycle of pain and spasm and it can become a never-ending loop of constipation.

So, what can be done? A pelvic floor physical therapist can assess your saddle muscles to see how tight they really are. Then, stretching within the rectum can be performed with a gloved finger to allow them to relax. It sounds pretty crazy, I know, but if you can get over the fact that a medical professional is in your bum, you will find that this treatment is extremely beneficial. I have treated many men like you. Once the indignity of the initial exam has been conquered, most patients report a sense of quiet in their pelvises when they are receiving the appropriate treatment. They report decreased pain in the rectum over time and have more regular bowel movements.

The action plan for you, Juan, is to find a pelvic floor physical therapist. I have a good feeling that this will allow your pelvis to return to a calm state and facilitate more consistent and pain-free bathroom relief.

By Michelle Dela Rosa, PT

It's the year 2020, and we're all hearing about new goals and unrealized dreams. I'd like to run in a 5K this year. I want to cut sugar from my diet. I'm going to spend more time with my family... We've treated thousands of people at Connect over the last 11 years, and I'm so proud to say that we have witnessed so many people's success stories, your success stories.

One common thread that runs through the most successful stories is that these people made different choices. Choices that have led to actionable change. Running a 5K means more than signing up for the gym. Commit to exercise 5 times a week. Bring on the savory! Instead of just avoiding your favorite sweet treats, meal plan for the week to include new and easy to make recipes. How will more time magically appear for your kids, parents, friends, or significant other? Set a time limit on social media, or eliminate an app altogether :)

Make choices that are going to lead to tangible, positive results. Each result should take you one step closer to your goal. This is how we create a plan for you to reach goals in physical therapy, and it's what we'd love to see for you outside of therapy. ​

​PS - Life is always going to "get in the way." Keep calm and carry on.

Here's my 3-year-old trying to break my commitment to exercise in the family room!

The obturator internus sits inside the pelvis and travels around out the back of the pelvis to the femur (thigh bone). This muscle rotates the hip out, moves the leg wide when it’s forward, and stabilizes the hip.  ​

​Question from Kirk: I am an avid bike guy. I go outdoor trail riding on weekends, over 60 miles, if the weather is good. On my weekdays, I do spin classes to stay in shape. I have begun noticing a dull ache in my testicles that won’t go away, even if I skip a day of riding. I went to my urologist because of my testicular pain. After some tests and an ultrasound, she said there is nothing wrong with my scrotum, but that I should lay off the bike riding. It is my favorite way to blow off steam after a long week at the office. Is bike riding related to my testicular pain? If so, do I have to stop altogether?

Answer from Becca: Kirk, I understand how distressing it is to have undiagnosable pain in your pelvis. While working in a pelvic floor physical therapy clinic, we treat men like you all the time. Your testicular pain may be caused by tension in the small muscles of the saddle region of your body. The nerves and soft tissues of the groin are delicate and often get upset when they are compressed, as they would be during prolonged sitting on your bike seat. In your particular case, these bodily structures are also being jostled around quite a bit, especially during your trail rides on bumpy terrain. Spin classes also present a particular strain on the saddle area, as you are likely raising your butt off the seat for increased resistance and then slamming your body right back down to a sitting position a few moments later.

Bike riding is your passion, and I wouldn’t want to rid you of something you like, especially if it is helping you “blow off steam after a long week at the office”. There are a few modifications that may help ease the pressure off your testicles and decrease your pain. Firstly, buy a seat for your trail bike that is specially designed for people with pelvic pain. There are many from which to choose, and they will often have a hole cut out of the seat, so that your pelvic floor will not be in contact with any surface while you ride. Secondly, when outdoors, try to bike on level surfaces for now. The rugged land of the trails is like riding a Jeep in the jungle. What you want to do to rest your pelvic floor muscles and scrotum is to travel on level terrain (cement), which will feel like riding your grandfather’s Cadillac with superb suspension. I know, it won’t be the same, but bear with me. Your testicles need this rest right now. Thirdly, if you are going to do spin classes, buy your own bike seat designed for pelvic pain sufferers, install it before a class, and avoid the alternating standing/sitting repetitions that spin classes are famous for.

In time, your testicles will heal and you may get back to the point when you can resume trail riding. Also, if you have the time, find a pelvic floor physical therapist. The tight muscles of your pelvic floor can be stretched and any possible soft tissue restrictions within your scrotum can be addressed as well. By doing this, you will be sending your testicles on a much-needed vacation and they will thank you for it in the future.

Question from Lou: My partner and I are fairly certain that we are done having children. I am considering having a vasectomy but am worried that something might go wrong. Can you tell me about this surgery and what I might expect if I get it in the future?

Answer from Becca: I understand that this is a major decision, Lou, and you are not alone in the vast number of men who consider this procedure and are held back by trepidation about what the long-term implications might be. Let’s start with the anatomy or plumbing in how all this works. The sperm of a male is stored in tiny little coil, called the epididymis, that is located directly above each testicle. That sperm waits until it is needed, and then travels from the epididymis down a long tube called the vas deferens. The sperm then mixes with seminal fluid and is ejaculated through the penis. (This is a highly simplified explanation, but you get the idea). The procedure known as the vasectomy entails cutting both of the long tubes that serve as a conduit of the sperm to the ejaculatory fluid.

The surgery involves one or two small incisions in the scrotum. The vas deferens is cut and a small piece may be removed, leaving a gap between the two ends. The physician then sears the ends of the tube, and ties little knots on each end. This is then performed on the opposite vas deferens. Afterwards, there may be one to two small scars on the scrotum which heal rapidly. Then, voila! This surgery is a 99% effective form of birth control.

​The recovery time after a vasectomy is quite short. You will need a few days of rest and some ice on the groin. After undergoing this surgery, many men are satisfied that they 1) no longer have to use condoms if they have a single sex partner and 2) do not have to burden their female partner with the more tricky forms of birth control, which do not offer as high a protection against pregnancy.

​There is a small risk of side-effects for this surgery, including the formation of a granuloma (a small lump of scar tissue where the vas deferens has been cut), though this is often not pain-producing. The sensation and quality of ejaculation will usually remain completely unchanged. I hope that I have answered your questions, Lou, and best of luck in making your decision!

Question from Sergio: I am in my mid-thirties and have a very high-stress corporate job. On the days when I work 12 plus hours, my girlfriend often wants to have sex late at night. I find that I take longer to finish and that my ejaculation is more like a dribble than the forceful explosions that I usually have. Is something wrong? What should I do about this?

​Answer from Becca: Sergio, this is a great question and a common cause of concern for men. It all boils down to the lives that we live today. Many men have high-stress corporate jobs. Which means they are under tremendous pressure for long hours, they are often sitting, and their tension is traveling down to the muscles upon which they sit. This is the perfect description of mild pelvic floor tension. Just as some people carry their muscular tension in their shoulders or low backs, you are storing it in your pelvic floor, Sergio. And these days, with the way that we work and live in our society, your need for increased time to ejaculate and the decreased power of your ejaculation are both incredibly common.

While it wouldn’t hurt to see a urologist to rule out any other problems, these sexual issues are likely caused by tightness in your pelvic floor muscles. In order for arousal to take place, the muscles of the pelvic floor should lengthen and allow blood to pool within the testicles and penis. If these muscles are tight, they may not be allowing enough blood into these tissues and erections may be less rigid. This would cause a delay in ejaculation, resulting in increased time to finish the job. Furthermore, that decreased blood flow into the groin would result in less pressure generated to create the “forceful explosions” that you typically experience, Sergio. A weak dribble of seminal fluid at climax may often result.
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In summary, there doesn’t seem to be anything wrong here, Sergio, except that you are living in the world today. My suggestion would be to practice some form of stress reduction at the end of these long workdays. It could be as simple as listening to some calming music during your commute home. You might want to do some simple stretches on the floor or spend time with your girlfriend without rushing into sex late in the evenings. Finally, you could reschedule sex for early mornings or weekends. This would assist your pelvic floor in being more primed and relaxed to achieve the quality of arousal and ejaculation that you deserve.

Foye: I think that the biggest problem is that the vast majority of physicians unfortunately have a huge blind spot when it comes to understanding coccyx [tailbone] pain. We learned almost nothing about the coccyx in medical school. This leads to four main problems.

1. First, unfortunately many patients suffer for months and years before anyone even figures out that the pain is coming from the coccyx.
2. Secondly, most doctors do not really try to figure out what is causing the tailbone pain. Instead they label this as "coccydynia"; which literally just means coccyx pain, which is a symptom. We need to find the cause of that symptom.
3. Thirdly, the doctors often do not take the pain seriously, telling the patient that it is “just“ your tailbone. They minimize the symptoms and are sometimes even dismissive, in a way they would not treat patients with pain at other body regions.
4. Fourthly, doctors will incorrectly tell patients that there is nothing that can be done to treat tailbone pain, or that the only treatment is surgically amputating the coccyx (coccygectomy). Those ideas are completely outdated and completely wrong.

Dela Rosa: Your book Tailbone Pain Relief Now! describes the many reasons why people end up with tailbone pain. Are there 1 or 2 causes of tailbone pain that are more common than others?

Foye: Great question! By far the most common cause coccyx pain is when there is an unstable joint between the bones of the coccyx. Many medical textbooks and websites incorrectly state that the coccyx is a single fused bone. But that is rarely true. In the vast majority of humans, there are 3 to 5 individual coccygeal bones, with variability in whether there is fusion between any of those bones. Most people have at least a few coccygeal joints. And most people with coccyx pain have joint hypermobility (excessive movement) as the source of their pain.

The second most common cause of coccyx pain is a "bone spur"; extending from the lowest tip of the coccyx. When this happens at the bottom of the coccyx, there is thickening of the bone that projects backwards, often coming to a sharp focal point. It’s almost like a tiny icicle made of bone. This bone spur pinches the skin between the spur and the chair where the patient sits, and especially when they sit leaning partly backwards.

Dela Rosa: Thank you for clarifying the common causes of tailbone pain. In your book, you detail some of the seat cushions and medications that may help. People ask about injections for pain. As a pain management doctor, would injections be helpful for these causes and if so, could you describe how and what kind?

Foye: Sure it's a great question. Medications by mouth have a couple of big problems with them, which is why a lot of times medication given focally by a small local injection could be superior. 

When medications are given by mouth, number one they go through multiple places throughout the body. If you're taking medication by mouth, they can cause side effects in the stomach, the intestines, the liver, and the kidneys, so the side effects can be quite limiting. 

The second problem with medications by mouth is that because the medicine travels throughout the entire body, it gets diluted out. So only a minuscule amount of the medication actually makes it to the tailbone where the patient needs it the most. Many of these patients do respond to medication given locally at the site. Typically, that's done under fluoroscopic guidance. Fluoroscopy is like x-ray up on a computer screen, and using fluoroscopy we can target a specific location at the tailbone. I'm generally opposed to blind injections, which is where injections are done without any image guidance because 1) you can't guarantee where the medication is going to go and whether it's actually given at a place where it's going to be helpful, and 2) you also can get into problems if it's given in the wrong place - it can cause side effects. 

So back to your question, which was about the diagnoses like hypermobility or a bone spur... Absolutely those can respond very, very well to placing medication locally at the spot under image guidance. Often that's a combination of steroid which helps to fight inflammation, and also local anesthetic which can be given as a nerve block and can be very helpful when there's hyperactivity or hyperirritability of the nerves.

Dela Rosa: How is the x-ray your center performs different than how many other facilities perform the test?

Foye: Here at the Coccyx Pain Center, the biggest difference is that we take coccyx x-rays while the patient is sitting down, since that is when tailbone pain hurts the most. I have trained the radiology technicians here regarding how to properly perform this technique, which was first developed in France. Very few places in the United States have ever heard of this approach and even fewer are experienced at doing these x-rays properly. We have evaluated and treated thousands of patients with tailbone pain, many of whom fly in from around the country and internationally. And it is extremely common that patients had previous imaging studies that were read as being normal. But then they come here and our seated x-rays show that when the person sits down and leans backwards (putting their body weight onto the coccyx) they often have very dramatic dislocations or other abnormalities that would be completely undetected if the x-rays had not been done while the patient was sitting. It is a huge relief for patients to finally have an answer as to what is causing their pain. Then, when we have identified a specific cause for their pain, we can provide treatments for that specific cause, which is much more likely to be helpful than generic treatments done blindly without a diagnosis.​

​Foye: A lot of this goes back to and starts with the general lack of awareness that physicians, radiologists and radiology technicians have about tailbone pain. Frequently, they lump it all in with low back pain. Lumbosacral pain is thousands of times more common than tailbone pain. A lot of the automatic checkoff boxes that people have on their radiology x-ray or MRI forms will have a box to check off for lumbar spine or lumbosacral spine, but they will not have a box to check off for the coccyx or tailbone just because it is thousands of times less common. So what happens is that the primary care doctor, or the orthopedic surgeon, or the pain management doctor, will check off the box and order lumbar or lumbosacral x-rays or MRI, and then that doesn't even include the tailbone at all. 

The next problem then is that the study gets done and the patient is told that there's nothing wrong, and that there's no explanation for their pain when really the images did not even include the symptomatic area, or worse yet, it shows an incidental finding of the lumbar spine that may not be causing any symptoms at all. But now they start down the treatment path of epidural injections, and even spine surgery and other things for a part of the body that wasn't even causing the problem. So basically back to your question about what the patient can do: 1) look at the orders, look at the x-ray or MRI orders, make sure that the ordering physician has specifically explicitly requested imaging of the coccyx, and 2) when you go into the radiology center, make a point of talking to the radiology technician and being crystal clear with them that this is not your lumbar spine, that this is not up in the small of your back at the belt line, that the pain is specifically down at the coccyx, and make sure that the radiology technician is going to include that part of the anatomy within the study. It really does require a certain amount of self-advocacy by the patient unfortunately to fight this uphill battle against the ignorance that's out there.

Dela Rosa: I'm just curious, have people come to you from outside of the US? Or are you mostly seeing people domestically?

Foye: Most of my patients travel in from out-of-state and about a third of my patients fly in. It's maybe 5% or less that are international. Within the last six to 12 months, I've had patients from Japan, Sweden, Africa, the UK, New Zealand, and I think two from Australia. Which really just gets back to that there's this unmet need out there and patients who are not able to find local clinicians who will either take them seriously or that know the appropriate testing and treatments to provide.

Dela Rosa:  How do you work with pelvic floor physical therapists in the treatment of tailbone pain?​

​Foye: As a physician specializing in Physical Medicine and Rehabilitation (PM&R), I'm a strong advocate for the role of physical therapists in treating patients who are suffering from painful musculoskeletal conditions. Historically, a big problem was that very few physical therapists were comfortable or experienced in treating pelvic floor problems. Fortunately, that has been improving in recent years.

The pelvic floor is often described as being like a muscular sling, or hammock, which supports and holds up the pelvic organs. The back end of that sling has attachments to the coccyx. Pelvic floor physical therapists and I often collaborate on figuring out the "chicken and the egg" phenomenon. By that I mean that we assess whether a patient is having tailbone pain due to pulling and tugging onto the tailbone caused by tightness and spasms of the muscles that attach to the coccyx. Or, sometimes it could be just the reverse: a painful condition at the coccyx itself might be causing reactive muscle spasm and guarding of the pelvic floor. If evaluation and treatment at one location is not providing adequate relief, then it often makes sense to collaborate and to consult each other, to help the patients find the answers and relief that they deserve.​