Category: Postpartum

Pain during sex is NOT normal

Featured ~ jesspreale ~ Leave a comment

I often get asked why I chose to become a pelvic PT. Many people postulate that I have my own pelvic health challenges (I do…but those came later after 2 c-sections). Others assume I’ve always been super into the pelvis. But neither is really the case. The answer is quite a long one… but, honestly, it all came down to the patients.

Sometimes you have a moment in time that ends up defining the trajectory of your life (if you know, you know). And for me, this moment happen during a rotation in Shreveport, LA, while I was working on my Doctor of Physical Therapy degree through Duke University. I had an amazing clinical instructor (Darla Cathcart, who I now teach with through Herman & Wallace), and we were working with a patient who had been experiencing painful sex for as long as she had ever tried to have sex. I remember her talking with us during her initial evaluation, telling us about the relationships that had ended because of this, and tearfully explaining how she wanted this to not be a factor for her current relationship.

Fast forward, several visits later, she came in for her session, sat down, and started crying. She looked up and said, “I had sex, and it didn’t hurt.” I still get goosebumps as I right this. I got goosebumps in that moment. And, it was then and there that I KNEW that I had to help more people like her. I felt such clarity in my path. And I have never looked back.

Painful sex is extremely common. In fact, some studies show that it impacts around 20% of women. Yes, my friend, that is 1 in 5. However, women aren’t the only ones dealing with pain during or after sex. All people can deal with it– regardless of gender or anatomy. And, it really tends to be one of those things that just isn’t talked about. Nearly every time I post about painful sex on social media, I end up with private messages from people who have been dealing with pain for years, and just thought it was normal. Common does not mean normal. A little louder (for the people in the back):

Just because pain during sex is common, does NOT mean it is normal. Not if you:

  • Have had a baby
  • Have never had sex before
  • Have had sex a lot
  • Have been told you are small
  • Think your partner may be large
  • Have had problems with bladder or other infections
  • Have sensitive skin
  • Anything else

While some of these factors may make someone more likely to have pain during sex (like if you had a baby and had a tear that took a while to heal), this still does not mean that pain is just something you have to deal with. Honestly, there are so many reasons why someone might have pain with sex. It could be related to:

  • Decreased lubrication
  • Hormones
  • Inflammation
  • Neural sensitivity
  • Dermatological conditions
  • Painful scar tissue
  • Orthopedic challenges (especially around the hip or low back)
  • Bowel dysfunction (hello constipation)
  • Conditions like endometriosis/adenomyosis, painful bladder syndrome/IC, or others.
  • Pelvic floor and abdominal muscle challenges

And many, many other things! And so so many different treatments to help! This can include finding the right moisturizers and lubricants for your body, additional medical interventions (medications, hormone creams, and more!) and working with a pelvic health specialist to help you optimize your pelvic floor muscles (through gentle manual therapy techniques, home exercises, lots of education, and a whole lot more!)

If you’ve been dealing with pain during sex, please know that you are not alone.

So so many other people deal with this too. And the great news is that enjoyable sex is possible for you. We can get there. There is treatment available. There are compassionate clinicians who care (if yours didn’t, pllleeeeasssseee go see a new one!). And we can work together to get you feeling better.

I have so much more to say about this!! But for now, I’m going to leave you with a few links for prior blogs with more information!

Vaginal Dilators for Painful Sex

How to Relax Your Pelvic Floor Muscles

Sex After Baby

Are you ready to get started?

We are offering 20% off through September 30th on our 90-min mini classes: Overcoming Painful Sex and Self-Treatment for Pelvic Floor Tension using the code, ENJOY20. These classes are full of awesome information, exercises, and resources for getting started!!

All my best,

Jessica

How to relax your pelvic floor muscles

balance macro ocean pebbles
Featured ~ jesspreale ~ Leave a comment

Whenever I teach coursework to pelvic PTs, a common theme tends to come up. While teaching someone to contract their pelvic floor muscles can be challenging, teaching someone to relax and lengthen? So much harder! And teaching someone to actually bear down (the way you need to move your muscles to have a bowel movement)? Way way harder! So, I wanted to take some time today to talk about how to relax and lengthen your pelvic floor muscles. This is super helpful for anyone experiencing pelvic floor overactivity– which often includes people with pelvic pain conditions, constipation, painful sex, and urinary urgency/frequency. And if you’re a rehab professional, this post will also give you tips to help train your patients to lengthen.

As an aside, if you’re a rehab professional and new to pelvic floor therapy, check out my facebook group, built just for you: Pelvic PT Newbies! This group was born after teaching so many new clinicians who just lack the support they need to grow into the incredible practitioners they can be! So, come join us! And, if you’re a more seasoned clinician who loves supporting newbies, you are welcome as well!

Back to the topic at hand, how do you learn to relax and lengthen your pelvic floor muscles? Let’s get started!

1. Locate and find your pelvic floor muscles

It’s tough to let go of tension in a part of your body you don’t really know. So, step one is locating these awesome muscles. The pelvic floor muscles are inside your pelvis like a hammock and run from your tailbone to your pubic bone. They support your organs, stabilize your pelvis and spine, control your sphincters, allow for sexual appreciation, and act as a sump pump to pump blood and lymphatic fluid in and out of your pelvis (Yep, those are the 5 S’s we teach at H&W). They are also super important for breathing–coordinating with your respiratory diaphragm, and play a big role in postural stability and movement. So, locate those muscles in your mind, and see what you know. Can you use those muscles and contract as if you were holding back gas or cutting off a urine stream? If you aren’t sure you’re doing it, grab a mirror, and take a look at your perineum. Do you see the anus pull in (like it’s winking) away from you and the perineal body (between the vulva/penis/scrotum and the anus) lift in? Or do you see the anus bulge out? If you have a vulva, you will also see a small amount of lift there and you will see the clitoris do a really tiny little nod of approval (that’s because the pelvic floor muscles superficially attach to the hood over the clitoris). If you have a penis, you’ll see the penis move as you contract.

Print

Once you connect with your pelvic floor muscles, the opening and lengthening can begin.

2. Pelvic Floor “Drops” with Diaphragmatic Breathing

This is my standby, go-to, exercise for encouraging lengthening and opening of the pelvic floor muscles. To perform this exercise, bring your mind back to your pelvic floor muscles. Then, aim to let go of the muscles and lengthen, as if you are starting a urine stream. Note– this does NOT mean bear down and push out. Urination actually should not require ANY pushing. This is simply opening, letting go, and lengthening. Another tip to help visualize this is to think about a straw in one of your orifices, then imagine that straw is in a cup of water, and you’re trying to gently blow bubbles in the water (believe me, I’m full of weird visual analogies!) After you drop and lengthen your muscles, let’s do slow, diaphragmatic breathing. Breathing well means allowing your chest, ribcage, and belly to expand as you inhale– Yes, this is NOT just belly breathing! Belly breathing really does not harness the diaphragm the same way! So, perform slow breathing inhaling, allowing your ribs to open, chest to lift, belly to expand AND pelvic floor muscles to open, then exhale gently. Repeat this slow breathing for 2-3 breaths. Then, check in with your pelvic floor muscles, drop them again, and repeat! If it is challenging to know if your muscles are opening or not, you can perform a very small (like 10-20%) activation of the pelvic floor muscles before letting them lengthen and open. That being said, if you have significant overactivity, even a small contraction can irritate the muscles– so pay attention to what you feel!

3. The Elevator Let-Go 

This is another visualization that can sometimes help you leg go all of the way of your pelvic floor muscles. To do this, visualize an elevator sitting in your pelvis. This is your main floor, and your building has 10 floors, and a basement. Now, use your muscles to gently lift that elevator to the first floor. Then, drop the elevator to the main floor. Take a deep breath while you visualize the elevator dropping all the way to the basement. Keep the elevator there while you gently take 2-3 breaths. NOTE: This also should not require much effort– we’re aiming to gently relax and lengthen. 

4. Happy Baby Breathing 

This is one of my favorite positions to encourage lengthening of the pelvic floor muscles. For this exercise, you’ll lie on your back and bring your knees up toward your chest, then open your knees and reach through to grab your ankles or your toes (whatever is comfortable and allows you to relax). In this position, take deep long breaths, focusing your breath into your abdomen and pelvis.

Hopefully this helps you get started! Believe me, lengthening the pelvic floor muscles can be challenging, so try not to get too frustrated if you find this difficult at first! If you’re struggling, reach out to a pelvic PT. We’re happy to help you figure this out, and have more tools available if these ones don’t resonate with you!

~ Jessica

5 Exercises to Move Better During Pregnancy

Featured ~ jesspreale ~ Leave a comment

Yesterday afternoon, I met my team of pelvic PTs at at the office for some photo and video time. Our model? Dr. Kellie, who is about to have her last week with us in the clinic before leaving on maternity leave for her second daughter. You see, working at a pelvic PT practice, we have to take advantage of one of our own being pregnant! How could we miss an opportunity to record videos and take pictures to expand our library! 🙂

Movement during pregnancy is incredibly useful. First, it can help with many of the aches and pains that commonly develop. It helps to keep your muscles active, and ultimately, can help prepare you for the process of labor and birth. We wrote a while back on healthy exercise during pregnancy, so start there if you want to know where you should get started for movement.

Today, I wanted to focus on movement to help you feel better. These exercises promote gentle movement around your spine and pelvis and activation of the muscles around your deep core.

Cat-Cow

Goal: Improve mobility around your spine and pelvis. Coordinate movement with breathing.

  1. Inhale slowly, and as you do, gently let your tailbone out, and lift your head

Try not to allow your back to dip super far down but stay within a comfortable range.

2. Exhale and gently tuck your head, lifting your belly up and rounding your spine, allowing your tailbone to tuck.

3. Repeat this flowing gently with your breath as you inhale and exhale

Aim to do this 10-15 times in a row, alternating with the modified child’s pose that is described below.

Modified Child’s Pose

Goal: Lengthen lower back, gluteal muscles, pelvic floor, and inner thighs. Encourages relaxation and opening around the pelvis.

This exercise works really nice to alternate between sets of the Cat-Cow.

  1. First, place pillows in front of you, leaving a gap for your belly. You can use 1-3 pillows, depending on your belly size.
  2. Sit back on your heels, and open your knees to a comfortable width.
  3. Lean over the pillow, allowing your body to relax and reaching your arms forward. Let your head rest to one side or the other.
  4. Relax in this position for 1-2 minutes.

Ball Pelvic Mobility

Goal: Improve the movement around your pelvis and spine

  1. Sit comfortably on an exercise ball with your feet supported on the floor
  2. Inhale, letting your pelvis out, allowing a small arch in your back
  3. Exhale, tucking your pelvis under gently pulling your belly in.
  4. Repeat this to warm-up x 10
  5. Then, add a rotation, inhaling and rotating clockwise with your pelvis until you reach the arched back position. Then exhale, continuing to rotate clockwise until you reach the tucked position.
  6. Repeat this x 5-10 repetitions, then switch to counter-clockwise.

Bird-Dog Progression

Goal: Activate your deep abdominals and pelvic floor muscles paired with your breath.

  1. Begin in a hands and knees position with your spine in a neutral position (not flexed or arched)
  2. Inhale to prepare, exhale and gently engage your pelvic floor muscles while gently drawing in your belly. Aim for a slight contraction (not hard!).
  3. While you do this, extend one arm in front of you.
  4. Exhale, lowering your arm and relaxing your muscles.
  5. Repeat, alternating lifting with your opposite arm. Be sure to keep your spine in a comfortable position while you are doing this exercise. Repeat this movement for 10-15 repetitions.
  6. To progress this exercise, you can also perform with an alternating leg movement, aiming to keep your spine in a neutral position.

Wall Squats

Goal: Coordinate movement with breath, activate pelvic floor with gluteal muscles

  1. Place a ball behind your back and lean against a wall. Keep your feet placed out in front of you, flat on the floor.
  2. Inhale while you bend your knees and lower.
  3. Exhale, engage your pelvic floor muscles slightly, and lift up to standing.
  4. Repeat this exercise for 10-15 repetitions, performing 2-3 sets.

Note: While doing this, keep your feet far enough in front of you that your knees don’t cross your feet.

I hope you’ve enjoyed these exercises! What exercises do you like to do to move well during pregnancy? Any favorites we need to add?

Look for more coming from us on all of this in the future!

5 Common myths about Pelvic Organ Prolapse

Featured ~ jesspreale ~ 2 Comments

“I was just showering and reached down and suddenly noticed a bulge”

“I had no idea something was wrong until my doctor examined me and told me I have a stage 2 cystocele”

“I started feeling heaviness in my pelvis, then was wiping after I went to the bathroom, and noticed something was there!”

Pelvic organ prolapse impacts a lot of people. Some studies show that between 50-89% of people experience prolapse after vaginal birth (if they’re examined and someone is looking for it!), however, people can experience prolapse when they have never been through pregnancy or childbirth. Prolapse is one of the “scary diagnoses” as I tend to call them– not because I think it’s actually scary– I don’t– but because there is so much AWFUL information about prolapse out there. And when people suddenly learn about this, they dive deep into a rabbit hole of research, and often end up scared about what the future holds for them. BUT– I’m here today to tell you that: 1) Prolapse is actually very common and 2) there is so much you can do to help this problem!

To digress slightly– Working with people dealing with prolapse is a passion of mine, and I’m super excited to be teaching a LIVE class on managing pelvic organ prolapse with my friends and colleagues, Sara Reardon & Sarah Duvall. It’s going to be happening this Sunday at 4pm EST, and registration is limited! I hope you’ll join us for this awesome class! (Note: If you’re reading this after the event, and missed it– no worries! The recording will be available– just click the link above!)

What is Pelvic Organ Prolapse?

Before we jump into the myths surrounding prolapse, let’s talk about what it actually is. Pelvic organ prolapse refers to a loss of support around the bladder, uterus or rectum, and this causes descent one or more of these organs into the walls of the vagina. The organs themselves are supported by fascia, ligaments, connective tissues and… you guessed it! Muscles! So, how can loss of support occurs? Well, it could be due to straining of these tissues like would happen during pregnancy and childbirth, particularly if people have injuries during birth like stretch injuries to the nerves of the pelvis, tears in the connective tissue and fascia, or tears in the pelvic floor muscles themselves. This can also be due to chronic straining of the tissues that might occur with age, chronic lifting (with poor mechanics) or chronic coughing problems. Other factors like hormones, body size and joint hypermobility can also be involved.

What does prolapse feel like?

Maybe you’ve been diagnosed with prolapse, maybe you just think this is a problem you have, or maybe you know that you have this problem. Regardless, let’s chat about what prolapse can feel like. These are some of the things people who have prolapse can feel:

  • A bulge coming out of the vagina
  • Pressure in the pelvis or perineum
  • Lower back ache
  • Difficulty emptying the bladder
  • Difficulty emptying the bowels
  • Heaviness or a dragging feeling in the pelvis

Symptoms are often better first thing in the morning, then worsen as the day goes on (thanks so much gravity!). Symptoms vary person to person based on where they have prolapse and the severity of their prolapse.

So, now that we know what it is and what it can feel like, let’s jump into prolapse myths.

Common Myths Surrounding Pelvic Organ Prolapse

Myth #1: “You’ll likely need surgery at some point.”

I hear this one all the time. A well-intending physician tells their patient that they have prolapse, then follows it with, “we can fix that whenever you’re done having children” or something along those lines. While some people do end up needing surgery– particularly with more severe prolapse or if their prolapse is significantly impacting their function, many people are able to manage well conservatively with specific exercises or pessaries.

Myth #2: Prolapse is probably the cause of your pelvic pain, pain during sex, or genital pain.

So, you’ll see that I listed low back pain in the symptoms, but I didn’t list other types of pelvic pain. While I get that prolapse can look like it would be painful, it typically is not a painful condition. It’s an annoying condition, and can lead to behaviors that may cause pain (like constantly trying to grip your pelvic floor muscles to prevent things from falling down!). Prolapse can cause a back ache that worsens as the day goes on, and this is due to the ligaments around the organs stretching as the descent occurs. Additionally, the pressure/bulge can be uncomfortable, and people may feel like something is being pushed on during sex. That being said, we very often find that people have prolapse and something else going on when they are dealing with significant pain.

Myth #3: Because prolapse is structural, physical therapists likely won’t be able to help.

So first, support of the organs requires coordination of forces– ligaments and fascia are involved for sure, but muscles are also involved. All that aside, prolapse is a problem related to pressure management– so it matters what is happening at the pelvis, but also, what is happening outside of the pelvis that is impacting the pressure system.

Pressures within the intrathoracic and intraabdominal cavities can impact what is happening in the pelvis. Several muscles are involved in this pressure system, including the glottal folds at the top, the intercostal muscles, the respiratory diaphragm, the transverse abdominis muscle, the multifidus, and the pelvic floor muscles. These muscles work together in a coordinated way to help manage pressure and spread the load (so it is not funneled down to the pelvic floor).

Physical therapists help people with pelvic organ prolapse by helping them manage their pressure system as optimally as they can. This means looking at posture, spinal mobility, movement patterns, hip function, breathing habits, and so much more! It also means optimizing the function of the pelvic floor muscles. With this approach, we see good improvements. A Cochrane review of 13 studies in 2016 found that most people saw good improvements in their prolapse symptoms and their severity of prolapse on exam. A multicenter trial published in 2014 found that individualized pelvic floor training led to good improvement in symptoms and severity of prolapse.

Myth #4: Pessaries are for “old people”

Not true. Pessaries are amazing medical devices that help to support the walls of the vagina and can be very useful for reducing symptoms of prolapse. There are lots of different types of pessaries, and generally, people who wear them really find them to be helpful! In fact, this study found that 96% of the people who were appropriately fit with a pessary were satisfied and thought it helped with the severity of their symptoms.

Myth #5: If you have prolapse, you should never do certain exercises and movements so your problem doesn’t get worse.

I’ve said this before, and I’ll say it again– there are no bad exercises– BUT there may be times when certain exercises may not be optimal for you. Ultimately, the best thing to do is to work with a professional who can watch you move, watch you exercise, and see how you modulate pressure during these movements. Then, they will be able to make recommendations specifically for you– help you modify where you need to modify, observe your form during movement, and then strategize with you to make a plan to get back to whatever movements you would like to get back to!

If you’re experiencing prolapse, or you think this might be you– there is hope available! I’m very excited to be working with Sara Reardon and our special guest, Sarah Duvall to jump further into this topic in our upcoming class this Sunday 10/25 at 4pmEST on Managing Pelvic Organ Prolapse. Come join us LIVE and get all of your questions answered! If you can’t make the live, no worries!! A recording will be available.

What prolapse questions do you have? Let me know in the comments!

~ Jessica

Meet the Obturator Internus

Featured ~ jesspreale ~ Leave a comment

You all know by now that I’m fairly nerdy. I love reading research articles, trying to understand complex topics, and everything about learning. Honestly, I think that is why I love pelvic health so much! The pelvis is so complicated! There’s so much to know, and the more I learn, the more I truly realize how much more there is to know! As an anatomy nerd, you know I have favorite muscles. I’ve written about the respiratory diaphragm, who is one of my most favorites, but I haven’t spent much time introducing you to my other love~ the obturator internus!

Meet the Obturator Internus

The Obturator Internus (Or OI, as they are known by friends) is a muscle that lives inside your pelvis in the obturator foramen and attaches to the hip via the greater trochanter. You can see it here:

The OI has several major functions for the body. First, it is a deep hip external rotator, and has shown to be active during the movements of hip extension, external rotation and abduction. In fact, this research showed that it was the first muscle to turn on in these motions (which I theorize could be part of it’s connection to the pelvic floor muscles and the anticipatory role the pelvic floor has in movement, pressure management and postural stability). My theory on this makes sense when we look at some of the research on the involvement of the OI in hip stability. This excellent article identifies the obturator internus & externus, quadratus femoris, and gemelli as important synergistic muscles that work together to modulate the position of the femoral head in the acetabulum during movement. This is particularly cool because in many ways, this function is very similar to the pelvic floor muscles! The authors suggest a dynamic stabilizing role for these muscles, making subtle alterations in force to control the femoral head position.

This study also recognizes the stabilizing role the OI can play, particularly when it works as a team with the other deep hip rotators. The authors here highlight that the obturator internus, obturator externus, superior & inferior gemelli (who I affectionately call the gemelli brothers) are essentially fused. And this fusion, actually leads to a decent cross-sectional area and ability for force generation. The orientation of the fibers adds further credence to the view that these muscles are crucial to hip stability.

The OI shares fascial connections and attachments with the pelvic floor muscles, which makes it an even more unique muscle. The iliococcygeus attaches to the arcus tendoneus linea alba, a fascial line that is also an attachment of the obturator internus. Additionally, the pubococcygeus and OI are fascially connected around the pubic bone, and the fascia around the bladder and urethra also is connected to the OI. What does this mean? It means that the OI can be impacted by what happens at the pelvic floor and can impact what happens at the pelvic floor. And research tends to show this. This study showed that the vast majority of people with pelvic girdle pain have obturator internus tenderness. This study found that most people with chronic pelvic pain have obturator internus tenderness with palpation. And here’s another study that found that 45% of people with pelvic pain had tenderness at the obturator internus. Another study found that in people with lumbopelvic pain, experiencing urinary urgency, and central sensitization made them 2x more likely to have concurrent pelvic floor and OI involvement.

Finding the Obturator Internus

One of the cool things about the OI is that it is a muscle that can be palpated both internally via the vagina or rectum, and also externally. The OI is palpated internally with an examining finger angling out toward the hip. You can see the palpation here on my lovely pelvic model.

My finger here is inserted, curving toward the left to access the OI

The OI can also be palpated by examining medial to the ischial tuberosity, then angling in toward the obturator foramen. You can see where palpation would be happening here.

Treating the Obturator Internus

If you think your Obturator Internus is involved in the pain or pelvic floor problems you’re experiencing, the first step is to have it examined. Your PT can palpate these muscles as described above. The muscles should be soft and move well, so they should not be sensitive or painful to touch. If they are, they could potentially be involved in the pelvic problems you are experiencing.

From a treatment standpoint, we can address the OI by first improving the mobility via gentle manual therapy, and then improving the overall hip stability (retraining the anticipatory function through the relationship between the pelvic floor & OI). It usually isn’t the “sole” problem happening. But including it within your treatment can be key to helping you get better!

Cheers!

Jessica

Do you leak when you run? Try this!

~ jesspreale ~ Leave a comment

I love running. To be honest, I’ve been out of a good running routine since Mary was born. She’s one now. I would like to change that. I’m scheduled (yes, my husband and I literally have to schedule everything with our crazy work weeks!) for a run this week and I’m thrilled.

As a pelvic physical therapist, my goal is always to help my support my patients in whatever exercise or fitness routine they enjoy. Sometimes, pelvic floor problems get in the way. I can’t tell you how many times I’ve heard things like: “I used to run all the time, but ever since I had a baby, I just can’t” or “I tried just wearing a pad while I was running, but I can’t get over the feeling that I’m making everything worse” or “I can run if I go first thing in the morning, empty my bladder before I leave, and then stop at the park on the way to go again.” Bladder leakage during running is ANNOYING. It can be so impacting to people, and for many, it can lead them to stop a movement or activity they enjoy, for the long-term.

5 years ago (has it really been that long!?!) I wrote on the topic, “Is running bad for the pelvic floor?” after receiving that question several times. Spoiler alert: There are times when it may be appropriate for someone to stop running for a period of time to retrain their body and regain their pressure modulating system optimization– however, running can be an excellent way for someone to exercise and move! There are no “Bad” exercises, just bodies that sometimes aren’t quite ready for them.

So, if you’re struggling with leaking every time you hit the pavement, what can you do?

running-573762_1920

Let’s consider what happens during running, from a pelvic floor standpoint. Several studies in the past few years have demonstrated that the pelvic floor muscles are active during running. This study from 2017 used EMG electrodes at the pelvic floor muscles, and found that there was increased activation of the pelvic floor prior to heel strike and reflexive activation after heel strike during running. This is in line with what we know about the pelvic floor muscles. They play a crucial role in anticipating movement, preactivating, then have modulating force during movement based on the task at hand. And, this is protective. We would want the muscles to have varying levels of activation so that we can support ourselves during movement, support around the urethra, not leak.

What happens then when someone is leaking with running? We of course, want to say that this reflexive thing is not happening. This review did show some alterations in the way that those who leak contract vs. those who do not leak. However, this study found that the reflexive action was the same in those who leaked and those who didn’t. This one also found that patterns of engagement were the same. So, it is likely that there are sometimes differences, but sometimes not. And this seems in line with what we know about leaking. Leaking during running is a pressure system problem. So, to help it improve, we have to address the whole system– which includes the pelvic floor muscles, but not only the pelvic floor muscles. It makes sense that sometimes the issue is stemming from these muscles not activating at the right time, with the right force–but sometimes, the pressure problem is from something else.

How can we address the pressure modulation system?

First, we need to evaluate the system to see how the structures are functioning, and this includes looking at you– the full person– to see how you control pressure through your pelvis. So, we need to look at how you move from head to toe, then evaluate your running mechanics, then look more closely at your breathing pattern, your abdominal wall, and your pelvic floor muscles. Once we do this, we often have a clear idea of what is happening and can make a strategy to get this better.

So, my big Tip #1– Go see a pelvic floor PT–but make sure it’s someone who is trained at looking at the whole person and can really evaluate you well.

If you’re nervous about doing this, I feel you. It can be hard to talk to someone about very private things. And I totally understand that the idea of having an internal examination can be a barrier for some people. BUT, know that those of us living in the pelvic floor world talk about this stuff ALL THE TIME. You won’t surprise us. Seriously, we hear this stuff all day. And, if you don’t think you’re ready for an internal exam, that’s cool. Honestly, we don’t mind. There is SO much that can be done to help the pelvic floor and bladder leaks that can be done without an internal exam! If you want to learn more, give us a call. One of our doctors of physical therapy will be happy to do a virtual consult with you and get you started!

Ok, off my soap box… What else can you do to impact the pressure modulation system and decrease leakage?

Tip #2: Breathe!

This seems so simple. I know, you’re thinking, “Of course I’m breathing!” But, are you? Or are you going through a series of breath holds? Next time you run, pay attention, and keep your breath flowing in and out as you run. The diaphragm is the major pressure regulator of the body. So, we need to keep your breath moving so pressure is spread out!

Tip #3: Let your ribcage move!

Many people tend to run with stiffness, locking down their ribcage. This can funnel pressure downward toward the pelvic floor muscles leading to increased load, and potential leaking. Instead, relax your ribcage, let your arms swing and allow your trunk to rotate. This will actually turn on more of the muscles around your core improving the synergistic activation of your pressure modulating system.

Tip #4: Lean into the hills! 

When going up or down hills, it is easy to lean back to try to control the movement. This can alter the position of your ribcage over your pelvis which will impact your pressure control. Instead of doing this, lean into the hill as if you have a strong wind blowing against you (I love this visual I got from my friend & colleague, Julie Wiebe!). When going downhill, lean into the downhill and let yourself pick up a little speed instead of leaning back to slow down. Relax into the hill. Many of my patients find that doing this actually reduces the pressure they feel and can decrease leakage.

Tip #5: Get a running evaluation!

Running form matters, it really does! So, go see someone and have them take a look at your running form to offer you guidance on how you can optimize it! Be sure you’re using the best type of shoes for your foot as well! This can make a big difference! Awesome running stores in your area should be able to help you with this!

I hope this is helpful! What questions do you have about running and the pelvic floor? Ask away! We are here to help!

Have a great week!

~ Jessica

 

Mother’s Day Specials!! My gift to YOU!

~ jesspreale ~ Leave a comment

Good morning friends,

With Mother’s Day around the corner, we’ve been wanting to give back and help out the mothers in our community (around the country…around the world!) who are struggling in this interesting new normal. Figuring out managing caring for children, homeschooling, work/family obligations, all while trying to keep their families safe, sane, engaged. Let’s be honest, being a mom is the hardest, but most rewarding job ever!

To celebrate our mamas everywhere, we have a few discounted specials to roll out to you!

50% off first Virtual Pelvic Floor Consultation

Mother's Day Sale-2

First, we are offering 50% off a virtual pelvic health consultation  with one of our incredible pelvic floor specialists. Honestly, we’ve never discounted our services before, but I just felt like this was the right thing to do. So, for $97 you (or the mama you gift this to!) can receive a 55-minute virtual consultation. If you live in Georgia, this will be a pelvic floor physical therapy evaluation. If you don’t, our license won’t let us provide you with physical therapy, but we can still offer you a virtual coaching consultation.  So, if you’re struggling with any pelvic health problem– constipation? pain with sex? bladder leaks?– or if you need help recovering after children, getting back to exercise, or preventing problems in the future– this deal is perfect for you! Don’t miss out on this opportunity!!

20% Off Online Classes

Copy of Copy of Copy of Copy of Copy of Copy of Copy of Black Friday (1)

Along with this, we are offering 20% off our on-demand classes via the Southern Pelvic Health x The Vagina Whisperer partnership! Each of these classes is 90-minutes and covers SO much information, with great bonuses included! Classes are normally $39 each, so this is a nice discount to get some solid information!! (Gift idea: Consider a birth package for that pregnant mama in your life! Combine our birth prep class with a posptartum recovery class so that new mom has all she needs to rock her birth and after!) Be sure to use promo code MOM20 at checkout! 

These specials are only available through Monday May 11, so don’t delay!

Happy Mother’s Day!

~Jessica

Diastasis Rectus Abdominis (Part 2): How can you help it?

~ jesspreale ~ 2 Comments

2 weeks ago, we chatted about what exactly is a diastasis rectus abdominus (DRA) and how to check to see if you have one. Today, we’re going to talk about how pelvic floor physical therapists evaluate a person with DRA, and what can be done to improve this. If you are struggling with support at your belly, I also hope you will join us for our upcoming LIVE class focused on this exact topic! Sara Reardon and I invited Sarah Duvall, an incredible expert, to join us for a 90-minute class on Diastasis Recti Rehabilitation. We took a lot of time to plan out this content, and I have to tell you all– this class is going to rock! The LIVE event is coming up Sunday May 3rd at 3pm EST, and it will be available after as a recording. We have a lot of great bonuses also– including handouts on exercises to get started and a lot more! Registration for the LIVE class is limited, so don’t wait to sign-up!

As we discussed previously, DRA involves an increased gap between the two bellies of the rectus abdominis muscle and a loss of support at the abdomen. Often times, people experiencing this will feel like they don’t have as much control or stability at their belly, and they may feel a bulging at their belly (some will even feel like they look pregnant when they aren’t!) We also discussed how to check to see if you do have a DRA. Now, let’s talk about how we approach making this better.

Your first visit 

When we first evaluate someone with a DRA, we always make sure we get a complete history of the problems and challenges they are experiencing. This includes discussing any pregnancies/births (if applicable), their pelvic health (yep– bladder, bowel and sexual function), musculoskeletal challenges, medical problems, and their fitness preferences and routines. Then, we discuss their diastasis and what is bothersome to them. Is it primarily the appearance or the knowledge that it is there? Are they also struggling with back pain or pelvic organ prolapse or other problems? Does their diastasis limit their ability to exercise or lift their children? Our goal here is to really have a complete picture on the challenges they are facing.

The exam

Next, we move into an examination. This can include many different parts. As a diastasis is a pressure system problem, we want to look at everything that could impact the system. This could include:

  • Movement patterns
  • Spinal mobility
  • Preferred postures/positions
  • Ribcage movement
  • Breathing patterns
  • Pelvic floor function (yep, sometimes people with DRA benefit significantly from a specific pelvic floor exam if they’re on board with it!)
  • Scar tissue mobility
  • Myofascial mobility at the abdomen and the back
  • Abdominal, hip, and pelvic motor control/strength

Each of these components can actually influence how much pressure is at the linea alba (between the two bellies of the rectus abdominis) and the control at the abdomen. If someone has decreased movement around their spine and ribcage, this can impact the fascia around the abdomen and contribute to widening at their midline. If they have less optimal breathing patterns, this could be funneling pressure where we don’t want it to go, instead of spreading the pressure out across the trunk and sharing the load.

Once we do a comprehensive evaluation, we develop a treatment plan to address the problems we found. This typically includes:

  • Improving global movement patterns
  • Improving breathing patterns (both in static postures and during movements/activities)
  • Restoring mobility and improving sensitivity at muscles and soft tissues (including scars)
  • Optimizing the pressure system
  • Retraining the abdominal wall

I want to talk a little bit more about how we can optimize the pressure system and retrain the abdominal wall.

Optimizing the pressure system

When improving DRA, it’s very important to keep the pressure system in mind. Pressure at the abdomen and pelvis depends on coordination of several muscles that work together in synergy. This includes the glottis, intercostal muscles, respiratory diaphragm, transverse abdominis, lumbar multifidis and the pelvic floor muscles. Mary Massery (who has contributed SO much to our understanding of these pieces) created an analogy of a soda pop can.

can-307312_1280

In this analogy, the glottal folds are at the top, the pelvic floor muscles at the bottom, and the respiratory diaphragm in the middle. The intercostals, lumbar multifidus, and transverse abdominis are around the can. So, basically, these structures together work together to keep pressure spread out, leading to a strong and functional core. In the soda pop can example, the thin aluminum is pressurized on all sides, leading to a strong can that is difficult to break (Of course, this changes if the can is open or has a hole in it!)

So, in the case of a diastasis rectus, the pressure system is often not working optimally. Basically, pressure in many cases is funneled toward the belly, instead of being spread to all the structures, and this can contribute to gapping, bulging and a loss of support.

So, from a treatment standpoint, our goal becomes to optimize this system. We get to play detective and find out which of these structures are working well, and which need some assistance to do their job optimally. Then, we retrain this system, focusing on the natural synergy that should be present. When this is done well, we help the body learn to spread the load, decrease the funneling of pressure to the belly (or elsewhere) and thus, we improve what the person is experiencing at their abdomen.

Retraining the abdominal wall

After we improve the pressure system, we need to retrain all of the muscles in the abdominal wall. This further helps to improve the pressure system, but it also can assist in stimulating the fascia in the abdomen. Often times, retraining the abdomen starts by building the pressure system base like we discussed up above. This base– the pelvic floor- diaphragm- transverse abdominis- lumbar multifidus- base– is the key to what else we need to do to improve function at the abdomen. The transverse abdominis is particularly important. This muscle helps to tension the linea alba, which improves force transfer through this structure.

Next, we use breathing and awareness of muscles to retrain these muscles in a variety of movements, postures, and exercises. This can start as a simple progression– learning to activate these muscles while breathing and lifting an arm, then lifting a leg– and progressing from there.

We also teach self-awareness of the abdomen. So, this helps you identify how you manage pressure in your abdomen, and this is very important in making sure you are challenging your system, while still being able to control pressure (and not allow the pressure to funnel in your belly and produce coning and doming). As we progress in exercises, we ultimately want to retrain this system within the rest of the muscles in the abdomen, and this is fun, because we can be very creative and often help people progress toward things they did not think would be possible for them. So, can someone struggling with a diastasis eventually do planks? sit-ups? Abdominal crunches? What about pilates? Yoga? Barre classes? Most of the time, we can work together to help you reach the goals you want to reach. I really believe there are not “bad” exercises, but the key thing is determining the readiness of the person to do the exercise well, and ensuring that they can modulate pressure while doing the movement.

So, if you’re struggling with your belly…

Know, that there is hope. There is so much we can do to help restore stability at the abdomen and improve the way you move and transfer force through your belly. Come and join our upcoming class (or get the on-demand recording if you’re reading this later!) If you’re struggling, there can really be so much value to being evaluated by a pelvic health provider in person. So reach out! And if you need help finding a pelvic PT, check out this prior blog post to help you!

As always, reach out if you have questions!

~ Jessica

Diastasis Rectus Abdominis (Part 1): What is it? Do you have it?

~ jesspreale ~ Leave a comment

If you’ve been pregnant before, you know the feeling of going out and having everyone comment on your beautiful belly. Of course, we all get the occasional, “wow, are you sure you’re not having twins?” “When are you due? You’re not going to make it there!” (And can we collectively just tell those people to leave us alone!!) BUT, the majority of the comments are, “you look amazing!” “Wow, she is really growing!” “How are you feeling? Congratulations on your baby!” Honestly, my own body self confidence was at a high during pregnancy.  But then, our sweet little love muffins are born. And society expects us to very quickly bounce back to our pre-baby state (and I have so many thoughts on that…because we just went through this transformative, incredible experience, that took nearly 10 months to build! And often times mamas are left alone to figure things out after birth).

As an aside, this was one of the BIG reasons that my friend and colleague, Sara Reardon, and I decided to partner together to create live & on-demand classes! We recognized that soooo many people are struggling with pelvic health problems. While individualized pelvic PT is so beneficial, it’s not always possible for people at the time they need it. For one…ummm…coronavirus/social distancing. But also, some people prefer trying to learn and work independently, may feel too nervous to discuss their problems with a provider, or may have a schedule/time constraints/financial constraints/geographical constraints that just don’t allow individualized care at the time they are wanting it. SO, these are our classes. We have 2 LIVE postpartum classes coming up– TOMORROW 4/14 is our “Postpartum Recovery After a Vaginal Birth” Class, and the following Wednesday 4/22 is our “Postpartum Recovery After a Cesarean Birth” Class (SO excited about this one as a mama of 2 Cesarean babies!). These classes are built for the consumer—BUT, if you are a health care provider, I can guarantee that you’ll learn a bunch also! We sold out before the start of our “Pelvic Floor Prep for Birth” class, so if you’re on the fence, register soon and reserve your spot!

Anyways…back to our topic at hand: Diastasis Rectus Abdominis.

The abdominal wall is stretched during pregnancy to accommodate the sweet growing munchkin, and in some cases (most cases, according to some research!), this leads to a stretching at a structure called the linea alba- the connection between the two sides of the rectus abdominis or “6-pack” muscle group. When this becomes larger than about 2 fingers in width, it is known as diastasis rectus abdominis (DRA). This is what it looks like:

Ultrasonography_of_diastasis_recti
Mikael Häggström, M.D. – CC0, obtained via Wikimedia Commons

The two “+” marks indicate each side of the lines alba, and you can see that it is wider than it likely was previously. Note, this is an ultrasound image of a 38 year old mom who had diastasis after her pregnancy. DRA is different than a hernia. When a hernia occurs, there is a defect that allows an organ or tissue to protrude through the muscle/tissue that normally contains it. So, someone could have a DRA and not a hernia. Or, they could have a DRA and a hernia. Make sense?

Diastasis rectus abdominis is common during and after pregnancy, and varies in severity. For some moms, they may not really realize it’s even there. Others may feel a complete lack of support at their belly, notice a bulge, or even worry that they still look pregnant.  A recent study published in 2016 found that among 300 women who were pregnant and gave birth, 33.1% had a DRA at 21 weeks gestation. At 6 weeks postpartum, 60.0% had a DRA. This decreased to 45.4% at 6 months postpartum and 32.6% at 12 months postpartum. So, basically, many pregnant folk get this, and while for some it gradually improves over time, for others it can persist.

The link between DRA and musculoskeletal dysfunction is not confirmed. A recent systematic review published in 2019 found “weak evidence that DRAM presence may be associated with pelvic organ prolapse, and DRAM severity with impaired health-related quality of life, impaired abdominal muscle strength and low back pain severity.” This makes a lot of sense to me. Conditions like pelvic organ prolapse and low back pain are complicated, but in some cases do have components related to pressure management. The abdominal wall is very crucial in helping to modulate intraabdominal pressure, so it makes sense that when it is not functioning optimally, a person could struggle with managing pressure well.

The intra-abdominal pressure system involves coordination between the respiratory diaphragm, low back muscles, transverse abdominis, and pelvic floor muscles. These muscles need to work together to control pressures through to abdomen and pelvis and create dynamic postural stability. When the abdominal wall has a loss of support, this system can be impacted and contribute to pressure problems like prolapse and low back pain. However, those diagnoses are complicated. There are many other factors involved (like connective tissue support, amongst other things), so this is why a comprehensive examination is often very beneficial. This is also why not everyone who has DRA has pain.

I think it’s important to note here, that for some people, their DRA may not be contributing to things like back pain or prolapse, but it may still be a huge problem for them. People can feel guilty about caring about the cosmetic component involved in some instances of DRA…you know…the pooch. But, you know what– if this matters to you, then it matters! Feeling confident and strong is so important! So, don’t let anyone tell you what is or isn’t important for you to care about!

So, how do you find out if you have a diastasis?

The best thing to do if this is sounding like you is to see a pelvic PT to be evaluated comprehensively. There are many different things that can contribute to a loss of support at the abdomen, so looking at the complete picture is the best option. We’re going to talk about some of those pieces and how we as pelvic PTs evaluate DRA in Part 2 of this blog series. However, there are ways you can examine yourself and find out if you have a diastasis rectus. First, lie down on your back with your knees bent.

IMG_9612
In this image, my two fingers are at my belly button, and my other hand is over the top, reinforcing what I feel.

 

Start by placing two of your fingers at your belly button. Next, lift your head and your shoulders up (like doing an abdominal crunch) and sink your fingers in, gently moving them back and forth to feel the sides of your rectus abdominis. Notice if your fingers sink in, and if you feel a gap between your muscles. Repeat this a few inches above your belly button, and again a few inches below your belly button. Also notice how you feel as you do this– do you feel tension at your fingers? Do your muscles feel strong? When you lift up, are your fingers pushed out or do they sink in? What do you notice? (This is great information for you to understand how much force you can generate through your “gap” and will be important as we start discussing how we treat this!)

How can you help a diastasis?

Well, the good news is that there is so much we can do to help improve diastasis, make your belly stronger, and help you feel better.  In part two of this series, we’ll discuss the ways pelvic PTs can best evaluate someone who has a diastasis, and the methodology we use to treat this problem. The method of treating this has changed over time, so I’m going to give you my best understanding of the research as it’s available today! Stay tuned to learn more!

Stay healthy during this time my friends– and wash your hands!

~ Jessica

 

 

 

 

Virtual Care & Pelvic Yoga at Home

~ jesspreale ~ Leave a comment

If you would have told me two weeks ago that I would have closed the doors to my clinic, Southern Pelvic Health, a week later, and shifted my practice to a virtual one, I would not have believed you. Maybe I was naive (yes, I probably was), but this change came quick to me. It almost happened overnight. And, here we are. I am moving into my second week of working with my patients online. While for many, that seems incredibly scary, I actually think that shifting to an online platform for a while is going to do a lot of good.

Last week, I worked with a few other colleagues to host a webinar on bringing pelvic health online– basically, how do pelvic floor PTs treat most effectively without actually touching their patients? It was a quick production–one built out of necessity–and it sold out in 24 hours because rehab professionals everywhere are trying to figure out how we can still be there for our patients and help them get better during this time. (For my colleagues out there, if you missed it, it’s still available as an on-demand purchase!) I brought together 5 experts from various corners of the country and the world, and we spoke for nearly 2 hours about how we assess the pelvic floor, evaluate patients, and actually help patients get better in a virtual setting. It was full of creative ideas, and also challenged some of the current practice patterns. As you know, I work hard to always question my own practice–learn more–do better– and I’m excited to see what this next period of time does for me as I learn to better and more effectively treat my patients, to be creative with self-care treatments and home strategies, and to use movement to help patients move when my hands are unable to. I will share what I learn with you here, of course.

Pelvic PTs are not the only professionals taking their skills online! Last week, my daughter and I joined a “Frozen Sing-A-long” through a local princess parties company. I have been thrilled to see some incredible resources for people with pelvic floor dysfunction hop online, and I am excited to share some of those with you today!

So, what can you join virtually this week? 

Yoga for Pelvic Health

My dear friend and colleague, Patty Schmidt with PLS Yoga, is incredible and specializes in therapeutic yoga for pelvic floor dysfunction. She is bringing several awesome classes online! AND, they are cheap– $15 per class (which honestly, is a HUGE value for the expertise she brings!) So, I do hope you’ll join in:

Patty also is teaching private sessions virtually at $30 for a 30-minute session. This is a steal, believe me!

I also need to share with you all of the FREE yoga resources through another friend and colleague, Shelly Prosko. Shelly has this incredible library of Yoga options for pelvic health, all available right here.

I hope you are able to partake of these awesome resources. Remember, we are in this together my friends! I’ll leave you with a quote from a much-loved movie in my house, Frozen II, “When one can see no future, all one can do is the next right thing.” Let’s all try to do the next right thing amidst this craziness!

Much love,

Jessica

PS- If you are struggling with pelvic floor problems at home, we’d love to help!! Schedule a virtual session or a complimentary phone consultation with us at SPH!