Yes, I realize it’s Friday and I am one day behind on my throw-back. I’m sorry. Anyways, today’s post was published here in 2013 after I presented at the Greenville Interstitial Cystitis Support Group. I always love working with local support groups, and I am excited to be presenting to and learning with the Atlanta Area Interstitial Cystitis Support Group next month! I had such a wonderful time with those ladies and I was introduced for the first time to Barley coffee–yes, you heard me right–coffee made from Barley. For many people with bladder problems including Overactive Bladder, Interstitial Cystitis/Painful Bladder Syndrome, and Urinary Incontinence, regular coffee is not tolerated well and can exacerbate symptoms. Barley coffee is a great alternative that packs a great taste (I was skeptical too, but it’s true!) but doesn’t have the acid and caffeine which irritate. Check out my post, and give it a try!
In April 2014, I was fortunate enough to meet with a lovely group of ladies at their support group for people who have been diagnosed with Interstitial Cystitis/Bladder Pain Syndrome. (For those of you who are not familiar with this condition, you can read about it here) This is a fantastic group started by Martha Fowler, RN back in 2010. Since then, I can tell you that Martha has been an amazing support for several of my patients! So many times, people feel alone when struggling with pelvic pain conditions, and it’s nice to talk with others who understand first hand what you are going through. For those of you reading this who live in other areas (such as Atlanta, like me!) there are tons of other support groups out there for people with IC/PBS. The Interstitial Cystitis Association (ICA) has a great list here.
Anyways, before we got started, Martha introduced us to Barley coffee—I know what you’re thinking—weird, nasty, gross—but I was shocked that I actually enjoyed this concoction! When I first tasted it, I will admit, I poured myself approximately ¼ cup (assuming I would hate it), but I quickly went back, filled it all the way up and drank the entire thing! SERIOUSLY! I actually think I may keep this on hand to drink on a regular basis. I have long wanted to cut back on my caffeine intake, and really, this may be the ticket!
Why the need for Barley Coffee?
For people with Interstitial Cystitis (and other bladder/bowel problems), coffee can be quite irritating to the bladder. Coffee is a double-whammy of irritation—not only does it have caffeine, but it is also highly acidic. Mix this together, and you get a very unhappy bladder—and if you have IC/PBS, that equals pain and strong urges to urinate.
What is Barley?
Barley is a grain and a member of the grass-family. You may recognize it from being used as animal food as well as in beer, bread, soups and stews. The Whole Grain Council (yes, it exists) has listed several health benefits of eating barley including lowering blood sugar, decreasing cholesterol, and possibly with weight loss. And what about drinking it? Well, I will admit it’s not quite the same since you are not actually consuming the grain—but, it seems like a good option for your bladder! And it tastes pretty darn good.
Check out the recipe!
Martha’s Barley Coffee
Ingredients:
1 bag of barley (dry—looks like rice)
Water
Directions:
1. Roast barley over medium heat, stirring constantly until browned. (WARNING: Per Martha, this may cause some smoke, so make sure your kitchen is ventilated! Stirring constantly reduces likelihood of burning). Best to roast slowly as this decreases the likelihood of burning
2. Allow to cool completely. Store in airtight container until ready to use.
3. Add a few tablespoons of roasted barley to a pot of water and heat over medium. The longer you heat the water/barley the “darker” your coffee.
4. Strain out barley & save for later use! Serve in your best coffee pot with cream/milk & sugar.
I hope you enjoy this wonderful coffee substitute! What other substitutes have you used for dietary intolerances?
Now, before I get started, I have to say that there are many, many websites/blogs with information on how to find a pelvic PT. But, I felt it necessary to have a post here so that people reading this site who needed a pelvic PT have a quick resource to understand how best to find one, and how to “shop around” and know that the person he or she is seeing is skilled. I hope it is helpful to someone at some point! So, once you have determined you would like to see a Pelvic PT or a Women’s Health PT, how do you find one?
Databases and PT Locators:
There are two main PT locators for Pelvic Physical Therapists and they are: The American Physical Therapy Association’s “Find a PT” and Herman & Wallace Pelvic Rehabilitation Institute’s Practitioner Directory. The APTA’s directory requires an APTA membership and H&W’s is open to any practitioner. The benefit of these directories is that they will help you locate a practitioner nearby and will provide information on any credentials or areas of specialty that person has designated. The limitations are of course that there is no guarantee that a person listed is skilled in your specific need, so you will have to do a little more work from here. The APTA’s directory does provide a space for the PT to put more practice information, etc–so you get a little more information there.
Ask a friend…or the mafia:
Social media is amazing and has truly revolutionized healthcare. Now, patients are really able to have experts at their fingertips with facebook, twitter, linkedin etc. Asking for a personal recommendation can be a great way to find a skilled PT. Patient groups online are also great resources for finding someone skilled in your particular need.
The #pelvicmafia is a twitter community of pelvic PTs who are truly doing great things to advance patient care, share research, and improve practice patterns across the board. Feel free to ask us for a recommendation by tweeting #pelvicmafia after your question. If we know of someone skilled living near you, we will be more than happy to share!
Also, know that most pelvic PTs are happy to help you if you ask! I have gotten several random phone calls from patients living in different areas, and I am always happy to give a recommendation if I have one! Find a reputable clinic anywhere in the US, and most PTs will be happy to do the same!
Finding the right PT for you:
Once you locate a PT, you’ll want to reach out and talk with her to make sure she is a good fit for you. First, what’s in a name? There are a few specializations/credentials you may need to be aware of. Let’s go through the basics:
Entry-level degree- BS, MSPT, or DPT: The first few letters behind the PT’s name basically just give you some information on when that person received his or her initial degree. A while back, becoming a physical therapist just required a bachelor’s degree (4 years of study)–then it became a master’s degree (6 years of study)–then became a doctorate (7 years of study) ~ 10 years ago. That being said, many people who originally had a BS or MS have gone on to receive additional education to attain a transitional doctorate degree.
WCS (Women’s Health), OCS (Orthopedic), SCS (Sports), etc. Clinical Specialists: These letters will be behind someone’s name who has either 1) completed a residency in that specialty and passed a written examination or 2) had 2000 hours of experience within that specialty, completed a case study reviewed by a board, and passed a written examination. The current field of women’s health includes not just pelvic floor disorders in women and children, but also includes evaluation and treatment of breast cancer related musculoskeletal dysfunction, lymphedema, osteoporosis, fibromyalgia as well as female athletes. The WCS has been around for about 8 years (my educated guess).
BCIA-PMDB: This is a certification for using EMG biofeedback for pelvic floor muscle disorders through the biofeedback certification international alliance. Becoming certified requires 28 hours of education, a 4 hour personal training session and 12 hours of mentoring time reviewing 30 cases with a mentor. This also requires passing a certification exam. This has been around for a longer period of time in terms of the Pelvic specific certifications.
PRPC: This refers to the Pelvic Rehabilitation Practitioner Certification through Herman & Wallace. This test is offered to other health care practitioners as well, but of note requires 2000 hours of patient care and a written exam to attain. This certification is specifically focused on treating pelvic floor disorders and has only been around for about 1 year.
Other letters: I could spend quite a chunk of time defining all of the letters out there and still probably would miss quite a few!! Fellowships, certification programs, and even some continuing education courses will assign letters that a person can put after his or her name. I recommend looking at those letters, then typing them into google and finding out what they mean and whether they apply to you.
After you have decoded the PT’s name, ask about any continuing education the PT has had after graduation. This will give you insight into how that person has chosen to advance his or her education. In my mind, this is one of the most important pieces for many reasons.
Most entry-level programs have minimum to no training included on evaluating and treating pelvic floor dysfunction. I graduated from Duke University which has more training than most–but even that only included a few lectures and a short elective course. That being said, most Pelvic PTs end up being trained while on internship, residency or after graduating from school via continuing education courses.
The largest continuing education training programs are the APTA Section on Women’s Health (SOWH) and Herman & Wallace Pelvic Rehabilitation Institute. I am involved with both, have taken courses through both, and think both are wonderful programs! Both include training for internal examinations and treatments which is so important and both have plenty of lab assistants to help make sure participants know what they are doing. I lab assist for H&W and I am on the Educational Review Committee for SOWH. SOWH also has a certification option called “CAPP” for both Pelvic and Obstetrics to indicate a person has gone through the series of courses and passed a reviewed case study. Note: Although not all pelvic floor dysfunctions require internal vaginal or rectal treatment, I do believe that having formal training in this is important for a PT who is specifically treating pelvic floor disorders.
Internships: Some students who are interested in pursuing pelvic health or women’s health will choose to do internships working with clinicians in those fields. I did this as a student and worked with Darla Cathcart, PT, DPT, WCS in Shreveport, LA for 5 months (She’s awesome!) . I have taken 2 students from Duke University myself. These internships are a great way to learn and give you information that the person you are seeing has had one-on-one training.
Residencies: These are 1-year programs focused on treating women’s health physical therapy. There are less than 10 of these in the country, so if your PT has done a residency, it shows a strong commitment to education, in my opinion.
Other Continuing Education: I really think this is so important so cannot emphasize this enough. There are so many options for education including courses, conferences and national meetings. Feel free to ask the PT to see his or her resume or CV to see which courses have been attended and how they fit with what you need.
Hopefully this information helps you shop around and find a PT who fits what you need! Please do not feel lost or hopeless if you cannot find a pelvic PT who lives close by– the unfortunate thing is that there are way more people who need pelvic PTs then there are currently PTs to treat them! In the field of physical therapy, it is one of the “newer” specialties, so we definitely have room to grow! If you find a PT who may not have the training you desired– don’t fret! All of us had to begin somewhere, and there is so much to be said for a passionate, dedicated person who desires to learn! I have known PTs with less than 1 year of pelvic experience who I would easily refer to because of their passion and dedication alone!
Today’s throw-back comes from a guest blog post I wrote for Share MayFlowers in 2013. SMF is a wonderful public health and awareness campaign supporting female pelvic and perinatal health. Jessica McKinney, PT, MS founded this organization and is an amazing pelvic PT and advocate for women dealing with pelvic floor and perinatal related dysfunction. I was asked to guest blog for their campaign over the month of May, and shared the following case study to help illustrate how nothing in our body works in isolation. I hope you enjoy! ~ Jessica
Note: This case study was selected as it demonstrates the synergy within the body. Our bodies are meant to function in unity with each joint, muscle and ligament doing its part. When one structure does not function optimally, the entire person is impacted and often other structures will have to “pick up the slack.” This can create pain, instability and a loss of function. Treating the pain means treating the person—finding the weakened structure and helping the entire person regain the synergy they need to fully support their bodies.
Subjective History: Mary* was referred to physical therapy by a local Urogynecology team for chronic pelvic pain which had been occurring for the past year, slowly worsening over time. She reported that pain caused frequent nausea and impacted her ability to participate in athletic activities. Prior to the onset of pain, she was active in athletics at her high school, playing soccer, volleyball and ice hockey. She had no complaints of changes in urinary function, but noted occasional constipation. She was not currently having sexual intercourse, but reported some pain with sexual stimulation. She had been seeing multiple different physicians before being referred to the Urogynecology team.
With further questioning, Mary reported that she experienced a fracture of the tibia (at the knee) 1 year ago while playing soccer. She was immobilized in a brace for 1 month, but did not have physical therapy after her injury….
I love books. I love picking out a new book, flipping through the pages, and escaping for a small time into a different world. My love of reading translates so easily into my clinical practice in women’s health and pelvic floor physical therapy. Clients who have worked with me know that I keep a shelf of related books in my practice for them to look through and enjoy. I find books are so helpful for my clients experiencing related problems. Often times, men, women and children with pelvic health problems feel alone and so isolated. The reality is that these issues are private ones–I will often treat clients whose own spouses are not aware that these issues are occurring! And there are SO many great pelvic health books out there! The biggest thing I love about my clients reading books is that it helps the to realize they are not alone. So many other people have these problems too–so many that there are books written about it! I also think that reading information helps the learning process for many so much more than just hearing information spoken by me! My hope in “book reviews” is to share some of those awesome books with you, so you can read them, recommend them and learn from them! Whether you are a patient seeking information, a health care provider, or just an interested individual, I hope these reviews will be helpful! Enjoy!
from amazon.com
I am so excited to introduce you today to a wonderful little book called, Why Pelvic Pain Hurts by Adriaan Louw, Sandra Hilton and Carolyn Vandyken. These authors are all physical therapists and both Sandy and Carolyn are Pelvic PTs. To be honest, I’ve followed Adriaan Louw for quite some time now. I have read some of his other educational books such as Why do I hurt? and I have even listened to his online educational seminar via Medbridge called “Teaching People About Pain.” He’s brilliant–so I knew I would love this book from the moment I heard it was being published! Who should read it?
Men & Women experiencing chronic pelvic pain
Clinicians working with men and/or women experiencing chronic pelvic pain
Families & friends of people experiencing chronic pelvic pain
Length: 67 pages with great illustrations, broken into 5 sections.
Understanding your body’s alarm system
Understanding your extra-sensitive alarm system
Understanding your pelvic pain
Understanding your Lion and how it impacts you
Understanding your treatment options
What’s so good about it? As you may know by reading my blog, I love how the current understanding of pain is so much more than just tissue damage. Our nervous system is powerful and incredible, and is significant in the pain experience. Often times, clinicians run into difficulty when they start talking with clients about the neuroscience related to chronic pain– mostly because these people have had bad experiences in the past with people thinking their pain is “all in their head.” Louw does a great job of emphasizing that pain is a real experience no matter what situation it occurs under, but that pain does not always correlate with tissue damage. Hurt does not always correlate with harm. This book uses fantastic metaphors and stories to help drive home key points. The book begins in the first two sections by describing the nervous system’s involvement in the pain experience, and goes into detail as to how these systems become overly sensitized in a person experiencing chronic pain. I especially love the pages where the authors highlight all of the situations that contribute to a more sensitized system (such as failed treatments, family concerns, fear/anxiety, ongoing pain, etc.) as I think this is such a big piece for people to understand. The next section focuses on pelvic pain specifically, initially beginning with highlighting one of the major problems in overcoming pelvic pain (the “taboo”). They then go on to utilize a wonderful analogy of a measuring cup being “filled” by the 400 nerves in the body passing information to the brain. This measuring cup “overflows” when a large volume of information is being sent or when emotions/stressors surround the experience (like a flame heating the water in the cup). This metaphor is used throughout the book with treatment focused on helping the water to stop boiling over. The rest of this section goes through various diagnoses related to pelvic pain, but also emphasizes that the pain experience (from a neurological perspective) is the same in most diagnoses despite the differences in the symptoms. Lastly, the authors describe the difference between tissue problems and a sensitive nervous system.
Your metaphorical pain “cup”
Section 4 utilizes a fantastic metaphor of being under attack by a Lion and describes in detail how the body feeling under a constant threat of danger and in a strong protective response can contribute to experiences such as tender areas in the body, mood swings, appetite changes, fatigue… and much more! They also describe the other areas in the brain that are involved with pain and the overlap with different tasks (such as sensation, movement, and even memory!). They also maintain compassion and understanding for the experience unique to people with pelvic pain, and beautifully state, “At the core of being human, being alive, there are certain bodily functions that should not only be pain-free, but enjoyable…when you have pelvic pain, you’re not only robbed of pleasure, but the pleasure is replaced with pain. How unfair is that?”
Don’t worry- the book does not end here :). Section 5 discusses treatment options emphasizing that treatment should be aimed at stopping filling or emptying the “cup” or extinguishing the “fire” under the “cup.” Then, the authors systematically go through current treatments including knowledge/education, manual therapy, soft tissue treatment, specific exercises, graded motor imagery, aerobic exercises, medication, sitting posture, breathing/relaxation, sleep, stress management, and activity pacing/graded exposure. Under each of these categories, clear explanations are given as well as recommendations to get started! I could write a whole other blog post on these recommendations…but then you wouldn’t be thirsty for more, would you? So, all of that to say– this was a wonderful book! I strongly recommend it for men and women experiencing chronic pelvic pain– it’s an easy read, cheap, and offers clear recommendations to get started toward pain-free relief. Knowledge truly is power when it comes to recovering from chronic pain. Do you have any questions about the book? Have you read it yet? What books do you love and want me to review next? I would love to hear from you in the comments below! ~ Jessica
Today’s throw-back comes from a post I wrote back in November here. I loved writing this post because I love running. I also loved writing it because it falls close in line with my heart-felt belief that there is no “bad” exercise, just sometimes bodies that are not quite ready for it. I hope you enjoy the post, and I do look forward to hearing from you!
Happy Thursday! ~Jessica
As some of you may know, I recently completed my second half-marathon. To make it even better, I completed it with my amazing and wonderful husband Andrew:
4 miles in and feeling great!
This was my second half marathon in 1 year, and my third *big* athletic event—the other two being the Disney Princess Half Marathon and the Ramblin’ Rose Sprint Triathlon. I started out 2013 with the goal of being healthier and developing strategies for life-long fitness, and I really am proud to say that I am still well on my way to better fitness. (Although in fairness, the craziness of moving to Atlanta did set me back a few weeks! But I’m back on the horse now!)
Running the Disney Princess Half Marathon with my sister Tara and friend Jenna!
After completing my last half-marathon, I received the following question from a previous patient of mine,
“Ok, I have to ask, after seeing your race pictures, isn’t running bad for a woman’s internal organs??”
My initial thought was to respond quickly with a, “Not always, but sometimes…” type of response. But then it got me thinking, and inspired me to really delve into the issue with a little more science to back my thought—although honestly, the gist will stay the same.
So… Is running bad for the pelvic floor? Let’s take a look.
When someone initially looks at the issue, there may be the temptation to respond with a resounding, “YES!” We initially think of running and think of “pounding the pavement,” identifying large increases in intra-abdominal pressure and assuming that this pressure must make a woman more likely to experience urinary incontinence and/or pelvic organ prolapse.
But, what does the research really show?
1. Urinary incontinence during exercise is common and unfortunate.
Jacome 2011 identified that in a group of 106 female athletes, 41% experienced urinary incontinence. However, they also found that UI in those athletes seemed to correlate with low body mass index.
2. High impact athletes often may require more pelvic floor strength than non-athletes.
Borin 2013 found that female volleyball and basketball players had decreased perineal pressure when activating their pelvic floor muscles compared to nonathletes which they concluded placed these women at an increased risk for pelvic floor disorders and especially UI.
3. Over time, physically active people are not more likely to have urinary incontinence or pelvic organ prolapse that non-active individuals. ******
Bo (2010) found that former elite athletes did not have an increased risk for UI later in life compared to non-athletes (although she did find that women who experienced UI when they were younger were more likely to experience UI later on in life).
In another study, Bo (2007) found that elite athletes were no more likely to experience pelvic girdle pain, low back pain or pelvic floor problems during pregnancy or in the postpartum period compared to non-athletes.
An additional study by Braekken et. al. (2009) also did not find a link between physical activity level and pelvic organ prolapse. However, they did find that Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP.
Is your head spinning yet?? Let’s make some sense of this research…
First, it does seem like UI is a common problem in athletes—the cross-fit video that had all of my colleagues up in arms identified this problem really well—and honestly, runners are no exception to this. Every week, I work with women who experience urinary leakage when they run or may have even stopped running due to leakage, and I can assure you this causes a huge impact to these women’s lives. I also can assure you that there are many women out there dealing with leakage during running or other exercises who suffer in silence, too embarrassed to get help or somehow under the impression that leakage with exercise is normal.
With that being said, I am not ready to throw away running or really any other form of exercise all together (other than sit-ups…let’s never do those again). Running has amazing benefits—weight control, cardiovascular improvements, psychological improvements/stress reduction—and these should not be cast aside due to a fear that running could cause a pelvic floor problem.
As a pelvic floor physical therapist working in a predominantly orthopedic setting, I see many men and women enter our clinics with aches and pains—and injuries—that began while starting or progressing a running program. Often times, our amazing PTs identify running gait abnormalities, areas of weakness, or biomechanical abnormalities which can be contributing to hip/knee/foot/etc. pain with running. Improving those movement patterns and improving those individual’s dynamic stability seems to make a huge difference in allowing the client to participate in running again without difficulty.
To be honest with you, I see pelvic floor problems in runners the exact same way. When a woman comes into my office complaining of urinary leakage during running, I look to identify running gait abnormalities, areas of weakness or biomechanical abnormalities which are impacting her body’s ability to manage intra-abdominal pressure during running.(And no, intra-abdominal pressure is not always the enemy–see this from my colleague Julie Wiebe) I also make sure I am managing other things—identifying pelvic organ prolapse when it may be occurring and helping the woman with utilizing a supportive device (tampon, pessary—with collaboration with her physician, or supportive garment if indicated), managing co-existing bowel dysfunction or sexual dysfunction, and making sure the patient has seen her physician recently to ensure she is not having hormonal difficulties, underlying pathology or medication side effects which could worsen her problems.
We know that intra-abdominal pressure is higher when running. A poster presentation at the International Continence Society in 2012 identified that running does in fact increase intra-abdominal pressure compared to walking—but not as much as jumping, coughing or straining (Valsalva). And not as much as sit-ups…
Kruger et. al. ICS Poster Presentation, “Intra-abdominal pressure increase in women during exercise: A preliminary study.” 2012
As you know by now if you follow my blog posts, I do not believe that the pelvic floor is the only structure involved in managing intra-abdominal pressure increases in the body. (This is why I get so annoyed with all of the studies trying to look at the effectiveness of pelvic floor muscle exercises used in isolation in treating pelvic floor dysfunction). The most current anatomical and biomechanical evidence supports the idea that the pelvic floor muscles work in coordination with the diaphragm, abdominals, low back muscles as well as even the posterior hip muscles to create central stability and modulate pressures within the pelvis. In order for a runner to not leak urine or not contribute to prolapse or pelvic floor dysfunction when she runs, she needs the following(well really, more than this…but let’s start here):
Properly timing diaphragm—that is used appropriately as she runs so she is not participating in breath holding during her exercise
Strong and adequately timed abdominals and low back muscles to assist in stabilizing her spine/pelvis and assist in controlling IAP.
Flexible and appropriately firing gluteal muscles to support her pelvis during each step as she runs
Appropriate shoes to support her foot structure and transfer the loads through her legs
A great sports bra to help her use good posturing while running
Now, is there a time when a woman shouldn’t run?
Yes, I do actually think there are times when running does more harm than good and it may be advantageous for a woman to take some time off from running to restore the proper functioning of structures listed above.
If a woman has pelvic organ prolapse, for example, she may need to take some time off from running and participate in other exercises emphasizing functional stability with less of an increase in IAP prior to resuming an exercise program. Some women can return to running in the meantime using a supportive device like a pessary or tampon to help support her organs; however, this may not ultimately mitigate the harm if a person is not stabilizing properly as she runs.
I also recommending taking a break from running if a woman is leaking significantly during running or experiencing pain with running. I generally believe that once these structures are appropriately restored to function, women can return to running with less difficulty.
The other time I will often recommend waiting is when a woman is further along in her pregnancy or early post-partum. At this time, the increased weight on the pelvis as well as the loss of stability occurring due to hormonal changes places a woman at a higher risk for pelvic floor dysfunction. This, of course, varies based on the individual, but in many cases it may be helpful for these women to choose alternative exercises until after they deliver their children. Most women who are pregnant who I have worked with tell me that they reached a point in running when it just “didn’t quite feel right.” I generally recommend holding off when that occurs, then restarting postpartum once their bodies are feeling up to it again.
And lastly, I do recommend a woman holds off on running immediately after gynecological surgery (no-brainer here folks). The research does not indicate that said woman should never return to running—but again, I do think she should allow her body to heal and build up the appropriate strength and coordination needed to support her organs and her pelvis when running.
This post got a little longer than I originally anticipated… so to sum it up… is running bad for your female organs? Not always… but sometimes.
Many of my colleagues have some fantastic blog posts regarding exercise and pelvic floor dysfunction. Check out a few of them below:
Vlog by Julie Wiebe providing an alternative to running:
What do you think? Let me know in the comments below!
~ Jessica
References:
Bo K, Backe-Hansen KL. Do elite athletes experience low back, pelvic girdle and pelvic floor complaints during and after pregnancy? Scand J Med Sci Sports. 2007 Oct;17(5):480-7. Epub 2006 Dec 20.
Bo K, Sundgot-Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life that non-athletes?
Borin L, Nunes F, Guirro, E. Assessment of pelvic floor muscle pressure in female athletes. PM R. 2013 Mar;5(3):189-93. Scand J Med Sci Sports. 2010 Feb;20(1):100-4
Jácome C, Oliveira D, Marques A, Sá-Couto P. Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet. 2011 Jul;114(1):60-3.
Urinary urgency, frequency and incontinence are complex and involve the interactions of multiple systems (somatic, visceral and neurological). These three problems are treated commonly in pelvic physical therapy and women’s health physical therapy practices. Urgency suppression strategies were initially developed based on these systems- with the understanding that the pelvic floor muscles were not contributing their part to the system. In my opinion, this was largely based on the understanding the incontinence/urgency occurred when the pelvic floor muscles were not strong enough to properly hold back urine. But, over time we have learned that this is not always the case. (See my recent post here).
So, do the same urgency suppression techniques apply for a tender pelvic floor muscle group? Hhow should urgency suppression techniques be modified for the overactive, shortened or hypervigilant pelvic floor?
To understand this, I first need to introduce you to the standard urgency suppression techniques.
Now, please don’t take this as “Jessica doesn’t think urgency suppression techniques work,” because that is simply not true. I use these in the clinic all the time—for my patients who are experiencing urgency or urge incontinence and have weak, under-functioning pelvic floor muscles. These techniques work for this population a few different ways:
Deep breathing facilitates the parasympathetic nervous system which helps to keep the walls of the bladder relaxed thus allowing the bladder to fill and decreasing urgency. This breathing also helps to decrease the emotional fear that a person may feel (“Ahh, I hope I make it to the bathroom!”) which also will calm urgency due to the impact this has on the brain.
Strong, quick, contractions are thought to stimulate the neurological connection between the pelvic floor muscles and the bladder. Basically, quick contractions tell the bladder “it is not yet time to empty” and the bladder relaxes its contractions (which make us feel the strong urge) helping to calm urgency.
Distraction/Visualization are ways to get the mind off of the bladder and on to something else. Remember when you needed to go to the restroom, but got busy and forgot you needed to go? This aims to utilize that same mechanism to calm urgency and allow postponement of the urge.
Sounds great, right? And it is—really great for people who are experiencing urgency and have weak, underactive pelvic floor muscles. But what about for the people having overactive/shortened/hypervigilant pelvic floor muscles?
My thought process is that these techniques have to be modified to allow them to be effective for this population. First, we will keep a few steps and here’s why:
Deep breathing & Distraction/Visualization: I actually love these (especially the calm breathing) for my patients with difficulty relaxing the pelvic floor muscles. I often find that people with overactive pelvic floor muscles tend to be in a sympathetic-drive state for their nervous systems. Remember, the sympathetic nervous system is the “fight-or-flight” response. People who have chronic pain or chronic urgency/frequency often will have a significant amount of stress and fear, and I find that this state of their system often facilitates poor breathing patterns and overall increased tension and poor force modulation (meaning, choosing the right amount of muscle activity for the current task at hand). My colleague, Seth Oberst, wrote an amazing post about this very thing recently (I could write an entire post applying all of that to the pelvic floor!). So, we’ll keep these steps—with an emphasis on slow, calm breathing, utilizing the diaphragm and emphasizing relaxation of the pelvic floor with the inhale and returning to baseline with the exhale.
But here’s where we modify:
Quick, strong, pelvic floor contractions: My issue with this component for the overactive or hypervigilant or shortened pelvic floor muscles stems from a few key points. Traditional “kegels” or pelvic floor strengthening exercises are contraindicated for people with pelvic pain (or in my mind, anyone who has a tender, hypervigilant or overactive pelvic floor). Performing quick contractions for this population often will create pain, worsen the patient’s symptoms and actually increase urgency. You heard that right. Did you know that the pelvic floor muscles can actually refer to the bladder? I have had many instances when examining a person’s pelvic floor muscles that he/she reported that even lightly pressing on certain muscles made him/her feel urgency. And we know that somatovisceral convergence (a muscle impacting an organ) is real, and does occur. So, what do we do about this step?
We use this relationship in our favor.
Instead of quick, hard contractions, the person can perform deep breathing and pelvic floor drops (emphasizing complete pelvic floor relaxation). Although initially, some of my clients will worry that relaxing the pelvic floor muscles will “open the flood gates” this does not typically occur. Instead, relaxation of the pelvic floor combined with breathing will often calm down the detrusor (bladder muscle) activity and allow them to feel decreased urgency.
So, what do these new urgency suppression strategies look like?
What do you think? If you have a tender pelvic floor and/or pelvic pain, I encourage you to give it a try! Let me know what you think! As always, I would love to hear from you!
Today’s throwback (yes, I know it’s Friday– I’m sorry, I was busy yesterday!) comes from a post I did a year ago on improving bathroom habits in children. This has been modified from my original post to reflect my most current thoughts and current practice patterns. Hope you enjoy!
As you may know, I have advanced training in working with children with bowel and bladder dysfunction in pelvic physical therapy. Often times, this is shocking to many people to hear as most of us are somehow under the impression that children don’t have these sorts of problems. But the truth is, these problems are SO common in children! Amazingly, there are many easy things parents can do to make huge differences for their children! I often here my adult patients say,
“But you don’t understand, I’ve been constipated since I was 5 years old– it must run in my family! ”
What if we changed the habits of our children early to promote healthy bowel and bladder habits? Could we truly make a difference for them later on in their lives? Could we prevent them going in to their physical therapist and having to say statements like the one above? I believe we can do just that!
Here are your 5 tips to start making those changes today!
1. Encourage adequate fluid intake (mostly water!) and fiber intake!
The average person should consume 5-8 8-oz cups of fluid per day–and your child is no different! Fluid is SO important for both the bladder and the bowels! For the bladder, having adequate fluid decreases the risk of urinary tract infections, encourages normal bladder urges, and allows for a normal light colored urine instead of a dark concentrated urine. As an aside, taking in too many sweet sugary drinks, caffeinated drinks, and carbonated drinks will actually irritate the bladder and is something we want to try to avoid. (Note: Remember this if your child has difficulty with bed wetting!). For the bowels, adequate fluid allows for a soft stool that is easy to pass! If your child is not getting enough water, he or she will likely have a more firm stool as the intestines have worked to absorb the fluid your child needs for normal bodily functions. Many a patient has been “cured” of constipation simply by drinking more fluid!
Fiber is also very important to encourage a good bowel consistency. The American Academy of Pediatrics recommends children take in between their age + 5 and their age +10 grams of fiber per day (i.e. a 5 year old would need between 10 – 20 grams/day). There is some debate in this, so check with your pediatrician to get their recommendations. Good fiber sources include fresh fruits and vegetables, whole grains, oatmeal, granola, seeds and nuts! For good recipes for your kids, check out Gina’s recipes from Skinnytaste.com that are “Kid Friendly” here. Also, one of my favorite books for parents,Overcoming Bowel and Bladder Problems in Children, has a wonderful index of fiber-filled kid recipes!
2. Encourage your child to listen to his or her normal body urges.
This goes for both the bladder and the bowels as well! Quick lesson on anatomy and physiology–We have a normal reflex in our colon that helps us hold our stool to empty at an appropriate time (Yay!). Unfortunately, if a person holds stool for too long, the normal colon response to help us poop is dampened–meaning it won’t work as well! For the bladder, over suppressing bladder urges can cause problems with emptying that bladder, daytime accidents and frequent urinary tract infections. Many times, children become distracted with playing, watching TV, etc. and will hold off on going to the bathroom when they do have that urge. Parents should try to be aware of how long it has been since their child has urinated, and try to encourage a frequency of at least once every 2 hours (this will vary some depending on the age of the child).
3. Get your kids moving!
I’m sure you’ve heard it in the news these days that children need to get moving more! But, to take a new spin on it, encouraging your kids to move more will actually help keep their bowels more regular! Yes, it’s true, exercise is a stimulant to the bowels. So, encourage your kids to get outside and play, ride their bikes, do family walks and games– the more your kids move the better!
4. Help your child develop a bowel routine
This one ties in perfectly with our last point. Here’s the scenario:
“8 year old Mary is not a morning person. Mom has a hard enough time getting Mary out the door in the morning, and this often means eating a bagel on the way to school. After Mary gets to school, she often needs to go #2, but is too embarrassed to go and holds it the whole day.”
Unfortunately, kids like Mary often develop constipation from over suppressing those urges! The sad thing with this is that if a child suppresses urges for bowel movements, the stool will often become hard and may even cause pain when the child does go to the toilet. Over time, children can end up with overly stretched colons and may even need to use laxatives/medication for a period of time to loosen the stool and help the colon return to it’s normal position. All of this can be minimized by building a routine for your kids in the morning (or evening) to help encourage a normal bowel movement.
This video from the Children’s Hospital in Colorado helps to shed more light on bowel problems in children:
We know that the colon LOVES consistency, so try to encourage your kids to spend some time (at least a few minutes) on the toilet at the same time each day. We also know that the colon loves fluid (hot especially), hot food, and exercise! So, a good bowel routine would look like this:
“To help Mary’s bathroom habits, Mom started waking Mary up 30 minutes earlier. Mary starts her day with a warm bowl of oatmeal, then plays with her pet dog. After they play, Mary heads straight to the bathroom to have a BM.”
Yes, building a routine takes some extra time–but it is well worth it to prevent constipation in your kiddos!
5. Encourage proper toilet positioning and breathing on the potty
Yes, there is a right way to sit on the toilet. For children, most toilets are too tall and this makes it difficult for them to relax the muscles around the anal canal to help them poop without pushing hard. Kids will compensate by straining, but over time this can be very detrimental to their pelvic health. To help them out, get a small stool to go in front of your toilet seat which will help encourage them to fully relax their muscles. Encourage them to lean forward and relax on their knees. This will help straighten out the rectum to encourage easy emptying.
Image from our good friends at squattypotty.com. Check them out!
Then, and most importantly, make sure they have time. Encourage them to read a book or magazine and give their colon a few uninterrupted minutes to “do its thing.” I recommend they spend this time doing slow breathing (Potty Yoga) and relaxing. If they feel like they need to push, encourage them to breathe while they push to avoid the typical valsalva maneuver we often see. Learning this will help them so much both now and in the future! For more information, read this excellent post from my colleague, Jenna Sires, called “Are you Pooping Properly?“
What have you tried to help encourage good bathroom habits for your kids? Are your children having problems not addressed above? Feel free to comment below! Here’s to a healthy upcoming generation!
As you may know, part of my goal in writing this blog was to have a forum to process things I learn, and of course, to allow you to benefit from my nerdiness in learning. This week, many of my physical therapy colleagues from across the nation are traveling to Indianapolis for the American Physical Therapy Association’s Combined Section Meetings—basically a week of excellent presenters, networking, and seeing old friends. Of course, my heart is SO sad that I won’t be there this year—so I just had to find a way to learn on my own!
Thankfully, Jessica Drummond clued me in on Twitter to the Becoming the Best Event– a week long summit of (FREE) interviews with top holistic health professionals in the country! I read the bios, and I was in. I have been following Jessica for years (Didn’t know you had a stalker, did you Jess?:) ) and I have truly enjoyed learning from her. Jessica is a physical therapist and the CEO and founder of the Integrative Pelvic Health Institute. She has created a unique model of treating the whole person—managing the hormonal and dietary aspects as well as the physical—and she is pretty awesome at doing it! I was fortunate to collaborate with her this past year in caring for a wonderful woman who was experiencing sexual pain, and I can say from my experience that Jessica really did make a difference in her life!
So, here is a summary of what I took from Jessica’s Interview:
In treating women, Health Care Providers (HCPs) must work to normalize women’s health issues. We should all ask about a woman’s menstrual cycle and reproductive history the same way we ask about diet, bowel movements and sleep habits. For some reason, women are taught from an early age that our normal cycle is something to hide and be embarrassed about. However, it is so important and can be one of the only clues to us that something is off! Did you know that an abnormal menstrual cycle could even be an indicator of Celiac’s Disease? I didn’t, until today.
Just like we individualize nutrition based on the person, exercise and fitness recommendations should be individualized based on the person. Jessica said this awesome statement during our interview, and I absolutely agree: “I actually don’t think there is any specific form of exercise that is bad—it’s the way, the intensity and your body’s readiness for it.”
What about high impact activities (running, jumping, gymnastics)? Not “bad” either but can put women at risk for problems if they do not understand how to adequately use their pelvic floor muscles. Increasing pressure on the pelvic floor without adequate timed recruitment can lead to problems like incontinence/prolapse. Jessica recommends that all athletic women should be mindful of their pelvic floors (not always Kegels!) and all HCPs working in wellness should ask questions and encourage seeking help when needed.
Women often ignore the benefits of our hormonal cycles—we are always encouraged to hide it from the time we are 12 years old! Estrogen and testosterone are at its highest right before ovulation (2nd week in the cycle). Women actually have more energy at this time, and will burn more fat when exercising these days! We can capitalize on that by eating a higher fat meal a few hours before we exercise to encourage our bodies to burn more fat. So, at mid-cycle- we should eat less sugar, healthy protein and good fats to encourage our body to utilize the natural hormonal environment. In the second half of the cycle, the body actually prefers using protein as energy! If a woman has a big fitness event at the end of the cycle- she may need to eat more often and will probably need more support since hormone levels are at their lowest. And what about running with gels and gus? Jessica actually says that doing this does not encourage our body to use the right fuels but rather pushes a simple sugar energy.
Women exercising intensely daily without modulating for hormonal cycle can end up being a negative thing—this does not necessarily allow for adrenal recovery and can negatively impact the system. Estrogen can become lower and this will put someone at risk for cardiovascular dysfunction (and poor bone health too!- JR add)
What about for pregnant women? There are some specific things that can be done to tweek a fitness program and get maximum benefits. First, it is important to recognize that the uterine environment is a very important environment to build. That environment can pre- program the genetic expression of the fetal genes. Weight issues, DM, PCOS, Metabolic issues can impact the environment. Clean eating (low sugar) with regular, healthy eating. Insulin sensitivity decreasing as pregnancy progresses can lead to big blood sugar swings which are also not ideal for womb environment. Eating healthy foods at regular intervals can help- focusing on eating nutrient dense foods, healthy fats and minimal sugars. Exercising (even just walking 30 minutes per day) can also help to control blood sugar and promote healthy blood sugar for the baby. Of note, pregnant women should be careful of actively detoxing during pregnancy and while nursing. Stored toxins are “hidden” from the baby and trying to “release” them can actually transmit those things to baby. That being said, a more intense detox before pregnancy can actually be a good thing.
Hormones are of course significantly impacted during menopause. Did you know we can help prepare for menopause? Jessica recommends women focusing on building strong adrenal function during their 30s and 40s, emphasizing addressing stress, nutrient density, and controlling blood sugar. Doing this can impact the entire hormonal environment and create better health for women as they age. During menopause, women lose the estrogen support from ovaries–but having healthy adrenal glands can help a woman make enough estrogen to minimize menopause symptoms (including hot flashes, discomfort and brain fog!)
And lastly, what about us health care professionals? How do we avoid adrenal burn-out? It is essential for us to create a fairly strict list of priorities focusing on our vision for our life: What do you want life and work to be like? What must your health be to support this life? Jessica encourages prioritizing self-care and in an oh so inspiration way, encouraged us to “Be an inspiration for patients rather than being the person resposible for ‘fixing them.'” She also encouraged eliminating the guilt we often feel from being unable to cure everyone. She said, “You are not everyone’s healer.” We cannot heal everyone, but there are specific people out there who need our specific skill sets. Our goal should be to provide the knowledge, wisdom and skills patients need to allow themselves to heal. When they see us as an inspiration, they will take the responsibility to own their healing, wellness and healthcare. And this is a total mindset shift! We don’t have to feel guilty when we cannot help someone! And this frees us to really be what we need to be for the people who need us.
Thanks so much Jess for all of this great information! Please check out Jessica’s website for more information about her and the awesome work she is doing! If you would like more information on the Becoming the Best Event, please feel free to check it out here! You can access all of the interviews for free for 24 hours after they air, or you can pay $97 to access them whenever you would like!
Hope you enjoyed this summary! Please let me know any thoughts/comments you have below! ~ Jessica
