Do you leak when you run? Try this!

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?

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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

 

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.”

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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! 

Pelvic Floor Problems in the Adult Athlete: Pelvic Floor Muscle-related Pain

I love the changes I’ve seen in our culture over the past 10 or so years. Healthy foods? Regular exercise? Joining gyms, boxes, studios, programs? This has become the norm for many people—and, that is so awesome! I love to see people being more active, taking responsibility for their health, and really striving to care for their bodies throughout their lifespans.

However, with this change and shift toward more activity, I have started seeing some pelvic problems become more common. And I don’t blame the exercise—I really don’t! I will stand firm in my belief that there is no such thing as a bad exercise—but all exercises require proper form and performance.  Sometimes when we consistently perform exercises that we may not be able to do correctly, problems can creep in.  I don’t see this to scare anyone off from exercises– please don’t think I mean that! But I think it is important to remember that Pain is never normal. Bladder leakage? Bowel problems? Sexual pain? Also never normal. 

So, the next two posts are going to address two of the major things I am treating regularly in higher level athletes. Today we are going to talk about Pelvic floor muscle pain, and next week I will post about stress incontinence. Let’s get started.

Pelvic floor muscle-related pain

What is it? This problem occurs when the muscle of the pelvic floor become tender, overactive or hypervigilant(basically contracting with too much intensity to guard/protect the pelvis) Often when this happens, people will feel pain in the lower abdomen, groin, hip, buttock or low back—or may feel actual vaginal/rectal pain. The pain may also be associated with changes in bladder function (like increased urinary frequency, urgency or leakage), bowel function (like constipation or difficulty emptying bowels) or sexual function (typically pain or discomfort during intercourse.) However, sometimes people will experience pain without any of these other symptoms at all.

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Image attributed to Open Stax College. CC https://commons.wikimedia.org/wiki/File:1115_Muscles_of_the_Pelvic_Floor.jpg

Why does this happen? This is the kicker–We don’t always know exactly why. However, there are some common reasons why the pelvic floor muscles might begin responding this way. First, we have to remember that the pelvic floor is just one part of a team of muscles that work together to modulate pressure within the abdomen and pelvis. So, the diaphragm, transverse abdominis, multifidus and pelvic floor work together to control intra-abdominal pressure, and pre-activate to support the spine and pelvis during movement.

Dysfunction in any one of these muscles can lead to problems with others. For example, I often find tender, irritated muscles in women after childbirth, especially those who have a diastasis rectus (separation at midline between the two rectus abdominis muscles). This separation impacts the stability at the abdominal wall, generally leading to gripping of the internal and external oblique muscles, alterations in ability to breathe optimally, and thus gripping at the pelvic floor muscles. We see a similar pattern occur in men and women with hypermobility. We can also see dysfunction creep in as a motor adaptation when someone has a history of low back, hip, neck, knee or other musculoskeletal problems.

In terms of athletes in particular (and yes, this includes those of you doing Crossfit, Barre, personal training, yoga, pilates, and other regular exercise— YOU are an athlete J), I often find that when a person lacks dynamic stability, the pelvic floor will compensate to give that stability. If a person is then doing regular exercise and does not have the adequate control, form, or force modulation to perform, these compensations become more prevalent and can then lead to pain.

What can you do about it? If you think your pelvic floor may be a contributor to pain, the first step is to seek evaluation. It can be helpful to initially seek a medical evaluation to rule out other potential pain contributors (ovarian cysts, inguinal hernias, etc.). Then, I do strongly recommend seeking an evaluation by a skilled physical therapist with advanced training in pelvic health. If you are living in a state that allows self-referral to physical therapy (like Georgia!), you can see a physical therapist without a physician referral; however, if in doubt, check with your local physical therapy office.

Treatment for pelvic floor related pain in athletes typically focuses initially on re-establishing the optimal function of the pelvic floor muscles within the team of muscles we spoke about earlier. This is done by teaching the patient how to relax the pelvic floor muscles, use the amazing diaphragm in the proper coordination with the pelvic floor and abdominals, and often includes manual therapy to help reduce muscle tenderness and/or improve connective tissue or neural mobility around the pelvis. A skilled pelvic floor PT will not only assess the pelvic floor muscles, but will examine you from a whole-body perspective—watching you move in various motions, looking at your hips/back/knees/ankles and assessing the soft tissues that could be contributors to your symptoms. This allows us to not only identify which tissues are contributing to the pain you experience, but also to identify any abnormal movement patterns which could be leading to the compensation in the first place.

Once the pelvic floor muscles are no longer hypervigilant/tender/overactive, we focus on restoring healthy movement. This includes integrating the pelvic floor and its team within those movements—the right way!  Typically at this point, we progress the athlete to his or her specific movements—whether that is Olympic lifting, squats, or a yoga warrior series—teaching the athlete proper form all while integrating the right muscle firing patterns to adequately stabilize.

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Do I have to stop exercising while in PT? This is always a tough one. I totally recognize that many adult athletes love their work-out routines and benefit so much by them—physically, socially, and emotionally. Sometimes there will be particular exercises that are aggravating symptoms or worsening the problems the person is experiencing. In those cases, I often will recommend holding off on those movements for a short time period. While holding off on some exercises, we often can still work together to find exercises and movements that are appropriate and totally acceptable to keep performing! I know this period can be frustrating for patients as it is difficult to take a break from something you love, but I promise, it’s short! Our goal ultimately is to get people back to the activities they love as quickly and safely as we can!

If you are having pelvic pain during exercise, and you live in the Atlanta area, I would LOVE to see you! Feel free to contact me or call my office for more information!

I always love to hear from you! Please let me know if you have any questions or feel free to chime in if I left something out! Happy Thursday!

~Jessica

What every female runner should know postpartum

I normally am not huge into re-blogging other people’s blogs–simply because I want my blog to mostly be filled with original thoughts, articles, etc…written by, well, me. BUT, when I read this blog by my colleague, Kate Mihevc Edwards, published on The Happiest Doula, I just had to. 

I have always loved running–ever since running cross-country and track & field in high school. I hope to run as long as I can–which is why I am passionate about women (& men!) having the ability to return to running and other forms of exercise if they have that desire. My love of running and love of all things related to pelvic floor health often is paired together (eg. this post on running and the pelvic floor). I actually planned on writing a post this week specifically on returning to running after a baby…but guess what? Kate did it for me! For those of you who don’t know, Kate is an amazing clinician who works for Back 2 Motion Physical Therapy (a sister clinic of mine) across town in Atlanta. She specializes in runners and triathletes, and is VERY good at what she does. Soooo, I hope you enjoy her awesome post: 

I am a mom, a runner and a triathlete. I have the benefit of being a physical therapist (PT) that specializes in treating runners and triathletes and I work in an office with two knowledgeable pelvic health PTs. My son just turned one and I, too, am still re-learning my body. Over and over I have heard friends and patients talk about wearing a pad when they run because of leaking or getting a stress fracture while they are breastfeeding. I hear about how exhausted they are how hard they are working to get their abs back to pre-pregnancy form.

In 2013, Running USA reported that female runners are at an all time high with 8.6 million female race finishers nationwide and females accounting for 56% of all race finishers. With over 4 million babies born in the U.S. each year, I wonder how many of these women have had babies and how many have had questions about how to return to running after their babies.

Whether you were a running before you had a baby or not, running is an attractive exercise option for moms. It is much easier to lace up your shoes run out the door than going to a gym. For me, running is a gift; it allows me a few minutes of alone time as well as some needed freedom by taking my son with me on the run. A recent study even found that women who ran while breastfeeding had a significantly lower incidence of postpartum depression.*

It is difficult to find information or resources for women when we return to running or start running postpartum. Most women have no idea where to start, what to expect, how their body should feel and what is/isn’t normal. By addressing these issues and educating ourselves and others about how our bodies change during the months after childbirth, we can significantly reduce the potential for injury.

Things I’ve learned along my journey back to running

(Click to read the rest of Kate’s fantastic blog post)