Happy Smells, Memories, and Neurotags

A few weeks ago, my husband returned from spending a few days at Barnsley Gardens Resort, where he helped with a fundraising event for the Atlanta Area Boy Scouts of America. Upon his happy return (for all parties involved– single moms: you are rockstars!), he gifted me with a bottle of my favorite relaxing lotion, scented with lavender and peppermint. It is heavenly, and we both adore it! It has become a tradition that he brings me a bottle every time he helps with the event in November. Why do we both love it so much? Well, 3 years ago, we spent 2 wonderful nights at Barnsley Gardens for a mini babymoon. It was our last getaway as a family of two. I was super pregnant, but we ate delicious food, relaxed in the pool, went on evening walks, and slept in. We had an incredible couples massage also, and this lotion was the smell of the spa. We bought a bottle then, and even now, 3 years later, using the lotion evokes feeling of peacefulness, joy, love, and overall relaxation.

So, what happened there? How do brain-smell associations work? (And I know some of you are sitting there thinking…what does this have to do with the pelvis?)

We’ve all been there, right? When I hear the song “Kiss me” by Sixpence None the Richer, I’m transported back to the middle of the summer working as a lifeguard. I smell sunscreen and chlorine and feel the warmth of the sunshine. When I smell a certain blend of middle eastern herbal tea, I’m transported back to Cairo, Egypt where I studied abroad in college, walking through the busy streets at the downtown market. Our brains are incredible like that. Certain memories impact us, and cause our brains to form neurotags– specific patterns of neural activation based on that single input. This is why all of the pieces of the memory come flooding back to you when you have the evoked stimulus (in my case recently, amazing lavender mint lotion).

Now let’s jump into pelvic health, and particularly, chronic pain. What if the brain forms neurotags about pain? For example, what if a person began having pain with sitting, and let’s say, for this example, they experienced a few situations where they needed to sit for a long period of time, and the pain was just awful. As we have discussed many many times, we know that all pain is produced by the brain, that the brain can play tricks on us, and that the brain does change over time due to pain and many other factors. The brain could then, build a neurotag about sitting. Basically, when the person in the above example goes to sit, the brain will activate the neural pathways to remember pain, negativity, perhaps anxiety/stress about the situation, etc. and instead of amplifying the feelings of peace and love (like my lotion!), the brain will amplify the feelings of distress and pain. What about a painful medical examination? A negative sexual experience?

Fascinating, right? So, what can we do about it? 

First, recognize a negative neurotag for what it is– your brain recognizing familiarity. And what it is not– a true interpretation of the current situation.

Next, change up the pattern to trick your brain. If you have pain when bending forward to pick something up, can you try the bending motion while lying down (ie pulling your knees up to your chest)? If you had a negative medical exam and start feeling anxious about your appointment, could you see a different provider at a different office? Perhaps request a different position for the exam?  If you have pain with sex, could you alter the experience? Maybe this means a different position, different location, different warm-up?

After that, aim to build new, positive neurotags for your brain. How do we build positive neurotags? It can start by building a positive association for your brain. So, this could mean diffusing a calming oil blend while listening to a guided relaxation track. Once this association builds for the brain, you could then try using the same scent within a typically negative situation (assuming you have also removed the negative stimulus!). For people with pelvic floor pain, we often use gentle manual treatment (either with a finger or vaginal trainers) to provide a safe input to the tissues in a way that the brain will not guard and protect by pain.  Now, envision pairing that calming scent with gentle pelvic floor muscle desensitization? The options are endless for creativity in building positive neurotags! Movement can also be great to build positive neurotags! If you find that pain limits what you can do, working with a physical therapist to develop movements you can do, that keep you at minimal to no discomfort can help your brain build neurotags for safety with movement again!

If this is fascinating to you (as you know it is to me!), here are a few other resources to check out:

These amazing Vlogs by Jilly Bond, one of my favorite physios across the pond (You may recognize a certain someone in the second video!):

Your Brain is Playing Tricks on You, Part 2: Pain

Guest Post: There’s a Pelvis….in Your Brain? 

What neurotags have you noticed in your life? Fun? Serious? I want to hear them all!

On Creating Agency as a Patient

Agency is defined as, “the capacity of individuals to act independently and to make their own free choices.” What does this mean for healthcare? How does the healthcare consumer maintain and create agency while also navigating the complexities of medicine?

A few weeks ago, I traveled to Washington DC to teach a group of 40+ physical therapists and occupational therapists about working with people who are dealing with various types of pelvic pain. Over this 3-day course, we covered topics related to diagnosis, medical management, manual therapies, movement interventions, and much more. On the third day of the course, I gave a lecture on “trauma-informed care.” What is trauma-informed care? Trauma-informed care means the “adoption of principles and practices that promote a culture of safety, empowerment and healing.” While we do focus on how widespread trauma is, the varying ways people experience trauma, and strategies to develop sensitivity, respect and consideration for the needs of our patients, we also strongly emphasize the importance of treating all patients in this way.  One of the key pieces in doing this is helping a person develop a strong sense of agency– the ability to make their own educated decisions and partner alongside their healthcare professionals, instead of being the recipient of directed care.

The idea of agency can seem fairly basic. Shouldn’t every patient feel like they can make their own decisions? Shouldn’t they feel like their healthcare providers are all members of the same team? But, that is often not the case. When a person loses this agency, they can end up in situations where things start happening to them, instead of with them, and this can create difficult and sometimes traumatic experiences. This could be a mother who feels pressured to have a birth intervention she was really not comfortable with having. This could be a person being scolded for not being “compliant” with their recommended home exercise program (as opposed to their clinician understanding what happened and partnering with them to fit exercise in their lives). Or, it could be feeling pressured to continue a painful examination that they otherwise would choose to stop.

There are many reasons why losing one’s agency is detrimental. Remember, the pelvic floor muscles respond to threat. So when a person is in a situation where they feel threat (whether that is due to stress, a difficult situation, or other circumstance), the pelvic floor  will activate. When someone is dealing with something like pelvic pain, sexual pain, and other diagnoses, this can lead to a problem becoming worse. So, how can you maintain your agency as a patient?

  1. Ask Questions. All the Questions. “The only stupid questions are the ones that are not asked.” If you aren’t understanding what is being recommended to you, ask more questions for clarification. Your healthcare provider should always be happy to answer any questions you may have to help you make the best decisions for your care. This also applies to times when you are in the middle of a treatment/procedure/etc. Ask away.  Try saying:
    • “Would you mind explaining my options again?”
    • “Can you clarify what the benefits and risks would be to…”
    • “Are there any risks in not moving forward with that treatment?”
    • “What are the reasons you think I need to…”
    • “I’m sure you have a busy day, but it would really help me if you could answer a few questions.”
  2. Don’t be afraid to slow things down. If your treatment session or medical appointment is going a direction you are uncomfortable with, or if something is happening that you don’t feel like you understand, feel free to take a break. Try saying:
    • “I need some time to think about that.”
    • “I would like to take a few minutes to consider my options.”
    • “I would prefer not to move forward with that today.”
    • “Can you explain _______ to me again?”
    • “I’m not sure I understand all of my options.”
    • “I’d like to go home and think about all of this. I’ll let you know what I think at our next visit.”
  3. Bring a friend. If you know that you tend to get overwhelmed at your appointments and have difficulty expressing your needs or how you feel, consider bringing a friend/partner/spouse who will have your back! Tell them in advance what you want their role to be and how they can help you! This could be stepping in to ask for some time to consider options, asking a provider to slow down and repeat their explanation, or simply being a person to be present with you during a difficult appointment.

I hope these tips have been helpful in helping you develop strategies to create agency as a patient. If you are a healthcare provider, I urge you to reflect on your own practices. Do your words and actions support your patients in maintaining autonomy? support agency? Do you unintentionally pressure patients into participating in treatments or exams that they may not feel comfortable with? Do you shame patients when they don’t follow your recommendations? None of us are perfect. I truly believe that most health care providers have the best of intentions. But, we can all do better. Reflect on our own words, habits, body language, and be better partners for our patients!

What other strategies have you found to help you improve your agency as a patient?

~ Jessica

 

 

5 Ways Pelvic PTs Can Help with IBS

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This month is IBS Awareness Month!

Irritable Bowel Syndrome (IBS) can be an incredibly life-impacting condition, affecting around 10-20% of the population (80% of those individuals being female!). The exact cause of IBS is unknown, but it is thought to likely be multifactorial.

IBS is characterized by abdominal pain paired with constipation and/or diarrhea. When many people hear about IBS, they may not automatically think that working with a physical therapist could be useful; however, there is so much that physical therapists can do to help improve symptoms related to IBS. Here are a few!

1.) Assist the client in developing optimal bowel habits.

We’ve discussed in detail several times how our habits can be extremely connected to our bowel function. This is also very true for individuals dealing with IBS–whether struggling with constipation, diarrhea or both! Training bowel habits includes developing a consistent bowel routine, optimizing dietary habits, and even toilet positioning/defecation strategies. These factors basically aim to help make sure your habits are working for you instead of against you. Sometimes these components require a more multidisciplinary team. This can include working with your GI physician, pelvic PT, as well as a dietician, functional medicine provider, and other specialties.

2.) Global downtraining and stress management.

Did you know you have an extensive neural network throughout your GI system? This network has been termed “the second brain” due to its ability to function even when cut off from the rest of the system. It’s also often called “the emotional brain of the body,” which makes sense when we think about how often we feel our emotions in our gut (i.e. “butterflies in your stomach” or “my gut reaction”) All is this means that our GI function can often be influenced by our stress, emotional regulation, and general psychological well being.

Qin et al. (2014) stated, “More and more clinical and experimental evidence showed that IBS is a combination of irritable bowel and irritable brain.”  They went on to add that psychological stress can impact intestinal mobility, motility, secretions and permeability. They concluded that, “IBS is a stress-sensitive disorder, therefore, the treatment of IBS should focus on managing stress and stress-induced responses.”

Pelvic PTs utilize strategies promoting downtraining and neuromuscular relaxation to help calm the nervous system and promote a more parasympathetic dominant state.  This can be done through movement, relaxation strategies, mindfulness/meditation, and many other techniques. Want to get started on mindfulness now? Check out this prior post on Mindfulness, Meditation and Pain.

3.) Specific exercises aimed at promoting better movement.

This may not seem connected at first, but the reality is that when people aren’t feeling well or when someone is struggling with constipation/diarrhea, people tend to move less. This can often impact bowel function as regular exercise tends to stimulate more regular bowel movements. This 2019 review of 14 studies involving exercise interventions aimed at improving IBS symptoms found that exercise does seem to have a role in helping bowel function (Note: many of these studies were not so great, and found to have a high risk of bias, so more studies are definitely needed!)

Schuman et al. (2016) performed a review of 6 randomized-controlled trials looking at the role of yoga in helping people with IBS. I’ll be honest, I absolutely love yoga and find the pairing of breathing, mindfulness and movement to be so beneficial to myself and my patients. So, I was not surprised to see this review showing that the groups participating in yoga had decreased bowel symptoms, IBS severity and anxiety.

Additionally, it is common for someone with chronic constipation and/or diarrhea to have restrictions in the movement of their hips and spine. Restoring this movement through specific exercise can facilitate better function of the muscles around the pelvis, including those involved directly in bowel function.

4.) Treat the myofascial components of the problem.

We have discussed the viscerosomatic and somatovisceral reflexes in the past. Basically, when a person has an organ problem (in this case, IBS), we often will find that the myofascial tissues around the organ can become restricted and sensitive. This can be interconnected where myofascial dysfunction can worsen a visceral problem and a visceral problem worsens myofascial dysfunction. Thus, addressing both sides of the problem can often be very optimal. From a musculoskeletal standpoint, this means identifying structures around the abdomen and pelvis which may be sensitive or not moving as optimally. This can often include the abdominal wall, hip muscles, thigh muscles, buttocks muscles and the muscles around the low and mid back.

5.) Treat underlying or co-existing pelvic floor problems.

Prott et al. (2010) found that there were relationships between pelvic floor symptoms and anorectal function in individuals with IBS. Dysfunction of the muscles of the pelvic floor can present as weakness, which can lead to either difficulty holding back stool or poor support around the rectum. It can also include overactivity and poor relaxation of the pelvic floor muscles. This can contribute to pain, but also can influence how well the muscles can open for defecation , or hold back when they need to. Additionally, people can experience difficulties with coordination of the pelvic floor– basically, when the muscles do not contract or relax when they should. Dyssynergic defecation occurs when the pelvic floor muscles contract instead of relax when a person has a bowel movement. This can be a significant problem for those struggling with constipation. I wrote a whole article on that, and you can find it here. Sphinctor dyssynergia can occur in individuals with IBS as well as other types of constipation, and can be treated with pelvic PT (lots of treatment options, including SEMG biofeedback which has been found to be helpful for people with and without IBS).

IBS can be so impacting to a person’s life, and you don’t have to suffer alone! I encourage you to build your multidisciplinary team and start getting the help you need to get the most out of life!

What strategies have you found most helpful in dealing with IBS? As always, I’d love to hear from you!

~Jessica

Y’all, I’m published in Sexual Medicine Reviews!

Last summer, Sara Sauder asked me to collaborate with her and Amy Stein on a submission to Sexual Medicine Reviews, highlighting the role physical therapy can play in helping men and women with sexual dysfunction. I was thrilled to have the opportunity to collaborate with Amy and Sara, and for the next year or so, we worked together to create “The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment.”

In this article, Amy, Sara and I discuss the role the pelvic floor muscles play in sexual health and common dysfunctions that can occur. We also discuss the process of physical therapy evaluation and treatment for sexual dysfunction, as well as the evidence regarding the efficacy of such treatments. Submitting to a peer-reviewed journal was humbling and exciting, and honestly, gave me much more respect for the process. I have been wanting to get involved with research for some time now, and I hope that this will be a springboard to more involvement and more writing.

The journal gives authors access to full-text of the article for the next 45 days, and I am excited to have the opportunity to share it with all of you!! Please let me know what you think of the article, and enjoy!

CLICK HERE to access full text of, “The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment.” 

All the best,

Jessica

Interview with “The Vagina Whisperer” on Pregnancy & Postpartum Health, Advocacy, Being a Mom, and Everything in Between!

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About 2.5 years ago, I had the incredible opportunity to join Herman & Wallace Pelvic Rehabilitation Institute as a Faculty instructor for the Pelvic Health Series. This was an absolute dream come true for me, as I completely love teaching and had always dreamed of teaching continuing education in pelvic health. (Seriously… as a new grad, I remember asking an instructor at a course what advice they had for someday becoming an instructor. Funny story is that I now co-teach with that very instructor!).  Teaching in pelvic health has been such a incredible blessing for me– not only do I get to travel across the country and help other clinicians learn to treat my most favorite population of patients, but I also get the opportunity to co-teach with inspiring and incredible experts in pelvic physical therapy.

This past September, I had the opportunity to teach with Sara Reardon, PT, DPT, WCS, BCB-PMD, who is not only an incredible clinician, but is also hilarious, down-to-earth, and passionate about women’s health. One night at dinner, Sara, Darla Cathcart, and I had a long conversation about pregnancy, childbirth, the postpartum period, and becoming moms. At one point, I think all of us had tears in our eyes, as we shared our own journeys, challenges we/our family/our patients have had, and our hopes for making everything better. After that chat, I just knew I needed to interview Sara here so all of you have the opportunity to learn from her and feel her passion! I hope you enjoy this interview! Please feel free to leave any questions or comments below!

If you would like to see Sara’s work, check her out at www.thevagwhisperer.com. Here, you will find information about seeing Sara in-person, her online therapy options, mentoring options, and her instagram/blog presence!

Happy New Year!

Jessica

If you want to see all of our expert videos in one place, be sure to check out my youtube channel! This video as well as the others can be found here!

 

 

How to Poop

3 years ago, I wrote a post on dyssynergic defecation that over time has become the most viewed post I have ever written. Y’all, people are struggling with pooping. Bowel health is something we all tend to take for granted until it stops working right. So, what is dyssynergia? Basically, dyssynergia refers to a state where your muscles are working against you when you have a bowel movement. Instead of the muscles coordinating well to open and relax to allow the stool to come out, the muscles will contract and fight against the stool coming out. This is a big problem for people struggling with constipation. In fact, this review suggested that around 40% of people with constipation have this problem.

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How do you properly poop? 

“Why aren’t we ever taught these things?!” I hear this all the time from patients after we discuss the often basic techniques to improve bowel and bladder health. In reality, these habits should be learned and passed down through families, but the reality, more often than not, is that that majority of people do not learn proper habits until problems start happening. So, let’s get started, and get to healthy pooping.

Step 1: Use Optimal Pooping Posture & Positioning 

Yes, how you sit on the toilet really does matter. The optimal toilet positioning is one that will allow the muscles around the rectum to relax. This helps to open the angle between the rectum and the anus, and will allow stool to pass more easily. Our friends at Squatty Potty have made major $$$ on this concept with their handy stool. They do have some great videos, and this one listed here gives a nice overview on why a squatted position is more optimal for defecation.

Now, as an aside, should everyone sit with their knees elevated that high on the toilet? That’s going to be a big NO. The optimal position for you may not be the optimal position for the person next to you. The key here is that you need to be as comfortable as possible while sitting on your throne. If your hips hurt, or your back feels tight, etc. when you are squatted like this, change the angle until you find the best position for you. 

Step 2: Take Your Time 

We all know those people who grab a book and head to the bathroom, only to be seen 30+ minutes later, right? Well, they actually do have the right thought process. Many people get into a pattern of sitting on the toilet and immediately straining and pushing to empty their bowels. This is not often necessary, and actually overrides the normal processes of your colon and rectum. The best habit is actually to 1) Head to the bathroom as soon as you can when you feel the urge to have a BM and 2) Sit and relax on the toilet, giving your body at least 5 minutes to get things moving on its own. If you do need to push or help the body in the process, move on to the next step.

Step 3: If You Need to Push, Push Properly. 

Is it ok to sometimes need to push a little to get the poop out? Absolutely! Our bodies are made to be able to do this when needed to assist in getting the stool out. Did you know your GI system actually has several reflexes that aid in pooping? The intrinsic defecation reflex is a reflex that is stimulated when stool enters the rectum. This reflex will trigger the sequence of events that leads to defecation. When this reflex is suppressed (via another reflex, the Recto-anal inhibitory reflex), the colon will be helping you less in getting the stool out. This means that you may need to do a little pushing to assist in the process. So, how do you push?

Proper pushing requires a few things 1) abdominal muscle activation 2) pelvic floor muscle relaxation and 3) breathing. So, if you are holding your breath when you push, that is NOT proper pushing. Before we get started, it can be helpful to test yourself and see what your current habits are. To do this, place your hands on your belly while you sit on the toilet. Perform a fake “push” and see what happens. Did you hold your breath? Did your belly push out into your hands or pull in away from the hands? What did you feel happen at your pelvic floor?

So, now, let’s talk about how to push properly. First, be sure you are in  your optimal toileting position. Now, place your hands on your belly and relax your belly forward. Do you feel how relaxing your abdominal wall allows your pelvic floor muscles to also relax? Interestingly enough, the pelvic floor and the transverse abdominis muscles have a neurological relationship. Thus, for the majority of people, these muscles contract together. So, since the transverse abdominis muscle will pull the belly in (leading to pelvic floor muscle contraction), we want to do the opposite–> keep the belly out. Next, with your “belly big,” take a deep slow breath in. Then, as you blow out, think about blowing into your belly, gently tightening the muscles of your abdomen without allowing the belly to draw in. We call this “belly hard.” Lastly, as you are doing this breathing, think about relaxing, lengthening and opening your pelvic floor as you gently bear down (“pelvic floor drop”). So, in summary, this is what we are aiming for:

  1. Belly Big— relax the belly forward and take a breath in.
  2. Belly Hard— As you exhale, push into the belly, tensing the abdominal muscles, but not shortening them!
  3. Pelvic Floor Drop— while you are exhaling, gently bear down, allowing your pelvic floor to open and relax

(Note- several amazing clinicians have developed these concepts and verbiage that best connects with people. Pauline Chiarelli has a great book called Let’s Get Things Moving: Overcoming Constipation, and she discusses this in detail there. “Belly Big, Belly Hard, Pelvic Floor Drop” is a phrase we teach in our H&W Curriculum, and I believe it is also a phrase used by Dawn Sandalcidi, an excellent pelvic PT and faculty member out in Denver, CO.)

Who knew pooping was so complicated?

Please let me know if you have any questions! If you’re a pelvic PT, I would love to hear from you–especially if you have other strategies you like to use to help people learn how to poop! Let me know in the comments!

~ Jessica

Treatment Highlight: Vaginal Dilators/Trainers for Sexual Pain

 

Last week, one of my favorite things to happen in the clinic happened again. A sweet patient I had been working with over the past few months came in to her session, and as soon as we closed the door, she exclaimed, “We had sex and it didn’t hurt!” As a pelvic PT, there is nothing better than sharing in the joy of the successes of your patients. Treating sexual pain is close to my heart, particularly because this was one of the reasons I became a pelvic PT to begin with. “Treating Sexual Pain” was actually the focus topic for my small group mentoring program this month, so I thought it would be fitting to highlight a common treatment tool/strategy used in pelvic PT to help people experiencing painful penetration.

What are vaginal trainers? 

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Used with kind permission from Intimate Rose 

Vaginal trainers are tools used to help to desensitize the muscles and tissues of the canal. They are often helpful when a person is wanting to participate in penetration activities, and is having difficulty doing so due to pain. Vaginismus is a particular diagnosis that refers to painful vaginal penetration due to muscle spasm. Women experiencing vaginimus in particular can be very good candidates for this type of treatment program. That being said, trainers can also be helpful for people with pelvic pain in performing self-manual treatment to the pelvic floor muscles, or for other vulvar pain conditions. Trainers also come in rectal variations, and some patients benefit from these as well depending on their primary complaints and goals.

Trainers generally come in graded sizes, often ranging from very small (think pinky finger) to large. There are several different companies that make trainers, and I’ll share a few of the different types here:

  • Silicone Dilators/Trainers: These are smooth silicone, and bend and move very easily, so they are what I consider to be top-of-the-line trainers. Soul Source and Intimate Rose are two companies that sell these trainers. Both are great, but I do really like how smooth and soft the intimate rose dilators are. These are a little pricey, so range from $18-50 per trainer $80-200 for a set. (As an aside, Intimate Rose was actually designed by a pelvic PT, Amanda Olson, DPT, PRPC. Amanda has excellent resources on her website, including this great video providing a breathing exercise for pelvic pain)
  • Plastic Dilators/Trainers: These are hard plastic, so they do not move and bend the way silicone trainers do. However, they do tend to be on the cheaper side. Vaginismus.com sells a trainer set including 6 sizes with a handle for about $45. The Berman Vibrating Set includes 4 sizes and often sells on amazon for less than $25. Syracuse Medical also makes a set without handles that is solid plastic, and those trainers are sold individually ($10-20 each) or as a set ($45-80).

How do you decide which to pick?

Well, it depends on a lot of things. Some of my patients prefer to go the cheapest route possible, so for them, it makes sense to get the $25 Berman set off of amazon or the $45 Vaginismus.com set. For others, they really like the softness and bendiness of the silicone sets, so they feel comfortable spending a little more for that type of set. Some sets come with varying sizes, so it is important to pick one that has the sizes you (or your patient) needs to accomplish their treatment goals. Usually, I sit down with my patients, show them a few different sets, then allow them to pick the set they feel the most comfortable with.

Wait…Trainer or Dilator? What’s in a name? 

So, you’ll see these terms used interchangeably quite a bit, but honestly, I think the name really does matter. The term “dilator” never really settled well with me…because…well…dilation is a fairly strong word. Dilation refers to passive opening. I think pupil dilation. I think cervical dilation (although one could argue that is not totally passive!). Honestly, dilation is not what we are aiming for when it comes to the pelvic floor muscles. Trainer on the other hand, is an active term. It requires participation, focus, involvement. It is not a passive process, but rather, is an active journey. And that, my friends, is what utilizing trainers to improve penetration should be.

Getting started with trainers 

A word of advice- please do not try this on your own. I have had so many patients who become discouraged, sore, or get worse from using trainers without the guidance of a pelvic PT. If you are struggling with sexual pain, and you would like to try trainers, please please please make an appointment with a pelvic PT who can evaluate you and guide you in this process.

Once my patients purchase their trainer sets, I have them bring the trainers to the clinic. We then will use them together in the clinic before they begin using them as part of their home program. I have a few rules when it comes to trainers:

  1. We are gently introducing a new stimulus to the vagina; therefore, we do not want to do anything that leads to the body guarding and protecting by pain. So, when people use trainers, all discomfort should be 2/10 or less, and should reduce while we are using the trainer.  (Note: Some very well-intending clinicians will give advice to “insert the largest dilator you can tolerate and leave it there for 10-15 min.” Tolerate is a very strong word, and I find this approach tends to lead to a lot of pain as well as fear and anxiety associated with the treatment.) 
  2. We cap out at 10-15 minutes. I encourage patients to set a timer when they start, and whenever that timer ends, to go ahead and end their session. This keeps the session reasonable in time commitment, and also avoids over-treating the area.
  3. We avoid setting “goals” for the sessions or the week. The goal of using trainers is to gently provide graded exposure to the muscles and the tissues, to allow relaxation and opening without anything being threatening or painful. Our muscles are impacted by many different things, so many patients will find that the size of trainer they use or the level of insertion that happens can vary based on the day, week, etc. So, for this reason, we avoid setting a goal to accomplish, but rather, just aim to spend time focused on breathing, relaxation, opening, and gentle desensitization.

So, how do we use the trainers? 

My approach to using trainers is strongly influenced by my friend and mentor, Darla Cathcart, PT, DPT, WCS, CLT. Darla was my clinical instructor back when I was getting my doctorate 10 years ago, and her approach to using trainers is gentle, progressive, and based in our understandings of muscles and neuroscience. (As an aside, Darla recently started teaching for H&W and I could not be more excited!! We taught our first class together a few months ago, and we will be teaching together again in 2019!! She is the absolute best, and is actually currently doing her PhD research on women with vaginismus. I’ll try to share more as she gives permission to do so in the future!)

Back to trainers, I encourage people to start with the smallest trainer (or for some, I may recommend a different size based on what I noticed with the exam). First, I encourage creating a comfortable environment to use the trainers– this means calm lighting, comfortable space, pillows to support legs and torso so that muscles can relax, and sometimes even a nice candle or soft music. We begin with placing the smallest dilator at the opening of the vagina, then slowly insert until the person feels discomfort (2-3/10) or guarding. When this happens, we stop moving, and they take slow long breaths focusing on relaxing and opening the pelvic floor muscles. They can then gently (like with 25% force) contract and relax the pelvic floor muscles, aiming to completely let go and rest the muscles. If the tenderness/guarding they felt resolves, they continue to slowly insert the trainer and repeat this process until the trainer is completely inserted. If at any point the discomfort does not reduce, we then will back the trainer out a little bit and rest/breathe there for a minute, then try again. If it still does not reduce, then the body is giving a cue that it is ready to take a break from trainers, and we go ahead and stop the session.

Once the trainer is completely inserted, we add movement. This can include turning the trainer side-to-side, or pressing it right, left or down. We avoid turning or pressing the dilator toward the pubic bone as the bladder and urethra live there, and they don’t generally like being mashed on. We can also move the trainer slowly in and out, stopping again during this process if anything is uncomfortable and repeating the steps above.

One that size trainer is completely comfortable, we move on to the next size and repeat the process. This continues until the 10-15 minute session ends, and then wherever we are, we stop for the day. We can add modifications in to trainer sessions, and this will depend on the particular patient. Sometimes this includes partner involvement with trainers or it can include visualizations or imagery to aid in the process.

With this slow, graded, and gentle approach, I find that most patients can do very well and this can be an excellent treatment to help them achieve their goals! I hope this was helpful in better understanding an approach to this treatment! If you are a patient and think you may benefit from using this approach, I would strongly recommend discussing this with your physician and seeking out a pelvic PT to help you guide the process!

If you are a pelvic PT, feel free to share any additional tips or recommendations you have for trainers in the comments below!

Have a happy Thanksgiving!

~Jessica