Complementary and Alternative Therapies for the Overactive Pelvic Floor

Fig. 19.1

Ten most common complementary health approaches among United States Adults in 2007. Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Reports #12. Complementary and Alternative Medicine Use among Adults and Children: United States, 2007. December 2008

Fig. 19.2

Diseases/Conditions for Which CAM Is Most Frequently Used Among Adults. Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Reports #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008

19.2 Nutrition

The cornerstone of any therapy or health plan should rest firmly upon nutrition. This section will address common nutrition as it relates to the health of the pelvic floor. Many patients with chronic pelvic dysfunction/pain also have complaints of bowel dysfunction such as bloating, constipation, flatulence, and irritability. Addressing nutrition to improve pelvic floor function will not only benefit the pelvic floor but also the entire body as a whole. By assisting the patient to obtain an optimal weight and stable blood glucose level, improvements in both mood and digestion can be seen. The use of fiber supplements along with appropriate fluid intake can regulate bowel movements in many patients. The use of probiotics in selected patients can also help to regulate bowel function. In the authors’ clinic the recommendation for a Mediterranean diet is given. The use of an elimination diet is also used for selected patients. Referral to a registered dietitian can also be of benefit to those patients who need additional guidance, or coaching in order to improve compliance with implementing the needed dietary changes. Dietary supplements can also be used in patients whose diet is less than ideal. Many patients will find that combining a healthy diet with herbal support can decrease many of their pelvic floor symptoms and lead to an improved generalized well-being.

If an elimination diet is recommended to the patient, guidelines as to which foods should be avoided are provided to the patient. The foods and beverages that are most likely to be problematic include wheat, dairy, soy, corn, sugar, and wine. These foods and beverages should be removed from the diet for 21 days. If the symptoms improve, then it is likely that one of the foods eliminated is the problem source. The patient can then reintroduce one food at a time over a period of weeks to see which food or foods cause symptoms to return.

Patients may get frustrated initially, because they feel there are few foods left to eat, but many of the foods that they give up during the test will turn out to be harmless and can be reintroduced. Foods found to cause problems should be given up indefinitely [see Mediterranean Diet Pyramid , (Oldways Preservation and Exchange Trust, http://www.oldways.com) (Fig. 19.3)].

Fig. 19.3

19.3 Mind–Body Therapies

The mind and the body are intimately connected and communicate via the nervous system, endocrine system, and immune system. Mind–body is defined as taking into account the physiological, psychic, and spiritual connections between the state of the body and that of the mind [4].

How our body and mind interprets input can influence our physiological and biochemical response, which in turn affects our health [5]. In the 2007 NHIS [6] mind–body therapies ranked among the top ten CAM practices of United States adults. The survey found that deep-breathing techniques were used by 12.7 % of adults, 9.4 % of adults used meditation and 6.1 % of adults practiced yoga. These percentages reflect an increase of use when compared to the previous survey completed in 2002.

What are the therapies that are included in mind–body work? Several of these therapies can be categorized under multiple modalities. Some of these therapies are as follows:

Relaxation therapy
Meditation/prayer
Hypnosis
Imagery
Yoga
Tai Chi
Pilates
Feldenkrais
Music therapy
Breath work
Massage
Art therapy

19.3.1 Relaxation Therapy

Relaxation therapy also known as relaxation technique or relaxation response technique includes a number of modalities such as progressive relaxation, guided imagery, biofeedback, self-hypnosis, and breath work as defined by the U.S. Department of Health and Human Services, NCCAM .

Each of these techniques shares a common goal which is to engage the body’s natural relaxation response. These therapies have been used to alleviate medical conditions such as hypertension, nausea and vomiting with chemotherapy, mood state management, epilepsy, and importantly for our discussion, pelvic floor pain and bladder control [7].

The use of relaxation therapy involves more than a change in a state of mind; body functions physically change as well. The “relaxation response” involves the relaxation of breathing to a slower rate, a decrease in both blood pressure and oxygen consumption and in many people a sense of overall well-being. Being able to use this relaxation response may offset the long-term effects of chronic stress. The benefits of relaxation therapy are most useful when practiced regularly and combined with exercise, healthy diet, and social support. Relaxation therapy is a low-risk intervention for most patients, is easy to use, and can be incorporated into the patient’s conventional medical care [7].

19.3.1.1 Relaxation Techniques

There are numerous relaxation techniques which could be used to decrease pelvic floor discomfort and hypertonic muscles. There are multiple modalities of relaxation techniques which patients could employ. Relaxation techniques work on reducing the chronic “fight or flight” response of stress. Using these techniques on a voluntary basis can reduce the negative effects of stress. While neurophysiological responses differ according to gender, stress activates the limbic system which is the area associated with the processing of emotion. The use of relaxation techniques that access these emotional and biobehavioral pathways may have an increased benefit to women [7].

Autogenic training involves focusing one’s attention on the actual sensation of breathing or heartbeat. The body is then pictured as warm, heavy, and relaxed.
Progressive relaxation is also known as Jacobson’s progressive relaxation or progressive muscle relaxation . It is a technique in which one focuses on tightening and then relaxing each muscle group. This therapy is often combined with guided imagery and deep-breathing exercises.
Guided imagery also uses focus as a means of relaxation. In this technique negative images are replaced with pleasant ones. Guided imagery can be self-guided or delivered by a practitioner either present or on an audio device. This technique is also called visualization. Caution must be used in patients who are suffering from posttraumatic stress disorder or acute mental illness as this can trigger reemergence of negative images. Deep-breathing or breathing exercises are used to consciously slow down breathing and to focus on taking regular, deep breaths. These exercises often involve holding the breath and then exhaling to a counted measure. A popular breathing technique used by the author is the “4-7-8” breathing exercise taught by Dr. Andrew Weil at the University of Arizona’s Integrative Medicine Program. The patient is taught to breath in through the nose for four counts, hold the breath for seven counts, and then breathe out with a rush through the mouth. The tip of the tongue touches the front teeth to complete an energy path according to Ayurvedic practice (author’s personal experience).
Hypnosis uses a phrase or nonverbal cue to induce the relaxation response. It is an altered state of consciousness characterized by an increased responsiveness to suggestion. A hypnotist or hypnotherapist helps the patient to the relaxed state. Once this state is achieved, the hypnotist helps the patient focus the attention on a narrow range of objects or ideas [8]. This shifting of attention can be used to effect positive changes and treatment outcomes.
Meditation refers to a group of techniques which originated in Eastern religions or spiritual traditions [9]. The use of meditation teaches a person to focus her attention and calm the stream of thoughts that is ongoing in the mind. It can improve psychological balance, increase overall calmness and relaxation, aid in coping with chronic illness, and improve health and sense of well-being.
Yoga is a system that incorporates simple meditation, controlled breathing, and specific body postures to achieve emotional and body equilibrium. It is practiced for health and relaxation. All forms are based on hatha yoga. Forms or schools are based on the teachings of the preeminent yogi. The use of yoga has been noted to be of benefit in those patients experiencing chronic pain by reducing the intensity of pain.
Tai Chi . This form of physical meditation is used by all age groups. It is a system of slow, graceful movements that meld mind and body.
Qi-gong is yet another system of physical meditation which uses slow, gentle, and deliberate movements, breathing, and mediation to improve the life force and emotional health. It can incorporate movements from both kung Fu and Tai Chi.
Pilates is a movement therapy which increases the core strength. It increases body awareness, reduces stress, and promotes proper body alignment.
Feldenkrais promotes strategies that release the body from habits, which have become damaging. Body awareness, improved flexibility, and reduction of chronic pain are a few of the goals of this movement therapy.

19.3.2 Herbal/Botanical Therapies

There is a paucity of research to support herbal and botanical therapies. Existing studies are often small, lack proper scientific methodology, and frequently report conflicting results. The use of herbals is based on a synergistic approach to healing. Each herb brings a complex array of constituents to bear on treatment. It is difficult to extract a single agent and define the exact benefit attributed by this component. With any therapy, be it allopathic or integrated, the risks versus benefits must be assessed prior to implementation.

The use of herbal therapies should be based on possible causes of pelvic dysfunction. When the cause is not clear, the treatment approach is one of support and symptom relief. The use of herbal therapies should be considered thoughtfully and holistically and by experienced practitioners.

One of the oldest traditional herbal modalities is known as The Wise Woman Way . According to renowned herbalist, Susun Weed in her book, Down There: Sexual and Reproductive Health, healing focuses on nourishment of the whole being: by food, rituals, and trusting the body’s wisdom [10]. The Wise Woman Way seeks to empower women in their healing choices. From this point of view, Weed has used the six steps of healing modalities when working with clients. These six are as follows:

Step 0 : Do Nothing. An important, vital step in which you listen to the voice inside of you. Support your health by sleep, meditation, and unplugging.
Step one: Collect information. Research information on your condition. Listen to the wise healers in your community; be they conventional healthcare providers, wise women, or integrative practitioners.
Step two: Engage the energy. Use mind–body medicine such as prayer, guided imagery, ritual, reiki, to name a few.
Step three: Nourish and tonify. Supportive care with food, herbal long infusions, movement, walking, yoga.

The first four steps help build health and should be used daily.

The remaining steps are more invasive and should be approached in a thoughtful and educated manner.

Step four: Stimulate/sedate: CAM such as acupuncture, chiropractic, naturopathy, herbalism, massage. This step is an excellent starting point for those struggling with chronic issues. Herbs used here are more tonics.
Step five: Use drugs: the use of prescribed and over-the-counter drugs. Supplements are also included in this step as well as are essential oils.
Step six: Break and enter: this step includes invasive procedures.

The patient can use any of these steps in no set order. There can be concurrent use of multiple steps by the patient. For example, patients could be using acupuncture for relief of chronic pain while supporting their overall health with organic oatstraw long infusion. Based on these steps, the recommendations of Weed for patients with chronic pelvic floor dysfunction are as follows:

Step 0: Do nothing. The techniques used in this step mirror those of mind–body therapies such as relaxation breathing, meditation, and guided imagery.
Step one: : Collect information and do research. Explore and address possible causes. The link between pelvic floor dysfunction and trauma should be evaluated. Prior pelvic surgeries should also be taken into consideration.
Step two: Engage the energy. The pelvis and abdomen are the center of the body according to Eastern medical and martial arts practice. The Qi or life energy flows from this center. The pelvis is important to the immune system. Chronic pelvic pain or dysfunction is the message from this energy source that the patient does not feel safe in her body.
Step three: Nourish and tonify. The use of whole body massage, Mayan Abdominal Massage (MAM) or electromagnetic therapy relaxes the pelvic muscles and normalizes the nervous system. Weekly sessions are recommended until pain is relieved. MAM is a therapy described as a “noninvasive, external massage which guides internal abdominal organs into their proper positions for optimal health.” Additional information on this technique can be found at www.arvigomassage.org (Accessed 5/21/14). The use of nourishing herbal infusions is used to calm nerves, ease muscle spasms, and reduce pain. Oatstraw (Avena sativa), comfrey (Symphytum uplandica x) and linden (Tilea europea) are typically used in pelvic floor dysfunction. Oatstraw is an excellent nervine herb which both nourishes and tones the nervous system [11]. It is safe to use by most individuals. Use of comfrey ( Symphytum uplandica x ) also known as Russian comfrey, has been questioned due to the incidence of liver damage. On further review there are two species of comfrey: the first is wild comfrey (Symphytum officinale) and cultivated comfrey (S. uplandica x) the x means that the plant is a hybrid. These two plants are very dissimilar in appearance. The wild comfrey is a small plant with yellow flowers. The cultivated comfrey is a large plant with purple or blue flowers. The plants themselves have different constituents. The roots of comfrey contain pyrrolizidine alkaloids or PAs which are harmful to the liver. This underscores the importance of receiving treatment by educated practitioners trained and experienced in herbology. Eliminating foods which are high in omega-6 fatty acids which increase the inflammatory response may be useful.

The use of hot compresses applied to the abdomen can ease pain. Comfrey leaf, castor oil, plantain oil, or calendula oil are those recommended for relief. Patience must be used to see benefit. Compresses can be applied 4–7 times per week, covered with saran wrap and a heating pad can be applied over this compresses. They can be used for 1–3 h to help reduce pain and cramping in the abdomen. The use of compresses is not recommended during menses or when pregnant [12]. To normalize tone of the pelvic muscles, refer to a physical or occupational therapist specialized in pelvic floor dysfunction.
Step four: Stimulate/sedate. The use of acupuncture may reverse nerve disruption, muscle spasms, and muscle pain in patients with an OPF. Biofeedback, electrotherapy, and ultrasound can be helpful for some patients. Magnet therapy used continuously for 1 month has been shown to reduce chronic pelvic pain in a small double-blind study [13]. Using herbal pain relievers to ease the pain often associated with OPF can be safe and nonhabit forming. Skullcap (Scutellaria lateriflora) or passionflower ( Passiflora incarnate ) tincture as well as meadowsweet ( Filipendula ulmaria ) can be used for pain relief. St. John’s Wort (Hypericum perforatum) tincture can be used as a muscle relaxant. Patients who choose to use herbal products should consult a knowledgeable herbalist prior to starting any herb. They also should be encouraged to try one herb at a time to assess for any possible side effects (Fig. 19.4).

Fig. 19.4

Skullcap (Scutellaria lateriflora)
Step five: Use of conventional drugs. Nonsteroidal anti-inflammatory medications such as ibuprofen or aspirin can help reduce pelvic pain. Muscle relaxants, anticonvulsants, tricyclic antidepressants, opiates also relieve pain. Trigger point injections with lidocaine can bring relief but is short acting. Many women find taking birth-control pills helpful in decreasing chronic pelvic pain, depending on its cause.
Step six: Break and enter. Orgasm or intravaginal/intrarectal massage can counteract pelvic floor muscle spasms. This can be self or partner administrated or administered as myofascial release by an occupational or physical therapist. Caution should be exercised with this modality as it can cause increased muscle spasms and consequently perpetuate the pain cycle. Surgery to remove inflamed tissue or adhesions caused from prior surgery/inflammatory processes may be helpful but entail the potential of scarring and reformation of adhesions with continuation of the pain.

Dr. Aviva Romm, herbalist and physician, is a world renowned expert in medical botanics skilled in the use of a wide variety of botanical medicines with a scientific approach [14–16]. She is active in organizations currently involved in botanical medicine credentialing [17]. She has published her findings providing additional knowledge on the holistic treatment of chronic pelvic pain. Dr. Romm acknowledges the multifactorial nature of chronic pelvic pain. These factors include, but are not limited to, endometriosis, pelvic inflammatory disease, adhesions, pelvic congestion syndrome, and cyclic uterine pain, uterine myomata, and history of psychosexual trauma [18].

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