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!!
Today’s throw-back comes from a post I wrote back in November here. I loved writing this post because I love running. I also loved writing it because it falls close in line with my heart-felt belief that there is no “bad” exercise, just sometimes bodies that are not quite ready for it. I hope you enjoy the post, and I do look forward to hearing from you!
Happy Thursday! ~Jessica
As some of you may know, I recently completed my second half-marathon. To make it even better, I completed it with my amazing and wonderful husband Andrew:
This was my second half marathon in 1 year, and my third *big* athletic event—the other two being the Disney Princess Half Marathon and the Ramblin’ Rose Sprint Triathlon. I started out 2013 with the goal of being healthier and developing strategies for life-long fitness, and I really am proud to say that I am still well on my way to better fitness. (Although in fairness, the craziness of moving to Atlanta did set me back a few weeks! But I’m back on the horse now!)
After completing my last half-marathon, I received the following question from a previous patient of mine,
“Ok, I have to ask, after seeing your race pictures, isn’t running bad for a woman’s internal organs??”
My initial thought was to respond quickly with a, “Not always, but sometimes…” type of response. But then it got me thinking, and inspired me to really delve into the issue with a little more science to back my thought—although honestly, the gist will stay the same.
So… Is running bad for the pelvic floor? Let’s take a look.
When someone initially looks at the issue, there may be the temptation to respond with a resounding, “YES!” We initially think of running and think of “pounding the pavement,” identifying large increases in intra-abdominal pressure and assuming that this pressure must make a woman more likely to experience urinary incontinence and/or pelvic organ prolapse.
But, what does the research really show?
1. Urinary incontinence during exercise is common and unfortunate.
Jacome 2011 identified that in a group of 106 female athletes, 41% experienced urinary incontinence. However, they also found that UI in those athletes seemed to correlate with low body mass index.
2. High impact athletes often may require more pelvic floor strength than non-athletes.
Borin 2013 found that female volleyball and basketball players had decreased perineal pressure when activating their pelvic floor muscles compared to nonathletes which they concluded placed these women at an increased risk for pelvic floor disorders and especially UI.
3. Over time, physically active people are not more likely to have urinary incontinence or pelvic organ prolapse that non-active individuals. ******
Bo (2010) found that former elite athletes did not have an increased risk for UI later in life compared to non-athletes (although she did find that women who experienced UI when they were younger were more likely to experience UI later on in life).
In another study, Bo (2007) found that elite athletes were no more likely to experience pelvic girdle pain, low back pain or pelvic floor problems during pregnancy or in the postpartum period compared to non-athletes.
An additional study by Braekken et. al. (2009) also did not find a link between physical activity level and pelvic organ prolapse. However, they did find that Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP.
Is your head spinning yet?? Let’s make some sense of this research…
First, it does seem like UI is a common problem in athletes—the cross-fit video that had all of my colleagues up in arms identified this problem really well—and honestly, runners are no exception to this. Every week, I work with women who experience urinary leakage when they run or may have even stopped running due to leakage, and I can assure you this causes a huge impact to these women’s lives. I also can assure you that there are many women out there dealing with leakage during running or other exercises who suffer in silence, too embarrassed to get help or somehow under the impression that leakage with exercise is normal.
With that being said, I am not ready to throw away running or really any other form of exercise all together (other than sit-ups…let’s never do those again). Running has amazing benefits—weight control, cardiovascular improvements, psychological improvements/stress reduction—and these should not be cast aside due to a fear that running could cause a pelvic floor problem.
As a pelvic floor physical therapist working in a predominantly orthopedic setting, I see many men and women enter our clinics with aches and pains—and injuries—that began while starting or progressing a running program. Often times, our amazing PTs identify running gait abnormalities, areas of weakness, or biomechanical abnormalities which can be contributing to hip/knee/foot/etc. pain with running. Improving those movement patterns and improving those individual’s dynamic stability seems to make a huge difference in allowing the client to participate in running again without difficulty.
To be honest with you, I see pelvic floor problems in runners the exact same way. When a woman comes into my office complaining of urinary leakage during running, I look to identify running gait abnormalities, areas of weakness or biomechanical abnormalities which are impacting her body’s ability to manage intra-abdominal pressure during running.(And no, intra-abdominal pressure is not always the enemy–see this from my colleague Julie Wiebe) I also make sure I am managing other things—identifying pelvic organ prolapse when it may be occurring and helping the woman with utilizing a supportive device (tampon, pessary—with collaboration with her physician, or supportive garment if indicated), managing co-existing bowel dysfunction or sexual dysfunction, and making sure the patient has seen her physician recently to ensure she is not having hormonal difficulties, underlying pathology or medication side effects which could worsen her problems.
We know that intra-abdominal pressure is higher when running. A poster presentation at the International Continence Society in 2012 identified that running does in fact increase intra-abdominal pressure compared to walking—but not as much as jumping, coughing or straining (Valsalva). And not as much as sit-ups…
As you know by now if you follow my blog posts, I do not believe that the pelvic floor is the only structure involved in managing intra-abdominal pressure increases in the body. (This is why I get so annoyed with all of the studies trying to look at the effectiveness of pelvic floor muscle exercises used in isolation in treating pelvic floor dysfunction). The most current anatomical and biomechanical evidence supports the idea that the pelvic floor muscles work in coordination with the diaphragm, abdominals, low back muscles as well as even the posterior hip muscles to create central stability and modulate pressures within the pelvis. In order for a runner to not leak urine or not contribute to prolapse or pelvic floor dysfunction when she runs, she needs the following(well really, more than this…but let’s start here):
Properly timing diaphragm—that is used appropriately as she runs so she is not participating in breath holding during her exercise
Strong and adequately timed abdominals and low back muscles to assist in stabilizing her spine/pelvis and assist in controlling IAP.
Flexible and appropriately firing gluteal muscles to support her pelvis during each step as she runs
Appropriate shoes to support her foot structure and transfer the loads through her legs
A great sports bra to help her use good posturing while running
Now, is there a time when a woman shouldn’t run?
Yes, I do actually think there are times when running does more harm than good and it may be advantageous for a woman to take some time off from running to restore the proper functioning of structures listed above.
If a woman has pelvic organ prolapse, for example, she may need to take some time off from running and participate in other exercises emphasizing functional stability with less of an increase in IAP prior to resuming an exercise program. Some women can return to running in the meantime using a supportive device like a pessary or tampon to help support her organs; however, this may not ultimately mitigate the harm if a person is not stabilizing properly as she runs.
I also recommending taking a break from running if a woman is leaking significantly during running or experiencing pain with running. I generally believe that once these structures are appropriately restored to function, women can return to running with less difficulty.
The other time I will often recommend waiting is when a woman is further along in her pregnancy or early post-partum. At this time, the increased weight on the pelvis as well as the loss of stability occurring due to hormonal changes places a woman at a higher risk for pelvic floor dysfunction. This, of course, varies based on the individual, but in many cases it may be helpful for these women to choose alternative exercises until after they deliver their children. Most women who are pregnant who I have worked with tell me that they reached a point in running when it just “didn’t quite feel right.” I generally recommend holding off when that occurs, then restarting postpartum once their bodies are feeling up to it again.
And lastly, I do recommend a woman holds off on running immediately after gynecological surgery (no-brainer here folks). The research does not indicate that said woman should never return to running—but again, I do think she should allow her body to heal and build up the appropriate strength and coordination needed to support her organs and her pelvis when running.
This post got a little longer than I originally anticipated… so to sum it up… is running bad for your female organs? Not always… but sometimes.
Many of my colleagues have some fantastic blog posts regarding exercise and pelvic floor dysfunction. Check out a few of them below:
Vlog by Julie Wiebe providing an alternative to running:
Urinary urgency, frequency and incontinence are complex and involve the interactions of multiple systems (somatic, visceral and neurological). These three problems are treated commonly in pelvic physical therapy and women’s health physical therapy practices. Urgency suppression strategies were initially developed based on these systems- with the understanding that the pelvic floor muscles were not contributing their part to the system. In my opinion, this was largely based on the understanding the incontinence/urgency occurred when the pelvic floor muscles were not strong enough to properly hold back urine. But, over time we have learned that this is not always the case. (See my recent post here).
So, do the same urgency suppression techniques apply for a tender pelvic floor muscle group? Hhow should urgency suppression techniques be modified for the overactive, shortened or hypervigilant pelvic floor?
To understand this, I first need to introduce you to the standard urgency suppression techniques.
Now, please don’t take this as “Jessica doesn’t think urgency suppression techniques work,” because that is simply not true. I use these in the clinic all the time—for my patients who are experiencing urgency or urge incontinence and have weak, under-functioning pelvic floor muscles. These techniques work for this population a few different ways:
Deep breathing facilitates the parasympathetic nervous system which helps to keep the walls of the bladder relaxed thus allowing the bladder to fill and decreasing urgency. This breathing also helps to decrease the emotional fear that a person may feel (“Ahh, I hope I make it to the bathroom!”) which also will calm urgency due to the impact this has on the brain.
Strong, quick, contractions are thought to stimulate the neurological connection between the pelvic floor muscles and the bladder. Basically, quick contractions tell the bladder “it is not yet time to empty” and the bladder relaxes its contractions (which make us feel the strong urge) helping to calm urgency.
Distraction/Visualization are ways to get the mind off of the bladder and on to something else. Remember when you needed to go to the restroom, but got busy and forgot you needed to go? This aims to utilize that same mechanism to calm urgency and allow postponement of the urge.
Sounds great, right? And it is—really great for people who are experiencing urgency and have weak, underactive pelvic floor muscles. But what about for the people having overactive/shortened/hypervigilant pelvic floor muscles?
My thought process is that these techniques have to be modified to allow them to be effective for this population. First, we will keep a few steps and here’s why:
Deep breathing & Distraction/Visualization: I actually love these (especially the calm breathing) for my patients with difficulty relaxing the pelvic floor muscles. I often find that people with overactive pelvic floor muscles tend to be in a sympathetic-drive state for their nervous systems. Remember, the sympathetic nervous system is the “fight-or-flight” response. People who have chronic pain or chronic urgency/frequency often will have a significant amount of stress and fear, and I find that this state of their system often facilitates poor breathing patterns and overall increased tension and poor force modulation (meaning, choosing the right amount of muscle activity for the current task at hand). My colleague, Seth Oberst, wrote an amazing post about this very thing recently (I could write an entire post applying all of that to the pelvic floor!). So, we’ll keep these steps—with an emphasis on slow, calm breathing, utilizing the diaphragm and emphasizing relaxation of the pelvic floor with the inhale and returning to baseline with the exhale.
But here’s where we modify:
Quick, strong, pelvic floor contractions: My issue with this component for the overactive or hypervigilant or shortened pelvic floor muscles stems from a few key points. Traditional “kegels” or pelvic floor strengthening exercises are contraindicated for people with pelvic pain (or in my mind, anyone who has a tender, hypervigilant or overactive pelvic floor). Performing quick contractions for this population often will create pain, worsen the patient’s symptoms and actually increase urgency. You heard that right. Did you know that the pelvic floor muscles can actually refer to the bladder? I have had many instances when examining a person’s pelvic floor muscles that he/she reported that even lightly pressing on certain muscles made him/her feel urgency. And we know that somatovisceral convergence (a muscle impacting an organ) is real, and does occur. So, what do we do about this step?
We use this relationship in our favor.
Instead of quick, hard contractions, the person can perform deep breathing and pelvic floor drops (emphasizing complete pelvic floor relaxation). Although initially, some of my clients will worry that relaxing the pelvic floor muscles will “open the flood gates” this does not typically occur. Instead, relaxation of the pelvic floor combined with breathing will often calm down the detrusor (bladder muscle) activity and allow them to feel decreased urgency.
So, what do these new urgency suppression strategies look like?
What do you think? If you have a tender pelvic floor and/or pelvic pain, I encourage you to give it a try! Let me know what you think! As always, I would love to hear from you!
Today’s throwback (yes, I know it’s Friday– I’m sorry, I was busy yesterday!) comes from a post I did a year ago on improving bathroom habits in children. This has been modified from my original post to reflect my most current thoughts and current practice patterns. Hope you enjoy!
As you may know, I have advanced training in working with children with bowel and bladder dysfunction in pelvic physical therapy. Often times, this is shocking to many people to hear as most of us are somehow under the impression that children don’t have these sorts of problems. But the truth is, these problems are SO common in children! Amazingly, there are many easy things parents can do to make huge differences for their children! I often here my adult patients say,
“But you don’t understand, I’ve been constipated since I was 5 years old– it must run in my family! ”
What if we changed the habits of our children early to promote healthy bowel and bladder habits? Could we truly make a difference for them later on in their lives? Could we prevent them going in to their physical therapist and having to say statements like the one above? I believe we can do just that!
Here are your 5 tips to start making those changes today!
1. Encourage adequate fluid intake (mostly water!) and fiber intake!
The average person should consume 5-8 8-oz cups of fluid per day–and your child is no different! Fluid is SO important for both the bladder and the bowels! For the bladder, having adequate fluid decreases the risk of urinary tract infections, encourages normal bladder urges, and allows for a normal light colored urine instead of a dark concentrated urine. As an aside, taking in too many sweet sugary drinks, caffeinated drinks, and carbonated drinks will actually irritate the bladder and is something we want to try to avoid. (Note: Remember this if your child has difficulty with bed wetting!). For the bowels, adequate fluid allows for a soft stool that is easy to pass! If your child is not getting enough water, he or she will likely have a more firm stool as the intestines have worked to absorb the fluid your child needs for normal bodily functions. Many a patient has been “cured” of constipation simply by drinking more fluid!
Fiber is also very important to encourage a good bowel consistency. The American Academy of Pediatrics recommends children take in between their age + 5 and their age +10 grams of fiber per day (i.e. a 5 year old would need between 10 – 20 grams/day). There is some debate in this, so check with your pediatrician to get their recommendations. Good fiber sources include fresh fruits and vegetables, whole grains, oatmeal, granola, seeds and nuts! For good recipes for your kids, check out Gina’s recipes from Skinnytaste.com that are “Kid Friendly” here. Also, one of my favorite books for parents,Overcoming Bowel and Bladder Problems in Children, has a wonderful index of fiber-filled kid recipes!
2. Encourage your child to listen to his or her normal body urges.
This goes for both the bladder and the bowels as well! Quick lesson on anatomy and physiology–We have a normal reflex in our colon that helps us hold our stool to empty at an appropriate time (Yay!). Unfortunately, if a person holds stool for too long, the normal colon response to help us poop is dampened–meaning it won’t work as well! For the bladder, over suppressing bladder urges can cause problems with emptying that bladder, daytime accidents and frequent urinary tract infections. Many times, children become distracted with playing, watching TV, etc. and will hold off on going to the bathroom when they do have that urge. Parents should try to be aware of how long it has been since their child has urinated, and try to encourage a frequency of at least once every 2 hours (this will vary some depending on the age of the child).
3. Get your kids moving!
I’m sure you’ve heard it in the news these days that children need to get moving more! But, to take a new spin on it, encouraging your kids to move more will actually help keep their bowels more regular! Yes, it’s true, exercise is a stimulant to the bowels. So, encourage your kids to get outside and play, ride their bikes, do family walks and games– the more your kids move the better!
4. Help your child develop a bowel routine
This one ties in perfectly with our last point. Here’s the scenario:
“8 year old Mary is not a morning person. Mom has a hard enough time getting Mary out the door in the morning, and this often means eating a bagel on the way to school. After Mary gets to school, she often needs to go #2, but is too embarrassed to go and holds it the whole day.”
Unfortunately, kids like Mary often develop constipation from over suppressing those urges! The sad thing with this is that if a child suppresses urges for bowel movements, the stool will often become hard and may even cause pain when the child does go to the toilet. Over time, children can end up with overly stretched colons and may even need to use laxatives/medication for a period of time to loosen the stool and help the colon return to it’s normal position. All of this can be minimized by building a routine for your kids in the morning (or evening) to help encourage a normal bowel movement.
This video from the Children’s Hospital in Colorado helps to shed more light on bowel problems in children:
We know that the colon LOVES consistency, so try to encourage your kids to spend some time (at least a few minutes) on the toilet at the same time each day. We also know that the colon loves fluid (hot especially), hot food, and exercise! So, a good bowel routine would look like this:
“To help Mary’s bathroom habits, Mom started waking Mary up 30 minutes earlier. Mary starts her day with a warm bowl of oatmeal, then plays with her pet dog. After they play, Mary heads straight to the bathroom to have a BM.”
Yes, building a routine takes some extra time–but it is well worth it to prevent constipation in your kiddos!
5. Encourage proper toilet positioning and breathing on the potty
Yes, there is a right way to sit on the toilet. For children, most toilets are too tall and this makes it difficult for them to relax the muscles around the anal canal to help them poop without pushing hard. Kids will compensate by straining, but over time this can be very detrimental to their pelvic health. To help them out, get a small stool to go in front of your toilet seat which will help encourage them to fully relax their muscles. Encourage them to lean forward and relax on their knees. This will help straighten out the rectum to encourage easy emptying.
Then, and most importantly, make sure they have time. Encourage them to read a book or magazine and give their colon a few uninterrupted minutes to “do its thing.” I recommend they spend this time doing slow breathing (Potty Yoga) and relaxing. If they feel like they need to push, encourage them to breathe while they push to avoid the typical valsalva maneuver we often see. Learning this will help them so much both now and in the future! For more information, read this excellent post from my colleague, Jenna Sires, called “Are you Pooping Properly?“
What have you tried to help encourage good bathroom habits for your kids? Are your children having problems not addressed above? Feel free to comment below! Here’s to a healthy upcoming generation!
For the next few weeks, I plan to re-blog/update every Thursday a previous post originally written by me when working in Greenville, SC for the Proaxis Pelvic PT blog (http://proaxispelvicpt.wordpress.com), in hopes of building a comprehensive library of posts at jessicarealept.com. Selfishly- I like having them all in one place since I often refer patients who come to see me in Atlanta for pelvic PT to my old posts to read as “homework.”
That being said, today’s post is one published a while back here, originally titled, “Yes, you have incontinence. No, I do not necessarily want you to do Kegel exercises.” It has been modified/updated for you today 🙂 Enjoy!
Recently, I was fortunate to evaluate a nice middle-aged woman referred to me by her urogynecologist for urinary incontinence. When we first sat down, she looked at me and said, “I’m not sure why I am here. My doctor specifically told me that I have a strong pelvic floor. I really don’t think you can help me.” I smiled. I hear this same thought process on a weekly basis (See my previous article on common misconceptions of pelvic physical therapy) You see, at some point the world became convinced that from a musculoskeletal perspective, stress urinary leakage is always due to a weak muscle. And the best way to fix a failed muscle is to strengthen, strengthen, strengthen. But, if that’s the case, then why do I have so many patients walking into my office telling me that they have done “Kegel” exercises and still leak? Why would a patient like the one above have a “strong” pelvic floor that cannot hold back urine? Why is urinary leakage associated with low back pain and pelvic pain- disorders that we know can often include tight and irritated pelvic floor muscles?
Now, as a caveat to this article, let me say now that it is sometimes totally appropriate for a person to start a pelvic floor strengthening program. In fact, the person with a truly weak, overstretched, poorly-timing pelvic floor will likely be prescribed a strengthening program. With that being said, the truth is that the majority of patients referred to my clinic for evaluation of urinary incontinence are not issued a traditional kegel exercise program. My colleagues and I actually tend to be surprised when we evaluate a new patient who truly needs to start a true “strengthening” program for their pelvic floor at the first visit. The reason behind this is that Stress incontinence is not simply a failed muscle, but a failed system.
The urethra is supported within the continence system by fascia, ligaments, as well as muscular structures. When a downward force is applied to this system as occurs with coughing, sneezing, lifting, bending, etc, these structures function in a coordinated way to compress the urethra and prevent urine from leaking. In fact, Hodges et. al. in 2007 examined musculoskeletal activation occurring when a person performed an arm movement and found that the pelvic floor muscles pre-activated to prepare the body for movement. This helps to demonstrate that our pelvic floor muscles function as a member of the anticipatory core team. This team requires optimal and coordinated function of the diaphragm, the deep abdominal muscles, the deep low back muscles as well as the pelvic floor muscles. My awesome colleague, Julie Wiebe demonstrates that relationship very well in the video below (Note: Julie has an AWESOME blog/website- read more of her stuff here):
When any of these structures are not functioning well, leakage can occur. Now, the tricky part here is that optimal functioning requires both strength, flexibility and proper timing. A tight irritated muscle then becomes equally as dysfunctional as a weak over-stretched muscle. And, a strong, flexible muscle that doesn’t have the right timing contributes to a very dysfunctional system.
So, treatment for incontinence then must include retraining and reconditioning the system to ensure its proper functioning—which for me includes a bit of detective work to truly identify the faulty components. And, when it comes down to it, typically does not include doing 100 kegel exercises a day. More often, it includes learning to relax the pelvic floor and teach the pelvic floor to be a working team member– learning to coordinate the pelvic floor with the diaphragm, eliminating trigger points and restrictions which may be inhibiting this function, and then retraining the motor control of the lumbopelvic girdle as a system.
So, for now, take a deep breath and relax. We’ll save Kegels for another day.
A few months ago, I had the opportunity to be interviewed for a story in the Greenville News on Urinary Incontinence.
Many women (and men too!) don’t realize that there are effective non-surgical options for UI. My hope is that articles like this can help spread awareness and encourage people to be proactive in seeking out help! Women’s Health and Pelvic Floor Physical Therapy can make a huge difference for people struggling with these problems!!
Enjoy the article here! Will be added to our News page for future viewing!