Monthly Archives: January 2015

Throw-back Thursday: When “Kegels” are not appropriate for Urinary Incontinence

For the next few weeks, I plan to re-blog/update every Thursday a previous post originally written by me when working in Greenville, SC for the Proaxis Pelvic PT blog (http://proaxispelvicpt.wordpress.com), in hopes of building a comprehensive library of posts at jessicarealept.com. Selfishly- I like having them all in one place since I often refer patients who come to see me in Atlanta for pelvic PT to my old posts to read as “homework.” 

That being said, today’s post is one published a while back here, originally titled, “Yes, you have incontinence. No, I do not necessarily want you to do Kegel exercises.” It has been modified/updated for you today 🙂 Enjoy! 

~ Jessica 

Recently, I was fortunate to evaluate a nice middle-aged woman referred to me by her urogynecologist for urinary incontinence. When we first sat down, she looked at me and said, “I’m not sure why I am here. My doctor specifically told me that I have a strong pelvic floor. I really don’t think you can help me.” I smiled. I hear this same thought process on a weekly basis (See my previous article on common misconceptions of pelvic physical therapy) You see, at some point the world became convinced that from a musculoskeletal perspective, stress urinary leakage is always due to a weak muscle. And the best way to fix a failed muscle is to strengthen, strengthen, strengthen. But, if that’s the case, then why do I have so many patients walking into my office telling me that they have done “Kegel” exercises and still leak? Why would a patient like the one above have a “strong” pelvic floor that cannot hold back urine? Why is urinary leakage associated with low back pain and pelvic pain- disorders that we know can often include tight and irritated pelvic floor muscles?

Now, as a caveat to this article, let me say now that it is sometimes totally appropriate for a person to start a pelvic floor strengthening program. In fact, the person with a truly weak, overstretched, poorly-timing pelvic floor will likely be prescribed a strengthening program. With that being said, the truth is that the majority of patients referred to my clinic for evaluation of urinary incontinence are not issued a traditional kegel exercise program. My colleagues and I actually tend to be surprised when we evaluate a new patient who truly needs to start a true “strengthening” program for their pelvic floor at the first visit. The reason behind this is that Stress incontinence is not simply a failed muscle, but a failed system.

The urethra is supported within the continence system by fascia, ligaments, as well as muscular structures. When a downward force is applied to this system as occurs with coughing, sneezing, lifting, bending, etc, these structures function in a coordinated way to compress the urethra and prevent urine from leaking. In fact, Hodges et. al. in 2007 examined musculoskeletal activation occurring when a person performed an arm movement and found that the pelvic floor muscles pre-activated to prepare the body for movement. This helps to demonstrate that our pelvic floor muscles function as a member of the anticipatory core team. This team requires optimal and coordinated function of the diaphragm, the deep abdominal muscles, the deep low back muscles as well as the pelvic floor muscles. My awesome colleague, Julie Wiebe demonstrates that relationship very well in the video below (Note: Julie has an AWESOME blog/website- read more of her stuff here):

When any of these structures are not functioning well, leakage can occur. Now, the tricky part here is that optimal functioning requires both strength, flexibility and proper timing. A tight irritated muscle then becomes equally as dysfunctional as a weak over-stretched muscle. And, a strong, flexible muscle that doesn’t have the right timing contributes to a very dysfunctional system.

So, treatment for incontinence then must include retraining and reconditioning the system to ensure its proper functioning—which for me includes a bit of detective work to truly identify the faulty components. And, when it comes down to it, typically does not include doing 100 kegel exercises a day. More often, it includes learning to relax the pelvic floor and teach the pelvic floor to be a working team member– learning to coordinate the pelvic floor with the diaphragm, eliminating trigger points and restrictions which may be inhibiting this function, and then retraining the motor control of the lumbopelvic girdle as a system.

So, for now, take a deep breath and relax. We’ll save Kegels for another day.

For more information, check out the following:

I hope you enjoyed this throw-back- please feel free to share any thoughts or questions below!

~ Jessica

Partners in Health: Building a Strong Patient-Provider Relationship

doctor-1228629_640

In my mind, one of the most important aspects of patient care is building a strong patient-provider relationship. I find that treatment outcomes truly depend on the patient being able to trust the provider and the provider truly listening to the patient. For many patients, seeking treatment can be intimidating and produce fear—of the unknown, of what the diagnosis could be, etc! This fear can lead to patients feeling a need to hold back thoughts or beliefs and can ultimately create barriers in treatment which leads to frustration by both the provider and the patient. Providers, on the other hand, can often contribute to fear or stall progress without intending to by not individualizing treatment and partnering with patients.

So—this post is for all of us! These are a few of my thoughts—both advice for the patient and for the provider on how to better build a partnership in healthcare. But more importantly, I want to hear from you. So, read on, and comment at the end so we can all learn to work together better and improve the way we deliver and receive healthcare.

For the patient:

  1. Remember that you have control: I have had several instances where a patient will say “yes” to a prescribed medication or will feel pressured into having a surgery that he or she really did not feel comfortable in having. If a physician, PT or other healthcare provider recommends a treatment that you are uncomfortable with, don’t be afraid to speak up and say so! Remember that we as providers want to help you get better as quickly as we can. If you are unhappy with the treatment plan, that won’t happen!
  2. Don’t be afraid to speak up: Many times, we as providers forget that not everyone has the same background knowledge we do when it comes to the human body. If you are being told something you don’t fully understand, speak up! I always thank my patients when they ask me questions because helping you understand and feel understood is such a key piece of my practice. Often times, those questions help me personalize treatment approaches and often I find we end up in a better place by those conversations we have. Along with that, don’t be afraid to question the treatment approach your PT/provider is recommending. Did you read a blog or article which recommended something different? Did your friend hear of a new treatment approach? Share those thoughts and ideas! I love to have those conversations with my patients because often times there are specific reasons why I recommended what I did and having that conversation helps both of us to be on the same TEAM. Occasionally patients may suggest new treatment approaches I am not as familiar with—and that’s great! That gives me an opportunity to learn and work together with my patient to determine how we should proceed.
  3. Make sure your goals are being addressed: If your goal is to be able to walk around the house, make sure your provider knows that! Sometimes there can be a mis-match between what your provider thinks your goal is and what your goal actually So, speak up! Let us know what you hope to get back to so we can work together to help you move!
  4. Be open to new ideas: When it comes down to it, we (the providers) do genuinely care about you and want you to get better as quickly as you can! Sometimes your provider may suggest something that seems “weird” or “unconventional,” but listen to what they have to say! I have had many patients who initially were hesitant about a treatment I recommended then later were SO glad they chose to give it a try!

For the provider:

  1. Listen to your patient!: When I was in PT school, I remember having a professor say to me, “If you listen to the patient, they will tell you what is wrong with them!” Seems so simple, but often our minds jump to immediately categorizing the patient and planning ahead to our next steps. So, let’s all stop, take a breath, and give our patients a chance to tell us what they need to tell us.
  2. There is no “I” in TEAM: To truly help a patient achieve optimal results, we have to partner with our patients and develop a treatment plan that is unique to them and their goals and values. For example, if I think my patient would benefit from doing a yoga/pilates routine but my patient hates that type of exercise, our plan is ultimately not going to be successful. However, that patient may love to swim and lift weights, so we could develop a program that might achieve the same goal in a method the patient will enjoy.
  3. Don’t be afraid of “not knowing”: Sometimes we become anxious if we do not know the answer to a question a patient asks or if we reach a point where we are not really sure how to proceed to help the patient achieve the results that patient is hoping for. I am often shocked how admitting I do not know but will work to learn actually builds a stronger patient relationship! Trust is not only in being able to help, but also in knowing when you need to seek answers from elsewhere. So, be vulnerable. Admit you do not know. Seek additional consultations or refer out if you need to! In the end, the patient is the one who will benefit from your humility.
  4. Watch your language!: No, I do not mean avoid cursing with your patients (that’s a no-brainer!), but be careful with what you say and how you explain things. My sister went to physical therapy and was told, “Your rib on one side is ‘out of place’.” She totally freaked out—not knowing what that meant, she worried something was structurally wrong with her body. She was scared, and guess what? Her pain actually got worse that week. Recent studies have shown that our words do not always mean the same thing to us as they mean to our patients. Check out this awesome blog post by Matthew Low which summarizes several studies on the subject. Pay attention to what you say and make sure your words promote healing and health—not fear!

Let’s partner together and work toward better health! These are just my thoughts…. So, what do you think?

Patients- What would you like your health care providers to know to better help you in your recovery? Have you had any bad experiences with providers you would like us to learn from?

Providers- What would you like patients to know when coming to see you? What can we all do to work together better?

Cheers!

~ Jessica

Interview on PT for Urinary Incontinence in Greenville News

A few months ago, I had the opportunity to be interviewed for a story in the Greenville News on Urinary Incontinence.

Many women (and men too!) don’t realize that there are effective non-surgical options for UI. My hope is that articles like this can help spread awareness and encourage people to be proactive in seeking out help! Women’s Health and Pelvic Floor Physical Therapy can make a huge difference for people struggling with these problems!!

Enjoy the article here! Will be added to our News page for future viewing!

Happy Thursday!

Taking the first step: Getting moving when experiencing chronic pain

active-84646_640

As many of you know, I recently took a huge step in my career and moved to Atlanta with my husband, accepting a job as a pelvic health physical therapist for a newly opening private practice with One-on-One Physical Therapy. Leaving my patients behind was one of the hardest parts of moving (if you’re reading this prior patient, I miss you!). One of the things I realized when working to find colleagues to treat my current patients was that I treat quite a number of people with chronic pain. And I love it. When I left Greenville, I would estimate that close to 50% or more of my caseload were men and women who had been experiencing pelvic pain for 6 months or more (and many of them, much longer than that!). Often times, people experiencing chronic pain feel trapped in an inactive state—fearing movement, exercise and even social activities as they correlate increased activity with increasing pain. The sad truth about this is that reality and current research tends to show the complete opposite:

Movement is medicine for chronic pain.

 Now, let’s take a step back…

What is chronic pain and what isn’t it?

 I promise this blog post is going to stay on track. Honestly, there are so many people much smarter than I am who have written amazing books, articles, and blog posts on understanding chronic pain. So, I will be succinct here, but give you some good resources at the end if it leaves you thirsty for more.

In short, all pain is produced by the brain. (Your pain is real, not all in your head, but the brain is always really involved!) Pain is an alarm system used by the brain when it perceives damage or even sees a threat of damage to the body. Pain is there to motivate the body to action—basically to help you eliminate the source of “threat.” Example: I step on a tack. I feel “pain.” I move my foot off of the tack.

This alarm system works really well for situations like the one above. There is a threat. We remove the threat. We feel better. But it is important to recognize that the amount of pain does not always correlate with the amount of damage. Example: A man walks into the emergency room with a knife sticking out of his leg, but isn’t experiencing “pain.” A papercut can be felt as VERY painful.

 The point is, the brain takes information in about our current situation, past experiences, emotions, etc. to create an experience of pain that it perceives as useful to us for the time being. This experience is influenced by situation (i.e. needing to get to the emergency room so the knife doesn’t “hurt”) emotion (i.e. No one knows what is wrong with me, so it must be really really bad!), fears (i.e. I am never going to be able to run again!), and life stressors (i.e. going through a divorce when the pain initially began).  

30d490ce9760c3202eca35538740017511b77faa

 So, how does this relate to movement?

For many people experiencing pain, movement often becomes a “threat” to the brain. For example, if a person is experiencing pelvic pain and the brain believes that walking will worsen the pain, then often walking will be a pain producing activity—to protect you from the “threat” of walking! Over time, the threshold for pain can change and people can become more sensitive to movements or activities—basically, the brain becomes very good at playing the pain “tune.” Lorimer Moseley uses the example of an orchestra in his book Explain Pain. If an orchestra plays the same song again and again, they become very very good at playing that song. Our brain works in the same way.

With that being said, we have learned that if we can help a person to move in a way that his or her brain is not protecting or guarding by pain, we can actually reduce the sensitivity to those movements and help a person get back to an active lifestyle with less pain. This is as true for a person experiencing chronic pelvic pain as it is for a person with chronic low back pain or neck pain or ankle pain.

Does it actually work?

 The awesome part is that research has shown that movement and exercise are extremely helpful in pain reduction!  A meta-analysis in 2014 published by the American Journal of Physical Medicine and Rehabilitation found that regular aerobic exercise improved pain, disability and depression/anxiety scores in people with low back pain. Another meta-analysis and systematic review published in 2014 by the Archives of Physical Medicine and Rehabilitation found that walking exercise helped to reduce pain levels in men and women experiencing chronic musculoskeletal pain. Even pregnant women with low back and pelvic girdle pain see benefits of exercise in pain reduction as noted in this 2012 review by the Journal of the Section on Women’s Health.

To see even more benefits of exercise, check out this awesome video by Dr. Mike Evans:

 

So, how do you get started if you hurt?

The key piece here is that we want to start moving at low pain levels in a way that will be therapeutic for your body—not in a way that will cause your body to guard and produce increased pain. When I treat patients with chronic pain, I start recommending movement at the first or second visit (of course, depending on the specific patient). Here is where I typically start:

  1. Begin with small, manageable movement goals: If you have spent the last 5 years moving from bed to the couch, it is probably not the best thing for you to begin a running program. For these people who have been very sedentary, I recommend starting small by aiming to walk around the house once every hour and perhaps adding in a small series of shallow squats at their kitchen counter along with a few other easy exercises. On the other hand, if you are fairly active, but have avoided regular exercise, try to slowly build up to a routine again. I generally recommend starting at 10-15 minutes and building up to 30-60 minutes depending on the person.
  2. Explore new and different exercise options: I have seen time after time that a person may be frustrated that she cannot do an exercise she enjoyed (i.e. running) so will stop exercising all together. Often times, I find that although one exercise may aggravate symptoms, another will be much more tolerated! I recently worked with a wonderful patient experiencing chronic pubic joint and pelvic pain—she loved walking for exercise, but found that walking was aggravating her pubic joint. We tried exercise in the pool, and she LOVED it! Not only could she begin moving again, but her pain seemed to stay at a low level while she exercised! So explore other options—walking, swimming, yoga, pilates, etc. Be open!
  3. Try not to be afraid of pain: Remember to see pain for what it really is! I often tell my patients that if an activity keeps their pain low or improves their pain, it is likely a good, safe exercise for them to be doing. That being said, sometimes patients will try an exercise and it will severely worsen their symptoms—and that is part of the learning process. Generally, we find if we hold off on that activity for a short time while finding another activity that is more tolerable, we can often return to the other activity at a later date with much lower levels of discomfort.
  4. Work with a team: I always recommend that my patients work closely with myself or another health care provider while they are getting back to movement. Sometimes, it is a little of trial and error learning what movement strategies are the most optimal to start with. Be patient, share your experiences, and be open to suggestion for different things to try!

 So, good luck! Get started, and let me know if you have any questions! Thankfully, I am not by any means the only person who has written on this topic, so check out these excellent resources from my colleagues working with people with pain.

 On Pain & the Brain:

 On Exercise for Pelvic Pain:

Do you have any other resources you love? What has worked for you in the past? PTs, what are your favorite suggestions to give patients? Let’s share and learn together in the comments below!

~ Jessica

Welcome!

Greetings and welcome to my professional website & blog!

I hope that you will find the information on this blog to be enlightening, thought-provoking, educational, and hopefully occasionally inspiring :)! I am creating this blog for both personal and professional reasons–both to help myself process information, learn more, and thus help my patients more, and also to spread awareness about issues related to pelvic health and thus hopefully create hope for many men, women, and children struggling with these problems.

The mission of this blog is to motivate, educate and encourage all people to adopt healthy movement patterns and attain optimal health of the whole body. Of course, my heart lies in the pelvis, but the pelvis lies in the body and thus, I hope to spread awareness regarding the importance of treating the whole person, not simply a single body part. My hope is that this blog will be a helpful tool for both individuals and professionals in better understanding how to care for the pelvis within the body as a system.

I also hope this can eventually become a forum for positive, helpful conversation and intellectual debate. I hope to create an atmosphere of learning where patients and professionals alike can grow together to work as a team to improve current healthcare practices. I also plan to use this blog to share information from courses, conferences and literature I learn from to hopefully assist in educating the community as a whole.

Please let me know if there are any topics you are interested in, and I will do my best to address them! I hope we can all enjoy learning and growing together!

~Jessica