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:
Gentle Yoga (Via Vista Yoga)– this really could be great for anyone with persistent pain, I think!: Tuesday, March 24th at 12p.m., Thursday, March 26th at 10 a.m.
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!
Exercise has so many incredible benefits for overcoming pain, optimizing cardiovascular health, and facilitating psychological well-being. Unfortunately, for many struggling with pelvic floor dysfunction (whether it is in the form of pelvic pain, urinary/bowel dysfunction, or pelvic organ prolapse), thoughts of exercise and fitness are often accompanied by fear. Fearthat moving incorrectly will lead to a worsening of their symptoms. Fearof a set-back. Fearof creating a new problem. Finding an exercise program that will not only be safe, but actually aid in a person’s recovery and pelvic floor health is a fine art. Seeing a skilled pelvic floor physical therapist can be a good step in finding an individualized exercise program, but many may not have the luxury of working with a professional.
Recently, I did some research to help a few my patients find on-demand options for guided fitness that were pelvic floor friendly. I am grateful to have such an incredible community of pelvic health professionals to learn from and learn with, and I wanted to share these fantastic resources with you here. As always, please know that what works well for one person may not work well for another, thus, an individualized assessment is always the best option to determine the most appropriate exercise program for you.
For those with pelvic pain or pelvic floor tension (often the case in cases of pelvic pain, constipation, overactive bladder):
Creating Pelvic Floor Health with Shelly Prosko- Part A: Pelvic Floor Muscle Relaxation.“30 minute practice of releasing the pelvic floor muscles through pelvic floor awareness, visualization and breathing methods, during mindful movements and yoga postures.” Shelly is an incredible physiotherapist from Canada, with a practice specializing in using yoga interventions to help people with pelvic floor dysfunction. Shelly was kind enough to offer blog viewers 10% off her combined package using the discount code: ClientDiscount10
FemFusionFitness by Brianne Grogan– Brianne (also a physical therapist) has an excellent youtube channel, with several playlists offering movement options for those dealing with pelvic pain or pelvic floor tension. Her “Painful Sex” series includes 2 30-minute yoga sequences emphasizing pelvic floor relaxation, and it’s free!
For those with pelvic floor weakness (often the case–but not always! in situations like urinary incontinence, pelvic organ prolapse, diastasis rectus, fecal incontinence):
Mutu System: This is an excellent post-partum recovery program. Very helpful for those with pelvic floor weakness or diastasis rectus after having a baby. This is often my “go-to” for people having these problems that are unable to travel to see a pelvic PT. She does a great job at encouraging appropriate referral for further evaluation as well.
Fit2B: This is an online program with options for purchasing specific programs or for membership. It has a postpartum series, diastasis recti series, prenatal workshop, and foundational courses. I have had patients use this program who really enjoyed it.
Your Pace Yoga by Dustienne Miller:Dustienne has expanded her video library to include videos such as “Optimizing Bladder Control” which includes sequences to support pelvic floor engagement through yoga.
Pelvic Exercises by Michelle Kenway: Michelle has done excellent work creating videos and ebooks on safe exercise progressions for pelvic floor muscle weakness, prolapse, bowel dysfunction and surgical recovery. Check out her excellent videos here.
I hope these resources are helpful! Did I leave anything out? If you have other wonderful home exercise options that are “pelvic floor friendly” please let me know in the comments below!
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!
Wanna read more? Check out this prior post on connections between the diaphragm and the rest of the body!
This past weekend, I had the wonderful experience of assisting at Herman & Wallace’s Level 1 Pelvic Floor Course, held here in Atlanta. I have been assisting at these courses for the past 4 years now, and I absolutely love it. There’s nothing better than helping clinicians who are new to the field of pelvic health learn and grow in this fantastic specialty. I love the excitement, the slight fear (I mean, many of these folks are doing their first vaginal exams at these courses), and the growing passion for helping men and women with pelvic floor problems. And the most exciting thing is knowing that they are going out in their communities to begin offering this service to people who really need it. And, now you know how much that really means to me.
The initial level 1 course covers an introduction to pelvic floor dysfunction (all diagnoses), and covers bladder dysfunction in more detail. One of the prerequisites of the course is for all participants to complete a bladder diary which is then evaluated in the class. So, why keep a bladder or bowel diary?
First, let’s be honest, we are all horrible historians. Many of us can barely remember what we ate for breakfast, let alone remember all the details of our bathroom habits! Let me ask you this:
How many times did you urinate yesterday?
How much fluid did you drink? What exactly did you drink?
What did your poop look like? When did you poop?
If you’re like me, it’s probably tricky to recall these exact details. (Well, you may be slightly better at recalling than I am, now that my pregnancy brain is in full effect!). And, if you are having any problems with your bowels or bladder, these details really do matter. Here are a few examples:
Patient #1: Mary (obviously not her name) was a lovely 65 year old retired nurse experiencing urinary leakage on her way to the restroom several times each day. She had tried exercises, dietary changes, and medications, and her problem kept persisting. Her bladder diary was eye opening for both of us! We learned that she only leaked urine when she would hold her bladder for over 6 hours! After years of holding her bladder for entire shifts, she got into some pretty bad habits. Once we changed this, her leakage went away completely!
Patient #2: Sara(also, not her name) was a 10 year old girl having bowel accidents daily. Once we did a diary, we found out the problem! Her mother was a hair stylist who saw clients out of her home. Sara was afraid to have a bowel movement while her mom’s clients were there, and had started having accidents from getting too constipated! The three of us quickly determined a “code word” for Sara to tell her mom when she needed to go, and within 2 weeks, the problem was solved!
So, as you can see… these little diaries can be oh so powerful! So, let’s get into the details!
Who should do a bowel or bladder diary? Well, in my mind, everyone should try it at some point! It’s so cool to see what your patterns really are… but for sure, anyone who is having problems like urinary urgency or frequency, urinary leakage, constipation or bowel leakage.
How long should you keep one? Typically, I like people to track for at least 3 days. Preferably, two of those days should be “regular” and one can be “different.” For example, if you are working, you may choose two days to be work days, and one to be over the weekend.
What should you look for? The best thing to do if you are having problems is to bring your diary to your health care provider. He or she will be able to analyze it completely, and give you insight into what may be happening. However, I do think there is some benefit in doing a little sleuthing yourself. Here are a few things to identify:
How often are you going? Normal bladder frequency is typically around 5-8 times each day, and less than 1 time each night. Normal bowel frequency varies quite a bit from 1 time over 3 days to 3 times each day.
How strong are your urges when you go? Generally, I recommend grading urges on a 0-3 scale (from no urge –> gotta go right now!). Were most of your urges very small? Were you running to the bathroom all day?
How much did you urinate? The best way to track this is to actually measure your output (usually a cheap plastic cup or a dollar tree measuring cup works well). Normal output of urine is 400-600 mL per void. You can also try just counting the seconds of your stream, however, this does tend to be less accurate. We generally tell people that each stream should be at least 8 seconds.
What did your poop look like? Was your stool soft and formed? Little rabbit pellets? Did you have to push hard to empty your bowels or did they come out easily? Did you have any discomfort or pain?
What was your diet like? Do you notice any trends in what you eat or drink? Were you drinking some well-known bladder offenders (like caffeinated drinks, soda, coffee, artificial sweeteners or sugary drinks)? Did you eat at really regular intervals? (You know I love my bowel routines!)
Did you notice any trends? Did you always go to the bathroom when you had the littlest urge? Was most of your leaking with coughing or sneezing? Does running water send you running to the bathroom? Did you always have a bowel movement after your morning coffee?
As you can see, so much wonderful information can be gleaned from these diaries, so if you’re having problems, get started today! Knowledge is power, and once we become aware and identify trends in our habits, we can make the changes needed to really help us get the most out of our bodies!
So, get tracking! And, on a serious note– don’t forget that these diaries can also help to determine if you are having a more serious problem, so please, please please, see your health care provider for an evaluation if you are having the types of problems we discussed today!
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
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.
Stephanie 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.
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).
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:
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.
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”.
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.
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.
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.
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.
I’m sort of nerdy (you already knew that though, didn’t you!)… so periodically, I like to go to my favorite medical search engines to find what is new in the literature regarding all things pelvic health. This helps me to keep aware of new treatments that are available, and helps me to constantly re-evaluate the treatments I provide for patients to make sure I am providing the best treatment I can!
Urinary urgency/frequency, urge incontinence, and overactive bladder problems are often not as frequently discussed in physical therapy circles as stress incontinence. Surprisingly, pelvic PTs actually treat these problems equally as often, if not more! A comprehensive PT program can be extremely effective for these types of problems! (So, if you are having urinary urgency, frequency or overactive bladder problems, and you live near Atlanta, give me a call! :))
So, what’s new in the research to help with overactive bladder problems and urge-related incontinence?
Myofascial release techniques can be very helpful for patients with urinary urgency and frequency.I was pretty excited to see this study come out in the Journal of Female Pelvic Medicine and Reconstructive Surgery. Pelvic PTs have noticed for quite a while that many men and women with urinary urgency and frequency actually tend to have hypervigilant overactive pelvic floor muscles rather than the traditional weak and stretched out muscles people like to think they have. Manual therapy, included within a comprehensive rehabilitation approach, can be very effective for helping this population, and I’m excited to see a recent study supporting the same thing!
Mindfulness-based stress reduction (MBSR) seems promising in helping to reduce symptoms of overactive bladder and urge incontinence. I didn’t find this surprising at all, but was again, excited to see this coming out in the literature. If you see in my first note above, many people with urinary urgency and frequency actually have a “hypervigilant” or “overactive” pelvic floor muscles. Stress reduction and mindfulness techniques help to calm the whole body–pelvic floor included! Along with this, we often find that people with urgency/frequency problems tend to live in a more sympathetic nervous system dominated state (basically, the “fight or flight” response is in overdrive!). Calming this system can be very helpful in calming the bladder.
Pelvic floor muscle training continues to be recommended as a first line treatment for stress, urge or mixed incontinence. It’s true, the most updated Cochrane Review published in 2014 continued to recommend pelvic floor muscle training to assist in improving all bladder symptoms. Their review showed close to a 55% cure rate–which is pretty good, considering this was just retraining the muscles in isolation. Imagine what could happen when the right retraining of the pelvic floor muscle is combined with behavioral retraining, dietary training and retraining the pelvic floor within the body as a whole? I bet the results would be much much better.
Percutaneous tibial nerve stimulation may help to reduce urinary frequency and urge-related incontinence. This started becoming popular a few years ago, and honestly, there needs to be more higher quality studies in order for us to really see how effective this treatment is or isn’t. But, that being said, some of the initial results seem promising. If you are not familiar with this technique, it utilizes a very thin needle which is placed near the ankle to stimulate the posterior tibial nerve with a low electrical current. The thought is that this nerve comes from the same level in the spinal cord that the nerves to the bladder originate, so stimulation could possibly help modulate an overactive bladder. (Similar concept to the Interstim treatment which stimulates at the sacral nerves, but less invasive) Looking forward to what the research shows on this treatment in the future!
Losing weight can help improve bladder symptoms. This is true for both urge related incontinence and stress incontinence (although, seems to help stress incontinence a bit more). In this particular study, 46% of the participants in the weight loss program achieved more than a 70% reduction in their incontinence symptoms. So, if you are overweight or obese, beginning a weight loss program may be a great first step toward improving your bladder function.
The great news is that we continue to learn more and advance in our understanding of helping men and women with these problems every day! What new research have you seen that is promising? As always, I’d love to hear from you!
**Note: I didn’t include medication in this list… not because I don’t think it’s effective or that the research is exciting, it really is! Mostly, because this is where my search took me this time around. The right medication can be a significant helper to many people having these problems– perhaps a future blog can talk about that! 🙂
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.”
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.
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 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.
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.
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?
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!
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!
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!!