Tag Archives: pelvic PT

How to Poop

3 years ago, I wrote a post on dyssynergic defecation that over time has become the most viewed post I have ever written. Y’all, people are struggling with pooping. Bowel health is something we all tend to take for granted until it stops working right. So, what is dyssynergia? Basically, dyssynergia refers to a state where your muscles are working against you when you have a bowel movement. Instead of the muscles coordinating well to open and relax to allow the stool to come out, the muscles will contract and fight against the stool coming out. This is a big problem for people struggling with constipation. In fact, this review suggested that around 40% of people with constipation have this problem.

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How do you properly poop? 

“Why aren’t we ever taught these things?!” I hear this all the time from patients after we discuss the often basic techniques to improve bowel and bladder health. In reality, these habits should be learned and passed down through families, but the reality, more often than not, is that that majority of people do not learn proper habits until problems start happening. So, let’s get started, and get to healthy pooping.

Step 1: Use Optimal Pooping Posture & Positioning 

Yes, how you sit on the toilet really does matter. The optimal toilet positioning is one that will allow the muscles around the rectum to relax. This helps to open the angle between the rectum and the anus, and will allow stool to pass more easily. Our friends at Squatty Potty have made major $$$ on this concept with their handy stool. They do have some great videos, and this one listed here gives a nice overview on why a squatted position is more optimal for defecation.

Now, as an aside, should everyone sit with their knees elevated that high on the toilet? That’s going to be a big NO. The optimal position for you may not be the optimal position for the person next to you. The key here is that you need to be as comfortable as possible while sitting on your throne. If your hips hurt, or your back feels tight, etc. when you are squatted like this, change the angle until you find the best position for you. 

Step 2: Take Your Time 

We all know those people who grab a book and head to the bathroom, only to be seen 30+ minutes later, right? Well, they actually do have the right thought process. Many people get into a pattern of sitting on the toilet and immediately straining and pushing to empty their bowels. This is not often necessary, and actually overrides the normal processes of your colon and rectum. The best habit is actually to 1) Head to the bathroom as soon as you can when you feel the urge to have a BM and 2) Sit and relax on the toilet, giving your body at least 5 minutes to get things moving on its own. If you do need to push or help the body in the process, move on to the next step.

Step 3: If You Need to Push, Push Properly. 

Is it ok to sometimes need to push a little to get the poop out? Absolutely! Our bodies are made to be able to do this when needed to assist in getting the stool out. Did you know your GI system actually has several reflexes that aid in pooping? The intrinsic defecation reflex is a reflex that is stimulated when stool enters the rectum. This reflex will trigger the sequence of events that leads to defecation. When this reflex is suppressed (via another reflex, the Recto-anal inhibitory reflex), the colon will be helping you less in getting the stool out. This means that you may need to do a little pushing to assist in the process. So, how do you push?

Proper pushing requires a few things 1) abdominal muscle activation 2) pelvic floor muscle relaxation and 3) breathing. So, if you are holding your breath when you push, that is NOT proper pushing. Before we get started, it can be helpful to test yourself and see what your current habits are. To do this, place your hands on your belly while you sit on the toilet. Perform a fake “push” and see what happens. Did you hold your breath? Did your belly push out into your hands or pull in away from the hands? What did you feel happen at your pelvic floor?

So, now, let’s talk about how to push properly. First, be sure you are in  your optimal toileting position. Now, place your hands on your belly and relax your belly forward. Do you feel how relaxing your abdominal wall allows your pelvic floor muscles to also relax? Interestingly enough, the pelvic floor and the transverse abdominis muscles have a neurological relationship. Thus, for the majority of people, these muscles contract together. So, since the transverse abdominis muscle will pull the belly in (leading to pelvic floor muscle contraction), we want to do the opposite–> keep the belly out. Next, with your “belly big,” take a deep slow breath in. Then, as you blow out, think about blowing into your belly, gently tightening the muscles of your abdomen without allowing the belly to draw in. We call this “belly hard.” Lastly, as you are doing this breathing, think about relaxing, lengthening and opening your pelvic floor as you gently bear down (“pelvic floor drop”). So, in summary, this is what we are aiming for:

  1. Belly Big— relax the belly forward and take a breath in.
  2. Belly Hard— As you exhale, push into the belly, tensing the abdominal muscles, but not shortening them!
  3. Pelvic Floor Drop— while you are exhaling, gently bear down, allowing your pelvic floor to open and relax

(Note- several amazing clinicians have developed these concepts and verbiage that best connects with people. Pauline Chiarelli has a great book called Let’s Get Things Moving: Overcoming Constipation, and she discusses this in detail there. “Belly Big, Belly Hard, Pelvic Floor Drop” is a phrase we teach in our H&W Curriculum, and I believe it is also a phrase used by Dawn Sandalcidi, an excellent pelvic PT and faculty member out in Denver, CO.)

Who knew pooping was so complicated?

Please let me know if you have any questions! If you’re a pelvic PT, I would love to hear from you–especially if you have other strategies you like to use to help people learn how to poop! Let me know in the comments!

~ Jessica

Treatment Highlight: Vaginal Dilators/Trainers for Sexual Pain

 

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? 

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Used with kind permission from Intimate Rose 

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:

  1. 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.) 
  2. 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.
  3. 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!

Have a happy Thanksgiving!

~Jessica

Your Pelvic Floor as a Threat-o-meter

This past weekend, I was fortunate to work with an incredible group of practitioners at a Level 1 Pelvic Floor Course in my home city of Atlanta. I always leave these weekends renewed, excited, and yes, somewhat exhausted ;-). Not only do I get to teach with some pretty incredible colleagues (in this case, Sara Reardon– the VAGINA WHISPERER!!, and Darla Cathcart–who literally is the reason why I practice pelvic health!), but I also get the opportunity to see the transformation of clinicians who start the weekend a little nervous about the possibility of seeing a vulva, and end the weekend confident and empowered to start helping people who are experiencing pelvic floor problems. (Ok, some may not be 100% confident–but definitely on the road to confidence! ;-))

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Sara, Darla and I after our first day of teaching. This was before we were rained on and had to run to our hotel!

One of my favorite research studies of all time (yes, I am that nerdy) is always shared at this course with participants. This study by van der Velde and Everaerd examined the response of the pelvic floor muscles to perceived threat, comparing women who have vaginismus (painful vaginal penetration) compared to women who don’t.

Throughout my clinical career, the concept of stress and threat worsening pelvic floor problems has been a consistent thread. I frequently hear:

“My job has been so incredibly stressful this week. I am in so much pain today.” 

“Everything started this past year…during that time, my parents had been very sick and it was a very emotionally and sometimes physical stressful time for me” 

“I’ve been having a severe flare-up of my pain. Do you think the stress that I’ve been dealing with in going through a divorce/break-up/job change/move/new baby/new house/etc. etc. etc. could be related to this?” 

Honestly, I could go on and on with continued statements like this. Stress is a complicated topic, and there are many factors involved that can contribute to an alteration or increase in symptoms when a person is in a persistent stressful situation. So, back to my favorite study. In this study, the researchers had the participants watch four different film excerpts that were considered to be: neutral, threatening, sexually threatening or erotic. They then recorded the response of the pelvic floor muscles using EMG. The results of this study were fascinating. They found that with both the threatening stimulus(which happened to be an excerpt from the movie Jaws) and the sexually threatening stimulus (which was an excerpt from a TV movie called Without her Consent–which frankly, sounds awful to me!) the pelvic floor muscles demonstrated increased muscle activity. And this was true in both the groups of women who had vaginismus and the groups of women who did not. (side note: they also saw that the upper traps had this same activation pattern! Makes sense, right?)

Fascinating right? So, what does this mean? I always tell patients that the pelvic floor can be like a threat-o-meter. When a person is experiencing a threat–this can be a physical or emotional threat– the pelvic floor will respond. You can imagine then what happens when that stressful situation or threat stays around for a long period of time! This knowledge alone can sometimes be so empowering for people in better understanding why their bodies might be responding the way that they are.

So what can we do about it?

If you are dealing with pelvic floor muscle overactivity problems or pain, and you find yourself in a stressful or threatening period of time in life, try these ideas:

  • Be mindful of what is happening in your body: I encourage people to do regular “check-ins” or body scans throughout the day to feel how their pelvic floor muscles and other muscles might be activating. If you feel any muscles gripping, try to see if you can consciously soften and let go of tension you might feel. After doing this, try to take a slow long breath in and out thinking of letting tension release.
  • Remember that self-care is actually self-less: Taking care of our own needs allows us to better care for the needs of those around us. Remember the last time you flew in a plane– secure your own oxygen mask before helping those around you! Self-care can mean making time in your day for regular exercise, taking steps to ensure you get the right nutrition you need to feel healthy, taking a break for yourself when you need it, being conscious about following the recommendations given to you by your pelvic PT 😉 or spending time doing a guided meditation or relaxation exercise. 
  • Drop it like it’s hot: Your pelvic floor, that is. Several times throughout the day, consciously think about letting your pelvic floor drop and lengthen. If you have a hard time feeling what your muscles are doing, you can try performing a small (think 10-25%) activation first and then think about letting go of any muscle activity.
  • Don’t be an island: Know that there are so many resources to help you if you need them! Working with a skilled psychologist or counselor can be incredibly beneficial to many people! And, if your pelvic floor is giving you some problems, always remember that you can go see a pelvic PT– yes, even if you had worked with one in the past! We are always here to help you get through life’s hurdles! Sometimes people end up needing little “refresher courses” along the way to help when the body needs it.

So, what are your favorite ways to manage stress? Fellow PTs- how do you help patients handle flare-ups that happen when life starts to get stressful?

I love to hear from you, and meet you! Always feel free to reach out to me here! If you would like to take a course with me, check out the schedule listed on my For Professionals page! I hope to meet you in person soon!

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Meet your newest pelvic health professionals from PF1 Atlanta 2018!

 

 

Are you a physical therapist interested in small group mentoring? Help me out by taking a short survey!

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!

All the best,

Jessica

CLICK HERE TO ACCESS THE SURVEY ON SMALL GROUP MENTORING 

Treatment Highlight: Internal Pelvic Floor Manual Therapy

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!

~Jessica

Prioritizing Self-Care

So, as you may have realized, I periodically write about topics that hit close to home. This was especially true while I was pregnant and trying to live the advice that I often give to patients (Teaser: Do as I say, not as I do.). As a mom to a now 1-year-old, the topic of self-care has been on my mind quite a bit recently. I remember when my daughter was 6 months old, going to the dentist. As I tried to come up with a reason why they hadn’t seen me in almost a year, the best I could do was to honestly say, “Really, I haven’t done much of anything to take care of myself since my daughter was born.” And guess what? It was totally true. I was having a hard time getting back to exercise. I wasn’t sleeping all that well (I mean, who sleeps well with a new baby? If it’s you, don’t tell me.) And, I had skipped many of the typical self-care things that I normally enjoy doing regularly.

My experience unfortunately is not that unique to many new moms (and old moms, and lots of other people too!). In discussing this with my friends and patients, I often find that people live very busy lives and struggle with prioritizing themselves amidst an often hectic schedule. By the time we wake up, make lunches, get everyone out the door, work a busy job, cook dinner, tidy up the house, prepare for the next day, etc… there really doesn’t seem to be time left. The idea of adding in an hour for exercise, meal-prepping or seeing a doctor/dentist/physical therapist can feel impossible.

But, the truth comes down to two key points:

  1. We have time when we make time. 
  2. When we care for ourselves, we actually care better for others. 

Did you know that stress can worsen chronic pain? And that stress is connected to all sorts of illnesses (like heart disease, among others?) Did you know that exercise has all sorts of amazing benefits? (see the awesome whiteboard video below)

In short, when we care for ourselves through exercise, quiet time/meditation, quality time with friends/family, or necessary medical/dental/physical therapy visits, we actually equip our bodies with the tools we need to better handle the stress that comes our way and ultimately, to better care for the important people in our lives.

So, how do you make time for self-care? 

  • Set a realistic expectation: If you do not currently exercise at all, don’t start with a goal of exercising every day. You will probably fail. Instead, make a goal at exercising 2-3 times in the week. If you know that your mornings are completely hectic and busy, that may not be your best time for quiet time/meditation. Instead, perhaps in the evenings as you are wrapping up your day may be a better time.
  • Be specific on your when, what and how:  When I was in PT school, we learned that goals should be objective, measurable and achievable.  This not only sets our patients up for success, but lets us evaluate if our intervention is working. So, if your goal is to exercise, try being specific on your when, why and how. For example, I could aim to run 30 minutes on Tuesday and Thursday evenings after work.  The more specific and scheduled, the more likely you will be to achieve success.
  • Get help when you need it: If it is challenging to hold yourself accountable, talk to a friend or a partner to get some help. Verbally expressing your goals and detailed plan to another person can often help provide the necessary support and accountability for success. If you know you need more tangible help to be successful, make sure to ask for it. This may mean something like planning ahead with your partner to manage childcare responsibilities or it could mean finding a friend who will actually go and exercise with you.

What other strategies do you have for self-care? How have you been successful in the past?

As always, I would love to hear from you!

~Jessica

FAQ: Isn’t everyone’s pelvic floor a little tender?

“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!

Have a wonderful week!

Jessica

 

Can physical therapy help menstrual cramps?

Did you know that over 80% of women experience painful periods? And for some women, the amount of pressure in the uterus from those cramps can be just as severe as labor pains?

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As someone who has been in labor recently, I can tell you that it is no cakewalk. The truth is that menstrual pain (Dysmenorrhea) is a significant problem for many women. In fact, this study found that in a group of 269 female college students, 84% experienced pain in the abdomen and back, 84% experienced mood swings and 48% experienced dizziness. Another interesting stat from this study: 48% felt like their academic performance was impacted. (and I would bet women out of school probably feel like their work and home life are impacted too!)

With menstrual pain impacting women as much as it does, it is surprising how few effective pain-reducing options we have. Most women turn to pain relievers like tylenol and ibuprofen, but the effectiveness of those in actually reducing the pain isn’t really that great. The great news is that there are many ways in which physical therapy can actually help with menstrual pain, and several studies have shown that many physiotherapy interventions are just as (if not more!) effective as pain medications.

So, what can physical therapy do to help with those painful cramps?

Movement-based Approaches

Movement is what we do in physical therapy, and certain exercises which help with movement of the spine and abdomen can be very helpful in improving pain levels. This study, in particular, found that certain yoga postures–Cat, Cobra and Fish– helped with reducing pain. Another study found that a physical therapy program including aerobic exercise, strengthening, stretching and relaxation led to a reduction in pain during menses.

Modalities

So, modalities sometimes get a bad rap in the physical therapy world. And I get it, they are passive (meaning you, as the patient, don’t really have to do anything), and they are frequently over-used in cases when an active approach can be more helpful. But, certain modalities have been shown to be very helpful in reducing menstrual pain. In particular, applied hot packs were found to be equally beneficial to pain medication in this study! Transcutaneous Electrical Nerve Stimulation (TENS) applied to the low back/sacrum and/or abdomen has also been shown to have excellent results. The great thing about both of these options is that they are easy, reusable and effective options for a woman to use monthly without having to ingest medication.

Manual Therapy Interventions

The research regarding manual interventions for painful periods is honestly not fantastic, however, there have been some studies that have shown that treatments such as connective tissue mobilization, massage and acupressure have been helpful in reducing menstrual pain. When I used to work at a large clinic, many of my female co-workers would seek connective tissue mobilization and other soft tissue mobilizations from colleagues when having painful cramps. Clinically, I have seen that working with someone to reduce muscle sensitivity and tenderness (both in the pelvic floor muscles as well as muscles around the pelvis) does seem to reduce cramping during menses. I’m not positive the exact mechanism for this, but my working theory is that improving the “threat level” from muscles and tissues around the pelvis has effects that transfer to other situations (like cramping during periods), so the “threat level” during this situation is also reduced. I also think that hormones play a role in this as the tissues at the vulva/urethra are sensitive to estrogen, but also impacted by muscles and blood flow. So, hormonal changes that occur within a normal cycle (that lead to cramping, etc) could then be impacted by a decreased blood flow and decreased tissue mobility, thus causing the discomfort from cramping to be worsened.  There you go, that’s my working theory.

So, in summary, if you’re having pretty bad cramping during your periods, know that there are some options to help! Often times, women are the WORST at just dealing with problems they have (and things like painful cramps are often blown off by friends, family members and other healthcare providers!) If this sounds like you, it may be worth seeing a pelvic PT for a consultation to help you build a robust and effective toolbox for managing your pain!

What other options have you found helpful in reducing cramping pain during periods? I always love to hear from you! Have a great week!

Jessica

**Note: If your menstrual cramps are severe and truly limiting your life, make sure that your healthcare provider knows about it! There are some medical conditions which can contribute to severe cramping, and there are treatments available. 

Sex After Baby- 4 Reasons Why It Can Hurt and What To Do About It

“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? 

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  1. 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!)

  2. Hormonal Changes

    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).

  3.  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.

  4. 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!

Have a wonderful week!

Jessica

 

Interview with Sara Sauder, PT on Vestibulodynia, Contraceptives and Bladder Pain

A few weekends ago, I had the awesome opportunity to host Sara Sauder and Kelli Wilson in teaching their course, Vestibulodynia: An Orthopedic and Pelvic Floor Approach. The course was fantastic, and both Kelli and Sara are excellent instructors. Their course is unique in that it 1) focused on a very specific diagnosis (super great for those of us who have been practicing for a while 2) is very small–a max of 12 participants, meaning lots of one on one time with instructors 3) includes a facetime conversation with a well-known pelvic pain medical expert (in our case, Dr. Irwin Goldstein) and 4) allows participants to both perform treatments on instructors and have instructors perform treatments on participants.

Sara and I have been “virtual” friends for quite some time… in fact, I can’t remember when exactly we started e-mailing, but we became penpals of sorts. We share journal articles with each other, and I believe I even told her I was pregnant before I told many of my other friends (truth!). So, needless to say, I was SO excited for us to finally meet in person and become real friends. And, Sara was so gracious to agree to answer some of my questions to share some excellent insight with all of you on vestibulodynia and her course. I hope you enjoy!

JR: First, can you briefly explain what vestibulodynia is to my readers out there who are unfamiliar?

SS: Vestibulodynia is pain at the vestibule.  The vestibule is a specific tissue at the opening of the vagina.  The opening of the vagina itself has a name which is the “introitus”.  The vestibule is part of the introitus.  It is considered part of the vulva even though it may seem that it extends into the space between vulva and vagina.  Hence the name…vestibule.  It’s like a hallway.  Or…an alcove, if you will….
Other than that simple explanation, vestibulodynia can feel like pain, itching, burning discomfort at the opening of the vagina or at the urethra or the bladder.  The aftermath of this sort of pain can result in lots of other things happening, like feeling pain inside the vagina, at the other areas of the vulva including the clitoris.  

JR: Thank you for explaining that further. Now, there are so many pelvic pain diagnoses out there…why a course on vestibulodynia?

SS: Vestibulodynia is truly a common denominator in so much female pelvic pain.  I think that if we can start to recognize the vestibule hurts, then we can get to the root of why someone has pain.  There is a logical way to think about why the vestibule hurts and we if we can understand the true why of the pain, then we can treat it.  In treating that one core issue, we will see that other symptoms that may seem unrelated start to resolve.

JR: That’s a really good point. We see vestibulodynia as a common issue with so many different pelvic pain syndromes. One in particular, that we discussed in more detail at your course, is Interstitial Cystitis or Painful Bladder Syndrome. Now, most people see IC/PBS as a “Bladder Problem,” but you shared some interesting information about the relationship between pain at the vestibule and urethral/bladder pain. Can you explain that for our readers?

SS: The vestibule, urethra and lining of the bladder (including the urachus) are all made of endodermal tissue.  They are all part of the same embyrological tube.  Their needs are the same.  That’s why you often see pain at the vestibule with any bladder symptoms.  That’s why the reverse is true.  You will see bladder symptoms with pain at the vestibule.

JR: That is fascinating, and also helps us to understand why some treatments for one may also be effective for the other (for example, both populations can have an increased hystamine response–especially during allergy season– and may have a decrease in pain with using anti-histamines! Moving on, in your course (which was awesome!), you discussed some of the main causes of vestibulodynia. The role between oral contraceptive use and vestibulodynia was discussed in detail. So many people are surprised to hear that being on birth control could contribute to their vulvar pain. Can you explain that a little bit more?

SS: Any product that affects the body’s sex hormones can affect parts of the body that are dependent on sex hormones.  So, using a combined hormonal contraceptive or any other medicine that affects estrogen and testosterone will affect the vulvovaginal tissue.  These areas are sex hormone dependent, to varying degrees based on their different embryology.  We go into this in super detail in the vestibulodynia course.  The mechanics of it are repeated over and over because if this isn’t truly understood, we, as physical therapists, will never understand what kind of progress is or isn’t possible for our patients.  If a woman is on a medication that will lower their sex hormones and I keep treating her for symptoms of sex hormone reduction, I’ll be banging my head on the wall if I don’t understand that hormonally there are changes taking place that I can’t affect until the patient gets off of or alters that medication.

JR:  That is especially interesting to me, as I have seen several patients (as well as a few close friends!) who have used oral contraceptives develop vulvar pain or pain with sexual intercourse. Now of course, we know that not everyone who takes OCPs will develop vestibulodynia, but it seems like certain individuals may be more susceptible than others. And the current research seems to recognize some of these problems occurring, to the point that now OCPs are no longer the most recommended type of contraceptive for women (especially younger ones). I know this was something we chatted a little bit about with Dr. Goldstein during our facetime chat at your course. (ReadersHere’s an interesting article about contraceptives and vulvar/bladder pain you may find helpful!)

Now, Vestibulodynia can be a tough diagnosis for clinicians to treat. What are the most common mistakes you think physical therapists make when working with women with vestibulodynia?

SS: The most common thing I find with clinicians of any discipline in working with patients with vestibulodynia is that often we completely miss the fact that the patient has vestibulodynia in the first place.  Either the vestibule is completely removed from the assessment because it is pushed aside with a speculum, or it is not assessed via appropriate and specific q-tip testing.  If we miss that we are dealing with issues at the vestibule, we are missing the point.

JR: So, true of many diagnoses! So, wrapping things up…one of the things I love about you is how hard you work to advocate for your patients– it’s amazing! So, let’s say I’m a woman reading this, and I think I have vestibulodynia. What should I do?

SS: If you think you have vestibulodynia, definitely talk to your physician about it.  Explain your symptoms and ask to see a pelvic floor physical therapist.  When you get a referral, call the physical therapist before your evaluation.  Ask if they have treated vestibulodynia, ask how they treat it and ask about their success in treating it.

JR: Thank you so much for taking the time to chat with me about vestibulodynia, and for coming to our clinic to share such an awesome course this weekend! I know we all really enjoyed it and found it super useful in learning to provide the best care we can for the women we treat who are experiencing vulvar pain (and really, pelvic pain in general!)

If you are a clinician who works with women with pelvic pain, I highly recommend Sara Sauder and Kelli Wilson’s course, Vestibulodynia: An Orthopedic and Pelvic Floor Approach. For more information, please check out their website: http://www.alcoveeducation.com/

3377681_origSARA K. SAUDER PT, DPT
is originally from Dallas, has lived in Houston and prefers life in Austin. She received her Doctor of Physical Therapy from Texas Woman’s University in 2010, but began practicing with her Master in Physical Therapy in 2007.  She works at Sullivan Physical Therapy and specializes in pelvic pain and mentors pelvic floor physical therapists through a professional mentorship program. To focus her interests, she authors the blog, Blog About Pelvic Pain. Through this medium she voices her opinion and experiences with diagnoses and treatments for pelvic pain. She has also been a guest writer for popular blogs such as Pelvic Guru, Pregnant Chicken, Scary Mommy and Pelvic Health and Rehabilitation Center’s As the Pelvis Turns. Sara interviews and shadows internationally-recognized specialists alike. She is a member of the American Physical Therapy Association’s (APTA) Section of Women’s Health (SOWH), International Pelvic Pain Society (IPPS), the International Society for the Study of Women’s Sexual Health (ISSWSH) and the National Vulvodynia Association (NVA).  She is as blurry in person as she is in her photos.