Ok, so I have been SO excited to share this with all of you, but needless to say, I’ve been a little busy with nursing, diapers, and keeping a very active toddler happy.
Over the past 10 years, I’ve had the chance to treat hundreds of patients in a few different job settings. I’ve also helped to educate hundreds of other health care providers as they journey into pelvic health rehabilitation. I have learned so much through these experiences– both about patient care and creating a positive, motivating and enjoyable clinic environment for patients and clinicians alike!
So, I am thrilled to announce that I will be opening my own practice this fall! I have soooo many more details to share, but for now, I can tell you that I will begin seeing clients on October 1st, and will open scheduling in mid August! (If you want to be contacted first when the schedule opens, send me a message now!)
If you have any questions, please feel free to reach out!! Can’t wait to share more details with all of you in the next few weeks/months!!
I was interviewed for an article that was featured this month in Men’s Health! I wanted to share with all of you here! Excited to bring information on male chronic pelvic pain and pelvic floor physical therapy to such a big platform!
In the article, we discussed the scope of the problem, treatment recommendations, and even some details on what good pelvic PT should look like! I hope you all enjoy!
Irritable Bowel Syndrome (IBS) can be an incredibly life-impacting condition, affecting around 10-20% of the population (80% of those individuals being female!). The exact cause of IBS is unknown, but it is thought to likely be multifactorial.
IBS is characterized by abdominal pain paired with constipation and/or diarrhea. When many people hear about IBS, they may not automatically think that working with a physical therapist could be useful; however, there is so much that physical therapists can do to help improve symptoms related to IBS. Here are a few!
1.) Assist the client in developing optimal bowel habits.
We’ve discussed in detail several times how our habits can be extremely connected to our bowel function. This is also very true for individuals dealing with IBS–whether struggling with constipation, diarrhea or both! Training bowel habits includes developing a consistent bowel routine, optimizing dietary habits, and even toilet positioning/defecation strategies. These factors basically aim to help make sure your habits are working for you instead of against you. Sometimes these components require a more multidisciplinary team. This can include working with your GI physician, pelvic PT, as well as a dietician, functional medicine provider, and other specialties.
2.) Global downtraining and stress management.
Did you know you have an extensive neural network throughout your GI system? This network has been termed “the second brain” due to its ability to function even when cut off from the rest of the system. It’s also often called “the emotional brain of the body,” which makes sense when we think about how often we feel our emotions in our gut (i.e. “butterflies in your stomach” or “my gut reaction”) All is this means that our GI function can often be influenced by our stress, emotional regulation, and general psychological well being.
Qin et al. (2014) stated, “More and more clinical and experimental evidence showed that IBS is a combination of irritable bowel and irritable brain.” They went on to add that psychological stress can impact intestinal mobility, motility, secretions and permeability. They concluded that, “IBS is a stress-sensitive disorder, therefore, the treatment of IBS should focus on managing stress and stress-induced responses.”
Pelvic PTs utilize strategies promoting downtraining and neuromuscular relaxation to help calm the nervous system and promote a more parasympathetic dominant state. This can be done through movement, relaxation strategies, mindfulness/meditation, and many other techniques. Want to get started on mindfulness now? Check out this prior post on Mindfulness, Meditation and Pain.
3.) Specific exercises aimed at promoting better movement.
This may not seem connected at first, but the reality is that when people aren’t feeling well or when someone is struggling with constipation/diarrhea, people tend to move less. This can often impact bowel function as regular exercise tends to stimulate more regular bowel movements. This 2019 review of 14 studies involving exercise interventions aimed at improving IBS symptoms found that exercise does seem to have a role in helping bowel function (Note: many of these studies were not so great, and found to have a high risk of bias, so more studies are definitely needed!)
Schuman et al. (2016) performed a review of 6 randomized-controlled trials looking at the role of yoga in helping people with IBS. I’ll be honest, I absolutely love yoga and find the pairing of breathing, mindfulness and movement to be so beneficial to myself and my patients. So, I was not surprised to see this review showing that the groups participating in yoga had decreased bowel symptoms, IBS severity and anxiety.
Additionally, it is common for someone with chronic constipation and/or diarrhea to have restrictions in the movement of their hips and spine. Restoring this movement through specific exercise can facilitate better function of the muscles around the pelvis, including those involved directly in bowel function.
4.) Treat the myofascial components of the problem.
We have discussed the viscerosomatic and somatovisceral reflexes in the past. Basically, when a person has an organ problem (in this case, IBS), we often will find that the myofascial tissues around the organ can become restricted and sensitive. This can be interconnected where myofascial dysfunction can worsen a visceral problem and a visceral problem worsens myofascial dysfunction. Thus, addressing both sides of the problem can often be very optimal. From a musculoskeletal standpoint, this means identifying structures around the abdomen and pelvis which may be sensitive or not moving as optimally. This can often include the abdominal wall, hip muscles, thigh muscles, buttocks muscles and the muscles around the low and mid back.
5.) Treat underlying or co-existing pelvic floor problems.
Prott et al. (2010) found that there were relationships between pelvic floor symptoms andanorectal function in individuals with IBS. Dysfunction of the muscles of the pelvic floor can present as weakness, which can lead to either difficulty holding back stool or poor support around the rectum. It can also include overactivity and poor relaxation of the pelvic floor muscles. This can contribute to pain, but also can influence how well the muscles can open for defecation , or hold back when they need to. Additionally, people can experience difficulties with coordination of the pelvic floor– basically, when the muscles do not contract or relax when they should. Dyssynergic defecation occurs when the pelvic floor muscles contract instead of relax when a person has a bowel movement. This can be a significant problem for those struggling with constipation. I wrote a whole article on that, and you can find it here. Sphinctor dyssynergia can occur in individuals with IBS as well as other types of constipation, and can be treated with pelvic PT (lots of treatment options, including SEMG biofeedback which has been found to be helpful for people with and without IBS).
IBS can be so impacting to a person’s life, and you don’t have to suffer alone! I encourage you to build your multidisciplinary team and start getting the help you need to get the most out of life!
What strategies have you found most helpful in dealing with IBS? As always, I’d love to hear from you!
Last week, one of my favorite things to happen in the clinic happened again. A sweet patient I had been working with over the past few months came in to her session, and as soon as we closed the door, she exclaimed, “We had sex and it didn’t hurt!” As a pelvic PT, there is nothing better than sharing in the joy of the successes of your patients. Treating sexual pain is close to my heart, particularly because this was one of the reasons I became a pelvic PT to begin with. “Treating Sexual Pain” was actually the focus topic for my small group mentoring program this month, so I thought it would be fitting to highlight a common treatment tool/strategy used in pelvic PT to help people experiencing painful penetration.
What are vaginal trainers?
Vaginal trainers are tools used to help to desensitize the muscles and tissues of the canal. They are often helpful when a person is wanting to participate in penetration activities, and is having difficulty doing so due to pain. Vaginismus is a particular diagnosis that refers to painful vaginal penetration due to muscle spasm. Women experiencing vaginimus in particular can be very good candidates for this type of treatment program. That being said, trainers can also be helpful for people with pelvic pain in performing self-manual treatment to the pelvic floor muscles, or for other vulvar pain conditions. Trainers also come in rectal variations, and some patients benefit from these as well depending on their primary complaints and goals.
Trainers generally come in graded sizes, often ranging from very small (think pinky finger) to large. There are several different companies that make trainers, and I’ll share a few of the different types here:
Silicone Dilators/Trainers: These are smooth silicone, and bend and move very easily, so they are what I consider to be top-of-the-line trainers. Soul Source and Intimate Rose are two companies that sell these trainers. Both are great, but I do really like how smooth and soft the intimate rose dilators are. These are a little pricey, so range from $18-50 per trainer $80-200 for a set. (As an aside, Intimate Rose was actually designed by a pelvic PT, Amanda Olson, DPT, PRPC. Amanda has excellent resources on her website, including this great video providing a breathing exercise for pelvic pain)
Plastic Dilators/Trainers: These are hard plastic, so they do not move and bend the way silicone trainers do. However, they do tend to be on the cheaper side. Vaginismus.com sells a trainer set including 6 sizes with a handle for about $45. The Berman Vibrating Set includes 4 sizes and often sells on amazon for less than $25. Syracuse Medical also makes a set without handles that is solid plastic, and those trainers are sold individually ($10-20 each) or as a set ($45-80).
How do you decide which to pick?
Well, it depends on a lot of things. Some of my patients prefer to go the cheapest route possible, so for them, it makes sense to get the $25 Berman set off of amazon or the $45 Vaginismus.com set. For others, they really like the softness and bendiness of the silicone sets, so they feel comfortable spending a little more for that type of set. Some sets come with varying sizes, so it is important to pick one that has the sizes you (or your patient) needs to accomplish their treatment goals. Usually, I sit down with my patients, show them a few different sets, then allow them to pick the set they feel the most comfortable with.
Wait…Trainer or Dilator? What’s in a name?
So, you’ll see these terms used interchangeably quite a bit, but honestly, I think the name really does matter. The term “dilator” never really settled well with me…because…well…dilation is a fairly strong word. Dilation refers to passive opening. I think pupil dilation. I think cervical dilation (although one could argue that is not totally passive!). Honestly, dilation is not what we are aiming for when it comes to the pelvic floor muscles. Trainer on the other hand, is an active term. It requires participation, focus, involvement. It is not a passive process, but rather, is an active journey. And that, my friends, is what utilizing trainers to improve penetration should be.
Getting started with trainers
A word of advice- please do not try this on your own. I have had so many patients who become discouraged, sore, or get worse from using trainers without the guidance of a pelvic PT. If you are struggling with sexual pain, and you would like to try trainers, please please please make an appointment with a pelvic PT who can evaluate you and guide you in this process.
Once my patients purchase their trainer sets, I have them bring the trainers to the clinic. We then will use them together in the clinic before they begin using them as part of their home program. I have a few rules when it comes to trainers:
We are gently introducing a new stimulus to the vagina; therefore, we do not want to do anything that leads to the body guarding and protecting by pain. So, when people use trainers, all discomfort should be 2/10 or less, and should reduce while we are using the trainer. (Note: Some very well-intending clinicians will give advice to “insert the largest dilator you can tolerate and leave it there for 10-15 min.” Tolerate is a very strong word, and I find this approach tends to lead to a lot of pain as well as fear and anxiety associated with the treatment.)
We cap out at 10-15 minutes. I encourage patients to set a timer when they start, and whenever that timer ends, to go ahead and end their session. This keeps the session reasonable in time commitment, and also avoids over-treating the area.
We avoid setting “goals” for the sessions or the week. The goal of using trainers is to gently provide graded exposure to the muscles and the tissues, to allow relaxation and opening without anything being threatening or painful. Our muscles are impacted by many different things, so many patients will find that the size of trainer they use or the level of insertion that happens can vary based on the day, week, etc. So, for this reason, we avoid setting a goal to accomplish, but rather, just aim to spend time focused on breathing, relaxation, opening, and gentle desensitization.
So, how do we use the trainers?
My approach to using trainers is strongly influenced by my friend and mentor, Darla Cathcart, PT, DPT, WCS, CLT. Darla was my clinical instructor back when I was getting my doctorate 10 years ago, and her approach to using trainers is gentle, progressive, and based in our understandings of muscles and neuroscience. (As an aside, Darla recently started teaching for H&W and I could not be more excited!! We taught our first class together a few months ago, and we will be teaching together again in 2019!! She is the absolute best, and is actually currently doing her PhD research on women with vaginismus. I’ll try to share more as she gives permission to do so in the future!)
Back to trainers, I encourage people to start with the smallest trainer (or for some, I may recommend a different size based on what I noticed with the exam). First, I encourage creating a comfortable environment to use the trainers– this means calm lighting, comfortable space, pillows to support legs and torso so that muscles can relax, and sometimes even a nice candle or soft music. We begin with placing the smallest dilator at the opening of the vagina, then slowly insert until the person feels discomfort (2-3/10) or guarding. When this happens, we stop moving, and they take slow long breaths focusing on relaxing and opening the pelvic floor muscles. They can then gently (like with 25% force) contract and relax the pelvic floor muscles, aiming to completely let go and rest the muscles. If the tenderness/guarding they felt resolves, they continue to slowly insert the trainer and repeat this process until the trainer is completely inserted. If at any point the discomfort does not reduce, we then will back the trainer out a little bit and rest/breathe there for a minute, then try again. If it still does not reduce, then the body is giving a cue that it is ready to take a break from trainers, and we go ahead and stop the session.
Once the trainer is completely inserted, we add movement. This can include turning the trainer side-to-side, or pressing it right, left or down. We avoid turning or pressing the dilator toward the pubic bone as the bladder and urethra live there, and they don’t generally like being mashed on. We can also move the trainer slowly in and out, stopping again during this process if anything is uncomfortable and repeating the steps above.
One that size trainer is completely comfortable, we move on to the next size and repeat the process. This continues until the 10-15 minute session ends, and then wherever we are, we stop for the day. We can add modifications in to trainer sessions, and this will depend on the particular patient. Sometimes this includes partner involvement with trainers or it can include visualizations or imagery to aid in the process.
With this slow, graded, and gentle approach, I find that most patients can do very well and this can be an excellent treatment to help them achieve their goals! I hope this was helpful in better understanding an approach to this treatment! If you are a patient and think you may benefit from using this approach, I would strongly recommend discussing this with your physician and seeking out a pelvic PT to help you guide the process!
If you are a pelvic PT, feel free to share any additional tips or recommendations you have for trainers in the comments below!
It’s almost here! I have been working on developing a small group mentoring program over the past few months, and it is almost ready to be rolled out!
As an instructor for Herman & Wallace Pelvic Rehabilitation Institute, I have been fortunate to work with hundreds of excellent clinicians who are at various stages of their journeys into the exciting world of pelvic health. While some clinicians enter into the field with a vast network of seasoned pelvic floor experts to support them, others have the additional challenge of being an “island”–basically, being the sole practitioner in their practice, city, and for some, within a 100+ mi radius.
My goal with small group mentoring is to be a facilitator for those journeying into this incredible specialty–to help not only with building the skill, knowledge and clinical reasoning necessary to create outstanding clinicians, but also to help connect clinicians together so no one has to go at it alone.
If this resonates with you, and you’re interested in learning with me, I would love to hear from you! I created this survey to better assess the needs of those interested in small group mentoring. Please take a few minutes to complete this survey, and look out for future announcements when the program is ready for rolling out!
Over the past week, and really the past year, the cases of sexual abuse and assault perpetrated by Larry Nassar, a medical doctor with MSU and USA gymnastics, have rocked the nation. The horrific abuse he inflicted on well over 150 young women, under the guise of “appropriate medical intervention” is deplorable, and I know many of us were glad to see him held accountable for his actions with both the verdict and sentencing last week.
In the pelvic PT world, this hit very close to home, and made all of us completely infuriated. For this person to take a completely valid, evidence-based and extremely beneficial treatment technique, and contort it into being an avenue for abuse was unfathomable to those of us who have dedicated our careers to helping men and women with pelvic floor problems. Several colleagues have spoken out about this. Particularly, Lori Mize, the incoming Vice President of the Section on Women’s Health, wrote an excellent post for the Huffington Post, that I would strongly encourage you to read.
Over the next year, I want to highlight a variety of treatment techniques used in pelvic floor physical therapy to help you better understand treatment options, and hopefully alleviate some fear that some of you may have about “the unknown.” In light of these current events, I thought it would be meaningful to start by discussing internal manual therapy techniques for the pelvic floor muscles.
What is it?
Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Before we get started, if you want to better understand the anatomy of the pelvic floor, check out this post by my friend and colleague Tracy Sher. Tender or overactive pelvic floor muscles can occur when someone is experiencing problems like pelvic pain, painful sexual intercourse, tailbone pain, as well as urinary or bowel dysfunction.
These techniques are performed either vaginally or rectally by a skilled medical practitioner who has undergone advanced training to learn to evaluate and treat the pelvic floor muscles. They are only performed once the patient has been thoroughly educated about the treatment techniques and consents to participating in the treatment.
What does treatment involve?
The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles. Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), sidelying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the vaginal or rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening. These techniques can include:
Holding gentle pressure while the patient focused on relaxing and breathing
Holding gentle pressure while the patient performs a contact/relax of the muscles or a pelvic floor bulge.
Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
Sweeping stretches over the muscle belly
Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment. Personally, I tend to prefer more gentle approaches while also focusing globally on improving awareness and calming the nervous system. This is not a “no pain no gain” situation– in fact, most often we see the best results when we are able to keep pain at a very minimal level.
What type of training should the therapist have?
It is very important that the person performing this treatment has had specialized training in this technique. At minimum, they should have attended an initial continuing education course that teaches a beginner level evaluation and treatment of the pelvic floor, generally weekend course including at least 24 hrs of instruction. Many training programs now include a 3 or 4 course series, and I strongly encourage clinicians to complete the coursework to learn how to comprehensively care for their patients. At Herman and Wallace Pelvic Rehabilitation Institute, the organization I am a faculty member of, we have a 4-course series which includes a level 1, 2A, 2B and Capstone. The Section on Women’s Health has a 3- course series and there are now several other companies offering varying training programs. Of course, I’m biased as a faculty member of H&W and if you’re reading this and work in healthcare in pelvic rehab, you should definitely come to one of my courses!
Who does this treatment help?
As I mentioned above, manual therapy to the pelvic floor is helpful when a person has overactive, tender and/or shortened pelvic floor muscles that are contributing to the problem they are experiencing. This can occur when a person has pain in and around the pelvis or if the person is experiencing urinary, bowel or sexual dysfunction.
We are producing more and more research about these techniques every day, but here are a few snippets:
In this study, 50% of the men treated to address chronic scrotal pain saw a significant reduction in their pain.
In this study, 93 people were treated with pelvic floor techniques to address coccyx pain (as well as pain after coccyx removal). Overall, they saw an average of 71% improvement.
This study compared comprehensive pelvic PT to cognitive behavioral therapy for women with provoked Vestibulodynia. They found that 80% of the women in the PT group had significant improvements compared to 70% in the CBT group.
This study evaluated the effects of pelvic floor physical therapy techniques on pain reduction in men who had chronic pelvic pain. Treatment included internal and external techniques and over 70% experienced moderate or robust improvements.
This study found that 62% of women experiencing urinary frequency, urgency and/or bladder pain who were treated with physical therapy interventions, including internal manual therapy techniques, reported feeling “much better” or “very much better” following the interventions.
I hope this was helpful and removed some of the fear from this technique! If you think this treatment may be a helpful one for you, talk with your health care provider! As always, I love to answer any questions you may have!
“Does that feel tender or uncomfortable to you at all?”
“Well yeah, but it’s because you’re pushing on it. I mean, I think anyone would hurt if you pressed there.”
This conversation is a common one that takes place in my treatment room. As a physical therapist specializing in pelvic health, I am frequently the first person to actually examine in detail the muscles of the pelvic floor by a vaginal or rectal digital assessment. Tenderness in the muscles on examination is very common in those experiencing pelvic floor dysfunction; however, this is often surprising to many people. The assumption that “everyone” would have tenderness in their pelvic floor muscles is extremely common, especially if the person doesn’t have a primary complaint of vaginal or rectal pain to “explain” the pain they feel.
Should healthy pelvic floor muscles be tender? Does everyone have tender pelvic floor muscles?
It’s an important question with far-reaching implications. If everyone has tenderness in their pelvic floor muscles, then would it really matter if I found it on an examination? Would it be a waste of time to focus our energy in the clinic on trying to reduce that tenderness? Thankfully, research thus far has helped to shed some light on this issue. In summary, healthy muscles should not hurt. Thus, tenderness does help us see that some type of dysfunction is present. Let’s look at the research.
Montenegro and colleagues (2010) examined 48 healthy women as well as 108 women with chronic pelvic pain. They found that 58% of the women with chronic pelvic pain had pelvic muscle tenderness compared to just 4% of healthy subjects. They also, of note, found higher rates of pain during sexual intercourse and constipation in those who had pelvic muscle tenderness.
Adams and colleagues (2013) found the prevalence of pelvic floor muscle tenderness in 5618 women referred to a university-based practice to be around 24%. They also found that women with tenderness had higher levels of bothersome symptoms related to prolapse, bowel and bladder dysfunction (by close to 50%!)
Hellman and colleagues (2015) examined 23 women with chronic pelvic pain, 23 women with painful bladder syndrome and 42 pain-free control subjects. They found that the two groups experiencing pain had increased pain sensitivity with lower pain-pressure thresholds compared to the pain-free subjects. They also had a longer duration of pain after the initial sensation (3.5 minutes vs. 0-1 minute in controls)
What about in pregnancy? Well, Fitzgerald and Mallinson (2012) examined 51 pregnant women– 26 with pelvic girdle pain and 25 without–and guess what they found? Significantly more women in the pain group had tenderness at the pelvic floor muscles and obturator internus compared to the group without pain.
What about in women who have never been pregnant? Well, Kavvadias and colleagues (2013) examined 17 healthy volunteers who had never been pregnant and found overall very low pain scores with palpation of the pelvic floor muscles. They concluded that pain in asymptomatic women should be considered an uncommon finding.
So, in summary. Healthy muscles should not hurt. If you are having problems like urinary, bowel or sexual dysfunction and you have tender pelvic floor muscles, this may be something worth addressing! See a pelvic PT– we are happy to help!