The Mastitis Spectrum 

Does your patient have plugged ducts? Mastitis? An abscess?  Back in 2022, The Academy of Breastfeeding Medicine (ABM) put together an update on all of the above.  All of those diagnoses now fall under the umbrella of the mastitis spectrum.  The update breaks down each type of mastitis and how it is to be treated, so let’s look at what is under the umbrella. 

To start out, the word Mastitis literally breaks down into breast inflammation.  Many times, mastitis is exactly that: inflammation. It has been taught for many years that if the breast is red and painful for more than 24 hours, then it needs to be treated with antibiotics.  In the age of antibiotic stewardship, that is certainly not the case and the Academy of Breastfeeding Medicine stresses that. 

The first topic is plugged duct, otherwise known as a galactocele.  This is what people generally think of when they picture mastitis.  There is a “blockage” in the duct with a build up of milk behind it that is palpable and often painful.  The blockage is usually initially caused by inflammation which narrows the lactiferous duct.  The inflammation results in a shift in the microbiome in the duct, which further narrows it and can eventually partially occlude it due to the inflammation present.  Milk then has difficulty passing through and can build up, creating the painful lump. 

The second topic is phlegmon.  I had not even heard of phlegmon prior to seeing the ABM protocol, but once I read it, it made perfect sense.  A phlegmon is not a galactocele, but it is still inflammation in the breast tissue.  It is more akin to cellulitis.  There is diffuse inflammation throughout the tissues and no blockage of milk.  The difference can be easily seen on ultrasound: diffuse inflammation (phlegmon) vs pocket(s) of fluid (galactocele). 

Both of these issues are inflammatory, but over time can progress and become infectious.  When the patient is having fevers, chills, and the tissue gets that you-know-it-when-you-see-it level of redness to it, infection has now set in.  As therapists we have all seen it with our surgical patients- there is the usual inflammation around the surgical wound, but one day you look at it and you just know that you need to call the doc because that is no longer inflammation.  The issue is similar with mastitis, no matter the part of the spectrum it is on. 

 The most serious issue on the mastitis spectrum is abscess.  An abscess needs to be drained, have a Penrose drain placed and the patient needs to be placed on antibiotics.  This issue is for physicians to manage and if it is suspected, there should be an immediate referral. 

   The Academy of Breastfeeding Medicine recommends ice and NSAIDS to help to decrease the inflammation present.  They also suggest wearing a supportive bra to help with swelling.  I will add that a PROPERLY fitting bra is extremely important. One that is too small or digging into places is not going to help the mastitis at all. 

It is safe to breastfeed on the side where there is mastitis, even if taking antibiotics.  It is important not to try to feed or express more milk than usual so as not to make the inflammation worse.  If there is no milk flowing on the side with mastitis, the patient should stop trying to feed or pump on that side and allow the swelling to improve first. They should see a lactation consultant to be sure that any breastfeeding issues such as hyperlactation are under control. 

For preventing mastitis, the ABM suggests to not pump large amounts of milk to store as this contributes to hyperlactation.  If the patient does have hyperlactation, please refer them to a lactation consultant to help manage it.  If possible, avoid pumping and use breastfeeding or hand expression to avoid nipple damage.  The lactation consultant can also assist to be sure that the flange and pump pressure are optimal for those who are exclusively pumping. 

Again, as a PT, I will add my 2 cents.  The baby also needs to be evaluated.  How is that baby latching? Does that baby have tension in its body that is contributing to abnormal tension at the breast? Is the baby sucking in a manner that is occluding part of the nipple during feeds? Is the baby creating its own nipple and breast trauma that is leading to mastitis?  We have skills as PTs/OTs to fix those issues in infants.  In my clinical experience, I have found that often I need to treat the infant in order to manage the mastitis. 

Why Pelvic Health? 

Back when I first started as a physical therapist (PT) it was 1992 and I was working in inpatient rehab.  I worked with stroke and trauma patients.  At that point in time, any form of pelvic PT was in its infancy, if not fetal stage.  Our last segment in PT school covered pelvic issues.  There was no discussion about pelvic floor evaluation, but we did discuss kegels. 

There was not much for me to do regarding pelvic rehab (or so I thought) while working inpatient rehab.  Nursing did bowel and bladder care, and sex was only discussed if the patient brought it up. A part of me wants to go back in time and do things differently to help manage the incontinence and discuss sexual questions that patients and their partners had.  I am certain that pain and prolapse issues were also rampant. 

If I am to be totally honest, I would not have been comfortable working with pelvic floor issues when I first graduated.  I was raised in a very large catholic family and basically taught that I did not exist from my belly button to my knees and that region of the body was to never be discussed.  It took me many years to move past the shame that I was brought up with.  I needed to feel comfortable with my own pelvis and human sexuality before I could be comfortable working with patients in this area. 

A decade later I was working in outpatient clinics and specializing in myofascial release, lymphatic drainage, and visceral manipulation.  I was much more comfortable with myself and had moved through a lot of that shame.  At one point I had a patient with back pain that was adamant that her issues were due to the pelvic floor and begged me to work on it.  I was not aware that any continuing education courses were offered and had no idea where to look, so I hit the books.  I self-educated and agreed to treat her.  I extrapolated the manual treatments that I already knew and applied them to the pelvic floor and viscera with amazing results.   

I quickly came to love working with the pelvis. I found that working with bowel, bladder and sexual dysfunction gave my patients profound improvements in their quality of life.  It was an area of their lives that they often did not feel comfortable sharing with friends and family members.  Many of them felt isolated and had pulled back socially.  Others had relationships that were shaky that blossomed as their bodies and confidence improved. What a privilege it is to be able to work with someone who is sharing their most intimate issues, feeling alone in the world, feeling like they have no control of their bodies, and often in pain-physically and emotionally.  

Aside from bladder, bowel and sexual dysfunction, the pelvic floor can have impacts on pain and dysfunction in the body well outside of the pelvis.  Many therapists are aware of how the pelvic floor can impact low back pain.  Some are aware that it can impact or mimic hip pain.  But the pelvic floor can also impact other body parts like the jaw, neck, GI tract, and knees. Being fluent in pelvic floor therapy can help a therapist treat the region of the body that is the primary location of the dysfunction in a more timely manner.   

As a therapist, you do not need to have expertise in the pelvic floor, just like you do not need to be a certified hand therapist to work in any setting.  However, having a basic understanding of the pelvic floor is important for the overall well-being of our patients.  Knowing who the skilled pelvic floor practitioners are in your area is extremely important. If you are not comfortable with directly asking questions relating to the pelvic floor, have it on an intake form as part of a screening tool to know who might need that referral.  We all want the best for our patients, which is why knowing about pelvic health is so important. 

Visceral manipulation to treat frequent urination? 

Visceral manipulation sounds harsh. Why wouldn't it? It sounds like somebody would be doing some sort of chiropractic manipulation to your organs. Before we can go into what visceral manipulation is we need to look at anatomy. 

The organs are surrounded by connective tissue and attached to the skeleton by ligaments. The heart, for example, is surrounded by the pericardium. The pericardium is a sack of connective tissue. The pericardium is then connected to the sternum in front of it by ligaments. It is attached to the diaphragm below it by ligaments, and it is attached to the vertebrae by ligaments. The lungs are surrounded by pleura, which again is connective tissue. The inner aspect of the ribs are also surrounded by another layer of pleura. These two layers allow the lungs to inflate and glide without catching on the ribs.  

The uterus is also surrounded by connective tissue. It has ligaments that support it in all directions from the pubic bone in the front to the sacrum in the back and the sides of the pelvis. The uterus sits on top of the bladder, which also is surrounded by connective tissue. The bladder has ligaments that attach it to the pubic bone in the front and there are also ligaments attach it all the way to the sacrum in the back. As the bladder fills with urine it expands, and the uterus above it needs to move as well. If that connective tissue or ligaments around the bladder or uterus is too tight, the bladder will be giving signals saying that it is full and needs to be emptied when there is not much urine in it yet.  

Another example would be in the shoulder, tight ligaments may impede the range of motion of the arm. As a physical therapist (PT), I may work on the ligaments and tight connective tissue in the shoulder to improve the range of motion of the shoulder. And this is exactly what I would do to work on the lungs or the heart.  

The same goes for the bladder if someone came to me and they were complaining that they need to pee far more often than they feel they should, and yet when they go there is not a lot of urine there. I would look at the connective tissue around the bladder to check for its mobility. I would look at the connective tissue around the uterus to see if it was preventing the bladder from being able to fill properly. I would make sure that the ligaments that attach the bladder to the pelvis are mobile and I would make sure that the motion of the bladder in all directions is normal. I would also assess the connective tissue around the small intestines (peritoneum) to ensure that it is mobile and is not pressing on the bladder. 

This is what visceral manipulation is. It is working with the ligaments and connective tissue that surround and support the internal organs just as we would work on the ligaments and connective tissue that surrounds a joint.  

5 things I wish everyone knew about their pelvic floor 

There is a lot of buzz out there these days about the pelvic floor. It seems every exercise class tells you to work your pelvic floor.  Lots of celebrities and influencers have advice and gimmicks to help you “strengthen” your pelvic floor muscles.  

I have been a physical therapist for over 30 years and have been a pelvic PT for about 20 of those years.  Here are 5 things I wish people knew about the pelvic floor: 

Number 1: Everyone has a pelvic floor. Every woman. Every man. Every nonbinary and trans person.  There is a misnomer that only women have pelvic floors.  Everyone does. The pelvic floor is the group of muscles that help you to be able to control when you want to pee and poop.  They contract during orgasm.  They contract when you cough and sneeze.  They contract as you move.  These muscles are the floor of your core. 

Number 2: Not everyone should be doing Kegels!!! While it is important to have a strong pelvic floor, not everyone needs to or should be doing Kegels. Some people chronically hold their pelvic floors too tightly.  Some people have significant pain or dysfunction.  For these people, Kegels can actually worsen their issues.  These people need to learn how to relax the pelvic floor, NOT strengthen it. Additionally, there can also be problems with scar tissue preventing the urethra from closing properly. No amount of Kegels will fix that problem, either. 

Number 3: Around 70% of people do Kegels wrong. This is what bothers me most about the Kegel craze. People are being told to do Kegels in exercise classes and on TikTok and Instagram.  Yes, pelvic floor strength is important.  However, all of those Kegels are not going to help if a person is not contracting the correct muscles. I have worked with a lot of patients to try to get them to do a Kegel. With some of them, I have run through every cue I know and still cannot get them to contract that pelvic floor. Some people will contract gluts, some their adductors, some their abs, and others will do all of the above. Unless you know for sure you are truly contracting your pelvic floor, please do not try to add it into your exercise program. 

Number 4: You don't need to do a million Kegels. When you cough or sneeze, the pelvic floor contracts to help prevent urine from escaping. The difference between peeing or not peeing when you cough or sneeze is milliseconds.  A million Kegels will not change that. You can have really strong muscles, but if they do not contract when you need them to, it will not help. Sometimes it is a matter of getting the brain to remember to fire those muscles.  So, try contracting the pelvic floor and then do a fake cough.  If you need to cough or sneeze, contract first, then cough.  After a while, the brain can relearn to fire those muscles when needed.  
 

Number 5: Pelvic Physical Therapists (PTs) exist. We treat bladder, bowel, and sexual dysfunction.  Any pelvic PT can help you to understand your pelvic floor.  Whether someone is struggling with pain, incontinence, constipation, prolapse, or pain with sex, they can help. Many unnecessarily suffer in silence. No one should. There is help. 

What is the difference between a lymphatic massage and treatment by a certified lymphedema therapist? 

Before we talk about what the difference is between a lymphatic massage and treatment by a Certified Lymphedema Therapist, I think we need to talk about what the lymphatic system is. The lymphatic system is connected to the circulatory system. The arteries bring the blood out to the cells. The veins bring 90% of the fluid back to the heart. The lymphatic system runs parallel to the venous system and picks up the other 10% of the fluid, sends it to the lymph nodes which are full of white blood cells, and then returns it to the bloodstream shortly before it dumps into the heart. 

The lymphatic system is made up of lymphatic vessels and lymph nodes.  Most people know that the lymph nodes swell when they are sick. The lymph nodes are full of white blood cells which are a vital part of your immune system.  That swelling in the lymph nodes means that there are more white blood cells working in those nodes to clear that infection. 

Let’s go a little deeper into this process.  For example, those lymph nodes can also swell after a vaccine (and that is very normal and very appropriate).  Think of it this way: you are on the International Space Station. You find out that aliens want to dock with your ship and then take over.  You get a copy of their docking mechanism through intel. Everyone goes to work: Communications lets everyone know what their plan looks like. Your engineers figure out a way to cap it so it cannot dock. The team then makes those caps. Security patrols the region keeping watch. The white blood cells in the nodes are doing the same thing. 

Your body is always doing this in the background. You eat food. Your body needs to process what microbes were in that.  You breathe.  There are more than 10,000 bacteria alone per square meter that you breathe.  Your body is always interacting with the microbiome inside and outside.  Your immune system is amazing, and the lymphatic system typically does a fabulous job 24/7. 

So why would you need someone to work on your lymphatic system? For most people, the lymphatic system works just fine. Just like a massage can make your muscles feel better, a lymphatic massage can help clear excess congestion within the lymphatic system. 

Someone who is doing a lymphatic massage has some training in the lymphatic system, but typically just the normal lymphatic system.  They know what direction the lymph is supposed to flow, what type of strokes to do with their hands and what sequence to do those strokes. Generally, you will feel better after the session.  You may find you are tired or need to urinate a bit more because the extra fluid and waste products that your body has been more sluggishly moving through the system has just made it back to the blood. 

Comparatively, a Certified Lymphedema Therapist has significantly more training in the lymphatic system and knows how to manage issues when things have gone wrong.  These people will typically be a physical or occupational therapist, but could also be a massage therapist, physician or nurse.  

The most typical scenarios, in which things have gone wrong, are swelling in the arm after breast cancer surgery and radiation or swelling of the legs with major vein problems.  The type of swelling that happens is called lymphedema. When lymphedema is involved, the lymphatic system or vascular system is not normal, and you need someone who knows the ropes.  Treating the body like it has a normally functioning venous and lymphatic system when one or both systems is compromised is not going to be helpful. 

Treatment for lymphedema goes far beyond a lymphatic massage.  There may also be the need for some manual therapy to manage scar tissue. The direction of the “massage” is different.  There can also be a need for bandaging, wound management, and compression garments. 

If you have a normal lymphatic system and want a lymphatic massage, go for it. There are lots of trained massage therapists out there who do lymphatic massage.  If you have been diagnosed with lymphedema, please see a Certified Lymphedema Therapist to help you manage the issues that are specific to your case. 

References: 

Grada AA, Phillips TJ. Lymphedema: Pathophysiology and clinical manifestations. J Am Acad Dermatol. 2017 Dec;77(6):1009-1020. doi: 10.1016/j.jaad.2017.03.022. PMID: 29132848. 

Global airborne bacterial community—interactions with Earth’s microbiomes and anthropogenic activities, Jue Zhao, Ling Jin, Dong Wu, Jia-wen Xie, Jun Li, Xue-wu Fu, Zhi-yuan Cong, Ping-qing Fu, Yang Zhang, Xiao-san Luo, Xin-bin Feng, Gan Zhang, James M. Tiedje, Xiang-dong Li, PNAS 2022, DOI: https://doi.org/10.1073/pnas.2204465119, https://www.pnas.org/doi/full/10.1073/pnas.2204465119 

My Birth and Breastfeeding Experiences 

Mary Ellen Kramp, DPT, CLT 

I have had 3 kids with 3 vastly different birth experiences and rather similar breastfeeding experiences.  
 

With my first pregnancy, I was 23 years old and I had a very easy pregnancy.  My water broke at 37 weeks. Labor started about three hours later and the contractions quickly went to five minutes apart. At that point I went to the hospital and was told that I was only dilated to one centimeter and to go home.  (I could go into a rant here about the importance of caring nurses on a labor and delivery unit, but that is another blog.)  My contractions quickly escalated to one minute apart and I went back to the hospital at 7 PM, two hours later, and luckily a different nurse was on and I was allowed to stay. I managed my pain by walking through each contraction.  The contractions remained a minute apart for the next six hours where I had a natural delivery and only had to push for 15 minutes. The doctor I had was a family practice doctor, and he very much believed that nature was going to take care of 90% of births with no intervention. He was a perfect fit for that pregnancy for me. I felt great after that delivery and was itching to go home almost immediately.   

Breastfeeding went fine, although knowing what I know now, I would really like to go back in time and reassess some things.  She latched well, but for the first 2 weeks it felt like rocks were being pulled through my nipples for the first 2 minutes of every feed. My nipples leaked non-stop for 4 months and my breasts were definitely in overproduction mode. I am pretty sure I could have just fed my kids from across the room if my husband held the child in the right spot with its mouth open.  I went through the exact same song and dance with the next two kids for breastfeeding.  The birth stories, however, were vastly different. 

My second pregnancy went well, but this child was significantly larger than the first.  I found myself going for an ultrasound early on to be sure it was not twins.  He was measuring 7 lbs 6 oz at 36 weeks, so I underwent an induction 2 weeks later.  Being forced to stay in a bed did not work well for me for managing my pain, so I had an epidural. The size of my son’s head made the seasoned OB utter, “Oh my god! What are the shoulders going to look like?”  I laid there thinking, dude, you are literally 3 feet from my head, I can hear you.  My son did look like a linebacker in that little incubator to be fair.  He was only 8 ½ lbs but had a head circumference that was not on the chart.  I was not as itchy to get home immediately after that delivery, but again, I did just fine. 

My third delivery did not go as easily.  Everyone always says that births get easier with each successive one.  I found the opposite to be true.  This labor was also induced for the same reason the second one was induced.  This baby was also large.  People had long stopped asking me when I was due and were asking how many I was having. Again, I opted for an epidural because I was not allowed to walk around to manage my pain.  I am rather sensitive to most meds and was doing well with the induction.  When it was time for the next dose of meds, the nurse decided to give them because she did not want the labor to stall.  Shortly after that, my uterus went into tetany- it was one long sustained contraction.  Then came the drugs to reverse that situation and allow the uterus to relax.  

Within the next hour or so I was almost fully dilated, but now her heart rate was falling with contractions.  The OB said we needed to do a c-section STAT.  I had worked for hospitals for years and always heard those overhead STAT announcements.  I always felt badly when I heard them called for the OB floor.  It was unnerving to hear them at that moment and know those STAT calls were for me.  I suddenly had a team in my room prepping me for the OR.  In a flash I was in the OR and put under general anesthesia.  The umbilical cord had prolapsed and was cutting off her oxygen during contractions. My daughter was out and thankfully doing well.  The well-timed c-section saved her life and prevented probable brain damage. I, however, was hemorrhaging.  The meds that reversed the induction were now not allowing my uterus to contract fully, which is what it needs to do to stop the bleeding after the placenta pulls away from the wall of the uterus.  My blood pressure was now 50/0.  The OB managed to get my uterus contracting again and the bleeding stopped.  The anesthesiologist eventually got my blood pressure back up to survivable levels.   

When I was finally stable, I was sent to recovery.  There a nurse asked if I was having any pain at the moment that I was first opening my eyes.  I said a little, so she injected Demerol into my IV.  I was not recovered from the anesthesia enough to handle that, so I promptly stopped breathing.  I remember the feeling of needing to breathe, feeling too tired to do so and watching a small version of myself curling up and going to sleep instead of taking that breath.  My husband (an ER doctor) stood over me and kept my breathing until the meds wore off enough for me to breathe consistently on my own.   

I ended up with a massive infection after the c-section and was in the hospital on IV antibiotics for almost a week.  My daughter did just fine, but she was HUNGRY.  I tried feeding her as frequently as I could the first few days (basically until my nipples were bleeding), but she needed some formula supplementation to satisfy her.  Looking back, I am not sure if the highly medicalized birth caused me to produce less colostrum at the time, or if this baby who was over 9 lbs and initially hypoglycemic just needed more than I could produce. Normally large babies tend to lose more weight in the first week.  She gained a full pound that week. And as with the prior two babies, breastfeeding was painful for the first 2 minutes of each feed for the first 2 weeks, then went very smoothly.  And I would still love to go back in time and evaluate myself and the babies!