A Biopsychosocial Approach to Healing Chronic Pain and IC
IC You Podcast Episode 23
Hosted By: Callie Krajcir
Featuring: Evelyn Hecht
Callie: Today I have Evelyn Hecht with me, a pelvic floor physical therapist!
Evelyn: When I was first starting there really was no pelvic floor physical therapists working in the field. I took one course and learned more about the pelvis and I started to treat patients with their permission and they were getting amazing results with my biomedical treatments of muscles and nerves and education. So I morphed into learning how to approach a patient with new information about pain neuroscience, which basically means why does a brain continue to send pain long after the tissues have healed? That the nervous system and immune system, they're the ones that bring information from the outside, from your thoughts, from social interactions, from how you feel about your life. Psychological thinking, as I just mentioned what you say to yourself as well as physical threats, are all combined together as one grouping threat. So if one is thinking negative thoughts, too many danger messages being sent, received, and now sent to the brain is going to interpret the messages as a threat and is going to start sending more signals of burning, is going to send signals to pelvic floor muscles to tighten up, etc. Science is incredible at what it is uncovering. It is uncovering a myriad of things that you can do at home to send your nervous system and immune system signals of safety. Your body’s gonna send those dopamine, endorphins, serotonin. We have these feel good hormones in our brain, in our gut, we have a medical chest of the most potent naturally produced medicine. The cannabinoids, the opioids we have already stored within our brain, within our gut. Once we learn, if our brain can learn a different way of feeling more safety messages, of feeling less in threat, it's going to now learn a new technique. It's gonna learn a new pattern versus the old pattern of constant protection.
Callie: I definitely in my experience have noticed a lot of people with Interstitial Cystitis falling into exactly what you're talking about. Getting into that chronic fight or flight state and the body is just protecting us from the perceived threat.
Evelyn: Right. This is making sure that you are safe as the body. So it's always gonna be looking out for danger. It tends to look out for the negatives and the dangers, and it does less looking for the positives or looking for the goods. The thing about wiring is that it can be rewired. I saw this with my patients when I taught them these rewiring techniques, small things like breathing exercises. Breathing helps to lower the pelvic floor muscle tension. A deep diaphragmatic breath physically moves the pelvic floor, and now the brain says, oh there's movement happening in the pelvic floor. That means, that means she feels good. I'm gonna send her some signals to decrease the holding pattern of the pelvic floor. So breathing techniques, you can think of three things once a night, maybe once every other night things that you're grateful for. Being able to give your child a beautiful meal. Being able to take a walk today in nature and what you noticed, we're talking small things, but the small things of positivity or of ease and calm really translates well into the nervous system and immune system. I started to teach a guided body scan and I would actually work. I would actually talk them through a guided body scan. They started to become aware that a guided body scan is a way for you to become aware that not all your body is in pain. A lot of people, when they have long standing pain and chronic issues, they start to think their whole body is inflamed. The whole body is involved with the process and you're gonna create a new pattern. This is the beauty of neuroplasticity, which is that the ability of the nervous system to change, the brain has the ability to be rewired and does not have to stay in that same pattern.
Callie: There was one thing that you said about people, and this includes me, that holds their tension in their pelvic floor. I think that you said that this approach can help with that. So what is the mechanism there? How does that work?
Evelyn: It's very interesting. We're learning that the pelvic floor is one of our natural body's defense mechanisms. So there was a study done with a group of women and they were shown a film. They had surface electrodes placed on their shoulders, upper back, inner thighs, pelvic floor. The researchers wanted to find out when a woman is under stress or fear what muscle groups tend to tighten first? What reaction do they have? And invariably, the first group of muscles that tightened up was the pelvic floor. Followed by the upper shoulders and neck. We are learning that the pelvic floor is our primary defense mechanism. Doing mind work, self-care work allows patients to make the most amazing changes in a shorter period of time, months, compared to the majority of years or decades that I've seen patients have their dysfunction. I developed this program, Pelvic Sense, www.pelvicsense.com, it is focused for women and it's focused on all areas of pelvic distress. So women who have endometriosis, interstitial cystitis, IBS, constipation, sitting pain, pain with intimacy, it's really meant for a targeting of the pelvic region, though with mind, body work, you're really connecting the whole body, but there's a lot of focus on the step by step process. I ask people to do this 20 minutes, just three days a week. I talk about the diaphragm, which is your breathing muscle, I talk about how your breath can be connected with the pelvic floor, tips for urinary stream, how to have a great bowel movement, achieving intimacy with your partner, how to use dilators and what's the effect of stretching, what's the importance of sleep, etc. All evidence based healing techniques with readings about them. If you could, in the morning, that's the best time to do this, where you're listening to something, not anything specific, to say a low level zoning out or you're just feeling and listening to the way your breath moves. You're eliciting a different brain wave, which calms and stops that chatter.It goes deeper into a feeling of heaviness, of a buzz of warmth. Like you hardly even notice your hands for a moment, cuz you're in that deep, deep, quiet state. The brain loves that, but you need to help yourself get there. So eliciting the relaxation response is one of the key aspects to helping your brain feel more at ease and to break that central sensitization cycle. They use visualizations like imagining a golden ball of light slowly enveloping your head down to your ears over your shoulders. I guide people in that meditation or mindfulness work sending love and kindness to your body. They're all videos about 8 or 10 minutes in length, some a little bit longer as they go along.
Callie: Do you feel like your program or your methods can help people struggling with food fear? I work with people with IC and help guide them through an elimination diet and what I've noticed is that so many people in the IC community are just terrified to eat and that's because their doctor gave them the IC diet handout and told them to avoid all of these foods and end up only eating the same 10-15 foods out of fear of causing a flare. Can this technique or method help in that sense?
Evelyn: Yes. Part of learning why the body has pain is where it comes from. That's the first step. Certain parts of the brain are super activated and other parts are chilled. So if a person has food fear, now they're understanding that what triggers pain is my fear and my worry. But how do I get over that? So what I have people do in my program is something called graded motor imagery. So let's say they're in their testing period and they wanna test strawberries. I have people look at a photo of the item or of an activity. What does your body feel when you're looking at those strawberries? Are you getting sweaty? Is your heart palpitating? How do you feel? If you feel fine, now I'm gonna have you watch a video of a person eating a strawberry. You're starting a very slow process of desensitizing the fear of doing this activity or for this person eating a strawberry. So note that it's the fear of, it's not the item that they're going to eat. It's the fear of it. That's the trigger for the nervous system to hear a threat.
Callie: I notice with my clients that they can trigger a flare that was caused by their nervous system's reaction to that perceived threat. Chances are, they can tolerate that item but they're having that fear based reaction. When they go through the elimination diet and they're in that testing phase trying those foods, the way that I do it is each item has a three day testing period. On day one they have a bite of the item, and then day two they increase it to a couple bites, and then the third day it's whatever a regular size portion looks like for them. The reason we do that is because the body can have a delayed response to the item. They can be triggered in a certain amount. I notice that people do struggle with the mental side of things.
Evelyn: So maybe before they start doing that actual testing, they get into the relaxation mode. The healing is a biopsychosocial approach. It's the body. It's your psychological processes of how you think. Are you spending a lot of time thinking about the negative loops? Are you more fear based? How can we change that? How can we have you become in control and send more soothing to your brain? This is a beauty of neuroplasticity, the ability for our nervous system and our brain to relearn, to unlearn old faulty patterns and chronic pain is a faulty pattern. Unless there's an underlying heavy medical cause, taking out those underlying medical causes, the reason there is even more research now with fibromyalgia, we learning that the reason why one reason why a person might develop fibromyalgia is because of highly activated threat messages coming into the nervous system and immune system. When the immune system gets so much stress or a threat, it's going to produce more of those pro-inflammatory cytokinin. It does not produce many anti-inflammatory cytokinin. So we have a lot to do with our healing abilities. It's the skills of self-healing that are massively effective.
Callie: Do you recommend doing your program in addition to if you're doing pelvic floor PT or if you're working with someone like me, a dietician, or your physician.
Evelyn: Yes. It's best if you do it concurrently with care. A pelvic physical therapist for example may not have enough time to teach you what you can do on your own at home, meaning the mindfulness aspect. This program is written for anybody to work with their physicians and their healthcare practitioner. We only recommend 20 minutes a day, three days a week. The brain is learning. As you practice it, even as you think about it, you've learned something about pain neuroscience, how the immune system can now switch off its pro-inflammatory cytokines and you can change it to make anti-inflammatory molecules.