Interview with Sara Sauder, PT on Vestibulodynia, Contraceptives and Bladder Pain

A few weekends ago, I had the awesome opportunity to host Sara Sauder and Kelli Wilson in teaching their course, Vestibulodynia: An Orthopedic and Pelvic Floor Approach. The course was fantastic, and both Kelli and Sara are excellent instructors. Their course is unique in that it 1) focused on a very specific diagnosis (super great for those of us who have been practicing for a while 2) is very small–a max of 12 participants, meaning lots of one on one time with instructors 3) includes a facetime conversation with a well-known pelvic pain medical expert (in our case, Dr. Irwin Goldstein) and 4) allows participants to both perform treatments on instructors and have instructors perform treatments on participants.

Sara and I have been “virtual” friends for quite some time… in fact, I can’t remember when exactly we started e-mailing, but we became penpals of sorts. We share journal articles with each other, and I believe I even told her I was pregnant before I told many of my other friends (truth!). So, needless to say, I was SO excited for us to finally meet in person and become real friends. And, Sara was so gracious to agree to answer some of my questions to share some excellent insight with all of you on vestibulodynia and her course. I hope you enjoy!

JR: First, can you briefly explain what vestibulodynia is to my readers out there who are unfamiliar?

SS: Vestibulodynia is pain at the vestibule.  The vestibule is a specific tissue at the opening of the vagina.  The opening of the vagina itself has a name which is the “introitus”.  The vestibule is part of the introitus.  It is considered part of the vulva even though it may seem that it extends into the space between vulva and vagina.  Hence the name…vestibule.  It’s like a hallway.  Or…an alcove, if you will….
Other than that simple explanation, vestibulodynia can feel like pain, itching, burning discomfort at the opening of the vagina or at the urethra or the bladder.  The aftermath of this sort of pain can result in lots of other things happening, like feeling pain inside the vagina, at the other areas of the vulva including the clitoris.  

JR: Thank you for explaining that further. Now, there are so many pelvic pain diagnoses out there…why a course on vestibulodynia?

SS: Vestibulodynia is truly a common denominator in so much female pelvic pain.  I think that if we can start to recognize the vestibule hurts, then we can get to the root of why someone has pain.  There is a logical way to think about why the vestibule hurts and we if we can understand the true why of the pain, then we can treat it.  In treating that one core issue, we will see that other symptoms that may seem unrelated start to resolve.

JR: That’s a really good point. We see vestibulodynia as a common issue with so many different pelvic pain syndromes. One in particular, that we discussed in more detail at your course, is Interstitial Cystitis or Painful Bladder Syndrome. Now, most people see IC/PBS as a “Bladder Problem,” but you shared some interesting information about the relationship between pain at the vestibule and urethral/bladder pain. Can you explain that for our readers?

SS: The vestibule, urethra and lining of the bladder (including the urachus) are all made of endodermal tissue.  They are all part of the same embyrological tube.  Their needs are the same.  That’s why you often see pain at the vestibule with any bladder symptoms.  That’s why the reverse is true.  You will see bladder symptoms with pain at the vestibule.

JR: That is fascinating, and also helps us to understand why some treatments for one may also be effective for the other (for example, both populations can have an increased hystamine response–especially during allergy season– and may have a decrease in pain with using anti-histamines! Moving on, in your course (which was awesome!), you discussed some of the main causes of vestibulodynia. The role between oral contraceptive use and vestibulodynia was discussed in detail. So many people are surprised to hear that being on birth control could contribute to their vulvar pain. Can you explain that a little bit more?

SS: Any product that affects the body’s sex hormones can affect parts of the body that are dependent on sex hormones.  So, using a combined hormonal contraceptive or any other medicine that affects estrogen and testosterone will affect the vulvovaginal tissue.  These areas are sex hormone dependent, to varying degrees based on their different embryology.  We go into this in super detail in the vestibulodynia course.  The mechanics of it are repeated over and over because if this isn’t truly understood, we, as physical therapists, will never understand what kind of progress is or isn’t possible for our patients.  If a woman is on a medication that will lower their sex hormones and I keep treating her for symptoms of sex hormone reduction, I’ll be banging my head on the wall if I don’t understand that hormonally there are changes taking place that I can’t affect until the patient gets off of or alters that medication.

JR:  That is especially interesting to me, as I have seen several patients (as well as a few close friends!) who have used oral contraceptives develop vulvar pain or pain with sexual intercourse. Now of course, we know that not everyone who takes OCPs will develop vestibulodynia, but it seems like certain individuals may be more susceptible than others. And the current research seems to recognize some of these problems occurring, to the point that now OCPs are no longer the most recommended type of contraceptive for women (especially younger ones). I know this was something we chatted a little bit about with Dr. Goldstein during our facetime chat at your course. (ReadersHere’s an interesting article about contraceptives and vulvar/bladder pain you may find helpful!)

Now, Vestibulodynia can be a tough diagnosis for clinicians to treat. What are the most common mistakes you think physical therapists make when working with women with vestibulodynia?

SS: The most common thing I find with clinicians of any discipline in working with patients with vestibulodynia is that often we completely miss the fact that the patient has vestibulodynia in the first place.  Either the vestibule is completely removed from the assessment because it is pushed aside with a speculum, or it is not assessed via appropriate and specific q-tip testing.  If we miss that we are dealing with issues at the vestibule, we are missing the point.

JR: So, true of many diagnoses! So, wrapping things up…one of the things I love about you is how hard you work to advocate for your patients– it’s amazing! So, let’s say I’m a woman reading this, and I think I have vestibulodynia. What should I do?

SS: If you think you have vestibulodynia, definitely talk to your physician about it.  Explain your symptoms and ask to see a pelvic floor physical therapist.  When you get a referral, call the physical therapist before your evaluation.  Ask if they have treated vestibulodynia, ask how they treat it and ask about their success in treating it.

JR: Thank you so much for taking the time to chat with me about vestibulodynia, and for coming to our clinic to share such an awesome course this weekend! I know we all really enjoyed it and found it super useful in learning to provide the best care we can for the women we treat who are experiencing vulvar pain (and really, pelvic pain in general!)

If you are a clinician who works with women with pelvic pain, I highly recommend Sara Sauder and Kelli Wilson’s course, Vestibulodynia: An Orthopedic and Pelvic Floor Approach. For more information, please check out their website: http://www.alcoveeducation.com/

3377681_origSARA K. SAUDER PT, DPT
is originally from Dallas, has lived in Houston and prefers life in Austin. She received her Doctor of Physical Therapy from Texas Woman’s University in 2010, but began practicing with her Master in Physical Therapy in 2007.  She works at Sullivan Physical Therapy and specializes in pelvic pain and mentors pelvic floor physical therapists through a professional mentorship program. To focus her interests, she authors the blog, Blog About Pelvic Pain. Through this medium she voices her opinion and experiences with diagnoses and treatments for pelvic pain. She has also been a guest writer for popular blogs such as Pelvic Guru, Pregnant Chicken, Scary Mommy and Pelvic Health and Rehabilitation Center’s As the Pelvis Turns. Sara interviews and shadows internationally-recognized specialists alike. She is a member of the American Physical Therapy Association’s (APTA) Section of Women’s Health (SOWH), International Pelvic Pain Society (IPPS), the International Society for the Study of Women’s Sexual Health (ISSWSH) and the National Vulvodynia Association (NVA).  She is as blurry in person as she is in her photos.

Biofeedback for Vulvodynia: An Update 

“Do you do Glazer’s protocol?”

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I have been asked this question several times over the past few years, by searching, hopeful women, looking for help after suffering from vulvar pain for far too long. I generally respond with, “I’m familiar with Glazer’s protocol, and would be happy to discuss it with you. Why don’t you come in for an evaluation and we can discuss treatment options specific to you?” This, in place of the, “I know it, but it’s more than likely not appropriate for you.”

Glazer’s protocol was a popular treatment approach, utilizing SEMG biofeedback to teach patients a method of contracting their pelvic floor muscles, to ultimately “fatigue” the muscles, and with the hope that doing so would relieve pain. Dr. Glazer was one of the first to publish research about treating the pelvic floor muscles in helping women with Vulvodynia, and all of us working with men and women with pelvic pain are grateful for his contributions.

However, as time goes on, we learn more and more. Which is awesome. And as we learn more, we hopefully change how we practice to provide the best treatment we can to our patients. Recently, my colleagues Sara Sauder and Amy Stein (2 fantastic clinicians and educators in pelvic pain) wrote an excellent commentary summarizing the evolution of biofeedback in helping women with vulvar pain. I was thrilled to see their commentary, and I thought many of you would benefit from it as well!

Sara and Amy very eloquently explain how the understanding of treatment to the pelvic floor muscles have changed over the years. Glazer’s protocol was based off the idea that frequent contractions of the pelvic floor muscles (both holding contractions and quick ones) would fatigue the muscles and thus lead to relaxation and pain relief. However, our current understanding of the pelvic floor musculature is quite different.

Shortened, Tender Pelvic Floor Muscles 

Amy and Sara go on to explain that as we have learned about the pelvic floor and seen the presentations of women experiencing vulvar pain, we have found that most women actually present with shortened, tender pelvic floor muscles. Typically, when this is found on examination, the optimal treatment includes a combination of relaxation strategies as well as manual treatment vaginally to encourage lengthening of the pelvic floor muscles. And what about fatiguing them by doing lots of kegels? Well, we have found that when shortened muscles do lots of contractions, they can actually get irritated and more shortened!

So, what’s the place for biofeedback? 

First, it is important to realize that the term “biofeedback” is not exclusive to EMG. Really, biofeedback can be any cueing to encourage a patient to perform an exercise accurately. Sara and Amy give a few great examples: a finger in the vagina to encourage and cue the patient to relax and lengthen their muscles. A clinician teaching a patient the optimal way to harness the diaphragm with breathing. All biofeedback. And what about SEMG? It can offer some help for some patients to learn to relax and let go of their muscles. However, it can also be a little tricky because women with shortened muscles may appear “normal” on SEMG. Why? It’s complicated, but in summary, SEMG reads electrical activity… so, when a muscle is held at a shortened position for a long period of time, the body will adjust to this position as the new normal. Thus, this can “trick” a patient or clinician (especially if SEMG is done to replace an internal examination) into thinking the muscles are relaxed and functioning well, when they are actually shortened.

In summary, Glazer was a pioneer who really helped us in the process of better understanding Vulvodynia. But as all treatments and understandings do, we have evolved and changed to better understand what the most effective treatment techniques are for women experiencing Vulvodynia. Biofeedback should be a part of any treatment program… but SEMG biofeedback will have some utility for specific populations and limited utility for others.

I would encourage you to read Sara and Amy’s commentary yourself! You can find it here. If you are a physical therapist treating this population, you have the opportunity to learn from Sara in person! She teaches via Alcove Education, and has an excellent course: Vestibulodynia: An Orthopedic and Pelvic Floor Approach. My clinic is fortunate to host this course in just a few weeks! (Our course is sold out… but you can find upcoming courses here).

Sara and Amy are excellent clinicians, educators and advocates for men and women with pelvic pain. Sara runs a wonderful blog, Blog About Pelvic Pain, and Amy has created fantastic self-help tools, including her book Heal Pelvic Pain and her instructional DVD, Healing Pelvic and Abdominal Pain. I hope you enjoy these resources! 

Have a wonderful week!

Jessica

I’m back! And I have a really really cute baby!

Ok, I know you must be totally shocked to hear from me! But, I am back! For real!

My beautiful daughter, Emma Caroline, was born on October 26th at 1:32 pm, weighing 7 lbs 14 oz and 23 inches long. In case you are super observant, yes, the little girl who threatened to come early actually ended up coming a week late! We delivered her via c-section after 37 hours of labor. Yes, 37. I’m hoping her dramatic streak ends here. I’ll spare you the details now, but I’m sure some will come out along the way as they fit with future posts!

I was so fortunate to spend 12 weeks at home with my little girl, but I am back in the clinic seeing patients now, and back to writing! In fact, I promise you’ll get another post (a real, hopefully educational one!) before the week is through!

2017 is going to be a great year! I have some exciting things planned for the blog (hoping to finally start some fun video posts, more book reviews, and some interviews with colleagues who are super smart!), and I am SO excited to start teaching for Herman and Wallace Pelvic Rehabilitation Institute and continue teaching online webinars! See my “for professionals” section for current course listings! I would love to meet you in-person!

Wishing you and your family a happy and healthy 2017!

Jessica

My sweet little Emma, visiting her mama on my first day back at work!

An Update

Hello my friends, colleagues and blog readers! I know what you’re thinking… a post from Jessica? We haven’t heard from you in ages. And you’re right, you haven’t. And I’m sorry. There have been quite a few things going on, and I wanted to fill you in so you would understand why I’ve been a little MIA.

As most of you know, I am currently pregnant, expecting an adorable, sweet baby girl in October! My pregnancy has been wonderful overall, and it has been incredible to be on the “other side” of learning about pregnancy. Unfortunately, a few weeks ago, I began experiencing regular contractions, which ultimately resulted in a short hospital stay, and being placed on modified bedrest. (Now I know what you’re thinking… isn’t bedrest really bad and no longer recommended? It’s modified…meaning, I can move around, etc…but they don’t really want me working as high levels of activity are causing me to contract more, and my little girl needs to cook for a bit longer). This all happened the same exact day I was supposed to give my live webinar on pregnancy (Ha!). Thankfully, Andrew and Karl with Therapy Network Seminars were very understanding, and we canceled the webinar, ultimately rescheduling for next Wednesday, September 14th! So, if you missed it the first time, there is still time to sign up! And I would love to have you on the webinar!

So, back to my current situation… the initial plan was to keep me at home for a few weeks, allow the contractions to slow down, then return to work. Well, unfortunately, my little daughter has other plans for us. So, long story short, I will be out of the clinic until after my daughter is born to give her the best opportunity to grow and develop safely. I do plan to write a few more blogs for you between now and her arrival, but honestly, haven’t been too motivated to do so over the previous few weeks (I think my little mommy nesting brain was so focused on making sure everything was ready for her, should she arrive earlier than we expected!).

My husband and I truly appreciate all of the love, support, meals and prayers that we have received over this time! We are grateful that our sweet daughter is staying put for now, and seems to be healthy, happy and content (I like to think she is completely oblivious to what is happening in the uterus around her!). For those current and prospective patients, I will be scheduling patients again in early January. I plan to keep this information updated on my contact page.

Thank you for your understanding and support! I look forward to continuing this learning and growing journey with you in the future!

~ Jessica

Upcoming Webinar (RESCHEDULED): Management of Musculoskeletal Pain During Pregnancy

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“Management of Musculoskeletal Pain During Pregnancy” 

LIVE Webinar, Wednesday September 14th, 8-9:30 p.m. EST 

I am thrilled to be partnering again with Therapy Network Seminars to present this live webinar providing participants with an introduction to the management of musculoskeletal pain during pregnancy!

So often, clinicians feel ill-equipped and lacking in knowledge to provide quality treatment to women during this important stage of life. Often, clinicians are fearful of complications or precautions their patients may face, or may not know how to modify examination procedures or exercises to accommodate a woman who is pregnant. I hope that this webinar will help more clinicians feel confident in helping their pregnant clients, and inspire many to help reach a population who so very much needs our help!

I hope you’ll join me on Wednesday September 14th for this live 90-minute webinar! Registration is available via Therapy Network Seminars! Let me know if you have any questions and I hope to see you there!!

NOTE: This webinar was rescheduled from the original date of August 18th. If you can’t make this webinar, or would like to listen to some previous webinars, they are available on-demand! Check out the topics available here

Exercise during pregnancy

So, I’ll be honest… I’m writing this as much for myself as I am for you. You see, as a women’s health specialist, I have preached the benefits of exercise during pregnancy for years. I’ve taught classes to women in the community on how to exercise safely and encouraged them in all the way exercise would help their babies, their bodies, their overall health. I’ve lectured other health care professionals on how to help pregnant women start exercise programs, how to monitor them for safety, and which specific exercises are better for women during pregnancy.

But the thing is…I’m now pregnant. 26 weeks to be exact. With this darling, sweet little angel GIRL!

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You have to admit, she’s already adorable, isn’t she?

And it has been wonderful, amazing, incredible to experience…and… educational. I thought that I would be the perfect fit pregnant lady. I would follow all of my own advice on everything and stay super active and fit throughout the pregnancy (I mean, I’ve told so many people that pregnant women can keep exercising at the same level they did before pregnancy!). But, then reality hit… First trimester, I was reallllllyyy realllyyyy tired. Like super tired. In fact, I sometimes just fell asleep on the couch after work (and I am really not a napper). My bedtime effectively became 8pm. And, on top of that, I was nauseous. Which creates the perfect combination for not being a super active, fit pregnant lady. But, I tried to do the best I could! Which mostly meant walking sometimes (on the treadmill or outside). Better than nothing though!

Then, second trimester hit, and all of my symptoms got so much better (just as we tell people they should!). I had more energy, could stay up until at least 9pm, and no longer felt nauseous. Buuuttt… I also was in the process of buying a new house, cleaning and updating said house, then moving, unpacking, and trying to organize our home… So, needless to say, I was not the picture perfect fit pregnant lady over that time either.

So now we reach today. 26 weeks, 2 weeks away from starting my third trimester, and walking as well as a little bit of yoga/pilates is still the best I have done for exercise (Not saying anything bad about walking… I have loved it during pregnancy, it has great benefits, and I plan to continue it! But, I also want to add some variety and a little more frequency to my routine!) So, this post serves both to give you some great information, hopefully motivate a few of my fellow pregnant ladies to jump-start their fitness, and also hopefully to motivate me to up my exercise frequency and throw a little variety in the walking routine. 🙂

So, why exercise during pregnancy?

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For many years now, exercise has been supported as effective and helpful during pregnancy. The benefits of exercise during pregnancy are actually pretty incredible:

  • Cardiovascular benefits (improving blood pressure, heart rate, etc) are passed on from mother to baby… so baby can actually have a healthier little heart when born!
  • Decreased weight gain during pregnancy, which actually can prevent obesity in both mom and baby. Recent studies have suggested that women who gain excessive weight during pregnancy (when starting at normal or overweight BMI) are more likely to have larger babies. The interesting this is that when this occurs both mom AND baby are at risk for developing obesity in the future.
  • Decreased risk of gestational diabetes (and improvements in women with GDM)
  • Decreased likelihood of Caesarean or operative vaginal delivery
  • Improved recovery postpartum
  • Improved psychological functioning during and after pregnancy

How should you exercise during pregnancy?

The great news is, most women can actually continue exercising at the same level they were exercising prior to being pregnant. The American College of Obstetrics and Gynecology just updated their recommendations on exercise during pregnancy this past December. The most recent guidelines recommend that pregnant women exercise 20-30 minutes at moderate intensity most days of the week. The safest types of exercise identified by the committee include:

  • Walking
  •  Swimming
  • Stationary cycling
  • Low-impact aerobics
  • Modified Yoga
  • Modified Pilates
  • Running or jogging
  • Raquet sports (as long as able to do so maintaining good balance)
  • Strength training

The following types of exercise are recommended to be avoided (for mostly obvious reasons):

  • Contact sports (ice hockey, boxing, soccer, basketball)
  • Activities with a high risk of falling (downhill skiing, water skiing, surfing, off-road cycling, gymnastics)
  • Scuba diving
  • Sky diving
  • “Hot” yoga or pilates (due to temperature regulation issues in many pregnant women)

How hard should you exercise?

You may be familiar with the standard method of determining intensity of exercise by monitoring heart rate. This method is not reliable during pregnancy as cardiovascular function changes with pregnancy, thus, the numbers won’t provide accurate guidelines. Instead, women are encouraged to utilize a scale such as the Borg Rate of Perceived Exertion Scale. Basically, this scale goes from 6 (sedentary) to 20(maximal exertion). Pregnant women are encouraged to aim for moderate intensity (13-14 somewhat hard) during exercise. Another option for monitoring intensity of exercise is the familiar “talk test.” Basically, as long as you can continue a conversation the intensity is likely not getting overly difficult and should be safe.

When shouldn’t you exercise?

There are several times when it would not be indicated for a pregnant woman to start or continue an exercise program. Absolute contraindications for exercise are shown in the following table (taken from the recent committee opinion listed above):

An absolute contraindication means that if this is occurring, the person should not engage in an exercise program for any reason. A relative contraindication means that a person should take caution and consult with her physician prior to engaging in exercise. The relative contraindications are listed below:

When should you STOP exercising?

There are instances during pregnancy when it may become unsafe to continue an exercise session. If these situations occur, it is important to immediately stop exercising and contact your physician, as continuing to exercise in these scenarios may be harmful to the mother or the baby:

  • Vaginal bleeding
  •  Regular painful contractions
  • Amniotic fluid leakage
  • Dyspnea (shortness of breath) before exertion
  • Dizziness
  • Headache
  • Chest pain
  • Muscle weakness impacting balance
  • Calf pain or swelling

Getting started

If you are pregnant and have not started exercising, it’s really not too late! There are a few things to keep in mind as you get started!

  1. Talk to your Obstetrician. If exercise is not routine for you, talk to your doctor first before you start a program to make sure it will be safe for you to exercise during your pregnancy.
  2. Start gentle and slow. It generally is better to slowly ease into exercise. Remember, the guidelines encourage 20-30 minutes of moderate intensity exercise most days of the week. But, when you first start, it may be wise to start with smaller increments and make 20-30 minutes your goal. Walking, gentle prenatal yoga or water aerobics may be a good, safe place to start.
  3. Something is a lot better than nothing. It really is. And I feel ya, some days you’re exhausted or nauseous and just can’t get to the gym. So, when that happens, do what you can. Go for a short walk. Try some home prenatal exercise videos. Or, just take the day off and rest. Then try again tomorrow.
  4. Listen to your body. And I really mean it. If something isn’t feeling right, pay attention to it! Talk with your doctor if you notice anything unusual or if something isn’t feeling well when you are exercising. Take breaks as you need to, and don’t push yourself too hard.
  5. Get some help! Reach out to your local Women’s Health physical therapist to come in for a session and get some help developing a program that will work for you! Also, talk with your physician, midwife or doula about resources in the area. If you live in the Atlanta area, like me, there are great programs like OhBaby! Fitness offering exercise classes for new or expectant moms. Remember, you don’t have to do this alone!

What motivated (or is currently motivating!) you to stay active during your pregnancy? What are your favorite exercises? As always, I’d love to hear from you!

Have a great week!

~Jessica

Your bladder and bowels need a diary.

This past weekend, I had the wonderful experience of assisting at Herman & Wallace’s Level 1 Pelvic Floor Course, held here in Atlanta. I have been assisting at these courses for the past 4 years now, and I absolutely love it. There’s nothing better than helping clinicians who are new to the field of pelvic health learn and grow in this fantastic specialty. I love the excitement, the slight fear (I mean, many of these folks are doing their first vaginal exams at these courses), and the growing passion for helping men and women with pelvic floor problems. And the most exciting thing is knowing that they are going out in their communities to begin offering this service to people who really need it. And, now you know how much that really means to me. 

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Cathy Neal (an awesome PT who assisted with me), Susannah Haarmann (an awesome PT who instructed the course), and myself! 🙂 We’re just missing Amanda Shipley and Pam Downey! Photo courtesy of Susannah!

The initial level 1 course covers an introduction to pelvic floor dysfunction (all diagnoses), and covers bladder dysfunction in more detail. One of the prerequisites of the course is for all participants to complete a bladder diary which is then evaluated in the class. So, why keep a bladder or bowel diary? 

First, let’s be honest, we are all horrible historians. Many of us can barely remember what we ate for breakfast, let alone remember all the details of our bathroom habits! Let me ask you this:

  • How many times did you urinate yesterday?
  • How much fluid did you drink? What exactly did you drink?
  • What did your poop look like? When did you poop?

If you’re like me, it’s probably tricky to recall these exact details. (Well, you may be slightly better at recalling than I am, now that my pregnancy brain is in full effect!). And, if you are having any problems with your bowels or bladder, these details really do matter. Here are a few examples:

Patient #1: Mary (obviously not her name) was a lovely 65 year old retired nurse experiencing urinary leakage on her way to the restroom several times each day. She had tried exercises, dietary changes, and medications, and her problem kept persisting. Her bladder diary was eye opening for both of us! We learned that she only leaked urine when she would hold her bladder for over 6 hours! After years of holding her bladder for entire shifts, she got into some pretty bad habits. Once we changed this, her leakage went away completely! 

Patient #2: Sara(also, not her name) was a 10 year old girl having bowel accidents daily. Once we did a diary, we found out the problem! Her mother was a hair stylist who saw clients out of her home. Sara was afraid to have a bowel movement while her mom’s clients were there, and had started having accidents from getting too constipated! The three of us quickly determined a “code word” for Sara to tell her mom when she needed to go, and within 2 weeks, the problem was solved! 

So, as you can see… these little diaries can be oh so powerful! So, let’s get into the details!

Who should do a bowel or bladder diary? Well, in my mind, everyone should try it at some point! It’s so cool to see what your patterns really are… but for sure, anyone who is having problems like urinary urgency or frequency, urinary leakage, constipation or bowel leakage.

How long should you keep one?  Typically, I like people to track for at least 3 days. Preferably, two of those days should be “regular” and one can be “different.” For example, if you are working, you may choose two days to be work days, and one to be over the weekend.

What should you look for?  The best thing to do if you are having problems is to bring your diary to your health care provider. He or she will be able to analyze it completely, and give you insight into what may be happening. However, I do think there is some benefit in doing a little sleuthing yourself. Here are a few things to identify:

  • How often are you going? Normal bladder frequency is typically around 5-8 times each day, and less than 1 time each night. Normal bowel frequency varies quite a bit from 1 time over 3 days to 3 times each day.
  • How strong are your urges when you go? Generally, I recommend grading urges on a 0-3 scale (from no urge –> gotta go right now!). Were most of your urges very small? Were you running to the bathroom all day?
  • How much did you urinate? The best way to track this is to actually measure your output (usually a cheap plastic cup or a dollar tree measuring cup works well). Normal output of urine is 400-600 mL per void. You can also try just counting the seconds of your stream, however, this does tend to be less accurate. We generally tell people that each stream should be at least 8 seconds.
  • What did your poop look like? Was your stool soft and formed? Little rabbit pellets? Did you have to push hard to empty your bowels or did they come out easily? Did you have any discomfort or pain?
  • What was your diet like? Do you notice any trends in what you eat or drink? Were you drinking some well-known bladder offenders (like caffeinated drinks, soda, coffee, artificial sweeteners or sugary drinks)? Did you eat at really regular intervals? (You know I love my bowel routines!)
  • Did you notice any trends? Did you always go to the bathroom when you had the littlest urge? Was most of your leaking with coughing or sneezing? Does running water send you running to the bathroom? Did you always have a bowel movement after your morning coffee?

As you can see, so much wonderful information can be gleaned from these diaries, so if you’re having problems, get started today! Knowledge is power, and once we become aware and identify trends in our habits, we can make the changes needed to really help us get the most out of our bodies!

If you want to get started today, try using one of these free templates available online (John Hopkins’ Bladder Diary, Continence Foundation Diary, or Movicol’s “Choose your Poo!” Diary) There are also wonderful apps available now for tracking bowel/bladder function! This is a sample of a diary I frequently use in the clinic (see below).

Bladder Diary

So, get tracking! And, on a serious note– don’t forget that these diaries can also help to determine if you are having a more serious problem, so please, please please, see your health care provider for an evaluation if you are having the types of problems we discussed today!

Happy Wednesday!

~Jessica

Why I specialize in pelvic health

At least a few times a week, I get the question, “So, what in the world made you want to do this??” And it’s fascinating on a lot of levels. First, there’s the assumption that “this” meaning, my profession, is a strange and weird specialty to be in. (I could write a whole post on that topic, but I won’t…at least not right now.) I doubt my colleagues practicing in Orthopedics or Neurology get that question with that look as frequently as I do. Generally, there’s the assumption that I must have had a pelvic problem that was treated by a pelvic PT, that inspired me to move into this specialty. Also, not true. Although it could be (and who knows what will happen in the future, with this little sweet one on the way in October!!), and that would be inspiring, I’m sure, but it’s not my story.

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Sweet Baby Reale, due in October!! 🙂

The truth is, I sort of fell into the pelvic health world. I remember clearly when I first learned that there were physical therapists who did vaginal and rectal examinations. I was a first year doctoral student at Duke, and we were in the midst of our very first clinical experiences– observing for one afternoon each week at various physical therapy clinics and hospitals around the area. A few of my fellow students were assigned to “Women’s Health” (I was not). We all sat around as they shared in horror their experience of watching a physical therapist do an internal examination, and I stated, pretty clearly, “Wow, that is so gross. Why would anyone ever want to do that?!”

Yet, here I am, dedicating my career completely to this population. At the time of first-year Jessica in PT school, I was positive I wanted to specialize in Vestibular Dysfunction and Neurology. I had interned at a clinic for 2 years in undergrad that specialized in this population, and I loved it. The problem was, Duke required that one of our long internships (5 months long to be exact) be in the Orthopedic realm. So, not knowing what exactly I wanted to learn about during that “unnecessary” second internship, I made my list of “split” affiliations, to make me a well-rounded clinician. And, my list looked like this:

  1. Orthopedics/Vestibular Rehab
  2. Orthopedics/Aquatic Therapy
  3. Orthopedics/Women’s Health

And guess which one I got? Yep, you got it. Orthopedics/Women’s Health. My third choice. I was assigned to a 5 month rotation in Shreveport, Louisiana, interning both at a Sports Medicine Clinic and a Women’s Health Clinic, with the most amazing and inspiring Darla Cathcart, PT, DPT, WCS (now a good friend, and always a great mentor).  And you could say, the rest is history.

I fell in love with the pelvic health population within the first few weeks. I remember one of the first patients I treated was a young woman suffering from severe pain with sexual intercourse. She had been experiencing this pain for more than 10 years, and had several relationships end by her inability to participate in sex. I remember the day she came in and tearfully told us that she had been able to have sex with no pain for the first time in her life. I get goosebumps even typing it. It was then, in that moment, that I knew, I just had to treat this population. 

So, from that moment forward, I was in. I spent all of my free time researching pelvic health problems. I attended 2 continuing education courses as a student. And that amazing neuro rotation I was looking forward to? I spent my days off observing with their pelvic floor specialists. I even did my inservice on management of constipation in adults after experiencing strokes. You see? I was 100% in. And I have been ever since.

So, why in the world would I want to be a pelvic health PT? 

  • Because close to 50% of women and 25% of men experience urinary incontinence in their lifetimes, and close to 90% have a difficult time telling their healthcare providers about it, and seeking treatment.
  • Because 10-15% of people experience chronic pelvic pain and have to see an average of 6 different healthcare providers before getting the help they so desperately need.
  • Because almost 1 in 5 women experience pain with sexual intercourse

These people need us. They need me. And honestly, I need them. I learn about perseverance as I help my patient who has had chronic pain for 10+ years work hard and fight to move forward toward a pain-free life. I learn about courage, as I see the strength in the young lady I am helping overcome pain with sexual intercourse as she decides to try again for the first time. I learn about bravery as I listen to my patient who has been struggling with leaking urine tell me about spending the day shopping without wearing a pad.

The truth is… my patients change me every day as much if not more than I hope I can help to change them. And that, my friends, is why I am thankful every day to be in this profession. That, is why I am a pelvic health physical therapist.

Got pelvic health problems? There’s an app for that!

Technology in our current time is incredible. With our smartphones so quickly at our finger tips, we have apps for pretty much everything. Need to find a good restaurant near by? There’s an app for that. Want to quickly edit your photos into beautiful photo masterpieces? Just download the app. Last year over Christmas, I even found an app that turned anyone’s face into Santa Claus. (The results were amazing if you’re wondering).

And pelvic health is no different. There are so many apps available for people with pelvic problems or for general men’s and women’s health needs. I absolutely love apps for my patients that help them with the problems they’re experiencing or enhance their home programs. Here are some of the great ones out there! (Note: Special thanks to my colleagues on the Women’s Health Physiotherapy Facebook Group who added their suggestions to this list. I plan to keep this updated regularly so it can be a great resource for colleagues and our wonderful patients!) Enjoy!

Apps

 

Bladder/Bowel problems:

  • iDry: Free version includes a tracker for pad usage and bladder leakage. Premium version includes options for interventions (including pelvic floor exercises!), a more detailed chart tracker, reminders, and options to send to your health care providers!
  • UroBladderDiary: This app costs $1.99 but allows tracking of urinary frequency and volumes, leakage, and fluid intake. Also allows tracking of urgency level. Allows conversion to a PDF to e-mail to health care provider.
  • Bathroom Map: For those struggling with strong urinary or bowel urgency and/or incontinence, this app may become your best friend! It uses your location to quickly identify all of the restrooms nearby. It also grades each bathroom as green, yellow or red to indicate the availability of the restroom, comfort and cleanliness of the facility.
  • Poo Keeper: This app is a  quick tracker for someone struggling with bowel problems. Allows you to snap a quick photo of your stool and track your stool consistency.
  • BM Classic: For those with bowel problems, this app not only allows you to track your bowel frequency and stool consistency (using the awesome Bristol Stool Scale), but also allows you to track stress level, water intake, and dietary habits. Could be a great resource for someone struggling with bowel problems.

Pelvic Floor Exercises:

  • Squeezy: This app was designed by pelvic physiotherapists in the UK and is endorsed by the NHS. It allows for a personalized exercise program, has reminders, visuals and keeps a record.
  • Kegel Trainer: This app includes information on how to use pelvic floor muscles, and has various levels of exercise based on different contraction/relaxation intervals. Free version only includes first level, paid goes up to 15 levels. Includes reminders and an exercise tracker.
  • Pelvic Floor First: This is an awesome organization out of Australia, and I have used their website and handouts frequently for my clients for the past several years. Their app definitely does not disappoint! It offers a nice progressive exercise routine for someone struggling with pelvic floor weakness (like we commonly see with urinary incontinence, pelvic organ prolapse, and postpartum difficulties). The programs go from Starting Out (30 min), Moving On (40 min) to Stepping Up (50 min). Just be sure to chat with your pelvic PT before you jump in the program!
  • If you prefer a device for strengthening (and your pelvic PT thinks that would be helpful to you!), the following are apps that sync to insertable devices: Pericoach, Elvie, KGoal
  • BWOM: This app is great because it starts with a short quiz to help identify where someone may have a pelvic floor problem. It then has exercise programs (available for a small $$) based on that problem, including relaxation exercises! Designed by pelvic physios.
  • GoldMuscle: This app is focused on improving sexual performance rather than on those who may have pelvic health problems, so definitely has a different look to it. It includes various programs to focus on both endurance and quick contractions of pelvic floor, allows you to track progress, and get reminders for your exercises.

Pelvic Pain/Relaxation Apps:

  • RelaxLite with Andrew Johnson: This is one of my personal faves. Basically, it’s a 10-15 min guided progressive relaxation. He has a paid version too with lots of additional upgrades, but the free meditation is great!
  • Headspace: Free version includes a free 10 minute meditation to teach basics of meditation. Upgrade provides access to tons of different meditation options. Great way to start learning meditation.
  • Calm: Another great meditation app. Free version includes the “7 days of Calm” introductory program to learn the basics of mindful meditation, and also incluees access to soothing sounds to help relieve stress. Upgrade allows access to all of the different meditation programs (for sleep, calm, etc)
  • Insight Timer: Meditation community app, includes a timer to track meditation with different sound options, and includes over 1300 guided meditations. Also includes discussion groups and meet-up groups.
  • Binaural- Pure Binaural Beats:  This app allows you to listen (use headphones) to various sounds to promote brain wave activity correlated with relaxation, meditation, problem solving and activity. And all of it’s free!

Women’s Health: 

  • iPeriod: Paid versions only. Use to track periods, ovulation and fertility; Graphs of data available and includes availability to export data to take to physician visits. Lots of personalization options too!
  • Clue: Period tracker that predicts dates for your next period, and also allows you to track symptoms as they relate to your cycle (including pain, which is awesome!)
  • My Days: This app tracks and predicts periods, ovulation and fertility. Also allows options to track basal metabolic temperature, cervical mucus and cervix for those trying to become pregnant.

Pregnancy/Postpartum:  

  • Pregnancy Pelvic Floor Plan: This app by the Continence Foundation of Australia has both a tracker to see weekly milestones during pregnancy, but also has great information on pelvic floor health. Includes option to receive regular reminders to perform pelvic floor exercises.
  • Gentle Birth: This app promotes a positive pregnancy and birth experience. Includes mindfulness, breathing techniques, affirmations and hypnosis, combined with evidence based research. Customized programs based on the woman’s needs. Free for a sample program, then requires paid subscription.
  • Mind the Bump: Meditation app geared toward pregnancy/postnatal populations. Includes different meditations for different periods of time (first trimester-postpartum)
  • Pregnancy Exercise- Weekly Workout: This app by Oh Baby! Fitness (based out of Atlanta, and generally very evidence-based!) includes a new exercise for every week of pregnancy based on pilates, yoga and strength training. Through 10 weeks is free, then $5 to unlock the rest of the weeks.
  • Rost Moves: This app provides recommendations for body mechanics/movement options when performing different regular home activities. Especially a great app for new moms or pregnant women with pelvic girdle/low back pain.

Hope  you found this helpful! Did I miss any of your favorite apps?? Let me know in the comments below! I plan to update this page regularly for new apps we discover! Have a great week! ~ Jessica

The benefits of slowing down

“Ok, let’s try that again, but I want you to do it a little bit more slowly.” 

“Let’s see if you can do that with a little bit less tension.” 

“Do you feel how your neck is working while you’re trying to move your hips? Let’s see if you can do that with only moving your hips.” 

These statements (or variations of them) are ones I tend to make most days of the week. One of the most common things I notice in the men and women I treat with persistent pelvic pain is difficulty in modulating tension. I generally can see this from the moment they walk in my office:

  • Gripping postures, sitting with the shoulders elevated, gripping the chest or the glutes, tightening the back.
  • Minimal variability of movement (basically meaning it is difficult for them to move in different patterns, fully bend and rotate their spines and hips, etc)
  • Altered breathing patterns with poor diaphragmatic excursion

This type of high-tension behavior often occurs in conjunction with a dominant sympathetic nervous system (which we have discussed several times in the past– read here and here). In these cases, the body will feel constantly threatened (makes sense if you’ve had pain for a long time and don’t seem to get better) which can lead to the “fight-or-flight” response being pushed into overdrive. When this occurs, we typically see amped up muscle tension, changes in breathing patterns, and many additional physiological compensations (which you can read more about here). And, I believe this pattern tends to also lead to an overly gripped, hypervigilant pelvic floor muscle group. Then, what I typically see is that instead of the pelvic floor activating with variability, based on the required task at hand (meaning, small amounts of activation for small tasks, and large amounts of activation for bigger tasks), we will instead see loss of force modulation with very high amounts of activation for basic tasks and an inability to let go of that force for simple tasks or tasks that require relaxation (bowel movements, sex, etc).

So, with all of that being said, one of the best things a person with persistent pelvic pain can do is to learn to slow down and control his or her tension patterns. My patients typically begin working on this within the first week or so of treatment, and we continue working on this throughout the initial phase of their care. Basically, our goal is to create awareness of movement–to move mindfully and truly feel what the body is doing to accomplish a task. Typically, as a person becomes more mindful of the movements he or she is performing, we will see an alteration in the force required to perform the movement and this, along with other treatments we are working on, encourages a shift of the body from an overly sympathetic state to a more neutral one. 

So, how can you get started with slow and mindful movements if you are struggling with persistent pelvic pain? 

First, if you are already working with a pelvic PT, talk with them about your tension strategies. Ask her if she has noticed you moving with higher tension and discuss with her integrating slow and mindful movements within your treatment program. If you are not in pelvic PT, or wish to try something on your own, here is one of my favorite exercises to start with:

The Pelvic Clock 

  • This exercise is adapted from a Feldenkrais movement (I believe). I love it because I can integrate diaphragmatic breathing with pelvic floor relaxation, and it encourages awareness of the movement of the pelvis. I tend to find that many people with pelvic pain have difficulty truly knowing where their pelvis is in space and how it moves, and this exercise can help to improve that.  So, let’s get started.

Pelvic Clock

  • Begin in a relaxed comfortable position, lying on your back with your knees bent and your feet resting on the mat (bed, floor, whatevs). Visualize a clock sitting on your pelvis as is shown in the picture above.
  • Start with slow, diaphragmatic breathing. Remember, breathing with your diaphragm will allow the ribcage to expand in all directions, the belly and chest will lift, but the muscles of your neck and shoulders should stay relaxed. If you have not read much about diaphragmatic breathing, read this post and its links before moving forward)
  • Next, we will start to integrate your pelvic floor into your breathing. So, on the next inhale, visualize the breath allowing your pelvic floor to lengthen and relax. This should not be something forceful (ie. don’t push out your pelvic floor), but rather, just focus on letting go of tension as you inhale, allowing the pelvic floor to gently lengthen and the abdominal wall to let go of any tension.
  • Next, we will add in gentle movement of the pelvis with your breath. As you inhale, the pelvic floor will relax and pelvis will gently tilt toward 6 o’clock (allowing the tailbone to fall toward the mat). As you exhale, gently tilt the pelvis back to 12 o’clock allowing the low back to slowly come into contact with the mat. Repeat this slow pattern, focusing on trying to use small amounts of muscle tension to accomplish the task. Remember that this movement and really any other movement should not cause you to guard, tense your muscles or drive up any of the pain you are experiencing.
  • Once you feel confident and comfortable with the previous step, you can begin to add the rotational component. This time, as you inhale, slowly rotate the pelvis around the clock shifting from 12 –> 3 –> 6, ending in the position where your tailbone is gently dropped toward the mat. As you exhale, allow the pelvis to rotate from 6–> 9–> 12, ending in the position where your low back is gently resting on the mat.  Repeat this pattern for several breaths, then try to reverse the motion (inhaling as you move from 12 –>9–>6 and exhaling from 6–>3–>12)
  • Challenge yourself further by trying to allow the pelvis to move through all the numbers of the clock (12–>1–>2–>3… etc).

Remember, there is no rush to performing this exercise! The purpose is awareness– to really feel your pelvis move and shut off any additional tension in performing the task. Did you feel your neck tighten as you were moving? Try again with a focus on keeping it relaxed. Are your legs tightening and moving frequently as you move through the clock? Try to see if you can calm that tension and isolate the movement to your pelvis. Do you feel your pelvic floor gripping as you move? Try to see if you can keep the emphasis on relaxing the pelvic floor during your breathing.

Are you thirsty for more? 

A few of my other favorites for slow, mindful movements are found in both Yoga and the Feldenkrais method. I love Dustienne Miller’s (she’s a pelvic PT too!) home video, yoga for pelvic pain and have had many patients benefit from using it. I also enjoy the Awareness Through Movement lessons with the Feldenkrais Method. Several free online lessons are available here via the OpenATM program.

I hope you have found this helpful! What other movements have you found helpful for pelvic pain? Pelvic PTs and patients, feel free to chime in, so we can all keep learning together!

Happy Wednesday!

~ Jessica