Tag Archives: Exercise

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

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

Happy Thursday! ~Jessica 

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

4 miles in and feeling great!

4 miles in and feeling great!

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

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

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

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

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

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

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

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

But, what does the research really show?

1. Urinary incontinence during exercise is common and unfortunate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  • Properly timing, well-functioning, flexible pelvic floor muscle group.
  • Properly timing diaphragm—that is used appropriately as she runs so she is not participating in breath holding during her exercise
  • Strong and adequately timed abdominals and low back muscles to assist in stabilizing her spine/pelvis and assist in controlling IAP.
  • Flexible and appropriately firing gluteal muscles to support her pelvis during each step as she runs
  • Appropriate shoes to support her foot structure and transfer the loads through her legs
  • A great sports bra to help her use good posturing while running

Now, is there a time when a woman shouldn’t run?

Yes, I do actually think there are times when running does more harm than good and it may be advantageous for a woman to take some time off from running to restore the proper functioning of structures listed above.

  • If a woman has pelvic organ prolapse, for example, she may need to take some time off from running and participate in other exercises emphasizing functional stability with less of an increase in IAP prior to resuming an exercise program. Some women can return to running in the meantime using a supportive device like a pessary or tampon to help support her organs; however, this may not ultimately mitigate the harm if a person is not stabilizing properly as she runs.
  • I also recommending taking a break from running if a woman is leaking significantly during running or experiencing pain with running. I generally believe that once these structures are appropriately restored to function, women can return to running with less difficulty.
  • The other time I will often recommend waiting is when a woman is further along in her pregnancy or early post-partum. At this time, the increased weight on the pelvis as well as the loss of stability occurring due to hormonal changes places a woman at a higher risk for pelvic floor dysfunction. This, of course, varies based on the individual, but in many cases it may be helpful for these women to choose alternative exercises until after they deliver their children. Most women who are pregnant who I have worked with tell me that they reached a point in running when it just “didn’t quite feel right.” I generally recommend holding off when that occurs, then restarting postpartum once their bodies are feeling up to it again.
  • And lastly, I do recommend a woman holds off on running immediately after gynecological surgery (no-brainer here folks). The research does not indicate that said woman should never return to running—but again, I do think she should allow her body to heal and build up the appropriate strength and coordination needed to support her organs and her pelvis when running.

This post got a little longer than I originally anticipated… so to sum it up… is running bad for your female organs? Not always… but sometimes.

Many of my colleagues have some fantastic blog posts regarding exercise and pelvic floor dysfunction. Check out a few of them below:

Vlog by Julie Wiebe providing an alternative to running:

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

Safe exercise for those with pelvic pain:

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

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

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

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

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

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

~ Jessica

References:

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

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

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

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

Taking the first step: Getting moving when experiencing chronic pain

active-84646_640

As many of you know, I recently took a huge step in my career and moved to Atlanta with my husband, accepting a job as a pelvic health physical therapist for a newly opening private practice with One-on-One Physical Therapy. Leaving my patients behind was one of the hardest parts of moving (if you’re reading this prior patient, I miss you!). One of the things I realized when working to find colleagues to treat my current patients was that I treat quite a number of people with chronic pain. And I love it. When I left Greenville, I would estimate that close to 50% or more of my caseload were men and women who had been experiencing pelvic pain for 6 months or more (and many of them, much longer than that!). Often times, people experiencing chronic pain feel trapped in an inactive state—fearing movement, exercise and even social activities as they correlate increased activity with increasing pain. The sad truth about this is that reality and current research tends to show the complete opposite:

Movement is medicine for chronic pain.

 Now, let’s take a step back…

What is chronic pain and what isn’t it?

 I promise this blog post is going to stay on track. Honestly, there are so many people much smarter than I am who have written amazing books, articles, and blog posts on understanding chronic pain. So, I will be succinct here, but give you some good resources at the end if it leaves you thirsty for more.

In short, all pain is produced by the brain. (Your pain is real, not all in your head, but the brain is always really involved!) Pain is an alarm system used by the brain when it perceives damage or even sees a threat of damage to the body. Pain is there to motivate the body to action—basically to help you eliminate the source of “threat.” Example: I step on a tack. I feel “pain.” I move my foot off of the tack.

This alarm system works really well for situations like the one above. There is a threat. We remove the threat. We feel better. But it is important to recognize that the amount of pain does not always correlate with the amount of damage. Example: A man walks into the emergency room with a knife sticking out of his leg, but isn’t experiencing “pain.” A papercut can be felt as VERY painful.

 The point is, the brain takes information in about our current situation, past experiences, emotions, etc. to create an experience of pain that it perceives as useful to us for the time being. This experience is influenced by situation (i.e. needing to get to the emergency room so the knife doesn’t “hurt”) emotion (i.e. No one knows what is wrong with me, so it must be really really bad!), fears (i.e. I am never going to be able to run again!), and life stressors (i.e. going through a divorce when the pain initially began).  

30d490ce9760c3202eca35538740017511b77faa

 So, how does this relate to movement?

For many people experiencing pain, movement often becomes a “threat” to the brain. For example, if a person is experiencing pelvic pain and the brain believes that walking will worsen the pain, then often walking will be a pain producing activity—to protect you from the “threat” of walking! Over time, the threshold for pain can change and people can become more sensitive to movements or activities—basically, the brain becomes very good at playing the pain “tune.” Lorimer Moseley uses the example of an orchestra in his book Explain Pain. If an orchestra plays the same song again and again, they become very very good at playing that song. Our brain works in the same way.

With that being said, we have learned that if we can help a person to move in a way that his or her brain is not protecting or guarding by pain, we can actually reduce the sensitivity to those movements and help a person get back to an active lifestyle with less pain. This is as true for a person experiencing chronic pelvic pain as it is for a person with chronic low back pain or neck pain or ankle pain.

Does it actually work?

 The awesome part is that research has shown that movement and exercise are extremely helpful in pain reduction!  A meta-analysis in 2014 published by the American Journal of Physical Medicine and Rehabilitation found that regular aerobic exercise improved pain, disability and depression/anxiety scores in people with low back pain. Another meta-analysis and systematic review published in 2014 by the Archives of Physical Medicine and Rehabilitation found that walking exercise helped to reduce pain levels in men and women experiencing chronic musculoskeletal pain. Even pregnant women with low back and pelvic girdle pain see benefits of exercise in pain reduction as noted in this 2012 review by the Journal of the Section on Women’s Health.

To see even more benefits of exercise, check out this awesome video by Dr. Mike Evans:

 

So, how do you get started if you hurt?

The key piece here is that we want to start moving at low pain levels in a way that will be therapeutic for your body—not in a way that will cause your body to guard and produce increased pain. When I treat patients with chronic pain, I start recommending movement at the first or second visit (of course, depending on the specific patient). Here is where I typically start:

  1. Begin with small, manageable movement goals: If you have spent the last 5 years moving from bed to the couch, it is probably not the best thing for you to begin a running program. For these people who have been very sedentary, I recommend starting small by aiming to walk around the house once every hour and perhaps adding in a small series of shallow squats at their kitchen counter along with a few other easy exercises. On the other hand, if you are fairly active, but have avoided regular exercise, try to slowly build up to a routine again. I generally recommend starting at 10-15 minutes and building up to 30-60 minutes depending on the person.
  2. Explore new and different exercise options: I have seen time after time that a person may be frustrated that she cannot do an exercise she enjoyed (i.e. running) so will stop exercising all together. Often times, I find that although one exercise may aggravate symptoms, another will be much more tolerated! I recently worked with a wonderful patient experiencing chronic pubic joint and pelvic pain—she loved walking for exercise, but found that walking was aggravating her pubic joint. We tried exercise in the pool, and she LOVED it! Not only could she begin moving again, but her pain seemed to stay at a low level while she exercised! So explore other options—walking, swimming, yoga, pilates, etc. Be open!
  3. Try not to be afraid of pain: Remember to see pain for what it really is! I often tell my patients that if an activity keeps their pain low or improves their pain, it is likely a good, safe exercise for them to be doing. That being said, sometimes patients will try an exercise and it will severely worsen their symptoms—and that is part of the learning process. Generally, we find if we hold off on that activity for a short time while finding another activity that is more tolerable, we can often return to the other activity at a later date with much lower levels of discomfort.
  4. Work with a team: I always recommend that my patients work closely with myself or another health care provider while they are getting back to movement. Sometimes, it is a little of trial and error learning what movement strategies are the most optimal to start with. Be patient, share your experiences, and be open to suggestion for different things to try!

 So, good luck! Get started, and let me know if you have any questions! Thankfully, I am not by any means the only person who has written on this topic, so check out these excellent resources from my colleagues working with people with pain.

 On Pain & the Brain:

 On Exercise for Pelvic Pain:

Do you have any other resources you love? What has worked for you in the past? PTs, what are your favorite suggestions to give patients? Let’s share and learn together in the comments below!

~ Jessica