Category Archives: Constipation

Clinical Expert Interview with Susan Clinton, PT on Sensory Balloon Retraining for Bowel Dysfunction

In continuing my video series with clinical experts, I interviewed Susan Clinton, PT, DscPT, OCS, WCS, COMT, FAAOMPT (Yes, those are a TON of initials!!) regarding balloon training as a treatment for bowel dysfunction. Susan is well-known in our profession as an expert on bowel dysfunction, and her video definitely did not disappoint!

Curious about this treatment? Check out the interview below! If you want to learn more, here are a few research articles that mention balloon training as a treatment tool (this one and this one) Hope you enjoy!

Head, Shoulders, Knees…and Pelvic Floor!

I spent my first few years of practice going deep into the pelvis… and my most recent few years, desperately trying to get out. Now, I know that may seem like a strange statement to read coming from me, the pelvic floor girl. But bear with me. I love the pelvic floor, I really do. I enjoy learning about the pelvis, treating bowel/bladder problems, helping my patients with their most intimate of struggles. I like to totally “nerd out” reading about the latest research related to complex nerve pain, hormonal and nutritional influences, and complicated or rarely understood diagnoses. However, the more I learned about the pelvic floor, the more I discovered that in order to provide my patients with the best care I can possibly provide, I needed to journey outside the pelvis and integrate the rest of the body.

You see, the pelvic floor does not work in isolation.

It is not the only structure preventing you from leaking urine.

It is not the sole factor in allowing you to have pleasurable sexual intercourse.

It is not the only structure stabilizing your tailbone as you move.

It is simply one gear inside the fascinating machine of the body.

And, the incredible thing about the body is that a problem above or below that gear, can actually influence the function of the gear itself! And that is pretty incredible! One of the patients that most inspired me to really start my journey outside of the pelvis was an 18-year-old girl I treated 4 years ago. She was a senior in high school and prior to the onset of her pelvic pain had been an incredible athlete– playing soccer, volleyball and ice hockey. Since developing pelvic pain, she had to stop all activities. Her pain led to severe nausea, and was greatly impacting her senior year. When I examined her, I noticed some interesting patterns in the way she walked. With further questioning, she ended up telling me that a year ago, she experienced a fracture of her tibia (the bone by her knee) while playing soccer. She was immobilized in a brace for about a month, then cleared to resume all activity. (Yep, no physical therapy). Looking closer, she had significant weakness around her knee that was influencing the way she moved, and leading to a compensatory “gripping” pattern in her pelvic floor muscles to attempt to stabilize her hips and legs during movement. So, we treated her knee (She actually ended up having a surgery for a meniscal tear that had not been discovered by her previous physician), and guess what? Her pelvic pain was eliminated. BOOM. If you want to read more about her story, I actually wrote the case up for Jessica McKinney’s blog and pelvic health awareness project, Share MayFlowers, in 2013.

So, what else is connected to the pelvic floor? Here are a few interesting scenarios:

  • Poor mobility in the neck and upper back can actually lead to neural tension throughout the body– yes, including the nerves that go to the pelvic floor. (I’ve had patients bend their neck to look down and experience an increase in tailbone pain. How amazing is that?)
  • Being stuck in a slumped posture can cause a person to have decreased excursion of his or her diaphragm, which can then put the pelvic floor in a position in which it is unable to contract or relax the way it needs to.
  • Grinding your teeth at night? That increased tension in the jaw can impact the intrathoracic pressure (from glottis to diaphragm), which in turn, impacts the intra-abdominal pressure (from diaphragm to pelvic floor) and, you guessed it, your pelvic floor muscles!
  • An ankle injury may cause a person to change the way he or she walks, which could increase the work one hip has to do compared to the other. This can cause certain muscles to fatigue and become sore and tender, including the pelvic floor muscles!

Pretty cool right? And the amazing thing is that this is simply scratching the surface! The important thing to understand here is that you are a person, not a body part! Be cautious if you are working with someone who refuses to look outside of your “problem” to see you as a whole. And if you have a feeling in your gut that something might be connected to what you have going on, it really might be! Speak up!

As always, I love to hear from you! Have you learned of any interesting connections between parts of your body? For my fellow pelvic PTs out there, what cool clinical correlations have you found?

Have a great Tuesday!

Jessica

Wanna read more? Check out this prior post on connections between the diaphragm and the rest of the body!

 

Why get Pelvic PT first? And, join me for a webinar Thursday 12/10!

If you didn’t know, December 1st was a day that all PTs came together to share with the public all of the benefits of seeking PT! My colleague, Stephanie Prendergast, founder of the Pelvic Health and Rehabilitation Center in California, wrote an amazing blog post on why someone should get pelvic PT first. I thought it was great (as you know…I post lots of Stephanie’s stuff), and Stephanie gave me permission to re-blog it here. So, I really hope you enjoy it. If you aren’t familiar with Stephanie’s blog, please check it out here. You won’t regret it. 

On another note, I will be teaching a live webinar Thursday 12/10 on Pelvic Floor Dysfunction in the Adult Athlete. I really hope to see some blog followers there! Register for it here.  

Now… enjoy this great post by Stephanie. ~ Jessica 

Why get PT 1st? Here are the Facts. By Stephanie Prendergast

very-small-getpt1st

Vaginal pain. Burning with urination. Post-ejaculatory pain. Constipation. Genital pain following bowel movements. Pelvic pain that prevents sitting, exercising, wearing pants and having pleasurable intercourse.

When a person develops these symptoms, physical therapy is not the first avenue of treatment they turn to for help. In fact, physical therapists are not even considered at all. This week, we’ll discuss why this old way of thinking needs to CHANGE. Additionally, we’ll explain how the “Get PT 1st” campaign is leading the way in this movement.

We’ve heard it before. You didn’t know we existed, right? Throughout the years, patients continue to inform me the reason they never sought a physical therapist for treatment first, was because they were unaware pelvic physical therapists existed, and are actually qualified to help them.

Many individuals do not realize that physical therapists hold advanced degrees in musculoskeletal and neurologic health, and are treating a wide range of disorders beyond the commonly thought of sports or surgical rehabilitation.

On December 1st, physical therapists came together on social media to raise awareness about our profession and how we serve the community. The campaign is titled “GetPT1st”. The team at PHRC supports this campaign and this week we will tell you that you can and should get PT first if you are suffering from a pelvic floor disorder.

Did you know that a majority of people with pelvic pain have “tight” pelvic floor muscles that are associated with their symptoms?

Physical therapy is first-line treatment that can help women eliminate vulvar pain

Chronic vulvar pain affects approximately 8% of the female population under 40 years old in the USA, with prevalence increasing to 18% across the lifespan. (Ruby H. N. Nguyen, Rachael M. Turner, Jared Sieling, David A. Williams, James S. Hodges, Bernard L. Harlow, Feasibility of Collecting Vulvar Pain Variability and its Correlates Using Prospective Collection with Smartphones 2014)

Physical therapy is first-line treatment that can help men and women with  Interstitial Cystitis

Over 1 million people are affected by IC in the United States alone [Hanno, 2002;Jones and Nyberg, 1997], in fact; an office survey indicated that 575 in every 100,000 women have IC [Rosenberg and Hazzard, 2005]. Another study on self-reported adult IC cases in an urban community estimated its prevalence to be approximately 4% [Ibrahim et al. 2007]. Children and adolescents can also have IC [Shear and Mayer, 2006]; patients with IC have had 10 times higher prevalence of bladder problems as children than the general population [Hanno, 2007].

Physical Therapy is first-line treatment that can help men suffering from Chronic Nonbacterial Prostatitis/Male Pelvic Pain

Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) affects 2%-14% of the male population, and chronic prostatitis is the most common urologic diagnosis in men aged <50 years.

The definition of CP/CPPS states urinary symptoms are present in the absence of a prostate infection. (Pontari et al. New developments in the diagnosis and treatment of CP/CPPS. Current Opinion, November 2013).

71% of women in a survey of 205 educated postpartum women were unaware of the impact of pregnancy on the pelvic floor muscles.

21% of nulliparous women in a 269 women study presented with Levator Ani avulsion following a vaginal delivery (Deft. relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014 Feb 121: 1164 -1172).

64.3% of women reported sexual dysfunction in the first year following childbirth. (Khajehi M. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015 June; 12(6):1415-26.

24% of postpartum women still experienced pain with intercourse at 18 months postpartum (McDonald et al. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015)

85% of women stated that given verbal instruction alone did not help them to properly perform a Kegel. *Dunbar A. understanding vaginal childbirth: what do women understand about the consequences of vaginal childbirth.J  Wo Health PT 2011 May/August 35 (2) 51 – 56)

Did you know that pelvic floor physical therapy is mandatory for postpartum women in many other countries such as France, Australia, and England? This is because pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex.

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse?

Physical Therapy can help with Stress Urinary Incontinence

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse? 80% of women by the age of 50 experience Stress Urinary Incontinence. Pelvic floor muscle training was associated with a cure of stress urinary incontinence. (Dumoulin C et al. Neurourol Urodyn. Nov 2014)

30 – 85 % of men develop stress urinary incontinence following a radical prostatectomy. Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months postoperatively. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9).

Physical Therapy can help with Erectile Dysfunction

Several studies have looked at the prevalence of ED. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years. The prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years.1

Physical Therapy can help with Pelvic Organ Prolapse

In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone a hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. (Susan L. Hendrix, DO,Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6.)

Pelvic floor physical therapy can help optimize musculoskeletal health, reducing the symptoms of prolapse, help prepare the body for surgery if necessary, and speed post-operative recovery.

Did you know….

In many states a person can go directly to a physical therapist without a referral from a physician? (For more information about your state: https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf)

You need to know….

Pelvic floor physical therapy can help vulvar pain, chronic nonbacterial prostatitis/CPPS, Interstitial Cystitis, and Pudendal Neuralgia. (link blogs: http://www.pelvicpainrehab.com/patient-questions/401/what-is-a-good-pelvic-pain-pt-session-like/, http://www.pelvicpainrehab.com/male-pelvic-pain/460/male-pelvic-pain-its-time-to-treat-men-right/http://www.pelvicpainrehab.com/female-pelvic-pain/488/case-study-pt-for-a-vulvodynia-diagnosis/)

Pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex: http://www.pelvicpainrehab.com/pregnancy/540/pelvic-floor-rehab-its-time-to-treat-new-moms-right/

Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months in postoperative men following prostatectomy. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9). (Link blog: http://www.pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

A study from the University of the West in the U.K. found that pelvic exercises helped 40 percent of men with ED regain normal erectile function. They also helped an additional 33.5 percent significantly improve erectile function. Additional research suggests pelvic muscle training may be helpful for treating ED as well as other pelvic health issues. (link blog:http://www.pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

….that you can and should find a pelvic floor physical therapist and  Get PT 1st.

To find a pelvic floor physical therapist:

American Physical Therapy Association, Section on Women’s Health:

http://www.womenshealthapta.org/pt-locator/

International Pelvic Pain Society: http://pelvicpain.org/patients/find-a-medical-provider.aspx

Best,

Stephanie Prendergast, MPT

stephanie1-150x150Stephanie grew up in South Jersey, and currently sees patients at Pelvic Health and Rehabilitation Center in their Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.

Guest Post: Rib cage position, breathing and your pelvic floor

I am thrilled today to have my colleague and friend, Seth Oberst, PT, DPT, SCS, CSCS (that’s a lot of letters, right?!), guest blogging for me. I have known Seth for a few years, and have consistently been impressed with his expansive knowledge and passion for treating a wide range of patient populations (from men and women with chronic pain, to postpartum moms, and even to high level olympic athletes!) Recently, Seth started working with me at One on One in Vinings/Smyrna, which is super awesome because now we get to collaborate regularly in patient care!  Since Seth started with us, we have been co-treating several of my clients with pelvic pain, diastasis rectus, and even post-surgical problems, and Seth has a unique background and skill set which has been extremely valuable to my population (and in all reality, to me too!). If you live in the Atlanta area, I strongly recommend seeing Seth for any orthopedic or chronic pain problems you are having–he rocks! So, I asked Seth to guest blog for us today…and he’ll be talking about your diaphragm, rib cage position, and the impact of this on both the pelvis and the rest of the body! I hope you enjoy his post! ~ Jessica 

The muscles of the pelvic floor and the diaphragm (our primary muscle of breathing) are mirror images of each other. What one does so does the other. Hodges found that the pelvic floor has both postural and respiratory influences and there’s certainly a relationship between breathing difficulty and pelvic floor dysfunction. (JR note: We’ve chatted about this before, so if you need a refresher, check out this post) So one of the best ways we can improve pelvic floor dysfunction is improving the way we breathe and the position of our ribcage. Often times, we learn to breathe only in certain mechanical positions and over time and repetition (after all we breathe around 20,000 times per day), this becomes the “normal” breathing posture.

Clinically, the breathing posture I see most commonly is a flared ribcage position in which the ribs are protruding forward. This puts the diaphragm in a position where it cannot adequately descend during inhalation so instead it pulls the ribs forward upon breathing in. The pelvis mirrors this position such that it is tipped forward, causing the muscles of the pelvic floor to increase their tension. (JR note: We see this happen all the time in men and women with pelvic pain!) Normal human behavior involves alternating cycles of on and off, up and down, without thinking about it. However, with stress and injury we lose this harmony causing the ribs to stay flared and the pelvis to stay tilted. Ultimately this disrupts the synchrony of contraction and relaxation of the diaphragm and pelvic floor, particularly when there is an asymmetry between the right and left sides (which there often is).

Rib Flare PRI

Rib PRI

Jessica has written extensively on a myriad of pelvic floor issues (this IS a pelvic health blog, after all) that can be caused by the altered control and position of the rib cage and pelvis that I described above. But, these same altered positions can cause trouble up and down the body. Here are a few ways:

  1. Shoulder problems: The ribcage is the resting place for the scapulae by forming a convex surface for the concave blades. With a flared, overextended spine and ribs the shoulder blades do not sit securely on their foundation. This is a main culprit for scapular winging (something you will often see at the local gym) because the muscles that control the scapulae are not positioned effectively. And a poorly positioned scapula leads to excessive forces on the shoulder joint itself often causing pain when lifting overhead.
  2. Back pain: When stuck in a constant state of extension (ribs flared), muscles of the back and hips are not in a strong position to control the spine subjecting the back to higher than normal forces repeatedly over time. This often begins to manifest with tight, toned-up backs that you can’t seem to loosen with traditional “stretches”.
  3. Hip impingement: With the pelvis tilted forward, the femurs run into the pelvis more easily when squatting, running, etc. By changing the way we control the pelvis (and by association the rib cage), we can create more space for the hip in the socket decreasing the symptoms of hip impingement (pinching, grinding sensation in groin/anterior hip). For more on finding the proper squat stance to reduce impingement, read this.
  1. Knee problems: An inability to effectively control the rib cage and pelvis together causes increased shearing forces to the knee joint as evidenced in this study. Furthermore, when we only learn to breathe in certain positions, it reduces our ability to adapt to the environment and move variably increasing our risk for injury.
  2. Foot/ankle: The foot and pelvis share some real estate in the brain and we typically see a connection between foot control and pelvic control. So if the pelvis is stuck in one position and cannot rotate to adapt, the foot/ankle complex is also negatively affected.

So, what can we do about this? One of the most important things we can do is learn to expand the ribcage in all directions instead of just in the front of the chest. This allows better alignment by keeping the ribs down instead of sacrificing position with every breath in. Here are few ideas to help bring the rib cage down over the pelvis and improve expansion. These are by no means complete:

**JR Note: These are great movements, but may not be appropriate for every person, especially if a person has pelvic pain and is at an early stage of treatment (or hasn’t been treated yet in physical therapy). For most clients, these exercises are ones that people can be progressed toward, however, make sure to consult with your physical therapist to help determine which movements will be most helpful for you! If you begin a movement, and it feels threatening/harmful to you or causes you to guard your muscles, it may not be the best movement for you at the time. 

**JR Note: This squat exercise is very similar to one we use for men and women with pelvic pain to facilitate a better resting state of the pelvic floor. It’s wonderful–but it does lead to a maximally lengthened pelvic floor, which can be uncomfortable sometimes for men and women who may have significant tenderness/dysfunction in the pelvic floor (like occurs in men and women with pelvic pain in the earliest stages of treatment).

Here’s another one I use often from Quinn Henoch, DPT:

Our ability to maintain a synchronous relationship between the rib cage and pelvis, predominantly thru breathing and postural control, will help regulate the neuromuscular system and ultimately distribute forces throughout the system. And a balanced system is a resilient and efficient one.

Seth-Oberst

Dr. Seth Oberst, DPT is a colleague of Jessica’s at One on One Physical Therapy in Atlanta, GA. He works with a diverse population of clients from those with chronic pain and fatigue to competitive amateur, CrossFit, professional, and Olympic athletes. Dr. Oberst specializes in optimizing movement and behavior to reduce dysfunction and improve resiliency, adaptability, and self-regulation.

 

For more from Seth check out his website and follow him on Twitter at @SethOberstDPT

Dyssynergic Defecation (or…when the poop just can’t get out)

Great photo, right? Click on it to link to a wonderful article by my colleague and friend, Jenna Sires, written for the amazing group ShareMayFlowers, “Are you pooping properly?”

I’ll admit it… I like treating pooping problems. I know that grosses some people out, but it’s true. I think it’s because bowel problems really really impact people’s lives. I mean, pooping is a super basic human activity–so when it’s not working the way it should, it’s really awful.

I have recently had quite a few patients who are having difficulty evacuating their bowels. Now, there are multiple reasons why this could occur (I know, I’ve written about constipation a lot already, see here for evidence)–but today, we’re going to chat about one in particular, dyssynergic defecation or sphinctor dyssynergia.

What exactly is dyssynergic defecation? 

Basically, your pelvic floor muscles work with your colon reflexively. When your colon is contracting to push the poop out, and you are sitting on the toilet ready to empty your bowels, the muscles should relax and open to allow this to occur.  Sometimes, this relationship becomes dysfunctional, and basically, you think you are pushing and relaxing the sphinctor muscles, but instead, the muscles are contracting and closing the sphinctor. I know what you’re thinking– Jessica, I would know if I were actually contracting my muscles instead of relaxing them while I poop. But, no, you wouldn’t. In fact, many patients are shocked when I show them the actual coordination of their muscles.

Click on the image to go to the blog post I pulled the image from. Great info from a supporter of squatty potty 🙂

Typically, incoordination of the pelvic floor muscles is paired with poor coordination of the abdominal muscles, and often impaired sensation of the rectum. Dyssynergic Defecation is diagnosed typically by an anorectal examination, and anorectal manometry/defecography testing (like this, with an MRI, or by assessing muscle activity with EMG while the person attempts to expel a balloon, or other testing options)

Why does it happen? 

Dyssynergic defecation is very common in people who have constipation. In fact, this review suggested that close to 40% of people with constipation have this incoordination pattern. There are several factors that can contribute to dyssynergic defecation. This review estimated that close to 30% of adults with dyssynergic defecation patterns had constipation as children, and found that 46% had frequent straining to empty hard stool. But there are other factors that can contribute as well, such as:

  • pregnancy
  • traumatic injury
  • low back pain
  • history of sexual abuse/trauma
  • poor behavioral habits related to bowel health
  • nothing (like many other things, we sometimes just don’t know why it happens)

What are the signs and symptoms? 

As we discussed previously, dyssynergic defecation is extremely common amongst those struggling with constipation (typically meaning < 3 BMs per week, as well as symptoms of abdominal discomfort, bloating, and/or difficulty emptying bowels). This article looked at the most common reported symptoms of those with dyssynergic defecation, and found that many experienced the following:

  • Excessive straining to have a bowel movement
  • Feeling of incomplete evacuation after a bowel movement
  • Abdominal bloating
  • Frequent hard stools
  • Frequently utilizing digital maneuvers to empty stool (this means, using a finger to either help pull stool out of the rectum, or using a finger to press inside the vagina to help empty)

What can you do about it? 

The great news is that men and women (and kids too!!) with a dyssynergic defecation pattern can respond very well to conservative treatment! Pelvic physical therapists are typically the providers of choice when it comes to helping people with these problems, and work closely with GI and Colorectal Physicians to help these men and women. Treatment typically involves a few different components:

1. Developing amazing bowel habits. You know that has to be first on my list. If your bowel habits are not stellar, we can try to help your muscles all we want, but you will still have difficulties emptying. So, first things first, we need to make sure your dietary habits rock, you have a great bowel routine, and you know how to sit on the toilet in the most optimal way. Wondering what that toilet position is? Check out this sort of funny, mostly weird video by my favorite potty comedians and stool developers (pun intended), Squatty Potty.

2. Surface EMG Biofeedback training to improve muscle coordination: Biofeedback training uses surface electrodes placed at the anal sphinctor muscles and the abdominal muscles to identify the type of pattern a person uses to expel a bowel movement. Once we identify the pattern you currently use, we can work together to improve the pattern so that your sphinctor muscles relax when you generate abdominal pressure to empty your bowels. Seems pretty basic, right? But the right biofeedback training can make a HUGE difference–and the current research really supports this treatment for anyone with this proble4m. (See this article, this one, that one, and this one!)

Click on this picture to go to the open access article I pulled this from. Basically, this shows that after biofeedback, the person was able to still generate the right pressure, but the anal muscles relaxed and opened rather than contracting.

3. Making sure your pelvic floor muscles are strong, FLEXIBLE, and well-coordinated. So, we’ve talked in detail about the pelvic floor muscles on this blog. Remember, we all want muscles that can contract AND relax. And, for dyssynergic defecation patterns, the relaxation component is extremely important! Often times, people who have difficulty relaxing their muscles to have a bowel movement tend to have tender, overactive pelvic floor muscles to begin with. So, treatment will also focus on improving awareness of the pelvic floor muscles, learning to relax the muscles (dropping and lengthening them), and often will include some manual therapy (yes, internal vaginal or rectal) to help reduce the tenderness and improve the mobility of the muscles.

4. Balloon retraining. People love hearing about this one… but it really is an awesome and effective treatment for so many men and women!! (Research supports it also– see here and here!) This treatment basically uses a small balloon that is attached to a catheter and is inserted into the rectum, and slowly inflated. Often times, people with dyssynergic defecation patterns have decreased sensitivity in the rectum, so they will not feel the presence of stool (or a balloon!) in the rectum when they typically should. Based on what we find initially, we can use the balloon to improve the sensation in the rectum. We can also use a slightly filled balloon to work on proper expelling techniques. I know what you’re thinking, Wow Jessica, this sounds like a super fun and awesome treatment. I know, but honestly, it’s very very helpful for people who need it!

Now, this just scratches the surface in terms of what all we pelvic PTs do to help with dyssynergic defecation. But, I wanted to get the conversation started! This tends to be a topic many people don’t talk about… in fact, I have had men and women travel SO far just to get the initial diagnosis! And, I need that to stop… hence this blog post today. Lastly, if you are having problems with constipation and think you may have this problem– Go see a GI/Colorectal Physician! Honestly, make an appointment today! And, contact your local pelvic PT. If you live in Atlanta or the surrounding area, give me a call! It’s time to get your bowels back in order (or even in order for the first time!).

I always look forward to hearing from you! So please, ask any questions or make any comments below!!

~ Jessica

5 Ways to Decrease a Flare-up on Vacation

It never fails. Around this time of year, many of my patients are traveling, going on fun vacations (just like me! Yep, I was away last week– sorry for the lack of posts!), and the pelvic floor never seems to love that. Unfortunately, vacations for many mean a flare-up of symptoms–worsening of pain from sitting for long car or plane rides, constipation, or other unpleasant feelings. This seems to happen like clock-work. But the good news is, vacationing doesn’t have to be the start of a bad flare. You don’t have to be afraid to go on vacation. In fact, there are a few since steps you can take to reduce and manage the vacation blues.

bahrain-1369259_1920.jpg

 1. Pack your toolbox.  One of the big ways you can reduce the likelihood of a flare, is to plan ahead and pack the necessary tools that normally help you.  Do you normally take a fiber supplement daily to manage the bowels? Pack it. Use an ice pack when you start feeling pain? Pack it. Listen to a progressive relaxation CD or youtube video before bed? Make sure you bring it along!  The more you plan ahead, the better it will be if you do start having pain or see a change in your bowel/bladder symptoms.

2. Keep your bowels in check.  Now, some of you are probably thinking, “I have pain Jessica– not bowel problems!” BUT, keeping the bowels in a routine is so important for ANY pelvic floor problem. A bout of constipation can increase bladder leakage or worsen pelvic pain. Unfortunately, constipation is very common while traveling.  One of the main reasons for this is that most of us significantly change our habits when we travel. For example, I normally start my day with a protein shake and a piece of fruit—but on vacation, I will have french toast, or a big omelet, cheese danishes, and other larger, richer breakfast options. Delicious, right? But the bowels don’t love the change. The best thing we can do for our bowels while traveling is to stay consistent. Remember, your bowels love a good routine, so try to eat similar meals that you normally eat at similar times! Keep up with fiber or supplements to maintain a good consistency, and don’t forget your fluid intake!! For more tips for bowel health, check out my previous posts here.

3. Stay consistent with your routines. Yes, we just hit on this with the bowels, but this is equally true with the other routines you use to manage your pain or other problems. Vacation is a great way to relax, but many people will find they drop their helpful habits while traveling.  Sometimes this may mean waking up a few minutes earlier in order to get your morning stretching in, or perhaps taking a break in the afternoon to use an ice pack, or maybe even setting an alarm to make sure you do your exercises–but these small steps can really do a lot to decrease the risk of a symptom flare!

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4. Pace yourself. This one is most important for those dealing with pelvic pain. We know that movement is medicine for persistent pain, and a vacation is often a very motivating time to move! That being said, it is important to gradually add movement and take breaks as needed to allow your body time to rest and adapt to a higher level of activity. I often will see men and women who may be very sedentary in their day-to-day lives, but then, go on vacation and want to be on-the-go 24-7! It is a much better alternative to try to slowly increase your activity, giving yourself adequate time to rest based on your prior activity level and what your body needs. For example, if you are normally inactive, it may be helpful to plan an activity for a few hours in the morning, but to plan for a resting period after that (great time to ice and do your stretches!). If you have several activities you would like to do, consider making a list and spacing those activities out over the days you are traveling.

5. Try not to freak out.  I get it. Flares are scary–especially when you’ve been seeing progress and have been feeling great! But, don’t let it get the best of you! Remember to see a flare for what it really is– a flare.  Keep your mindset positive, use the tools you have, and you will be back to vacationing in no time! And if you feel like you need a boost, contact your pelvic PT (we really don’t mind!). We’re always happy to talk through some strategies to calm things down, and are happy to help get you back to relaxing! 🙂

What strategies do you use to decrease a flare on vacation? PTs out there– are there any other tips you like to give your patients? Let me know in the comments below!

~ Jessica

Sex, drugs, and… no poop?

Really, I could have left off the “sex” at the beginning of the title… it would be more appropriate to the topic by saying “no sex” for reasons you will see…but I just couldn’t. The title was too great. So, there you go.

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So, leaving out the “sex”- what do drugs and “no poop” have in common? Actually, a lot. Constipation is a common side effect or adverse reaction to many medications. I see this all the time when working with men and women for pelvic floor problems, as well as common orthopedic complaints. The problem is, many people do not really know how to handle it since stopping the medication would lose the benefits of the medication. Constipation is really the worst– pooping is one of those things many of us take for granted, but I’ll tell you, when things aren’t running smoothly, it truly impacts a persons quality of life. (see what I did there?) So, first, let’s go through what medications are known to have constipation as an adverse reaction/side effect:

  • Anticholinergics: These medications block the action of acetocholine in the brain, which basically decreases the involuntary movements of muscles. As a pelvic health PT, I generally see my patients with overactive bladder problems and urge related incontinence using these medications (detrol, ditropan, vesicare, oxybutnin, toviaz) as these medications can decrease the contractions of the bladder muscle. There are lots of other reasons a person may use other kinds of anticholinergics, and this website gives a good summary with a list of medications included in the group.
  • Opioids: Many people are familiar with these medications and know them as the strong pain medications (morphine, codiene, oxycodone). These medications block receptors in the brain, but also have strong constipating effects in many people.
  • Benzodiazepine derivatives: These medications impact the nervous system, and are commonly taken by people with anxiety/panic disorders and for sedative purposes. Some of the more common ones are xanax, valium, and ativan.
  • Antidepressants: These medications are of course taken for improving depression, but also can be used to help with chronic pain or certain pain disorders (like vulvodynia or fibromyalgia) due to the mechanisms of these medicines. Common antidepressants include cymbalta, amitryptiline (elavil), wellbutrin and effexor.
  • Propionic Acid derivatives (NSAIDS): Yep, this fancy name includes the common OTC medications ibuprofen and naproxen, as well as several other medications. Tricky thing here is that another more common adverse reaction of these medications is diarrhea– we see this type of thing happen all the time– so know that the GI system can be affected, one way or another. Constipation as a side effect happens more commonly in older adults.
  • Other: This is by no means an exhaustive list-– if you think your medication may be causing you some unwanted side effects, research the medication on a website like drugs.com. This website also has an interaction checker, which is SO important.

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So, what can you do if a medication is contributing to constipation? 

1. Talk to your prescribing physician: No, stopping the medication is not always the answer! If you just started the medicine and are noticing a change in your bowel function, I recommend talking with your prescribing physician to discuss the symptoms you are having and discuss alternatives medication options. I often will have patients who will stop a medicine if they notice side effects without allowing their provider the opportunity to help them! Remember, there are often several medications which can provide a similar benefit! You may not react as strongly to one vs. another.

2. Develop stellar bowel habits: We’ve talked about this in the past, and it’s always important, but I would argue it’s even more important when you have something working against you.

  • Eat a healthy diet with plenty of fiber-filled fruits and vegetables
  • Aim to get some level of physical activity each day– even a short walk around the neighborhood can help so much with bowel regularity!
  • Drink plenty of fluids, mostly water!
  • Keep consistent! Eat meals/snacks regularly and at similar times every day to help stimulate the normal colon reflexes.
  • Use optimal positioning on the toilet (squatting!) and make sure to relax, breathe, and spend a few minutes allowing your bowels the opportunity to empty.
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Image from my good friends at http://www.squattypotty.com–check them out!

3. Consider a little short-term help if you need it!  I’ll be honest– I don’t love long-term laxative use. My preference is always to try to help the body in a more natural way if possible. That being said, there are times when a short-term helper can be so important! I always recommend that my family members (names shall remain anonymous) use miralax (an over-the-counter osmotic laxative) during recovery from surgeries to help combat the side-effects of pain medications. A fellow pelvic PT used a laxative for a short period of time while she was pregnant because she had a difficult time getting the constipation under control. This can sometimes be super helpful! I always recommend talking with your physician and getting a good recommendation for something to try to help if it is needed.

I hope this is helpful! In conclusion, I just want to reiterate– communication is always SO important between the patient and ALL health care providers. If you are having undesirable side effects from a medicine, call your physician! Talk to your pharmacist! And develop amazing, awesome, and smooth bowel habits :).

Happy Wednesday!

~ Jessica

TBT: “Do you need to go potty?” 5 Tips to Improve Your Kiddo’s Bathroom Health

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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!

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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.

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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!

~ Jessica