Episode 1647 - When back pain isn't in the back

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses a case study where external pelvic floor treatment was beneficial for a patient presenting with complaints of low back pain. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today. JESSICA GINGERICH Good morning. Welcome back to the PT on Ice daily show. My name is Dr. Jessica Gingerich and I'm on faculty here in the pelvic division here at ICE. So I'm going to talk to you today about when back pain isn't coming from the back. So what I mean by that is that we have done our lumbar screen. The active range of motion, combined motions, overpressures, segmental exam, neural exam, and the neuro exam, if symptoms are passing the gluteal fold, are negative. I'm talking about when the hip screen, passive range of motions with overpressures, combined motions, palpation, and strength testing is also negative. So nothing is revealing the symptoms consistent with a subjective exam. In the pelvic space, it may be common for the general population to not correlate symptoms of pelvic floor dysfunction with pelvic pain or back pain or hip pain. Therefore, they may not disclose one of the symptoms, likely whichever is not bother or is least bothering, right? So if they have back pain, but they also have pelvic floor dysfunction, they may not disclose the pelvic floor dysfunction because the back pain is more important to them and they're not connecting the two. So for the internally trained PT, we're gonna assess the pelvic floor as well. We do this by looking at different tasks that the pelvic floor is doing. So we tell them to contract, we tell them to relax, we ask them to bear down. We do this with an external visual assessment. So there we're looking at their total range of motion. And we also palpate internally to see if we can Provoke any pain per the patient's consent. Screens for the non-internal pelvic floor PT will include subjective asterisk signs. So toileting behaviors. Are they bearing down when they have a bowel movement? Are they bearing down when they're voiding? Are they peeing just in case? Do they feel like they pee all the time or is the urge really sudden? Do they have pain with insertion, whether that is a penis, a tampon, bedroom toys, a speculum, all of these are important. What are their stress levels like at home, at work? Heaviness in the vagina, leakage, and also pelvic pain. So pelvic pain being pubic symphysis pain, tailbone pain, SI joint pain. Of course, we are gonna be grabbing ags and eases around back pain. But now you may be adding pelvic floor agonizes. So everything we just talked about above. And remember that the general population may not correlate their pain with pelvic floor symptoms, unless their pelvic floor symptoms may be pain, then they may connect them. But it's our job to connect the two. So from here, we need to dial in our hypothesis. Is it weakness of the pelvic floor? Is it a proprioception awareness? Where are they in space? Is it a behavioral issue like toileting? Can we change how they're going to the bathroom to make this something that is normal? We need to potentially teach them about the squatty potty, the NAC, general strength training, and even nutritional guidance around pelvic floor dysfunction. So I have a patient right now that I wanna talk about. And so she's this wonderful human. She stands all day for work and she came in with complaints of painful intercourse. From here, I asked her about if she had any pain and she disclosed that she also has back pain. And so she came in wanting pelvic floor PT. That was her main complaint. She did not correlate necessarily that her back pain and her pelvic pain or dyspareunia was the same or was correlated. So when I was asking her about her symptoms, it turns out that her back pain and then the time she noticed that intercourse was painful, it came on around the same time. So we decided between the two of us that we were going to stick with an external exam. We weren't going to do an internal exam for comfort reasons. So when we dialed that in we found that the octorator internus was painful upon external palpation. She denied any bearing down with bowel movements or urinating, which I will encourage you guys to, if you ask someone if they're bearing down with toileting behaviors, go back and ask them on their follow-up visit if they do that. Because chances are, they've been going to the bathroom the same way their whole life, that they're not necessarily paying attention to it. And you may notice that they actually do bear down, even though they thought they didn't. So for her, what we did was we started with the pelvic floor. We treated the pelvic floor first. For her, we started with the squatty potty, teaching her how to have a bowel movement where she can sit down and relax. We started by giving her exercises where she was actually thinking about where her pelvic floor was in space. Was she lifted really tight or was she able to relax? And it turns out that she was not able to. She did not know where her pelvic floor was in space. So that was her homework. She came back two weeks later and told me she knew where she was in space, that she actually felt her pelvic floor drop the more she practiced it. Now, before that two-week follow-up, she had emailed me 24 hours later and said that her following day at work, she had zero back pain. no back pain. This was something where she was carrying around a stool so she could sit down when she needed to. So from place to place she was dragging a stool around and she didn't have to do that. That's pretty powerful. So in my exam I didn't provoke her back pain. I didn't know that her back pain was potentially coming from her pelvic floor. I had my suspicions. So I treated what was important to her in that moment, thinking that maybe her back pain would respond, and it did. So from here on out, we are still treating the dyspareumia. However, we are also now loading the spine. And that has been really powerful. So we're about a month in, and she has had pain-free intercourse. and she's having pain-free days at work when she is standing. So, I'm gonna encourage you guys to go out there, try to correlate the two, whether you're an internal pelvic floor PT or a non-internal pelvic floor PT, or you don't consider yourself a pelvic floor PT at all, you are. So start asking the questions about leakage, pressure, heaviness in the vagina, any pain with insertion, and just following that up with the, hey, this may be related to your back, and I just wanna make sure I don't miss anything. If you are uncomfortable, speaking of this, please, please let me know. SUMMARY So I'm gonna end today with where we will be, the pelvic division. We will be live in Hendersonville, January 22nd, or excuse me, 27th, and our level two course will kick off April 30th. Here you will learn about advanced pelvic floor dysfunction, pelvic floor syndromes, managing pelvic issues post-op, sexual health, birth control and fertility, and birth prep for the athletic population. So we look forward to seeing you. Hopefully you guys sign up and we'll see you around. Have a great Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.