Tag Archives: Women’s Health

Guest Post: Rib cage position, breathing and your pelvic floor

I am thrilled today to have my colleague and friend, Seth Oberst, PT, DPT, SCS, CSCS (that’s a lot of letters, right?!), guest blogging for me. I have known Seth for a few years, and have consistently been impressed with his expansive knowledge and passion for treating a wide range of patient populations (from men and women with chronic pain, to postpartum moms, and even to high level olympic athletes!) Recently, Seth started working with me at One on One in Vinings/Smyrna, which is super awesome because now we get to collaborate regularly in patient care!  Since Seth started with us, we have been co-treating several of my clients with pelvic pain, diastasis rectus, and even post-surgical problems, and Seth has a unique background and skill set which has been extremely valuable to my population (and in all reality, to me too!). If you live in the Atlanta area, I strongly recommend seeing Seth for any orthopedic or chronic pain problems you are having–he rocks! So, I asked Seth to guest blog for us today…and he’ll be talking about your diaphragm, rib cage position, and the impact of this on both the pelvis and the rest of the body! I hope you enjoy his post! ~ Jessica 

The muscles of the pelvic floor and the diaphragm (our primary muscle of breathing) are mirror images of each other. What one does so does the other. Hodges found that the pelvic floor has both postural and respiratory influences and there’s certainly a relationship between breathing difficulty and pelvic floor dysfunction. (JR note: We’ve chatted about this before, so if you need a refresher, check out this post) So one of the best ways we can improve pelvic floor dysfunction is improving the way we breathe and the position of our ribcage. Often times, we learn to breathe only in certain mechanical positions and over time and repetition (after all we breathe around 20,000 times per day), this becomes the “normal” breathing posture.

Clinically, the breathing posture I see most commonly is a flared ribcage position in which the ribs are protruding forward. This puts the diaphragm in a position where it cannot adequately descend during inhalation so instead it pulls the ribs forward upon breathing in. The pelvis mirrors this position such that it is tipped forward, causing the muscles of the pelvic floor to increase their tension. (JR note: We see this happen all the time in men and women with pelvic pain!) Normal human behavior involves alternating cycles of on and off, up and down, without thinking about it. However, with stress and injury we lose this harmony causing the ribs to stay flared and the pelvis to stay tilted. Ultimately this disrupts the synchrony of contraction and relaxation of the diaphragm and pelvic floor, particularly when there is an asymmetry between the right and left sides (which there often is).

Rib Flare PRI

Rib PRI

Jessica has written extensively on a myriad of pelvic floor issues (this IS a pelvic health blog, after all) that can be caused by the altered control and position of the rib cage and pelvis that I described above. But, these same altered positions can cause trouble up and down the body. Here are a few ways:

  1. Shoulder problems: The ribcage is the resting place for the scapulae by forming a convex surface for the concave blades. With a flared, overextended spine and ribs the shoulder blades do not sit securely on their foundation. This is a main culprit for scapular winging (something you will often see at the local gym) because the muscles that control the scapulae are not positioned effectively. And a poorly positioned scapula leads to excessive forces on the shoulder joint itself often causing pain when lifting overhead.
  2. Back pain: When stuck in a constant state of extension (ribs flared), muscles of the back and hips are not in a strong position to control the spine subjecting the back to higher than normal forces repeatedly over time. This often begins to manifest with tight, toned-up backs that you can’t seem to loosen with traditional “stretches”.
  3. Hip impingement: With the pelvis tilted forward, the femurs run into the pelvis more easily when squatting, running, etc. By changing the way we control the pelvis (and by association the rib cage), we can create more space for the hip in the socket decreasing the symptoms of hip impingement (pinching, grinding sensation in groin/anterior hip). For more on finding the proper squat stance to reduce impingement, read this.
  1. Knee problems: An inability to effectively control the rib cage and pelvis together causes increased shearing forces to the knee joint as evidenced in this study. Furthermore, when we only learn to breathe in certain positions, it reduces our ability to adapt to the environment and move variably increasing our risk for injury.
  2. Foot/ankle: The foot and pelvis share some real estate in the brain and we typically see a connection between foot control and pelvic control. So if the pelvis is stuck in one position and cannot rotate to adapt, the foot/ankle complex is also negatively affected.

So, what can we do about this? One of the most important things we can do is learn to expand the ribcage in all directions instead of just in the front of the chest. This allows better alignment by keeping the ribs down instead of sacrificing position with every breath in. Here are few ideas to help bring the rib cage down over the pelvis and improve expansion. These are by no means complete:

**JR Note: These are great movements, but may not be appropriate for every person, especially if a person has pelvic pain and is at an early stage of treatment (or hasn’t been treated yet in physical therapy). For most clients, these exercises are ones that people can be progressed toward, however, make sure to consult with your physical therapist to help determine which movements will be most helpful for you! If you begin a movement, and it feels threatening/harmful to you or causes you to guard your muscles, it may not be the best movement for you at the time. 

**JR Note: This squat exercise is very similar to one we use for men and women with pelvic pain to facilitate a better resting state of the pelvic floor. It’s wonderful–but it does lead to a maximally lengthened pelvic floor, which can be uncomfortable sometimes for men and women who may have significant tenderness/dysfunction in the pelvic floor (like occurs in men and women with pelvic pain in the earliest stages of treatment).

Here’s another one I use often from Quinn Henoch, DPT:

Our ability to maintain a synchronous relationship between the rib cage and pelvis, predominantly thru breathing and postural control, will help regulate the neuromuscular system and ultimately distribute forces throughout the system. And a balanced system is a resilient and efficient one.

Seth-Oberst

Dr. Seth Oberst, DPT is a colleague of Jessica’s at One on One Physical Therapy in Atlanta, GA. He works with a diverse population of clients from those with chronic pain and fatigue to competitive amateur, CrossFit, professional, and Olympic athletes. Dr. Oberst specializes in optimizing movement and behavior to reduce dysfunction and improve resiliency, adaptability, and self-regulation.

 

For more from Seth check out his website and follow him on Twitter at @SethOberstDPT

Painful scars? Yes, you can do something about it!

 

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I can’t help it. Every time I think scar, I think… Scar (and yes, I used to have a much better picture of Scar from The Lion King for you…but I had to remove it in my attempt to make sure I’m not violating anyone’s copyright laws!)  I was going to try to think of some funny way to explain why scars and Scar are the same… but I can’t… I relate it to the 50,000 times I have watched The Lion King... so I’ll leave it at that.

Scars can be a big pain though– literally! I have treated women who even after several years cannot tolerate pressure on a c-section scar. Men who have nice huge abdominal scars that ultimately contribute to problems with constipation. And moms who have discomfort near their perineal tears every time they have sexual intercourse.  The truth is that scar tissue is often something skilled physical therapists will evaluate and treat as part of a comprehensive program in men and women with pelvic floor dysfunction(and really, with any type of problem!). And the best part– treating scar tissue can make HUGE differences!

So, what is a scar? 

When there is an initial injury (and yes, a surgical incision is an “injury”), the body goes through three phases of healing: Inflamation, Proliferation and Remodeling. Through this process, the body creates scarring to close up the initial injury. Scars are composed of a fibrous protein (collagen) which is the same type of tissue that is in the tissue the body is repairing (i.e. skin, etc).  The difference, however, is that scars are not quite organized the same way as the tissues they replace, and they don’t really do the job quite as well. (i.e. scars are much more permeable to UV rays than skin is). Scars can form in all tissues of the body– even the heart forms scar tissue after someone has a heart attack (myocardial infarction).

How do scars lead to problems? 

After the inflammation and proliferation stage of healing, comes the remodeling. This stage can take months to years! During this time, the body is slowly adapting and changing the scar to the stresses on the tissue. Have you ever noticed that some scars initially are pink and raised and then over time become light/white and flat? That’s remodeling.  Ultimately, there are a few major reasons why a person might develop pain from a scar:

  • Adhesions: Scars are not super selective when it comes to tissues they adhere to. So, sometimes, scars will adhere to lots of tissues around them and this pull can lead to discomfort.
  • Sensitivity: Scars can become very sensitive for a variety of reasons. Sometimes, small nerves can be pulled on by the scar which can lead to irritation. Other times, people themselves will have a significant amount of fear related to the scar. This fear, can often make people avoid touching the scar, and that, along with what we know about how our brain processes fear and pain (See this post, this one, and this one), can lead to a brain that is veeerrrryyy sensitive to the scar. Along with this, muscles near scars can become tender and sensitive. This can occur due to the scar pulling on the muscle or due to the sensitive nerves in the area.
  • Weakness/Poor Muscle firing: So, we know that when our tissues are cut, the muscles around the tissues are inhibited (have you ever seen someone after a knee replacement? It can be quite a bit of work to get those muscles to fire immediately after surgery). That’s why it’s important to get the right muscles firing and moving once a person is safely healed. Moving the right muscles improves blood flow too which promotes healing.
  • Changing Movement: Painful scarring can lead to altered movement. We can especially see this with postural changes after c-sections or other abdominal surgeries, but movement patterns can change with scars all around the body. We also know that abnormal movement patterns over time can lead to dysfunction and pain.

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What can we do about it? 

There are several ways physical therapists can help decrease pain from scars. Can we actually break-up/melt/eliminate scar tissue? I don’t really think so– honestly, scars are made from strong material and truly breaking up the scar is typically something that has to be done surgically– but most of the time, that is not necessary. We can decrease pain from scars by:

  • Improving the mobility of the scar: Gentle techniques to massage the scar and the tissues around the scar can facilitate blood flow to the area and decrease some of the pulling on the tissues around it. There is a thought as well that scar tissue massage can disrupt the fibrotic tissue and improve pliability of the scar (basically, help the scar organize itself a little better, and ultimately move better), and help to promote decreased adhesions of the scar to the tissues around it. Unfortunately, there really is not a lot of great research out there about scar tissue massage. However, this review published in 2012 found that 90% of people with post-surgical scars who were treated by scar massage saw an improvement in either the appearance of the scar or their overall function–which is very promising!
  • Desensitizing the scar and the nervous system: This is where I think we can make huge changes–both by improving someone’s worries/fears about the scar (calming the nervous system) and by slowly desensitizing the scar and the skin around the scar to touch. This is a slow process, but over time, many people who initially can barely tolerate pressure on the scar can be able to easily touch and move the scar without discomfort.
  • Promoting movement: So, we talked about how muscles can become inhibited or tender after a surgery? Part of improving scar tissue related pain is helping the muscles around the scar move well and learn to fire again. This can include some soft tissue treatment to the muscles to reduce the tenderness of the muscles, but ultimately leads to learning to use the muscles again in a variety of movement patterns. Movement is amazing for the body and can not only improve blood flow, but decrease pain too!

Wanna learn more? 

Several of my colleagues have written wonderful information about scar tissue! Check out this great, article and free handout by Kathe Wallace, PT on abdominal scar massage! My colleagues at the Pelvic Health and Rehabilitation Center have also written a few blogs on scars, which you can find here and here.

Have a great rest of your week!

~ Jessica

Preparing for Childbirth- Pelvic floor style!

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I love helping women prepare for childbirth- I really do. In fact, it made me want to consider becoming trained to be a Doula a few years ago! Unfortunately, most of the women I have helped have either been women who were already seeing me for low back or pelvic girdle pain during their pregnancies– or physicians/physical therapist colleagues who were wanting to be proactive in preventing future pelvic floor problems.

So, who should work with a pelvic physical therapist during pregnancy? Honestly, EVERYONE. I’m serious. A skilled pelvic PT can do so much to help a woman not only have a safe and healthy pregnancy (helping to manage pain that creeps in, fitting for support belts/braces if needed, coaching to help get the right exercise routine, and much much more), but we also can do quite a bit to help a woman prepare her pelvic floor for delivery.  My dream is that one day all women will be encouraged to work with a pelvic physical therapist while pregnant and after delivery. I think we would see happier mamas, and reduced problems in the long run.

So, how can a pelvic physical therapist help you prepare your pelvic floor for childbirth?

1.We can help you manage low back or pelvic girdle pain. I know what you’re thinking– this post is about preparing for childbirth, not treating pain during pregnancy! And you’re right, it is. But, pain during pregnancy matters for delivery.  We know that women with pelvic girdle pain during pregnancy tend to have tender pelvic floor muscles. Tenderness in the pelvic floor is often accompanied by a difficulty lengthening or relaxing the pelvic floor–which is totally needed for vaginal delivery, right?  So, in improving pain levels, we also improve the pelvic floor muscles’ ability to relax, which can assist in improving delivery. Did you know that close to 50% of women experience low back or pelvic girdle pain during pregnancy? Most tend to think it’s normal, but it really isn’t (One again, common is not the same as normal!) The great thing is that there is so much we can do to help this pain get better!

2.We can help you learn what your pelvic floor muscles need to function optimally. There used to be the thought that ALL pregnant women needed to be doing lots and lots of kegel exercises. But, as you saw above, we now know that there is a huge population that doesn’t really need to try to tighten constantly, but rather, needs to learn to lengthen, drop and open the pelvic floor muscles.  But should some be strengthening? Absolutely! A recent review found that performing strengthening while pregnant can reduce both urinary and fecal leakage after delivery. However, it’s important that these recommendations are individualized–and that is something a skilled pelvic PT can help you with.

3. We can teach you proper pushing mechanics. This is actually one of my favorites– I generally will spend a session with all of my pregnant women helping them learn how to push in a way that will encourage the pelvic floor to open, and lengthen. Pelvic PTs can use SEMG biofeedback to help you visualize what your muscles are doing and retrain the most helpful pattern of muscle lengthening.  I also focus on learning breathing strategies to learn how to coordinate the breath with the pelvic floor, and to encourage using the diaphragm in the best way we can. This helps women to feel more prepared to push when the time comes.

4. We can help you find out which positions for labor/delivery work best for you. For me, this is typically something I work on while helping women learn the right way to push. Now, some hospitals will require women to push in a certain position, but if your doctor is open to you laboring or delivering in different positions, it can be helpful to learn which positions are the most comfortable and relaxing to you. Typically, we try a variety of positions and see which position leads to the best muscle relaxation and helps facilitate the best pushing pattern. Now, of course all of this planning can go out the window depending on what happens during labor/delivery, but it is always helpful to practice and have a few ideas going in– I find this helps women feel prepared and can calm fears heading into delivery.

5. We can teach you perineal massage techniques to help your pelvic floor stretch during your delivery.  Did you know that massaging and gently stretching the opening of the vagina in the third trimester can help to reduce trauma and tearing during delivery? Well, it can–especially during your first delivery! Perineal massage is a safe (for most women) procedure that can help to not only improve the flexibility of the muscles near the vaginal opening, but also, can help a woman learn what relaxed vs. contracted feels like, and can help a woman to recognize the stretching sensations she will feel during her delivery. It is important to note that there are times when a woman should not perform perineal massage, so it is always important to consult with your obstetrician or midwife before getting started.

What else have you tried to prepare for your delivery? PTs- are there any other important pieces you would add? Let me know in the comments below!

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What every female runner should know postpartum

I normally am not huge into re-blogging other people’s blogs–simply because I want my blog to mostly be filled with original thoughts, articles, etc…written by, well, me. BUT, when I read this blog by my colleague, Kate Mihevc Edwards, published on The Happiest Doula, I just had to. 

I have always loved running–ever since running cross-country and track & field in high school. I hope to run as long as I can–which is why I am passionate about women (& men!) having the ability to return to running and other forms of exercise if they have that desire. My love of running and love of all things related to pelvic floor health often is paired together (eg. this post on running and the pelvic floor). I actually planned on writing a post this week specifically on returning to running after a baby…but guess what? Kate did it for me! For those of you who don’t know, Kate is an amazing clinician who works for Back 2 Motion Physical Therapy (a sister clinic of mine) across town in Atlanta. She specializes in runners and triathletes, and is VERY good at what she does. Soooo, I hope you enjoy her awesome post: 

I am a mom, a runner and a triathlete. I have the benefit of being a physical therapist (PT) that specializes in treating runners and triathletes and I work in an office with two knowledgeable pelvic health PTs. My son just turned one and I, too, am still re-learning my body. Over and over I have heard friends and patients talk about wearing a pad when they run because of leaking or getting a stress fracture while they are breastfeeding. I hear about how exhausted they are how hard they are working to get their abs back to pre-pregnancy form.

In 2013, Running USA reported that female runners are at an all time high with 8.6 million female race finishers nationwide and females accounting for 56% of all race finishers. With over 4 million babies born in the U.S. each year, I wonder how many of these women have had babies and how many have had questions about how to return to running after their babies.

Whether you were a running before you had a baby or not, running is an attractive exercise option for moms. It is much easier to lace up your shoes run out the door than going to a gym. For me, running is a gift; it allows me a few minutes of alone time as well as some needed freedom by taking my son with me on the run. A recent study even found that women who ran while breastfeeding had a significantly lower incidence of postpartum depression.*

It is difficult to find information or resources for women when we return to running or start running postpartum. Most women have no idea where to start, what to expect, how their body should feel and what is/isn’t normal. By addressing these issues and educating ourselves and others about how our bodies change during the months after childbirth, we can significantly reduce the potential for injury.

Things I’ve learned along my journey back to running

(Click to read the rest of Kate’s fantastic blog post) 

Prehabilitation for Pelvic Surgeries

Getting ready to have a knee replacement? You’ll have at least a few visits of pre-operative physical therapy.

What about a rotator cuff repair? The more you get that shoulder moving and stronger before surgery the better!

Now, how about that hysterectomy? Sling procedure? Prolapse repair?

  **SILENCE**

Why is it that men and women are easily referred to physical therapy prior to knee, hip or shoulder surgeries, yet so few are referred prior to pelvic surgeries?

Now, before you get fussy with me, I will say that I have worked with some fantastic surgeons who often referred women to physical therapy prior to undergoing pelvic surgeries—and we had great results working together! We would joke regularly that I made them look better and they made me look better. We were a great team! But, the unfortunate truth is that many women are not regularly referred to PT prior to having surgeries for incontinence or prolapse—and I really do believe that “prehab” would be significantly beneficial!

Here’s why:

Just like other orthopedic surgeries (knee, shoulder, hip), preoperative pelvic physical therapy can encourage proper muscle function prior to surgical intervention.  This is such an important piece! Restoring proper motor control patterns and overall muscle function can help a person recover more quickly and improve all aspects of pelvic health (bladder, bowel and sexual function). Remember, it’s not just about the pelvic floor! We also want to make sure the transverse abdominis (lower abdominal muscle), multifidus (low back muscle) and diaphragm (breathing muscle) are working optimally as a team to modulate and control pressures in the pelvis. In addition, we need to look at the whole person. Is an old neck injury impacting how you carry your pelvis? Did you have a hip replacement that is impacting your pelvic floor? A skilled pelvic PT can evaluate and address all of these components to help a person function as well as possible prior to having surgery.

In some cases, preoperative physical therapy can reduce the need for surgery. One of the physicians I worked with used to joke with his patients that I would regularly “steal his surgeries.” Now, this may be a scary thing for a surgeon to hear, but ultimately, isn’t it our goal to get patients better using as minimally invasive treatments as we can? From a surgical perspective, pre-operative PT helps to identify the patients who truly will benefit the most from surgery and those who may just need conservative care. We know now that many patients with urinary incontinence, fecal incontinence, and low-grade (typically grade I-II) pelvic organ prolapse respond very well to physical therapy interventions focusing on regaining optimal muscle function and improving behavioral habits related to bladder/bowel health and body mechanics.  That being said, there are of course many instances where surgery is indicated and very helpful—in pelvic health, the best situation is always a partnership between physical therapist and physician! I have the utmost of respect for my physician colleagues and we both found this partnership helped us identify the best treatments for patients to get them the best results as quickly as possible.

Preoperative physical therapy can reduce risk factors which could lead to worsening of problems after surgery.  Did you know that poor body mechanics with heavy lifting as well as constipation/chronic straining are risk factors for pelvic organ prolapse and urinary incontinence? Improving body mechanics is important to make sure that the “team” of muscles that support your organs are able to function optimally. Body mechanics are an especially important component for those people who participate in activities involving heavy lifting or heavy pressure (i.e. moms, healthcare workers, runners, etc.). Along with this, managing constipation and straining is a very important component. Learning how to develop a bowel routine, sit on the toilet properly, and use proper defecation dynamics (the coordinated relaxation of the pelvic floor muscles with abdominal activation to make bowel movements easier) is crucial in ensuring a person is not putting unnecessary pressure on the pelvic organs during bowel movements.

Preoperative physical therapy can help with managing nonsurgical components. I often will work with women who are having pelvic organ prolapse and pain during intercourse. Did you know that pelvic organ prolapse is not typically a source of pain (pressure yes, pain no!)? In fact, sometimes women with pelvic pain will even have worsened pain after pelvic surgeries as the muscles and nervous system respond to protect the “injured area.” Often times, prehab can help reduce pain prior to surgery through manual treatments, relaxation training and a lot of education! This can help make recovery easier and allow a person to have significantly reduced pain later on.  Another common nonsurgical component is urge related incontinence. Prolapse surgeries and incontinence surgeries can help with stress incontinence (leaking with increased pressure, like coughing/sneezing), but they do not help the urge component. Preoperative physical therapy can help with urgency or urge related incontinence through restoring proper muscle function, teaching urgency suppression strategies and retraining behavioral habits.

So, who would benefit from pelvic floor prehab? In my mind, anyone having a pelvic surgery! I would love to see all women before hysterectomies, sling procedures, or prolapse repairs. I would love to see all men before prostatectomies! The more we can help the body heal itself and promote optimal bladder, bowel and sexual function before a surgical intervention, the more likely we are to have high quality long-lasting results.

Lastly, here’s a little teaser for you– check out our gorgeous pilates studio at our newly opened clinic!! I just had to share!

Gorgeous pilates studio at One on One Physical Therapy in Smyrna!

Gorgeous pilates studio at One on One Physical Therapy in Smyrna!

So, what do you think? PTs- did I miss any of your key reasons why you like seeing men or women preoperatively? Have any of you out there had preoperative PT? I would love to hear your thoughts!!

~ Jessica