Category Archives: Pelvic Organ Prolapse

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!

 

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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

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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

Pelvic Floor Problems in the Adult Athlete (Part 2): Stress Urinary Incontinence or “I leak when I jump rope, box jump, run…etc”

As promised, this is part 2 of my series on pelvic floor problems in the adult athlete. Part 1 discussed pelvic floor pain- what it is, how it happens, and how it is treated. If you missed it, you can still check it out here. Today, we will cover stress urinary incontinence in athletes.

Guess what? Leaking is not normal. Ever. Never. Nope.

At some point over the years, women became convinced that after having children it suddenly becomes normal to leak urine when coughing or sneezing. Or, that if you work out really really hard, or jump rope really quick, or jump on a trampoline, it’s normal to pee a little bit. But guess what? It’s not. And I firmly believe that no woman (or man!) should have to “just deal with it.”

sandboarding-67663_1280

Bladder problems during exercise are very common– Here are some stats:

  • This summary article estimated that 47 % of women who regularly engage in exercise report some degree of urinary incontinence. (Other articles have shown big variety, with one review stating the prevalence varies from 10-55%)
  • This study found that in 105 female volleyball players, 65% had at least one symptom of stress urinary incontinence and/or urgency.
  • In elite athletes (including dancers), this study found a prevalence of urinary problems at 52%.

Summary: Urine loss during exercise is COMMON. And it’s about time we do something about it! 

So, what is stress urinary incontinence (SUI)? Basically, SUI is involuntary leakage of urine associated with an increase in intra-abdominal pressure.  For those who exercise regularly, this can occur with running, jumping (jumping rope, jumping jacks, box jumps, trampoline), dancing (zumba, too!), weight lifting, squatting, pilates/yoga, bootcamp classes, kicking, and many other forms of exercise.

**Note: Although SUI is one of the most common forms of urinary dysfunction we see in athletes, other problems can exist as well. This can include stronger urinary urgency, frequency (going too often), and/or difficulties emptying the bladder or starting the stream. Bowel dysfunction is also a problem with many athletes, and can include bowel leakage, constipation, or difficulty emptying the bowels. 

Why does it happen? There are many causes of bladder leakage, so it is always important to be medically evaluated. We know that hormones can play a role, as well as anatomical factors (pelvic organ prolapse or urethral hypermobility). Other factors can include childbirth history, body mechanics, breathing patterns/dysfunction, obesity–and I’ll add here, previous orthopedic injury or low back/pelvic girdle pain.

From a musculoskeletal viewpoint, SUI has to do with a failure of the body to control intra-abdominal pressure. Basically, there are forces through the abdomen and pelvis during movements, and our body has to control and disperse those forces. The deepest layer of muscles that work together for pressure modulation are the pelvic floor muscles, the transverse abdominis, the multifidus, and the diaphragm. In terms of the pelvic floor muscles specifically, remember that we want strong, flexible, well-timed muscles.  Tight irritated muscles can contribute to UI just as much as weak overly stretched out muscles. We have discussed this many many times on this blog, but if you’d like a review of that, read this piece on why kegels are not always appropriate for UI and check out the videos by my colleague, Julie Wiebe, posted there. It is also important that a person has properly firing muscles around the pelvis–especially the glutes! but also the other muscles around the pelvis that help to move you.

The way in which a person moves can also be a significant contributing factor to SUI. For example, if a person holds his or her breath during jump rope, the diaphragm is not able to move well and the entire pressure system will be impacted (leading to possible leaks!). I have also seen women develop SUI or pelvic organ prolapse after performing regular exercise using incorrect form/alignment or after performing exercises that were too difficult for them to do correctly. Often times, this leads to compensatory strategies that can make pressure modulation very difficult for the body.

What can you do about it? First things first–stop “just dealing with it!” I recommend a medical evaluation to start, but always encourage people to seek conservative treatments first prior to medications and/or surgery. The best person to evaluate you from a musculoskeletal perspective is a PT who is specialized in treating pelvic floor dysfunction (and if you live in metro Atlanta and have SUI, come and see me!). The physical therapist will do a comprehensive evaluation which will include:

  • A detailed history, including your obstetric history (if applicable), daily habits, diet/fluid intake, and your regular exercise routine
  • Evaluation of your movement patterns (specific exercises, weightlifting, etc.) which are causing you problems
  •  Head to toe evaluation of your spine, ribcage, abdominal wall, hips, breathing patterns, alignment/posture, knees…all the way down to your feet to see how your movement at each spot could be influencing your pressure system. We also look at how your various muscles fire to help to identify which muscles may not be firing at the right times or which muscles may be tight and impacting your movements.
  • Evaluation of the pelvic floor muscles. As the pelvic floor muscles are located internally, the best way to assess them is with an internal vaginal or rectal assessment. That being said, if you are uncomfortable with that, there are options for external assessment that will help the PT gather some information (just know that this will likely be less thorough).

Treatment for SUI often includes: 

  • Re-establishing the proper timing and coordination of the pelvic floor, diaphragm, multifidus and transverse abdominis to stabilize the lumbopelvic region and modulate pressure during movements. Remember, our goal is to optimize this team working together–it’s not just about the pelvic floor, and kegels are not always the answer.
  • Retraining the proper firing of the muscles around the pelvis during movements.
  • Correction of postural/alignment problems which could be contributing factors
  • Manual therapy and specific exercises to improve previous findings in spine, hips, knees, etc.
  • Education on proper alignment, breathing patterns, and movement sequences during preferred exercises.
  • Education on bladder health, dietary patterns, fluid intake, patterns for emptying bladder, toilet positioning, etc. to encourage healthy bladder function.
  • Treatment of co-existing bowel dysfunction, sexual dysfunction or orthopedic pain (as this is often all connected!).
  • **Some women also benefit from using assistive equipment like a tampon or a pessary to help stabilize the urethra or support the vaginal wall during exercise depending on her specific situation.

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My colleagues write very well, and have written several excellent posts on pelvic floor problems in athletes. Here are a few of my favorites:

I hope this was helpful to you! I would love to hear your thoughts– if you have questions or comments please leave them below! Have a great Wednesday!

~ Jessica

**Do you have an idea for blog post or is there a topic you’re just itching to learn about? Feel free to contact me or comment on any post to share your ideas! 

Prehabilitation for Pelvic Surgeries

Getting ready to have a knee replacement? You’ll have at least a few visits of pre-operative physical therapy.

What about a rotator cuff repair? The more you get that shoulder moving and stronger before surgery the better!

Now, how about that hysterectomy? Sling procedure? Prolapse repair?

  **SILENCE**

Why is it that men and women are easily referred to physical therapy prior to knee, hip or shoulder surgeries, yet so few are referred prior to pelvic surgeries?

Now, before you get fussy with me, I will say that I have worked with some fantastic surgeons who often referred women to physical therapy prior to undergoing pelvic surgeries—and we had great results working together! We would joke regularly that I made them look better and they made me look better. We were a great team! But, the unfortunate truth is that many women are not regularly referred to PT prior to having surgeries for incontinence or prolapse—and I really do believe that “prehab” would be significantly beneficial!

Here’s why:

Just like other orthopedic surgeries (knee, shoulder, hip), preoperative pelvic physical therapy can encourage proper muscle function prior to surgical intervention.  This is such an important piece! Restoring proper motor control patterns and overall muscle function can help a person recover more quickly and improve all aspects of pelvic health (bladder, bowel and sexual function). Remember, it’s not just about the pelvic floor! We also want to make sure the transverse abdominis (lower abdominal muscle), multifidus (low back muscle) and diaphragm (breathing muscle) are working optimally as a team to modulate and control pressures in the pelvis. In addition, we need to look at the whole person. Is an old neck injury impacting how you carry your pelvis? Did you have a hip replacement that is impacting your pelvic floor? A skilled pelvic PT can evaluate and address all of these components to help a person function as well as possible prior to having surgery.

In some cases, preoperative physical therapy can reduce the need for surgery. One of the physicians I worked with used to joke with his patients that I would regularly “steal his surgeries.” Now, this may be a scary thing for a surgeon to hear, but ultimately, isn’t it our goal to get patients better using as minimally invasive treatments as we can? From a surgical perspective, pre-operative PT helps to identify the patients who truly will benefit the most from surgery and those who may just need conservative care. We know now that many patients with urinary incontinence, fecal incontinence, and low-grade (typically grade I-II) pelvic organ prolapse respond very well to physical therapy interventions focusing on regaining optimal muscle function and improving behavioral habits related to bladder/bowel health and body mechanics.  That being said, there are of course many instances where surgery is indicated and very helpful—in pelvic health, the best situation is always a partnership between physical therapist and physician! I have the utmost of respect for my physician colleagues and we both found this partnership helped us identify the best treatments for patients to get them the best results as quickly as possible.

Preoperative physical therapy can reduce risk factors which could lead to worsening of problems after surgery.  Did you know that poor body mechanics with heavy lifting as well as constipation/chronic straining are risk factors for pelvic organ prolapse and urinary incontinence? Improving body mechanics is important to make sure that the “team” of muscles that support your organs are able to function optimally. Body mechanics are an especially important component for those people who participate in activities involving heavy lifting or heavy pressure (i.e. moms, healthcare workers, runners, etc.). Along with this, managing constipation and straining is a very important component. Learning how to develop a bowel routine, sit on the toilet properly, and use proper defecation dynamics (the coordinated relaxation of the pelvic floor muscles with abdominal activation to make bowel movements easier) is crucial in ensuring a person is not putting unnecessary pressure on the pelvic organs during bowel movements.

Preoperative physical therapy can help with managing nonsurgical components. I often will work with women who are having pelvic organ prolapse and pain during intercourse. Did you know that pelvic organ prolapse is not typically a source of pain (pressure yes, pain no!)? In fact, sometimes women with pelvic pain will even have worsened pain after pelvic surgeries as the muscles and nervous system respond to protect the “injured area.” Often times, prehab can help reduce pain prior to surgery through manual treatments, relaxation training and a lot of education! This can help make recovery easier and allow a person to have significantly reduced pain later on.  Another common nonsurgical component is urge related incontinence. Prolapse surgeries and incontinence surgeries can help with stress incontinence (leaking with increased pressure, like coughing/sneezing), but they do not help the urge component. Preoperative physical therapy can help with urgency or urge related incontinence through restoring proper muscle function, teaching urgency suppression strategies and retraining behavioral habits.

So, who would benefit from pelvic floor prehab? In my mind, anyone having a pelvic surgery! I would love to see all women before hysterectomies, sling procedures, or prolapse repairs. I would love to see all men before prostatectomies! The more we can help the body heal itself and promote optimal bladder, bowel and sexual function before a surgical intervention, the more likely we are to have high quality long-lasting results.

Lastly, here’s a little teaser for you– check out our gorgeous pilates studio at our newly opened clinic!! I just had to share!

Gorgeous pilates studio at One on One Physical Therapy in Smyrna!

Gorgeous pilates studio at One on One Physical Therapy in Smyrna!

So, what do you think? PTs- did I miss any of your key reasons why you like seeing men or women preoperatively? Have any of you out there had preoperative PT? I would love to hear your thoughts!!

~ Jessica

TBT: Is Running Bad for a Woman’s Pelvic Floor?

Today’s throw-back comes from a post I wrote back in November here. I loved writing this post because I love running. I also loved writing it because it falls close in line with my heart-felt belief that there is no “bad” exercise, just sometimes bodies that are not quite ready for it. I hope you enjoy the post, and I do look forward to hearing from you! 

Happy Thursday! ~Jessica 

As some of you may know, I recently completed my second half-marathon. To make it even better, I completed it with my amazing and wonderful husband Andrew:

4 miles in and feeling great!

4 miles in and feeling great!

This was my second half marathon in 1 year, and my third *big* athletic event—the other two being the Disney Princess Half Marathon and the Ramblin’ Rose Sprint Triathlon. I started out 2013 with the goal of being healthier and developing strategies for life-long fitness, and I really am proud to say that I am still well on my way to better fitness. (Although in fairness, the craziness of moving to Atlanta did set me back a few weeks! But I’m back on the horse now!) 

Running the Disney Princess Half Marathon with my sister Tara and friend Jenna!

Running the Disney Princess Half Marathon with my sister Tara and friend Jenna!

After completing my last half-marathon, I received the following question from a previous patient of mine,

“Ok, I have to ask, after seeing your race pictures, isn’t running bad for a woman’s internal organs??”

My initial thought was to respond quickly with a, “Not always, but sometimes…” type of response. But then it got me thinking, and inspired me to really delve into the issue with a little more science to back my thought—although honestly, the gist will stay the same.

So… Is running bad for the pelvic floor? Let’s take a look.

When someone initially looks at the issue, there may be the temptation to respond with a resounding, “YES!” We initially think of running and think of “pounding the pavement,” identifying large increases in intra-abdominal pressure and assuming that this pressure must make a woman more likely to experience urinary incontinence and/or pelvic organ prolapse.

But, what does the research really show?

1. Urinary incontinence during exercise is common and unfortunate.

  • Jacome 2011 identified that in a group of 106 female athletes, 41% experienced urinary incontinence. However, they also found that UI in those athletes seemed to correlate with low body mass index.

2. High impact athletes often may require more pelvic floor strength than non-athletes.

  • Borin 2013 found that female volleyball and basketball players had decreased perineal pressure when activating their pelvic floor muscles compared to nonathletes which they concluded placed these women at an increased risk for pelvic floor disorders and especially UI.

3. Over time, physically active people are not more likely to have urinary incontinence or pelvic organ prolapse that non-active individuals. ******

  • Bo (2010) found that former elite athletes did not have an increased risk for UI later in life compared to non-athletes (although she did find that women who experienced UI when they were younger were more likely to experience UI later on in life).
  • In another study, Bo (2007) found that elite athletes were no more likely to experience pelvic girdle pain, low back pain or pelvic floor problems during pregnancy or in the postpartum period compared to non-athletes.
  • An additional study by Braekken et. al. (2009) also did not find a link between physical activity level and pelvic organ prolapse. However, they did find that Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP.

Is your head spinning yet?? Let’s make some sense of this research…

First, it does seem like UI is a common problem in athletes—the cross-fit video that had all of my colleagues up in arms identified this problem really well—and honestly, runners are no exception to this. Every week, I work with women who experience urinary leakage when they run or may have even stopped running due to leakage, and I can assure you this causes a huge impact to these women’s lives. I also can assure you that there are many women out there dealing with leakage during running or other exercises who suffer in silence, too embarrassed to get help or somehow under the impression that leakage with exercise is normal.

With that being said, I am not ready to throw away running or really any other form of exercise all together (other than sit-ups…let’s never do those again). Running has amazing benefits—weight control, cardiovascular improvements, psychological improvements/stress reduction—and these should not be cast aside due to a fear that running could cause a pelvic floor problem.

As a pelvic floor physical therapist working in a predominantly orthopedic setting, I see many men and women enter our clinics with aches and pains—and injuries—that began while starting or progressing a running program. Often times, our amazing PTs identify running gait abnormalities, areas of weakness, or biomechanical abnormalities which can be contributing to hip/knee/foot/etc. pain with running. Improving those movement patterns and improving those individual’s dynamic stability seems to make a huge difference in allowing the client to participate in running again without difficulty.

To be honest with you, I see pelvic floor problems in runners the exact same way. When a woman comes into my office complaining of urinary leakage during running, I look to identify running gait abnormalities, areas of weakness or biomechanical abnormalities which are impacting her body’s ability to manage intra-abdominal pressure during running. (And no, intra-abdominal pressure is not always the enemy–see this from my colleague Julie Wiebe) I also make sure I am managing other things—identifying pelvic organ prolapse when it may be occurring and helping the woman with utilizing a supportive device (tampon, pessary—with collaboration with her physician, or supportive garment if indicated), managing co-existing bowel dysfunction or sexual dysfunction, and making sure the patient has seen her physician recently to ensure she is not having hormonal difficulties, underlying pathology or medication side effects which could worsen her problems.

We know that intra-abdominal pressure is higher when running. A poster presentation at the International Continence Society in 2012 identified that running does in fact increase intra-abdominal pressure compared to walking—but not as much as jumping, coughing or straining (Valsalva). And not as much as sit-ups…

Kruger et. al. ICS Poster Presentation, “Intra-abdominal pressure increase in women during exercise: A preliminary study.” 2012

Kruger et. al. ICS Poster Presentation, “Intra-abdominal pressure increase in women during exercise: A preliminary study.” 2012

As you know by now if you follow my blog posts, I do not believe that the pelvic floor is the only structure involved in managing intra-abdominal pressure increases in the body. (This is why I get so annoyed with all of the studies trying to look at the effectiveness of pelvic floor muscle exercises used in isolation in treating pelvic floor dysfunction). The most current anatomical and biomechanical evidence supports the idea that the pelvic floor muscles work in coordination with the diaphragm, abdominals, low back muscles as well as even the posterior hip muscles to create central stability and modulate pressures within the pelvis. In order for a runner to not leak urine or not contribute to prolapse or pelvic floor dysfunction when she runs, she needs the following(well really, more than this…but let’s start here):

  • Properly timing, well-functioning, flexible pelvic floor muscle group.
  • 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:

https://www.juliewiebept.com/video/integrative-programming-for-female-runners-with-incontinence/

Safe exercise for those with pelvic pain:

http://www.pelvicpainrehab.com/pelvic-floor-physical-therapy/2058/pelvic-pain-and-exercise-general-fitness-tips/

Tracy Sher, “Pelvic Guru” on Leaking during exercise:

http://pelvicguru.com/2013/06/22/dear-crossfit-and-crossfit-gynecologist-im-appalled-theres-help-for-peeing-during-workouts/

Seth Oberst’s 4-post series on the Diaphragm:

http://www.sethoberst.com/blog/category/breathing

What do you think? Let me know in the comments below!

~ Jessica

References:

Bo K, Backe-Hansen KL. Do elite athletes experience low back, pelvic girdle and pelvic floor complaints during and after pregnancy? Scand J Med Sci Sports. 2007 Oct;17(5):480-7. Epub 2006 Dec 20.

Bo K, Sundgot-Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life that non-athletes?

Borin L, Nunes F, Guirro, E. Assessment of pelvic floor muscle pressure in female athletes. PM R. 2013 Mar;5(3):189-93. Scand J Med Sci Sports. 2010 Feb;20(1):100-4

Jácome C, Oliveira D, Marques A, Sá-Couto P. Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet. 2011 Jul;114(1):60-3.