I love reading blogs about pelvic health, the human body, chronic pain, movement, neuroscience–and especially get excited if these things get combined together. Periodically, I’d love to simply do a blog on blogs, so that is what you get today. Basically, it is a quick list of blogs, journal articles, random articles, and possibly books that I am reading right now. There are SO many great things out there. I hope you enjoy, and have a great friday! 🙂
1. The Pudendal Neuralgia Wrecking Ball. Of the different diagnoses in the chronic pelvic pain world, pudendal neuralgia is often a scary one for a patient to hear. Not because it’s untreatable–it IS treatable. But simply, because , and unfortunately, many patients with this type of problem (like SO many other problems related to pelvic pain) are often misdiagnosed many times before receiving help and assurance, and often find scary and less than assuring things when researching online (leading to high levels of worry and fear). So, this article on US News and Reports came out recently. As pelvic PTs, we always love to have big news websites post information to bring awareness to pelvic pain problems. But we took some issue with exactly how that was done and some of the information which was provided…which lead to this excellent response by Stephanie Prendergast, PT of the Pelvic Health and Rehabilitation Center in California (If you don’t follow their blog, you really should! They consistently put out fantastic, high quality information.) And then, led to this response by Sara Sauder, PT, who writes her own blog, focusing all on pelvic pain (it’s great too!). Read these posts–they have great information in them!
2. Can’t Get Enough of the Diaphragm. March was really the month of the diaphragm. Not only did you get my post on the 6 reasons why the diaphragm is the coolest muscle ever, but Ginger Garner (who also has a great blog with a big emphasis on women’s health) went into great detail on this post, expanding on how important the breath really is. I’ve written a lot recently on the importance of breathing with movement and coordinating the breath with other muscle activation, but is holding the breath ever a good strategy? Julie Wiebe gave great insight into that in this post here. (And you know Julie posts awesome stuff!).
3. Movement Variability. As humans, we are designed for movement. Typically when people have pain, their movement patterns become more rigid, and they can often develop alterations where their bodies are guarding movements by pain. Retraining slow, controlled motions with a lot of variations is an important component of treatment! For those without pain, movement variety is key to keeping healthy bodies! That’s why I loved this post by Katy Bowman (my favorite biomechanist) on sitting variations while playing with her child.
4. Share MayFlowers: Women’s Health Awareness. My list would not be complete without a shout-out to Jessica McKinney’s excellent work with Share MayFlowers. SMF is a public health initiative aimed at improving awareness in Women’s Health, and Jessica has been posting excellent information all month long! She highlights women who are doing fantastic things to support WH initiatives, and links to great blogs, articles, etc. out there! A few of my faves from this month are this New York Times article which discussed an innovative form of sex education for adolescents, and this post, bringing awareness of obstetric fisulas.
Hope you enjoy! Now it’s your turn– what are you reading? I’d love to hear in the comments below!
Earlier this week, I asked the Twitter and Facebook PT world a simple question:
What are the common misconceptions you hear about the body?
My initial goal was a fun blog post on common misconceptions about anatomy, etc…but I was not prepared for the huge response I received—over 40 responses with SO many different things that people often misunderstand! Some pelvic, some general—and it made me realize there is SO much bad information out there!! So, what once was one post will become two. Today, we’ll hit on 10 common myths related to the pelvis (you knew I’d start there!). Then stay tuned for a future post hitting other misconceptions related to…well… the rest of the body, fitness, wellness, pain etc. So, here we go:
1. Men don’t have pelvic floor muscles: They do, I promise. And guess what? The anatomy is not quite as different as you would think! The same muscles that contribute to urinary, bowel and sexual function as well as lumbopelvic stability in women do that in men too. Pelvic PTs treat men with incontinence, pelvic pain, constipation, painful sexual intercourse and much more.
2.Vaginas need a lot of work to keep clean. No, they don’t. The Vulva (vagina really just refers to the canal itself) is actually self-cleaning. It does not need to be scrubbed with soap. You can totally just shower and run water over it, and it will be just fine. In fact, scrubbing the vulva can irritate it and even kill the good bacteria that prevent infections! I could say so much more, but you really should just read this article on Pelvic Guru by Sara Sauder, PT and this one by Dr. Jen Gunter.
3. Abdominal pain is always caused by organ problems. Not necessarily. Now, don’t get me wrong, abdominal pain can definitely happen with ovarian cysts, appendicitis, constipation, and much more—but abdominal pain can also happen when the organ is not to blame. This is so common in men and women with chronic pelvic pain. These people often will have very sensitive nervous systems, tender muscles around the pelvis and in the pelvic floor, as well as even neural irritation (lots of nerves run through the abdominal wall!). So, if the organ has been ruled out as a source of pain and the pain persists- it may be worth considering something different.
4. Not having enough sex OR having too much sex OR masturbating too frequently causes pelvic pain. I cannot tell you how many times I have had a patient timidly ask me if there sexual habits or frequency are to blame for their pain. No. Just no. You should be able to have sex as little or as frequently as you want without any problems or pain. Now, being forced to have sex—that may cause a strong protective response of the pelvic floor muscles. But, consensual sexual activity is normal and should be enjoyed by all without worrying about pain. And if you are having pain? Don’t ignore it– go talk with your physician or physical therapist!
5. Tight pelvic floor muscles are healthy pelvic floor muscles. Guess what? Tight ≠ strong. Flexible ≠ weak. Strong ≠ Well-timed. Functional pelvic floor muscles are non-tender, flexible muscles that are able to activate when they should activate (well-timed). We want the pelvic floor to stretch to allow you to poop and have sex, and we want the muscle to activate at the right time with enough strength to help you not leak urine when you cough.
6. If the doctor says “all looks good” 6 weeks after having a baby, it means your body is completely back to normal. Newsflash here, you’re body isn’t really going to go back to being exactly what it was like before the baby. It’s not meant to, and that is ok! It can still be an awesome, strong and well-functioning body– but you do need to take care of it. Remember that urinary or bowel leakage, constipation, persistent low back/pelvic pain, vulvar pain, and pain with sexual activity are NOT normal. If “all looks good” at 6 weeks, but you are having these problems, find a skilled pelvic PT near you to get evaluated and get some help! And even if you are not having these issues—your body has been through a lot! Take time and care in slowly getting your body back into good movements. Also, check out this article by Ann Wendel, PT on 5 myths surrounding the pelvic floor after pregnancy.
7.If a woman had a c-section, her pelvic floor was not impacted, and she doesn’t need to think about it. Guess what the biggest risk factor for urinary incontinence is? PREGNANCY. Although mode of delivery is important, simply being pregnant and carrying a baby puts significant pressure on the pelvic floor. Both vaginal deliveries and c-sections impact the body—remember, a c-section cuts through the abdominal wall! Remember that team of muscles that work together for lumbopelvic stability? The abdominal wall is a KEY member. Regardless of your mode of delivery, seeing a skilled physical therapist after having a baby is crucial to help your musculoskeletal system function optimally, manage unwanted pain or leakage, and get back to the fitness activities you enjoy. And guess what? It’s standard care for all ladies postpartum in many countries around the world.
8. Urinary incontinence is always due to a weak pelvic floor muscle group. I wrote a whole blog on this one, so I recommend you read it here. The short answer is, No. No problem is due to solely one muscle. Our body is a system, and we have to always treat it like that.
9. Hips and sacrums dislocate regularly in some people. This is such a common one too—I’ll have patients come in and say, “My hip keeps ‘going out’ and I have to do this <does weird hip movement> to put it back in.” OR “My SI joint keeps ‘popping out of place.’” Let’s all be honest about this- dislocations of joints do happen, but it tends to be pretty painful, likely traumatic, and if your hip dislocates, you bet you are going to the ER. That “pop” you hear? It’s likely just a joint cavitation- basically a decrease in pressure causes dissolved gasses in the joint fluid to be released into the joint. Same thing happens when you pop your knuckles. If it happens frequently and is associated with pain, talk with a physical therapist.
10. Sucking in the stomach constantly creates a strong “core” and a flat abdomen. You know what creates a flat abdomen? Eating healthy and exercising regularly. Contracting any muscle constantly is not functional, nor does it really do what we want it to do. Sucking in the stomach actually tends to make it more difficult for your diaphragm to move well when you breathe and also can cause the pelvic floor muscles to over contract and become tender/uncomfortable. It can also inhibit movement, and we know moving well with variety is SO key to a happy body. So, relax your stomach and allow yourself to breathe (remember how important that diaphragm is!)
I hope you gained a little insight with this list—it was fun to write! This is by no means an exhaustive list (over 40 responses, remember?), and I’d love to keep the conversation going! Special thanks to my world-wide pelvic health team! It’s so fun collaborating with such a great group!
Have you heard anything else about the body that does not seem to be right? Ask here and we’ll do our best to answer! Physical therapists out there—what are your other favorite myths to de-bunk? Let’s all work to spread accurate knowledge—knowledge really is power! Have a great Wednesday!
I have a small confession to make– I love the study of human anatomy. Always have. It was studying human anatomy and physiology that made me shift my undergraduate degree at Gordon College away from “Biology” and into “Movement Science” (which has now become “Kinesiology”… Who would have known that years later, “Movement Science” would have been the coolest name for a major ever? Am I right fellow PTs?). The human body is fascinating and incredible. So, it should come as no shock to you that I have favorite muscles. In PT school, my favorite muscles were the ones with the most fun names… like the Gemelli brothers (who are small hip external rotators) or Sartorius (a thigh muscle…best, if sung to the tune of “Notorious“). Of course, you know that now the pelvic floor muscle group ranks pretty high on that list…but the diaphragm, well… it just takes the cake. Here are some of the reasons why the diaphragm really is so cool.
1) We can contract our diaphragm voluntarily–but it also will contract without us consciously telling it to. How cool is that? You can activate your diaphragm by taking a long, slow, breath expanding your ribcage 360 degrees and allowing your belly to relax. But, before I brought your attention to your breath, you were using the diaphragm without even thinking about it!
2) The diaphragm helps to mobilize the ribs, lumbar spine and thoracic spine. The diaphragm attaches to the 1st, 2nd, and 3rd lumbar vertebrae, the inner part of the lower 6 ribs as well as the back of the sternum at the xiphoid process. The central tendon of the diaphragm then attaches to the 3rd lumbar vertebrae. During inhalation as the diaphragm flattens to allow the lungs to fill with air, the diaphragm will “pull” slightly on each of those attachments, effectively giving you a gentle mobilization. The ribs will also move during inhalation and exhalation to allow space for the lungs to fill.
3) The diaphragm is a key member of a team of muscles which help to create dynamic postural stability. You knew that would be one of my bullets, right? I think I mention this in almost every post…but… the diaphragm works together with the pelvic floor muscles, abdominal muscles (transverse abdominis) and low back muscles (multifidus) to pre-activate and provide support to the body during movement. Together, these muscles make up our “anticipatory core” and are important muscles for healthy pain-free movement patterns. Now, no post on the diaphragm would be complete without an excellent video explanation by Julie Wiebe, PT, who is amazing and has done so much to help advance the understanding of dynamic stability in PT practice.
4)Retraining proper firing of the diaphragm can help to reduce urinary incontinence AND low back pain. Now, that is pretty cool, right? Excellent research by Paul Hodges and colleagues has shown altered firing patterns of the diaphragm in people with low back pain or urinary incontinence. Amazingly, when people re-established proper firing of the diaphragm leading to full excursion, both low back pain and bladder problems reduced This is likely due to the relationship between the pelvic floor and diaphragm in controlling intraabdominal pressure within the abdomen and the pelvis. Proper breathing helps to restore the optimal pressures needed to control movements and support the pelvic organs. This relationship is so huge that problems with breathing and continence are more correlated with low back pain than obesity and physical activity.
5) Slow breathing with the diaphragm can calm down the nervous system. The breath is so connected to the autonomic nervous system. When a person is fearful or anxious, the sympathetic nervous system (fight or flight response) is activated, and a person will take quick shallow breaths to bring oxygen to the muscles as quickly as possible (think: being chased by a bear) the parasympathetic nervous system (rest and digest) is activated when in a more calm or relaxed state (yes, I am oversimplifying all of this… I know). In that state, a person will take slow calm breaths (think: sipping a cup of tea after a great massage). The cool thing is that we can use our breath to help us move toward a more relaxed state. Slow breathing will help calm stress, anxiety and promote a person being in a more parasympathetic state. And guess what? There’s an app for that! The Breathe2Relax app for iphone/android allows a person to program in his or her breath and then takes you through a guided breathing exercise.
6) Slow breathing with the diaphragm can reduce pelvic pain. As we discussed previously, the pelvic floor and diaphragm are coordinated and work together to control pressures through the pelvis. As the diaphragm is activated during inhalation, the pelvic floor relaxes to accept the contents of the abdomen/pelvis. As we exhale, the diaphragm returns to its rested position and the pelvic floor activates slightly. Long slow breaths then encourage complete relaxation of the pelvic floor and thus can help decrease pain for people with tender pelvic floor muscles.
So, there you have it! I bet the diaphragm just moved up a few notches on your favorite muscles list (you know you want one!). If you need more reasons, and enjoy “nerding-out” with Anatomy, check out these studies:
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….
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:
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!)
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…
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:
For the next few weeks, I plan to re-blog/update every Thursday a previous post originally written by me when working in Greenville, SC for the Proaxis Pelvic PT blog (http://proaxispelvicpt.wordpress.com), in hopes of building a comprehensive library of posts at jessicarealept.com. Selfishly- I like having them all in one place since I often refer patients who come to see me in Atlanta for pelvic PT to my old posts to read as “homework.”
That being said, today’s post is one published a while back here, originally titled, “Yes, you have incontinence. No, I do not necessarily want you to do Kegel exercises.” It has been modified/updated for you today 🙂 Enjoy!
Recently, I was fortunate to evaluate a nice middle-aged woman referred to me by her urogynecologist for urinary incontinence. When we first sat down, she looked at me and said, “I’m not sure why I am here. My doctor specifically told me that I have a strong pelvic floor. I really don’t think you can help me.” I smiled. I hear this same thought process on a weekly basis (See my previous article on common misconceptions of pelvic physical therapy) You see, at some point the world became convinced that from a musculoskeletal perspective, stress urinary leakage is always due to a weak muscle. And the best way to fix a failed muscle is to strengthen, strengthen, strengthen. But, if that’s the case, then why do I have so many patients walking into my office telling me that they have done “Kegel” exercises and still leak? Why would a patient like the one above have a “strong” pelvic floor that cannot hold back urine? Why is urinary leakage associated with low back pain and pelvic pain- disorders that we know can often include tight and irritated pelvic floor muscles?
Now, as a caveat to this article, let me say now that it is sometimes totally appropriate for a person to start a pelvic floor strengthening program. In fact, the person with a truly weak, overstretched, poorly-timing pelvic floor will likely be prescribed a strengthening program. With that being said, the truth is that the majority of patients referred to my clinic for evaluation of urinary incontinence are not issued a traditional kegel exercise program. My colleagues and I actually tend to be surprised when we evaluate a new patient who truly needs to start a true “strengthening” program for their pelvic floor at the first visit. The reason behind this is that Stress incontinence is not simply a failed muscle, but a failed system.
The urethra is supported within the continence system by fascia, ligaments, as well as muscular structures. When a downward force is applied to this system as occurs with coughing, sneezing, lifting, bending, etc, these structures function in a coordinated way to compress the urethra and prevent urine from leaking. In fact, Hodges et. al. in 2007 examined musculoskeletal activation occurring when a person performed an arm movement and found that the pelvic floor muscles pre-activated to prepare the body for movement. This helps to demonstrate that our pelvic floor muscles function as a member of the anticipatory core team. This team requires optimal and coordinated function of the diaphragm, the deep abdominal muscles, the deep low back muscles as well as the pelvic floor muscles. My awesome colleague, Julie Wiebe demonstrates that relationship very well in the video below (Note: Julie has an AWESOME blog/website- read more of her stuff here):
When any of these structures are not functioning well, leakage can occur. Now, the tricky part here is that optimal functioning requires both strength, flexibility and proper timing. A tight irritated muscle then becomes equally as dysfunctional as a weak over-stretched muscle. And, a strong, flexible muscle that doesn’t have the right timing contributes to a very dysfunctional system.
So, treatment for incontinence then must include retraining and reconditioning the system to ensure its proper functioning—which for me includes a bit of detective work to truly identify the faulty components. And, when it comes down to it, typically does not include doing 100 kegel exercises a day. More often, it includes learning to relax the pelvic floor and teach the pelvic floor to be a working team member– learning to coordinate the pelvic floor with the diaphragm, eliminating trigger points and restrictions which may be inhibiting this function, and then retraining the motor control of the lumbopelvic girdle as a system.
So, for now, take a deep breath and relax. We’ll save Kegels for another day.
As many of you know, I recently took a huge step in my career and moved to Atlanta with my husband, accepting a job as a pelvic health physical therapist for a newly opening private practice with One-on-One Physical Therapy. Leaving my patients behind was one of the hardest parts of moving (if you’re reading this prior patient, I miss you!). One of the things I realized when working to find colleagues to treat my current patients was that I treat quite a number of people with chronic pain. And I love it. When I left Greenville, I would estimate that close to 50% or more of my caseload were men and women who had been experiencing pelvic pain for 6 months or more (and many of them, much longer than that!). Often times, people experiencing chronic pain feel trapped in an inactive state—fearing movement, exercise and even social activities as they correlate increased activity with increasing pain. The sad truth about this is that reality and current research tends to show the complete opposite:
Movement is medicine for chronic pain.
Now, let’s take a step back…
What is chronic pain and what isn’t it?
I promise this blog post is going to stay on track. Honestly, there are so many people much smarter than I am who have written amazing books, articles, and blog posts on understanding chronic pain. So, I will be succinct here, but give you some good resources at the end if it leaves you thirsty for more.
In short, all pain is produced by the brain. (Your pain is real, not all in your head, but the brain is always really involved!) Pain is an alarm system used by the brain when it perceives damage or even sees a threat of damage to the body. Pain is there to motivate the body to action—basically to help you eliminate the source of “threat.” Example: I step on a tack. I feel “pain.” I move my foot off of the tack.
This alarm system works really well for situations like the one above. There is a threat. We remove the threat. We feel better. But it is important to recognize that the amount of pain does not always correlate with the amount of damage. Example: A man walks into the emergency room with a knife sticking out of his leg, but isn’t experiencing “pain.” A papercut can be felt as VERY painful.
The point is, the brain takes information in about our current situation, past experiences, emotions, etc. to create an experience of pain that it perceives as useful to us for the time being. This experience is influenced by situation (i.e. needing to get to the emergency room so the knife doesn’t “hurt”) emotion (i.e. No one knows what is wrong with me, so it must be really really bad!), fears (i.e. I am never going to be able to run again!), and life stressors (i.e. going through a divorce when the pain initially began).
So, how does this relate to movement?
For many people experiencing pain, movement often becomes a “threat” to the brain. For example, if a person is experiencing pelvic pain and the brain believes that walking will worsen the pain, then often walking will be a pain producing activity—to protect you from the “threat” of walking! Over time, the threshold for pain can change and people can become more sensitive to movements or activities—basically, the brain becomes very good at playing the pain “tune.” Lorimer Moseley uses the example of an orchestra in his book Explain Pain. If an orchestra plays the same song again and again, they become very very good at playing that song. Our brain works in the same way.
With that being said, we have learned that if we can help a person to move in a way that his or her brain is not protecting or guarding by pain, we can actually reduce the sensitivity to those movements and help a person get back to an active lifestyle with less pain. This is as true for a person experiencing chronic pelvic pain as it is for a person with chronic low back pain or neck pain or ankle pain.
Does it actually work?
The awesome part is that research has shown that movement and exercise are extremely helpful in pain reduction! A meta-analysis in 2014 published by the American Journal of Physical Medicine and Rehabilitation found that regular aerobic exercise improved pain, disability and depression/anxiety scores in people with low back pain. Another meta-analysis and systematic review published in 2014 by the Archives of Physical Medicine and Rehabilitation found that walking exercise helped to reduce pain levels in men and women experiencing chronic musculoskeletal pain. Even pregnant women with low back and pelvic girdle pain see benefits of exercise in pain reduction as noted in this 2012 review by the Journal of the Section on Women’s Health.
To see even more benefits of exercise, check out this awesome video by Dr. Mike Evans:
So, how do you get started if you hurt?
The key piece here is that we want to start moving at low pain levels in a way that will be therapeutic for your body—not in a way that will cause your body to guard and produce increased pain. When I treat patients with chronic pain, I start recommending movement at the first or second visit (of course, depending on the specific patient). Here is where I typically start:
Begin with small, manageable movement goals: If you have spent the last 5 years moving from bed to the couch, it is probably not the best thing for you to begin a running program. For these people who have been very sedentary, I recommend starting small by aiming to walk around the house once every hour and perhaps adding in a small series of shallow squats at their kitchen counter along with a few other easy exercises. On the other hand, if you are fairly active, but have avoided regular exercise, try to slowly build up to a routine again. I generally recommend starting at 10-15 minutes and building up to 30-60 minutes depending on the person.
Explore new and different exercise options: I have seen time after time that a person may be frustrated that she cannot do an exercise she enjoyed (i.e. running) so will stop exercising all together. Often times, I find that although one exercise may aggravate symptoms, another will be much more tolerated! I recently worked with a wonderful patient experiencing chronic pubic joint and pelvic pain—she loved walking for exercise, but found that walking was aggravating her pubic joint. We tried exercise in the pool, and she LOVED it! Not only could she begin moving again, but her pain seemed to stay at a low level while she exercised! So explore other options—walking, swimming, yoga, pilates, etc. Be open!
Try not to be afraid of pain: Remember to see pain for what it really is! I often tell my patients that if an activity keeps their pain low or improves their pain, it is likely a good, safe exercise for them to be doing. That being said, sometimes patients will try an exercise and it will severely worsen their symptoms—and that is part of the learning process. Generally, we find if we hold off on that activity for a short time while finding another activity that is more tolerable, we can often return to the other activity at a later date with much lower levels of discomfort.
Work with a team: I always recommend that my patients work closely with myself or another health care provider while they are getting back to movement. Sometimes, it is a little of trial and error learning what movement strategies are the most optimal to start with. Be patient, share your experiences, and be open to suggestion for different things to try!
So, good luck! Get started, and let me know if you have any questions! Thankfully, I am not by any means the only person who has written on this topic, so check out these excellent resources from my colleagues working with people with pain.