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!
“Ok, TMI…but is everyone having sex again? We tried last night and OMG it was awful! So painful!!”
I clicked on the thread in one of my Facebook moms groups, and slowly looked through the comments, hoping to see words of encouragement, support, and most importantly, solid health advice.
“I know, me too. I just try to avoid it as much as I can.”
“What is sex? LOL”
Then, I began my comment, “Hi, I’m a pelvic PT and also the mom to a 6 month old. I’m so sorry you’re hurting. It’s so important to know that pain is not something you have to live with. There is help out there…”
Why is painful sex after childbirth so overlooked in healthcare? Why do so many women feel like they just have to live with this as a normal “consequence” of having a baby?
This past fall, I went through the craziest initiation process to join one of the most exclusive clubs out there: Motherhood. It has been an incredible and humbling journey for me, especially as a health care provider who specializes in helping women with problems they experience while pregnant and postpartum. Becoming a mother has allowed me to experience and witness first-hand many of the challenges women face after having babies.
Pain during sexual activity is extremely common after childbirth (Note: I said common…NOT normal). In fact, a large study of over 1000 women found that 85% experience pain during their first vaginal intercourse postnatally. At 3 months postpartum, 45% still were experiencing pain and at 18 months postpartum, 23% were still experiencing pain. Let that sink in. When a mother’s baby is 18 months old, 1 in 5 mamas had pain during sex! And the sad thing is that pain during sexual intercourse is SO treatable!! So, let’s get down to business…
Why could sex hurt after a baby?
Perineal Trauma from Childbirth
Spontaneous tearing and episiotomies are very common during vaginal deliveries. In fact, this study looking at 449 women who had at least 1 delivery found that only 3% of them did not have any tearing/episiotomy. Many women are able to heal from tears without problems. However, for some women, these injuries can become sources of pain, especially during sexual intercourse. This is especially true with more severe tears extending into the external anal sphinctor and rectum (grade 3-4 tears). This study found that women who had tears extending into the anal sphinctor were 3-4 times more likely to have pain during intercourse at 1 year postpartum compared to their counterparts. Perineal scars can be very sensitive and move poorly in some women leading to persistent discomfort which can last for years after the baby is born when it is not treated (but guess what? It CAN be treated!)
Anyone who has had a baby can attest to the crazy hormonal fluctuations that happen during pregnancy and postpartum. One of my very best friends warned me about this telling me that she cried every day for the first week after the baby was born. Guess what? So did I. These crazy hormones can also impact what is happening down below, especially in breastfeeding mamas. Basically, the hormonal changes lead to decreased estrogen in the vulvar tissues often causing thinning and dryness. This is why breastfeeding is associated with painful sexual intercourse early on postpartum. Now, if you are reading this and you are a nursing mama like myself, should you stop to fix your sexual discomfort? Not necessarily. This study found that although nursing was associated with dyspareunia at 6 weeks postpartum, the association was eliminated by 6 months. Meaning, stopping nursing won’t necessarily fix the problem (so don’t let this be your deciding factor in the decision to breastfeed your babe).
Tender Pelvic Floor Muscles
The pelvic floor muscles themselves can become big sources of sexual discomfort if they are tender, shortened or irritated after childbirth. Perineal trauma and hormonal changes can lead to tenderness in the pelvic floor muscles, but the muscles can also stand on their own. Many people believe that C-sections protect the pelvic floor muscles from having problems, however, we have to remember that the pelvic floor are one member of a team of muscles (including the deep abdominal muscles, low back muscles and respiratory diaphragm) that work together to provide support and stability to the pelvis. That could be partially why C-section mamas are actually 2-3 times more likely to experience more intense pain during sexual intercourse at 6 months postpartum.
Because Babies are Hard
I had to add this one in. It’s important to remember than normal sexual function should include sexual desire, arousal, and orgasm. New mamas are exhausted, feeding sweet little babies around the clock, settling into a new routine whether they are returning to jobs or caring for their babies at home, sleep-deprived from often waking up multiple times a night, changing diapers, and worrying constantly about helping these little babies survive and thrive. And honestly, it can be really hard for many moms to have the same level of sexual desire and arousal that they had prior to having their babies (at least until life settles down– or I’m told–when the babies go to college LOL). When a woman experiences sexual desire and arousal, there is natural lubrication and lengthening of the vaginal canal, and this step is so important in having enjoyable sexual activity. Sometimes, when this step is skipped, women are more likely to experience discomfort with vaginal penetration.
So, what can be done to help?
Realize it is not normal. Don’t just deal with it. And check-in with your Obstetric provider.
The first step is seeing your OB or midwife to make sure everything is ok medically. She should evaluate you to make sure everything is healing the way that it should be healing and that nothing else is going on that needs to be managed medically. I have had patients who have had difficulties healing after tears and needed some medical help to encourage their tissues to heal the way they needed to. I have also worked with women who had underlying infections contributing to their pain, that of course, needed to be treated to move forward. This is not a step you should skip, so don’t be bashful! Tell your doctor what is going on.
Don’t be afraid to use a little help.
I get it. You never had to use lubricant before, and it’s annoying to have to use it now. But guess what? It can make a HUGE difference in reducing discomfort from thin or dehydrated vulvar tissues after babies! So, if you don’t already have a good one, go pick out a nice water-based lubricant to use. Some of my favorites for my patients are Slippery Stuff and Sliquid. I am also a big fan of coconut oil (but make sure to know that using it with condoms can cause condom breakdown).
If you are having difficulty with sexual arousal and desire since having your baby, and you feel comfortable with it (I know, some women don’t!), try using a small vibrator to help with improving sexual arousal and promoting orgasm. Many sex therapists I work with encourage couples to consider using this on days when they need a little assistance attaining the arousal they need.
Educate your sexual partner and empower them to help you
It can be so helpful to include partners in this process. Show them this blog post, so they can understand what could be going on, and empower them to help you! For some women having difficulties with arousal, having their partner do something like clean up after dinner and put the baby to bed so they can have time for a quiet relaxing shower can be just the ticket to helping them become more sexually aroused to decrease sexual discomfort. If you are having problems with painful perineal scars or pelvic floor muscles, consider including your partner in your medical or physical therapy visits so they can understand what you are experiencing. Many pelvic PTs (like myself) will often educate partners in methods to help with decreasing pain , and even in treating the pelvic floor muscles/scars (if both people feel comfortable and on-board with this!).
Go see a pelvic PT!
If you have tender pelvic floor muscles or painful scars, all the lubricant and sexual arousal in the world is not going to fix the problem. Working with a skilled pelvic floor physical therapist can be hugely beneficial in identifying where and what the problem is, and helping you move forward from pain!
A skilled physical therapist will spend time talking with you the first visit to understand your history (including specifics of your delivery), and will perform a comprehensive examination, head to toe, to see how your body moves, where you might not be moving as well as you could be, and how you transfer force through your body. They will also perform an examination of the abdominal wall (especially important for C-section mamas), and an internal vaginal examination of the pelvic floor muscles. Based on this examination, they will be able to work with you to develop a plan to help you optimize the function of your body and get back to a happy and healthy sex life!
This is first in likely a few series of posts I will be doing on postpartum specific problems. I hope you all enjoy! Please please please reach out if you have any questions at all!
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!
Technology in our current time is incredible. With our smartphones so quickly at our finger tips, we have apps for pretty much everything. Need to find a good restaurant near by? There’s an app for that. Want to quickly edit your photos into beautiful photo masterpieces? Just download the app. Last year over Christmas, I even found an app that turned anyone’s face into Santa Claus. (The results were amazing if you’re wondering).
And pelvic health is no different. There are so many apps available for people with pelvic problems or for general men’s and women’s health needs. I absolutely love apps for my patients that help them with the problems they’re experiencing or enhance their home programs. Here are some of the great ones out there! (Note: Special thanks to my colleagues on the Women’s Health Physiotherapy Facebook Group who added their suggestions to this list. I plan to keep this updated regularly so it can be a great resource for colleagues and our wonderful patients!) Enjoy!
iDry: Free version includes a tracker for pad usage and bladder leakage. Premium version includes options for interventions (including pelvic floor exercises!), a more detailed chart tracker, reminders, and options to send to your health care providers!
UroBladderDiary: This app costs $1.99 but allows tracking of urinary frequency and volumes, leakage, and fluid intake. Also allows tracking of urgency level. Allows conversion to a PDF to e-mail to health care provider.
Bathroom Map: For those struggling with strong urinary or bowel urgency and/or incontinence, this app may become your best friend! It uses your location to quickly identify all of the restrooms nearby. It also grades each bathroom as green, yellow or red to indicate the availability of the restroom, comfort and cleanliness of the facility.
Poo Keeper: This app is a quick tracker for someone struggling with bowel problems. Allows you to snap a quick photo of your stool and track your stool consistency.
BM Classic: For those with bowel problems, this app not only allows you to track your bowel frequency and stool consistency (using the awesome Bristol Stool Scale), but also allows you to track stress level, water intake, and dietary habits. Could be a great resource for someone struggling with bowel problems.
Pelvic Floor Exercises:
Squeezy: This app was designed by pelvic physiotherapists in the UK and is endorsed by the NHS. It allows for a personalized exercise program, has reminders, visuals and keeps a record.
Kegel Trainer: This app includes information on how to use pelvic floor muscles, and has various levels of exercise based on different contraction/relaxation intervals. Free version only includes first level, paid goes up to 15 levels. Includes reminders and an exercise tracker.
Pelvic Floor First: This is an awesome organization out of Australia, and I have used their website and handouts frequently for my clients for the past several years. Their app definitely does not disappoint! It offers a nice progressive exercise routine for someone struggling with pelvic floor weakness (like we commonly see with urinary incontinence, pelvic organ prolapse, and postpartum difficulties). The programs go from Starting Out (30 min), Moving On (40 min) to Stepping Up (50 min). Just be sure to chat with your pelvic PT before you jump in the program!
If you prefer a device for strengthening (and your pelvic PT thinks that would be helpful to you!), the following are apps that sync to insertable devices: Pericoach, Elvie, KGoal
BWOM: This app is great because it starts with a short quiz to help identify where someone may have a pelvic floor problem. It then has exercise programs (available for a small $$) based on that problem, including relaxation exercises! Designed by pelvic physios.
GoldMuscle: This app is focused on improving sexual performance rather than on those who may have pelvic health problems, so definitely has a different look to it. It includes various programs to focus on both endurance and quick contractions of pelvic floor, allows you to track progress, and get reminders for your exercises.
Pelvic Pain/Relaxation Apps:
RelaxLite with Andrew Johnson: This is one of my personal faves. Basically, it’s a 10-15 min guided progressive relaxation. He has a paid version too with lots of additional upgrades, but the free meditation is great!
Headspace: Free version includes a free 10 minute meditation to teach basics of meditation. Upgrade provides access to tons of different meditation options. Great way to start learning meditation.
Calm: Another great meditation app. Free version includes the “7 days of Calm” introductory program to learn the basics of mindful meditation, and also incluees access to soothing sounds to help relieve stress. Upgrade allows access to all of the different meditation programs (for sleep, calm, etc)
Insight Timer: Meditation community app, includes a timer to track meditation with different sound options, and includes over 1300 guided meditations. Also includes discussion groups and meet-up groups.
Binaural- Pure Binaural Beats: This app allows you to listen (use headphones) to various sounds to promote brain wave activity correlated with relaxation, meditation, problem solving and activity. And all of it’s free!
iPeriod: Paid versions only. Use to track periods, ovulation and fertility; Graphs of data available and includes availability to export data to take to physician visits. Lots of personalization options too!
Clue: Period tracker that predicts dates for your next period, and also allows you to track symptoms as they relate to your cycle (including pain, which is awesome!)
My Days: This app tracks and predicts periods, ovulation and fertility. Also allows options to track basal metabolic temperature, cervical mucus and cervix for those trying to become pregnant.
Pregnancy Pelvic Floor Plan: This app by the Continence Foundation of Australia has both a tracker to see weekly milestones during pregnancy, but also has great information on pelvic floor health. Includes option to receive regular reminders to perform pelvic floor exercises.
Gentle Birth: This app promotes a positive pregnancy and birth experience. Includes mindfulness, breathing techniques, affirmations and hypnosis, combined with evidence based research. Customized programs based on the woman’s needs. Free for a sample program, then requires paid subscription.
Mind the Bump: Meditation app geared toward pregnancy/postnatal populations. Includes different meditations for different periods of time (first trimester-postpartum)
Pregnancy Exercise- Weekly Workout: This app by Oh Baby! Fitness (based out of Atlanta, and generally very evidence-based!) includes a new exercise for every week of pregnancy based on pilates, yoga and strength training. Through 10 weeks is free, then $5 to unlock the rest of the weeks.
Rost Moves: This app provides recommendations for body mechanics/movement options when performing different regular home activities. Especially a great app for new moms or pregnant women with pelvic girdle/low back pain.
Hope you found this helpful! Did I miss any of your favorite apps?? Let me know in the comments below! I plan to update this page regularly for new apps we discover! Have a great week! ~ Jessica
One of my New Year’s resolutions was to build a better morning routine to help me use my time more optimally during the day. Part of that morning routine includes reading for 30 minutes over breakfast…and I have to tell you, it’s my most favorite part of the day. My first book of the year was Todd Hargrove’s A Guide to Better Movement, and I really really loved it.So much so, that I just needed to share it with you!
I was first introduced to Todd Hargrove through his blog post back in October, “Why do muscles feel tight?” I loved it, was hooked, and ordered his book the same day. Todd is a pretty smart guy, and has a unique background being a prior attorney and current Rolfer and Feldenkrais practitioner. I love learning from people who are not physical therapists because I find it challenges my viewpoints and helps me to see my clients from a different perspective. Todd’s book did not disappoint.
Who should read it?
Anyone who likes moving, should move, and wants to move better
Athletes (yes, this includes any of you who exercise regularly) who want to make sure they are caring for their bodies
Length: 277 pages, broken into the following sections:
Part 1: The Science of Moving Better
Defining Better Movement
Learning Better Movement
The Brain Maps the Body
Motor Development and Primal Patterns
Part 2: The Science of Feeling Better
The Science of Pain
Movement and Threat: Central Governors
Movement, Thinking and Feeling
Part 3: The Practice of Moving Better and Feeling Better
Strategies to Move Better and Feel Better
Lessons in Better Movement (pgs 149-277)
What’s so great about it? As you may know, my studies recently have sent me deep into the world of neuroscience, so I love reading books that integrate the whole body rather than just focusing on specific tissues. Hargrove does an excellent job of not only teaching the science related to movement and pain in a way that is easily understandable by clinicians and patients alike, but also offers strategies and lessons for improving movement and shifting away from a pain state. He uses excellent analogies throughout his book that all people will be able to relate to and understand. On another note, his book is full of great quotes… and I’ve always been a sucker for a good quote… so you’ll see some of my favorites here :).
In the first part, the science of moving better, Hargrove discusses the essential qualities of good movement (coordination, responsiveness, distribution of effort, division of labor, position and alignment, relaxation and efficiency, timing, variability, comfort and individually customized). I especially love his section on relaxation and efficiency as I believe this to be a huge factor for the men and women I treat experiencing chronic pelvic pain. So often, these people end up in states of chronically over-activating musculature to perform tasks, and I believe changing this can make a big difference for them. “Efficient movement requires skill in relaxation… thus developing movement skill is often more about learning to inhibit the spread of neural excitement rather than extending it.”
Next, he goes on to explain the process for learning better movements diving in to the motor control system, and then explains how the brain maps the body and the ways in which those maps can change over time. “The current organization of [a person’s] sensory maps already reflects a lifetime of effort to organize them in an optimal way to perform functional goals.” He uses a great analogy here of a skiier going down a hill. The first trip down, the person has endless options on the path to take down…but after going again, and again, deep grooves in the snow are formed and it can be difficult to take alternate paths.
Lastly in this section, he discusses motor development and primal movement patterns and the importance of training foundational movements with large carryover into a variety of functional tasks.
Part two, the science of feeling better goes into our favorite topic–pain science. Hargrove does a fantastic job of explaining pain and gives a plethora of examples and analogies to help the reader understand very advanced topics. Two of my faves from this section are,”Although nociception is one of the most important inputs contributing to pain, it is neither necessary nor sufficient for pain to exist,” and, “Pain is an action signal, not a damage meter.” This section also explores different options for moving past pain and discusses how the central nervous system responds with threat in order to protect the body. The last chapter in this section looks at movement and emotion and explains the way we now understand the mind to relate to the body. (Hint: the mind and the body are ONE).
The last section of this book, the practice of moving better and feeling better discusses strategies for improving movement and key components of training movement variety. Hargrove summarizes his thoughts on this in the following way, “Move playfully, experimentally and curiously, with full attention on what you are doing and what you are trying to accomplish. Focus on movements that are the foundation for your movement health, and have a lot of carryover to many activities, as opposed to movements that are specific and don’t have carryover. Move as much as you can without injury, pain or excess threat, wait for the body to adapt, and then move more next time.”
Hargrove ends the book by providing 25 lessons to help improve movement. These are based on the Feldenkrais Method (which I liked as I currently use some of these principles and movements within my clinical practice.). Each lesson offers options for progressing and provides guidance for attention and variations.
So, in summary…. I loved this book. I have already recommended it to clients, and plan to use some of the movement lessons within my practice. I hope you love it too!
Have you read any other great books recently? I’m looking for my next one to read!
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 love helping women prepare for childbirth- I really do. In fact, it made me want to consider becoming trained to be a Doula a few years ago! Unfortunately, most of the women I have helped have either been women who were already seeing me for low back or pelvic girdle pain during their pregnancies– or physicians/physical therapist colleagues who were wanting to be proactive in preventing future pelvic floor problems.
So, who should work with a pelvic physical therapist during pregnancy? Honestly, EVERYONE. I’m serious. A skilled pelvic PT can do so much to help a woman not only have a safe and healthy pregnancy (helping to manage pain that creeps in, fitting for support belts/braces if needed, coaching to help get the right exercise routine, and much much more), but we also can do quite a bit to help a woman prepare her pelvic floor for delivery. My dream is that one day all women will be encouraged to work with a pelvic physical therapist while pregnant and after delivery. I think we would see happier mamas, and reduced problems in the long run.
So, how can a pelvic physical therapist help you prepare your pelvic floor for childbirth?
1.We can help you manage low back or pelvic girdle pain. I know what you’re thinking– this post is about preparing for childbirth, not treating pain during pregnancy! And you’re right, it is. But, pain during pregnancy matters for delivery. We know that women with pelvic girdle pain during pregnancy tend to have tender pelvic floor muscles. Tenderness in the pelvic floor is often accompanied by a difficulty lengthening or relaxing the pelvic floor–which is totally needed for vaginal delivery, right? So, in improving pain levels, we also improve the pelvic floor muscles’ ability to relax, which can assist in improving delivery. Did you know that close to 50% of women experience low back or pelvic girdle pain during pregnancy? Most tend to think it’s normal, but it really isn’t (One again, common is not the same as normal!) The great thing is that there is so much we can do to help this pain get better!
2.We can help you learn what your pelvic floor muscles need to function optimally. There used to be the thought that ALL pregnant women needed to be doing lots and lots of kegel exercises. But, as you saw above, we now know that there is a huge population that doesn’t really need to try to tighten constantly, but rather, needs to learn to lengthen, drop and open the pelvic floor muscles. But should some be strengthening? Absolutely! A recent review found that performing strengthening while pregnant can reduce both urinary and fecal leakage after delivery. However, it’s important that these recommendations are individualized–and that is something a skilled pelvic PT can help you with.
3. We can teach you proper pushing mechanics. This is actually one of my favorites– I generally will spend a session with all of my pregnant women helping them learn how to push in a way that will encourage the pelvic floor to open, and lengthen. Pelvic PTs can use SEMG biofeedback to help you visualize what your muscles are doing and retrain the most helpful pattern of muscle lengthening. I also focus on learning breathing strategies to learn how to coordinate the breath with the pelvic floor, and to encourage using the diaphragm in the best way we can. This helps women to feel more prepared to push when the time comes.
4. We can help you find out which positions for labor/delivery work best for you. For me, this is typically something I work on while helping women learn the right way to push. Now, some hospitals will require women to push in a certain position, but if your doctor is open to you laboring or delivering in different positions, it can be helpful to learn which positions are the most comfortable and relaxing to you. Typically, we try a variety of positions and see which position leads to the best muscle relaxation and helps facilitate the best pushing pattern. Now, of course all of this planning can go out the window depending on what happens during labor/delivery, but it is always helpful to practice and have a few ideas going in– I find this helps women feel prepared and can calm fears heading into delivery.
5. We can teach you perineal massage techniques to help your pelvic floor stretch during your delivery. Did you know that massaging and gently stretching the opening of the vagina in the third trimester can help to reduce trauma and tearing during delivery? Well, it can–especially during your first delivery! Perineal massage is a safe (for most women) procedure that can help to not only improve the flexibility of the muscles near the vaginal opening, but also, can help a woman learn what relaxed vs. contracted feels like, and can help a woman to recognize the stretching sensations she will feel during her delivery. It is important to note that there are times when a woman should not perform perineal massage, so it is always important to consult with your obstetrician or midwife before getting started.
What else have you tried to prepare for your delivery? PTs- are there any other important pieces you would add? Let me know in the comments below!