Tag Archives: pelvic PT

Early Recovery After Caesarean Birth

6 weeks ago, we welcomed our second daughter into the world. Mary Lynn was 6 lbs 10 oz of squishy, adorable, babyness. And she came into the world via a Caesarean birth. And it was amazing. And hard. But good.

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In the recovery room right after Mary’s birth!

C-sections come with challenges, just like vaginal births do, and for me, these challenges included a significant blood loss that led to me fainting on the second day, a super low blood pressure due to a response to the epidural that contributed to the fainting but also meant going off of my epidural pain meds really early, and nerve pain that lasted for about a month after Mary was born. (We’ll y’all more about that another time.)

Since I am living the early postpartum life, I thought it would be fun to do a series of posts on my own rehabilitation journey (since, in many ways, each of my births has been a mini-case study for myself!).

So, let’s talk Cesarean rehab in the first 6 weeks!

Moving well after major abdominal surgery

I love when people imply that birthing via Cesarean section is somehow “the easy way out” compared to birthing via the vagina. Hello people, this is major abdominal surgery! All mommas get birthing badges– let’s support each other in our journeys, right?!

Initially after a Cesarean, movement alone can be challenging. Standing up from a chair. Rolling over in bed. Lying down in bed. But the good news is that with some easy tips, this movement can become much easier. First, as you are moving, bending, standing, etc. remember to “blow before you go.” This easy to remember phrase comes from my friend and colleague, Julie Wiebe. This means, begin to exhale before you initiate a movement. Breathing like this with movement helps to control pressures within the abdomen and pelvis, so it can significantly help you in your movement after having your baby- both in terms of ease but also in protecting your pelvis and abdomen.

When standing up from a chair, remember, nose over toes. Scoot to the edge of the chair first. As you go to stand, lean forward first. This puts your body weight over your legs and helps take the burden away from your core.

When you lie down or get up from lying down, channel your inner log. So, when you lie down, first sit on the edge of the bed. Slowly lift your legs onto the bed, then lower the rest of the body down, using your arms for support. If you need to roll over, bend your knees, then roll your body as a unit- like a log. Reverse these steps for getting up out of bed.

Abdominal Binders and Compression Underwear? It depends. It may be worth considering  using an abdominal binder for the first few weeks after your birth, progressing to wearing compression underwear or shorts(ie Spanx, SRS recovery shorts, Core shorts). These types of garments provide support to the abdomen and can be incredibly helpful for moving and walking around after your surgery. The flip side with compressing the abdomen is that it can impact how well you can move your ribcage and can influence pressure mechanics within the pelvis. So, if you are already struggling with pelvic organ prolapse or urinary leakage, or if you pushed for a period of time before having a Caesarean birth, it may be worth talking with a pelvic floor PT prior to utilizing this during your recovery. Generally, the compression underwear/shorts provide more support to the pelvic floor and abdomen, so they may be a little better with pressure modulation than the binder. For me personally, the binder and compression undies were amazing! They took away my nerve pain, and helped me move much better. I chose to wear these sporadically during the day (a bit on, a bit off), and practiced breathing well with my diaphragm during the times the binder was off.

Handling your incision

Initially, your main focus here is keeping your incision clean, and monitoring it to make sure it is healing well with no signs of infection. Around 6 weeks, if you are cleared by your physician, you can begin to gently mobilize the tissue around the scar and aim to desensitize the scar. I usually start above and below the scar, before working on the scar itself. You can perform gentle massage to the tissue above and below the scar and gently stretch the skin in all directions above and below the scar. You can also gently desensitize the scar by touching it with your fingers or a wet cloth, and gently rubbing across the scar in all directions. We can mobilize this scar tissue further, but we are going to talk about this in a future post as this post is focusing on the early period of healing.

At this time, you can also begin applying silicone gel or silicone strips to help soften your scar and prevent hypertrophic or keloid scars. Silicone is considered a gold-standard treatment for the prevention or treatment of hypertrophic scars. While most of the research regarding silicone is of poor quality with significant bias, evidence does tend to suggest a positive benefit. My first Caesarean did lead to a hypertrophic scar, so I began applying silicone gel to my scar once cleared by my OB to do so, around 4 weeks after Mary’s birth. I’ll report back on the difference between this new scar and the old one (See, mini case study!).

**I also have to note here that my colleague, Kathe Wallace, has a fantastic book that details some recommendations for scar tissue management after Caesarean. Kathe also offers a free abdominal scar massage guide at her website, which is a fantastic resource!

Exercise in the Early Postpartum Period

If I could give you one piece of advice on this early postpartum period, it would be to relax. Give yourself a break. Allow yourself to recover and heal. I find that so many people want to jump into too much, way too soon, and unfortunately, this can be more harmful than it is helpful. Remember, you just did something incredible. You just had major surgery. You deserve to rest. 

When we think about exercise during this initial period of healing, we are going to start very gently. Here are a few things you can get started on:

  • Walking: I’m not talking about going and walking several miles. During the first few weeks, it’s best to really rest, and give your body time to heal. Getting up, walking around the house as you feel comfortable can be very beneficial.  As you continue to heal, during the next few weeks, you can increase your walking. So, this may include some outings and short periods of walking between 2-4 weeks. Between 4-6 weeks, you can generally consider a leisurely walk in your neighborhood or a longer outing. The key here is to listen to your body. Rest when you need to, but gradually move to increase your endurance. After you see your OB for a postpartum visit around 4-6 weeks, and you are cleaned to do so, you can continue to gradually increase your walking as you are feeling comfortable.  Are you antsy to jump back into running? Zumba? Bootcamp? Pilates? Don’t. We’ll get there. But let’s rest right now.
  • Breathing: You all know I am fairly obsessed with the diaphragm. 4 years after this post was written, I still think it’s one of the coolest muscles in the body. The diaphragm works in coordination with the pelvic floor muscles, deep abdominal muscles and deep low back muscles to provide support to the abdominal organs, modulate pressure in the thorax and pelvis, and provide dynamic stability to our spine and pelvis. Slow breathing, aiming to expand your ribcage and relax your abdomen as you inhale, then slowly exhaling your air can be incredibly beneficial to re-establishing these normal functional relationships.
  • Gentle Pelvic Floor Muscle Activation & Relaxation: First, my biggest recommendation would be to SEE A PELVIC PT before and during your pregnancy so you really know your current function and can have an individualized plan to get the most out of your muscles and your body. I encourage people to discuss their delivery with their OB, and ask about beginning gentle pelvic floor and abdominal exercises. The timeline for starting this will depend on the specifics of your delivery, and we want to be smart when activating muscles that have been cut. When your provider is on-board with you starting, I like to pair gentle pelvic floor and abdominal wall activation with breathing. This looks like this:
    • Inhale, expanding your ribcage, relaxing your abdomen and your pelvic floor muscles.
    • Exhale and gently draw in your pelvic floor muscles, allowing your lower abdominal muscles to also gently draw in. Aim for a “moderate” effort to allow activation of the muscles but not overactivate them.
    • Then, relax your muscles again as you inhale, repeating this cycle.
    • Aim to do this for a minute or two, twice each day.

Stay tuned as we continue this journey over the next few weeks and months! What have been your challenges after childbirth? For my fellow health care professionals, what else do you like people to know immediately after a caesarean birth?

Have a great week!

Jessica

BIG NEWS: I’m opening my own practice!!!

Ok, so I have been SO excited to share this with all of you, but needless to say, I’ve been a little busy with nursing, diapers, and keeping a very active toddler happy.

My two little lovebugs!

Over the past 10 years, I’ve had the chance to treat hundreds of patients in a few different job settings. I’ve also helped to educate hundreds of other health care providers as they journey into pelvic health rehabilitation. I have learned so much through these experiences– both about patient care and creating a positive, motivating and enjoyable clinic environment for patients and clinicians alike!

So, I am thrilled to announce that I will be opening my own practice this fall! I have soooo many more details to share, but for now, I can tell you that I will begin seeing clients on October 1st, and will open scheduling in mid August! (If you want to be contacted first when the schedule opens, send me a message now!)

If you have any questions, please feel free to reach out!! Can’t wait to share more details with all of you in the next few weeks/months!!

~Jessica

Interview in Men’s Health Magazine on Chronic Pelvic Pain

Good morning!

I was interviewed for an article that was featured this month in Men’s Health! I wanted to share with all of you here! Excited to bring information on male chronic pelvic pain and pelvic floor physical therapy to such a big platform!

In the article, we discussed the scope of the problem, treatment recommendations, and even some details on what good pelvic PT should look like! I hope you all enjoy!

Click here to view the article in Men’s Health on male chronic pelvic pain!

~Jessica

Video Interview with Dr. Ken Sinervo: Internationally- Recognized Endometriosis Expert

Happy Endometriosis Awareness Month!

Did you know that Endometriosis affects more people that inflammatory bowel disease?

Did you know that 10-15% of women (and some men too!!) suffer with endometriosis?

Did you know that they often see 7+ physicians before being diagnosed with the condition?

Endometriosis is so common, and often can be a very life-impacting condition. As a pelvic PT, I often treat individuals with endometriosis, helping them with the musculoskeletal and neuromuscular sequelae of the condition. I have also helped many patients navigate the healthcare system to ultimately receive the appropriate care they so desperately have needed.

In honor of Endometriosis Awareness Month, I asked Dr. Ken Sinervo, the medical director for the Center for Endometriosis Care in Atlanta, GA to spend some time with me discussing this important diagnosis. Dr. Sinervo is an expert in treating endometriosis, and I can’t tell you how lucky I am that his office is about 20 minutes from mine! He is also a kind and humble person and a compassionate physician, and I was so excited to interview him for this post!

In the video below, we discuss: 

  • What is endometriosis and where does it occur?
  • What are the current theories on the causes of endo?
  • How can it be treated?
  • Excision vs. Ablation surgery
  • How to find an Endo expert
  • For pelvic PTs: How do you identify patients who may have endo?
  • And, as an extra bonus, cherry on top, Dr. Sinervo describes the research he is involving in trying to identify potential markers to actually test for endometriosis!!

I hope you enjoy the video as much as I enjoyed interviewing him! I apologize in advance if our video cuts out a little bit, but I don’t think it impacts the incredible content (Our weather in Atlanta was a little struggly, so I think my internet had some difficulties!).

 

Your First Visit to See a Pelvic PT

I started writing this post a few different ways. Over the past several years, I have had handouts and brochures detailing out what is included in a first visit with a pelvic PT, but I liked the idea of something a little less formal. So, I started writing a letter to that new pelvic PT patient, and I hope it helps you (and your patients!!) feel more comfortable getting started! 

Hello there soon-to-be pelvic health PT patient:

We are SO thankful you are trusting us in partnering with you in your healing journey. We’re very glad you’re here. I realize that taking this step and actually scheduling a visit with a pelvic floor specialist can be nerve-racking, and you should be quite proud of yourself for taking this important step! I want to take a few minutes to talk with you about your first session in pelvic PT. I find that much of the fear and uncertainty people may feel with a first visit is often connected with this “unknown.” So, I hope today I can take some of that away, so you can feel more comfortable on that first day. So, let’s get started:

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Your arrival to the clinic 

Before you arrive to the clinic, you likely had a good amount of paperwork to fill out (Sorry about that!). Some of it is the standard healthcare type stuff, but there also is a more specific questionnaire. This questionnaire gets fairly personal. You’ll see questions in it about your bladder health (how often you pee? what do you drink? are you leaking urine?), your bowel function (are you constipated? do you strain when you have a bowel movement? do you leak stool?), your sexual function (are you sexually active? do you have difficulties with pain during sexual activity? problems with arousal or orgasm?), and any pain you’re experiencing (where is your pain? what worsens or improves it? how much does it hurt?) I’ll also ask you about your medical history, your medications, and if it applies to you, your history of pregnancies and childbirth, etc. I know this is a lot of detail, but this is very helpful for me in providing your care! Please feel free to put as much or as little detail on this as you feel comfortable doing. We will have a chance to discuss all of this in person.

Nice to meet you, let’s get personal!

After you and I meet, I will take you back to a private room, and we will chat about what’s going on. This is when we’ll talk about your story, what brought you here,  what are the challenges you have been facing, what has been your journey, and what are your goals you want to reach. We’ll also discuss the questions you answered on that detailed questionnaire, and I may ask you some other questions to get more information about the challenges you have been dealing with. I know it can feel a little weird for some people to share details about your bowel habits or sexual function with a person you just met, but believe me, for those of us who practice in this specialty, we talk about these things all the time. As we are chatting, please feel free to tell me anything at all that you think might be important. Don’t hold back…believe me, I most likely have heard all of this before. On that note, please know that I want you to feel comfortable and safe in the clinic, and if you would prefer not to discuss something, that is totally okay too. Just let me know!

Your Exam

After we chat, I will talk with you a little bit about what I think may be going on from a musculoskeletal, movement, and/or behavioral (habits) standpoint. At this point, I usually pull out some images, a model of a pelvis, etc. and will talk with you about what normal anatomy and physiology looks like in the pelvis and about what I think may be happening with the problems you are experiencing. Then, I will let you know what I am recommending we examine to get a better idea of your function. This often includes:

  • A “Big picture” movement exam: I will watch you walk, stand, sit, and move in many different directions. I will look at how your spine moves (from your neck down), your shoulders, hips, knees, and ankles. I also look at your balance and preferred postures, and I’ll even watch how your breathe (yes, breathing really does matter!). While we do this, you’ll also let me know if any movements are challenging for you or lead to any pain, and this helps me understand how your body as a whole is moving.
  • Specific tests/movements: After the global movement screen, we may go through some specific tests. This can include tests to see how you transfer forces or control pressure through your pelvis by lifting a leg or moving in a certain way, tests to see  how the nerves in your spine glide and move, or tests to see what structures are contributors to pain you may be experiencing.
  • Myofascial palpation: Next, we’ll see what tissues are tender or not moving well around your abdomen, pelvis, or elsewhere if we need to. This includes gently touching the muscles around the belly, hips,  and legs to see if anything feels uncomfortable, and may include lifting and moving the skin and tissues under the skin to see where there may be restrictions in tissue movement.
  • Pelvic floor examination: After that, we will look more closely at the muscles of your pelvic floor. Because the muscles of the pelvic floor live inside the pelvis, the best way to examine them is by doing an internal vaginal or rectal examination. For this exam, you would undress from the waist down and lie down on a mat table, covered with a sheet. We don’t tend to use stirrups for our exams (which most people are grateful for!). We start by looking at the outside tissues. We’ll ask you to contract and relax your pelvic floor muscles, and gently bear down to see how your muscles move (Don’t worry if you’re not sure what to do, we can help teach you!). We may ask you to cough to see how the muscles move reflexively. Then, we often will lightly touch on the outside of the muscles to see if anything feels uncomfortable or sensitive to you. We may check how certain tissues move, if that applies to the problems you are experiencing. After that, we can examine the muscles in more detail by inserting one gloved and lubricated finger into the vaginal or rectal canal. We can then feel the muscles to see if they are tender or uncomfortable, assess the muscle strength and endurance, and assess muscle coordination.  *NOTE: While an internal exam is a very valuable examination technique, some people do not feel quite ready for this, or would prefer not to have an internal exam. If that’s the case, be sure to let me (or your pelvic PT) know, and we can offer some other options.  Also, remember that our exam should not be a painful experience for you. Your pelvic PT should tailor the examination to your needs, so that you leave feeling confident and comfortable, not flared-up and in pain.

Our Plan 

After we finish the exam, we should have a clear picture of what areas we can address to work together to help you achieve your goals (whether your goals are to have less pain, stop leaking, start pooping, or something different all together!). So, our next step is to talk about our plan– what you can get started on today, and what our steps will be to help you reach the goal you want to reach.  We also will talk about how often I am recommending you to come see me, and how long I think we might work together. Sometimes I’m really good at estimating this, but sometimes I’m wrong. We can adjust along the way if we need to.

I hope this helps you to feel more comfortable and more confident when coming in for pelvic PT! If you need help finding a skilled pelvic PT in your area, please check out this previous post. 

Please let me know if you have questions at all I can help answer! Have a wonderful week!

~Jessica

 

 

Interview with “The Vagina Whisperer” on Pregnancy & Postpartum Health, Advocacy, Being a Mom, and Everything in Between!

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About 2.5 years ago, I had the incredible opportunity to join Herman & Wallace Pelvic Rehabilitation Institute as a Faculty instructor for the Pelvic Health Series. This was an absolute dream come true for me, as I completely love teaching and had always dreamed of teaching continuing education in pelvic health. (Seriously… as a new grad, I remember asking an instructor at a course what advice they had for someday becoming an instructor. Funny story is that I now co-teach with that very instructor!).  Teaching in pelvic health has been such a incredible blessing for me– not only do I get to travel across the country and help other clinicians learn to treat my most favorite population of patients, but I also get the opportunity to co-teach with inspiring and incredible experts in pelvic physical therapy.

This past September, I had the opportunity to teach with Sara Reardon, PT, DPT, WCS, BCB-PMD, who is not only an incredible clinician, but is also hilarious, down-to-earth, and passionate about women’s health. One night at dinner, Sara, Darla Cathcart, and I had a long conversation about pregnancy, childbirth, the postpartum period, and becoming moms. At one point, I think all of us had tears in our eyes, as we shared our own journeys, challenges we/our family/our patients have had, and our hopes for making everything better. After that chat, I just knew I needed to interview Sara here so all of you have the opportunity to learn from her and feel her passion! I hope you enjoy this interview! Please feel free to leave any questions or comments below!

If you would like to see Sara’s work, check her out at www.thevagwhisperer.com. Here, you will find information about seeing Sara in-person, her online therapy options, mentoring options, and her instagram/blog presence!

Happy New Year!

Jessica

If you want to see all of our expert videos in one place, be sure to check out my youtube channel! This video as well as the others can be found here!

 

 

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