Tips for patients and physicians: Interview with Nelly Faghani, physiotherapist, colleague & friend
CPHC: Congratulations, Nelly on your recent publication in the Canadian Urological Association Journal regarding PT and chronic bladder pain. We were so excited so read our northern neighbor’s name that we had to reach out right away to say congratulations!
Nelly: Thank you! It’s always so great to hear from my two favorite American physiotherapists!
CPHC: What inspired you to write this article to educate providers about pelvic floor therapy and bladder issues?
Nelly: In Canada, I collaborate with urologist and other health care professionals to provide comprehensive pelvic health for patients. I was invited to write the article for the Canadian Urology Association. It is one chapter in a series of many articles.
CPHC: Wow, that is excellent news. We look forward to reading this one and all the other chapters that follow. After reading your article, I thought of our patients and sometimes physicians who are surprised what pelvic floor physiotherapy can achieve. They often say, “Who knew there is help for my bladder urgency?” Or, “I thought it was an old lady problem?” Or, “I wish I would have know about this treatment years ago, it’s so easy and so helpful!”
Nelly: We hear that all too often as well which is one of the reasons we created Pelvic Health Solutions. Pelvic Health Solutions is an evidence-based teaching company that was founded in 2010 out of the need to develop pelvic health resources in Ontario, an underserved health concern in this province.Our mission is to provide evidence-based, biopsychosocial resources to patients and health care practitioners for the assessment and treatment of pelvic health problems in our province and abroad.
We provide continuing education courses for a variety of practitioners, including mentoring and clinical resources for therapists to utilize with their patients. All health care professionals that have internal evaluation within their scope of practice are welcome to take our courses that involve internal palpation. Not all of our courses involve an internal exam, so look carefully at the course selection to see which ones might interest you the most.
CPHC: Tell us more about your tips to MD’s regarding how physical therapy can be helpful to treat the common symptoms that people experience every day.
Nelly: In my article I highlight a few ways a physician can really listen to their patient to hear their story and have a better understanding of their symptoms. So often the patient does not feel heard and active listening enables our patients to be heard and understood. Active and reflective listening helps to validate their symptoms. I know you and Sarah are so good at listening to your patients, and that allows you to determine the cause of their problem and build a trusting relationship.
CPHC: Yes, it is so critical to take time to listen and gain all the information in that first visit and at each encounter. We often hear from patients in our clinic that this is the first time someone listened to their whole story and problems. At Carolina Pelvic Health Center, we spend a whole hour with each of our patients to provide enough time to learn about their symptoms and problems. Often, we are also the first person to explain their muscular anatomy to them. However, as you state in the article, it is more than just the anatomy. How do physical therapists fit into the team of healthcare providers?
Nelly: Great question. Physiotherapists are one member of an interdisciplinary team that uses a comprehensive framework within the biopsychosocial approach. As I stated in the articles, the biopsychosocial approach takes into account not only the biological factors of pain ( muscles, nerves, tissue injury) but also the psychological state (emotions, thoughts, feelings) and social factors ( work, family, life style, social support system) of the patient. By considering all these factors we can effectively treat the whole individual and work as a member of the health care team.
CPHC: Treating chronic pain takes a whole team. Physiotherapists are one part of that integrated team. What tips to you have for the MD’s and patients about the evaluation or what to expect?
Nelly: It is very important to evaluate the pelvic floor muscles. If you are a patient, ask your doctor if they can palpate or touch your muscles for tone ( how tight or loose) and tender areas. In addition, the physician can assess your strength by having you squeeze around their finger. The muscles need to both contract and relax to function properly. If the muscles are too tight or overactive, they can contribute to pain, urgency and frequency. Some physiotherapist have the required advanced training to assess all layers of the pelvic floor muscles and global contributors to pelvic dysfunction. We can teach patients how to relax, contract and coordinate their muscles just like any other muscle group. With a well coordinated system, pain can resolve and bladder function returns to normal.
CPHC: Nelly, these are fabulous tips. I hope that women and men will educate their friends, family and physicians about pelvic floor muscles and how physical therapy can be helpful. We often hear that people have had bladder pain symptoms and urgency, frequency for many months or even years. How does the nervous system play a role in pain and how can physical therapists help?
Nelly: As you know, pain science is evolving rapidly and changing our views on how we talk, educate and interact with our patients. Therapeutic neuroscience education (TNE) is a first line treatment for reducing, pain, and catastrophization, and improving physical performance. It is essential to educate the patient regarding how their thoughts, senses, beliefs, attitudes, emotions and memories can affect their pain experience. By changing emotional thoughts and beliefs and recognizing these are nerve impulses from the brain we can help them change their pain. Again, active listening and education are a primary treatment modality for all of our patients in physiotherapy.
CPHC: At CPHC we love learning about the brain and neuroscience! Many of the tips you write about have effects on the central nervous system and help to reduce the hypersensitivity of the nervous system which is a common problem with bladder/pelvic pain and urgency/frequency disorders. Can you tell us more about those suggestions?
Nelly: Sure. Breathing is often one of the first exercise we teach our patients. Breathing is a simple and easy way to affect the autonomic nervous system to keep the two systems in balance and reduce overactivity of the flight or fight mode. The breathing diaphragm also has a direct relationship with the pelvic floor muscles. Slow, slow belly breathing will help relax the pelvic floor muscles and prevent rigid, overactive pelvic floor muscles that contribute to pain or bladder disorders.
CPHC: Breathing is something we can do anywhere. In fact, we have some videos on how to practice breathing techniques on our YouTube channel. I love that in the US and Canada we are all teaching our patients the same strategies. It is global effort to help women and men with these disorders!
Tell us more about how sleep has a role in bladder function. We have been reading a lot of the science regarding the importance of sleep.
Nelly: A good night’s sleep is important to reduce depression, anxiety, and chronic pain. In fact, more than 75% of people with persistent pain have disrupted sleep and 50%-80% of people with pain have chronic insomnia. Nocturia (voiding at night) contributes to poor sleep and insomnia. Here are a few tips to improve sleep: go to bed at the same time each night, avoid naps, reduce exposure to artificial light, especially blue lights, such as phones, tablet and TV at least one hour before bed, keep your room cool and avoid fluids before bedtime.
CPHC: I think there are few of those tips I could follow tonight! Okay, so how about diet and exercise. Can those play a role in bladder and pain disorders?
Nelly: One of the easiest behavioral changes someone can make is to change their fluid intake. Drinks with caffeine, alcohol, carbonated beverages, acid foods/fruits, tomato based, citrus foods and juices are all bladder irritants and may contributing to urgency, frequency, leakage and pain. Drinking water is a great way to stay hydrated and healthy. A simple bladder diary can be used in therapy to determine if behavioral changes such as adjusting your fluids and diet can be helpful to normalize bladder function. A physiotherapist can help administer the diary and interpret it to make an individualized bladder retraining program for the patient.
CPHC: This is wonderful! The American Urological Association also recommends behavioral modifications as the first line of treatment in the US for bladder urgency and frequency. Check out their guidelines here.
In addition to the above strategies, we know that physical therapists love to promote exercise and movement. What are your tips for exercise?
Nelly: Exercises that are patient-centered, fun, non-irritating, and novel will help remap the brain and have many conditioning and cardiovascular benefits. Our goal is to help the patient move in pain free ways and slowly increase their functional activity. We use a graded exercise approach as well as graded motor imagery, working both the body and the brain, to remap the brain to have pain free movements.
CPHC: Excellent! We find that one of tne of the simplest ways to start exercising is going for a daily walk. We often recommend starting with 10-15 minutes daily and working up to 30-45 minutes. Exercising with a friend or walking the dog can be a great motivator. A physical therapist can make an exercise plan specific to the patient’s needs.
Nelly, it has been a pleasure talking with you today! You are a wealth of knowledge and we have enjoyed reading and sharing your new article.
Any other comments or suggestions to share with our readers?
Nelly: I currently co-own and operate 7 physiotherapy clinics in the greater Toronto area. Although I participate in running these businesses and teach many weekends, my passion remains treating clients. I continue to treat full time and find it so incredibly rewarding. I am so grateful to have a career that I am so passionate about and love.
CPHC: Thank you again Nelly and we look forward to reading your next chapters! See you at the next conference!
If you are a physical therapist looking for courses to learn more about pelvic floor physical therapy techniques and skills, check out Pelvic Health Solutions for your next course!
For patients, learn more about how physical therapy can help you at Carolina Pelvic Health Center, Inc. or for our Canadian friends visit Pelvic Health Solutions patient resource page.