My Experience with Pelvic Physiotherapy

Today I went for my first Pelvic Floor Physiotherapy assessment.
I think the physiotherapist was a little curious as to why I was there. Usually she treats women who are pregnant, postpartum, having some sort of pelvic pain or a prolapse. I let her know that I had no children and was simply there to learn more about my pelvic health. I told her I was willing to bet that I had hypertonic or “tense” pelvic floor muscles because I’m always holding in my stomach muscles.

Here’s a little bit of background on myself. I grew up around artists. My parents are both singers and very creative individuals. Growing up I watched my dad sing on stage and my mom lead the soprano section in her choir. Seeing my parents perform instilled the performer in me, and for as long as I can remember I’ve been moving my body and speaking in front of crowds.

In high school I started to teach fitness classes, dance classes and off ice training to figure skaters for the Town of Georgina. I took this leadership/teaching role very seriously and thought (at 16 years old) if I didn’t “look the part”, nobody would want to learn from me. Insert my slight obsession with fitness and negative thoughts towards my body. This was the beginning of what I like to call my TIGHT TORSO PROBLEM.  Having a “tight” and trim body is usually thought of as a fabulous thing. Turns out that’s not necessarily the case.

FUN FACT: I used to perform 1000 crunches before bed because I thought that having rock hard abs was the most important thing on earth. (I was inspired to do this because Usher did it while he went on tour, to keep fit.) Crazy, right?

Fast forward…to when I was accepted to York University’s BFA Dance program. It was during these 4 years that my “tight torso problems” got worse.

In an effort to “look good” in dance class, I’d pull my stomach in to hold myself together. I started to notice that breathing became a challenge – both in and outside of the studio.
My breathing felt limited, as if it was stuck and I could never understand why I couldn’t take a FULL breath.  During class I could perform multiple pirouettes, do the splits, balance on one foot and have so much control over my body, yet I couldn’t figure out my damn breathing.

I felt restricted, as if I was trapped in a box and couldn’t get out.
Every day left me feeling frustrated, dizzy and constipated.

It wasn’t until I became a Pilates instructor that I really understood the mechanics of breathing.

When you inhale, your diaphragm should expand, dropping down towards the pelvic floor allowing air to fill your entire rib cage, and as you exhale the diaphragm should lift back to its resting position.  If you constantly “suck in” your tight torso, these breathing mechanics can’t work properly.

Today my pelvic physiotherapist explained the importance of having a functional pelvic floor and asked me to breathe for her.  This instantly triggered tension and anxiety in my body, as breathing has always been a very hard task.

She encouraged me to lift a raisin from my urethra, then a golf ball into my vagina and lastly a marble into my rectum (all common cues for contracting the pelvic floor muscles).  We discovered that my PF muscles were working optimally, not too tight and not too weak (yay!) but my problem stemmed from the constant tightening, and ‘holding in’ of my abdominal muscles. I needed to learn how to let go. Tight doesn’t mean functional.

As I was laying on the exam table in my Pelvic Physiotherapist’s office, it hit me: The reason I’ve found it so hard to breathe all these years is because I’ve been pulling IN my abdominal muscles too much.  Could it really be something as simple as this?

Was holding in my stomach, trying to “look the part” stopping me from getting a full breath?

YES.

I was tightening my abs so much that my diaphragm and pelvic floor couldn’t work together properly.  I was squishing my internal organs, not giving them the room they need to function. Because of this I’ve had lower back pain, problems with constipation, mental issues, body issues and bloating.

Here’s what I learned from that pelvic physiotherapy assessment:

  • You can’t fully contract a muscle, unless you can fully relax a muscle.
  • You should be able to contract your pelvic floor without the help of your abdominal muscles.
  • Sucking in, and wearing your pants too tight can do more damage than you think.
  • Pelvic health means something different for everybody. Some women need to engage more, whereas I needed learn how to release the tension.

Pelvic floor physiotherapists are SO knowledgeable and I would highly recommend seeing one if you’d like to get to know your body and want to get serious about strengthening your core from the inside, out.

I left my appointment with some homework…(for my body and life)

LET GO (of my stomach, and the things that don’t matter)

Latest Scientific Research on Diastasis Recti

Pregnancy-Related Diastasis Rectus Abdominis (DRA): Top Five Updated Insights!
The discussion points in this blog are based on the findings of a recent Canadian study co-lead by Dr. Sinéad Dufour (McMaster Univeristy, Ontario) and Stéphanie Bernard (Laval University, Quebec).

1) Determining the “gap” between the rectus abdominis muscles is not clinically relevant. Our experts agreed (over 80% consensus) that determination of the inter-recti distance (IRD), the conventional method of actually determining the presence of DRA, is not clinically relevant. Rather our experts contend that like dynamic tissues elsewhere in the body, meaningful assessment techniques need to garner aspects of the tissue function and behaviour. So, if determining IRD was not recommended by our experts, what is? Assessing for the development of tension through the linea alba during a voluntary pelvic floor contraction topped the list at almost 90% consensus.

Summary 1: Don’t get too obsessed about how many fingers you can fit inside the “gap”. The tension of your abdominal wall is what matters more! 

2) The function of the linea alba is interdependent with the function of the pelvic floor. As demonstrated in insight number one, our experts indicate a clear connection between the function of the linea and alba and the pelvic floor. Beyond assessment, this understood interdependence was highlighted in many of the other practice principles that were generated. For example, one practice principle highlighting this was applied to all three domains of perinatal care indicated the following: Commence inner unit exercises that facilitate optimal isolated and synergistic activation of the inner unit and once control achieved, progress with tailored outer unit and functionally oriented exercises.

Summary 2: Your pelvic floor and abdominal muscles work together! You need to ensure you know how to properly engage your pelvic floor muscles (aka kegels) to activate your core!  

Diastasis Recti

3) Optimal Management of intra-abdominal pressure is key.
Moving from the inner unit muscles to the concept of the canister these muscles actually create, of which the lina alba is anatomically and functionally a part of, is what we call the “manometric pressure system”. Our experts were clear in their agreement that DRA, as understood to be more than just widened IRD, needs to be considered within the context of the
manometric pressure system. The general summary statement that was developed conveys this important perspective and is outlined at the end of the article 1 Establishing best practice principles for pregnancy-related diastasis rectus abdominis: A consensus study. Presentations: ICS, Florence Italy; CSM, New Orleans. Manuscript in development.

Summary 3: Diastasis Recti is caused by excessive pressure pushing out on the abdominal wall (think growing baby, poor posture or breathing mechanics, even a man with a beer belly can get diastasis recti). It’s not as simple as just calling the condition “separated abs”.  

4) Women’s health physiotherapists have an importance advocacy role with respect to optimizing pelvic and abdominal health through labour and delivery. Although it was not until round 2 of the Delphi consensus that this insight was transpired, by
the end of round 3, four practice principles were established within the domain of intra-partum care. The two practice principles that were considered to be of primary importance in this domain were: Advocating for the ability to be mobile during labour and avoiding directed pushing practices that increase intra-abdominal pressure for sustained periods and close the
glottis (Eg. Valsalva manoeuver). It is exciting and important that our experts acknowledge important emerging roles for physiotherapists that promote women’s pelvic and abdominal health upstream!

Summary 4: To reduce unnecessary strain on the pelvic floor and abdominal wall, research shows that women should be allowed to be mobile during labour and not confined to a bed. They should also avoid intense valsalva bearing down style pushing, and ideally wait until they feel the urge to push themselves. 

5) There is no place to recommendations that could potentially induce fear of movement.
Our Delphi consensus commenced with 82 statements and ended with 28 developed practice principles after three rounds of iteration. The language in all 28 final practice principles was tweaked and modified through each stage based on experts’ feedback to ensure that potential fear of movement would not be elicited. As one of the lead researchers on this work I was happy but not surprised that our expert colleagues hold this important and scientifically substantiated perspective. Other recent research of mine on the topic of pregnancy-related pelvic girdle pain confirmed that pelvic health physiotherapists do a much better job of using language that will not elicit fear when compared to physiotherapists who do not have additional post-graduate pelvic health training.

Summary 5: Don’t be afraid to move! Movement is medicine. Find yourself a specialized pelvic physiotherapist to help you if you’re experiencing pelvic pain! 

To close, I leave you with a summary statement from this work that puts it all together. Pregnancy-related DRA represents an important and under-recognized concern. All relevant health and fitness providers working with pregnant women should know how to promote best care practices for this condition, however general agreement of what constitutes the best approach to is lacking. Given that the complex three-dimensional tissue of the linea alba is intrinsic to the thoraco-pelvic abdominal manometric system, compromised integrity of the linea alba needs to be considered within the context of this system. As experts in women’s health, we have come to understand that the impairments and dysfunctions related to DRA as multi-dimensional and multifactorial. Further, in line with other thoracic, lumbar and pelvic conditions we manage in the profession of physiotherapy, the interaction between the musculoskeletal, nervous and immune systems represents a central aspect of our global care approach, which is then individually tailored. Thus, our approach allows for the integrated targeting of modifiable factors that are potential drivers of DRA and associated impairments or participation restrictions across multiple dimensions. As a group we have agreed that a set of practice principles are needed when working with women in order to guide clinical decision making with respect to pregnancy-related DRA. These practice principles have been developed with intent of guiding practice of all relevant care providers.

 

 

“ELVIE” Review: a FitBit for your Kegels

We’ve come a long way. Pelvic health is becoming a less taboo topic, and women are starting to open up about their struggles with sneeze leaks, painful sex and prolapse – all very common postpartum issues that our own mothers and grandmothers often suffered from in silence. In fact, the latest statistic shows that incontinence affects 1 in 3 women.

So how do we treat these issues? The answer has almost always been to strengthen your pelvic floor and “do your Kegels!”

However, there are problems with this strategy. Here’s a list of them:

  1. Experts say 30% of women are doing Kegels wrong, bearing down instead of lifting up.
  2. Many women don’t get results from their Kegel exercises, and then give up.
  3. Many women are too focused on “holding their pee” when their pelvic floor muscle recruitment should really come from farther back near the perineum and rectum (try holding in a fart without squeezing your butt – you’re doing it now aren’t you!)
  4. Many women are already very tense in their pelvic floors, and need to learn how to release the muscle down before squeezing it up. Women with tight, hypertonic pelvic floors often suffer from painful sex and urge incontinence ( having to pee all the time and can’t hold it). Traditional Kegels for women with tight pelvic floors will make their issues worse!

So if traditional Kegels aren’t the answer, what is? Ideally a visit to your local pelvic health physiotherapist for a pelvic floor assessment and personalized therapy, followed by a focused exercise program to regain core and pelvic floor control.

However, there’s another option. While it’s not a replacement for pelvic physiotherapy, it makes a great add-on to a personalized program. I quite like it.

It’s called the “Elvie”, and it’s like a FitBit for your vagina. Yes that’s right. I recently got my hands on one, and have been testing it out for the past 6 weeks.

The Elvie looks pretty sleek and slick. It is an egg-shaped sensor-packed device made of silicone that you insert into your vagina before doing your Kegels.

It comes in a chargeable tube-shaped case, and can be paired with your smartphone app. The app (which feels like a video game) allows you to visually see if you’re doing the exercises well.  As you lift your pelvic floor, you can watch a little diamond bounce up and down on the screen, depending on the strength or frequency of your squeezing motion.  The 5 minute workout takes you through several different kinds of exercises. Lifting, pulsing, holding, speed and stepping. Strength is measured in LV’s – a unit of measurement created by Elvie, which isn’t totally clear. Regardless, I found this workout rather entertaining and actually became very competitive with myself.

Confession: I started squeezing my butt to get into the “perfect” zone on the score board, even though this is clearly cheating. My score went down once I stopped the butt clenching, but in the name of good form I had to leave my Pilates Instructor ego at the door. Sigh. The app instructions even guide you to relax as you breathe and not clench your stomach, buttocks and thighs. Ya, I know. Thanks for the reminder Elvie.  One day I will beat you. One day…

 

Here are my top 3 favourite benefits of the Elvie:

1) Elvie can help you learn how to relax your pelvic floor as you inhale

My favourite thing about this device is that it mirrors your breathing, and can help you connect to your “core breath” through biofeedback.  Your pelvic floor and diaphragm are a tag team – they move together like a piston. When you inhale, your pelvic floor and diaphragm drop down and expand (think release your Kegel as you inhale). When you exhale, the pelvic floor and diaphragm lift back up (lift your Kegel as you exhale).

Synching your breath with your Kegel is something most have struggled with at some point. In fact, learning correct breathing is the NUMBER ONE thing we prioritize in teaching our pre and postnatal Pilates classes – it’s that important for a strong, functional core. Too often women are so concerned with lifting their Kegels as much as possible and don’t learn how to release the muscles between reps.  They may end up hypertonic and tense in their pelvic floor. That’s the equivalent to walking around with your shoulders hiked up by your ears all day long.

The good news is that the Elvie CAN help teach you to relax your pelvic floor. When the exercises are done correctly, the gem on your screen will drop down when you inhale, and lift up when you exhale. If you’re not releasing your pelvic floor between reps, the gem won’t drop. You’ll see right away if you’re releasing enough.

2) Elvie teaches you to ‘lift’ the pelvic floor instead of bear down

30% of women studied will bear down when asked to do a kegel instead of lift and squeeze their pelvic floor. The Elvie sensors will not register if you bear down, and will ask you to try again.  In one exercise you need to keep a gem above a line; something that can’t be done unless you’re exercising your muscles correctly.

3) Elvie offers an adjustable fit 

Its silicone exterior and egg shape make for a comfortable fit that is small and discreet. And because not all vaginas are the same, Elvie comes with an optional cover that you can put on if you need it to be a bit bigger to fit your body perfectly.

Elvie was created by female-led startup Chiaro in collaboration with the designers and co-founder of Jawbone as well as engineers from Dyson. The female-led company is helping change the conversation around the vagina, and is giving women better technology to improve their pelvic health – something that has been sadly neglected for a long time.

This is a company and a mission I can get behind! While the device is not inexpensive, it’s an investment in your health (better sex, no more sneeze leaks, stronger core and more). The app is supported by both iOS and Android and the Elvie is available online for $199 USD.

 

 

Why Pelvic Health Physiotherapy will change your life

Why bother finding out what’s REALLY going on down there? If you answer yes to ANY of the follow statements then your pelvic floor muscles are not doing their job and it’s worth finding out why…

  • I leak when I cough/sneeze/exercise
  • I leak when I don’t make it to the bathroom on time
  • I often rush to get to the bathroom to avoid leaking
  • I pee ‘just in case’
  • I pee more than 10 times a day
  • I feel pressure in my vagina/rectum
  • I feel like my insides are falling out
  • Things don’t feel right down there
  • Sex is painful
  • My back pain keeps re-occurring
  • I’m constipated no matter how much fiber I eat/water I drink
  • I still look pregnant (mummy tummy) even though I exercise and eat healthy

Your doctor may have told you “go home and do some kegels” to help with any or all of the above issues but did they ever explain where the muscles are or how to activate them? Most women I see in my physiotherapy practice say no one has ever shown them where these muscles are. It’s not surprising that a large percentage of women are doing kegels incorrectly! The pelvic floor muscles attach from your pubic bone to tail bone (front to back) and sitz bones (side to side). They act as a trampoline and have many jobs including supporting your bladder/uterus/rectum (and your baby when pregnant), stabilizing your low back/pelvis and closing the openings where urine and stool come out. In my opinion they are one of our most important sets of muscles our body has (men have them too) and are kind of a BIG DEAL!

pelvicfloor

Some common myths about your pelvic floor (a.k.a kegel) muscles:

1)    If you are pregnant or have had children it’s normal to have incontinence/urine leakage….FALSE

A: It is common but NOT normal to leak urine at ANY time. If your pelvic floor muscles are doing their job and activating at the correct time, then you should never be leaking regardless of your age or how many children you have given birth to.

2)    If you have had children your pelvic floor muscles must be stretched out and weak….FALSE

A: Your pelvic floor muscles can actually be tight even after having children. Just like any other muscle in the body, your pelvic floor muscles can have knots/trigger points. They can be tight for various reasons including; poor posture, stress, constant clenching, scarring from tearing during childbirth and/or pelvic surgeries. Try picturing doing a bicep curl…if your pelvic floor muscles are tight, it’s the same as only activating the top part of the bicep curl instead of a full contraction and relaxation which is required to prevent leaking and pelvic organs from descending as well as connecting with your core 4 to resolve an abdominal separation.

3)    If you haven’t had children, your pelvic floor muscles must be doing their job….FALSE

A: Women who haven’t had children can experience all of the above symptoms including abdominal separation. Doing sits ups/crunches increases pressure in your abdomen which pushes out on your abdominal wall and can create/worsen a separation over time, pushes down on your organs and pelvic floor which can cause incontinence and pelvic organ prolapse. Also if you have tight pelvic floor muscles you may experience pain with sex and have incontinence for the same reasons mentioned above. Lastly, if you have had low back pain, pelvic pain, or sacroiliac joint pain and these muscles have not been re trained- they may not be working optimally. Basically, not having children doesn’t mean you get to steer clear of checking in with your pelvic floor.

So what is involved with a pelvic physiotherapy assessment?

We take a detailed history including your concerns, goals, medical / injury history and ask about your fluid intake, how often you void (both number 1 and number 2). This information is important in determining how your pelvic floor is currently functioning. We look at your posture, core stability, spine mobility and also check your external muscles that connect into your pelvis. For the internal portion of the assessment we talk you through the process and make sure you are comfortable at all times. It involves palpation of the muscles at the opening of your vagina and inside your pelvis. An internal assessment is the gold standard for assessing your pelvic floor muscle tone/tightness, strength, control and coordination/timing. We also assess any scarring/tearing (vaginal and c-section) you may have experienced with childbirth or other surgeries as this can contribute to pain and/or poor activation of your pelvic floor muscles.

I have many women ask – how did I get into the area of pelvic physiotherapy? Well, I began my career as an orthopaedic physiotherapist treating necks, backs, shoulders, ankles and still continue to do so. I use Pilates as a form of rehab for my clients so as you can guess, the core 4 (pelvic floor, transversus abdominis, diaphragm and multifidus) has always been a part of my treatment. In the past I would often refer to pelvic physiotherapists once I began to hear from my clients about their history that included leaking, prolapse and abdominal separation as I knew these issues would directly affect the progress and outcome of their rehabilitation. I then decided to learn how to assess and treat these muscles internally to better help my clients’ outcomes and increase my holistic understanding of the body. Since then I’ve never looked back! My passion is to help women pre-conception, during pregnancy and post-partum to prevent and resolve any issues which can affect the entire body. I treat incontinence, pelvic pain, pelvic organ prolapse, diastasis rectus abdominis (abdominal separation), back pain, hip pain and tail bone pain. I also enjoy educating women during pregnancy about ways to help with labour and delivery including positioning to help decrease the likelihood of tearing, how to properly push and what to do post-partum to help safely and effectively restore their core.

Remember…It is never too early or late to get your pelvic floor assessed and resolve any of the listed symptoms regardless if they have been occurring for 10 weeks or 10 years.

Why Kegels may be bad for some Women

Originally published by The Belle Method in The Purple Fig and The Huffington Post 

We Pilates teachers love to talk about kegels. Like, all the time. Not just in class but at dinner parties, too (well, maybe that’s just me). It’s for good reason: engaging your kegels works your pelvic floor. The pelvic floor muscles are a group of muscles that attach to the front, back and sides of the bottom of the pelvis. They are like a hammock or a sling, and they support the bladder, uterus, prostate and rectum. They also wrap around your urethra, rectum, and vagina.

Kegel_exercises_diagram

A strong pelvic floor keeps you from leaking urine, holds your internal organs in place, supports your spine and pelvis and is needed for sexual function. Yes to strong pelvic floors, please! So many of us have been taught to dutifully “do our kegels,” especially after giving birth to make sure things stay where they belong and sex stays enjoyable. When you’re hypotonic (weak) in that area, kegels done correctly are fantastic.

But what if your pelvic floor is too tense, or “hypertonic.” Basically that means it is constantly contracted (think of your shoulders hiked up to your ears when you’re stressed…now picture that happening down there). Doing kegels in that situation would be like trying to hike those shoulders up even higher; NOT a good solution to decreasing tension and improving muscle function.

Symptoms of a hypertonic pelvic floor include:

  • Urinary frequency, urgency, hesitancy, stopping and starting of the urine stream, painful urination, or incomplete emptying
  • Constipation, straining, pain during or after bowel movements
  • Unexplained pain in your low back, pelvic region, hips, genital area, or rectum
  • Pain during or after intercourse, generalized vulvar burning, inability to orgasm, throbbing, spasm, “pressure in the vagina”

The troubling thing is that so many women suffer silently with undiagnosed hypertonic pelvic floors. Many are doing exercise that is making them worse. Kegels are so often recommended to post-partum women, but how they are performed is almost never assessed in North America. Dr. Arnold Kegel started teaching pelvic floor contraction exercises in the 1940s by using internal palpation to cue the proper muscles. Somehow we’ve stepped away from that and kegels have become something women told to do without any real instruction other than “hold your pee.”

By contrast, in France every woman is offered six pelvic floor physiotherapy appointments after giving birth to prevent pelvic floor dysfunction. This is the way it should be! Let this be a public service announcement for the benefits of Pelvic Floor Physiotherapy. Just go get yourself checked, even if you haven’t had children.

So what causes a hypertonic pelvic floor?

Chronic stress: Tension patterns in the pelvic floor used to be unequivocally linked to sexual (or other types) of abuse. However researchers are finding that the vagina automatically fires (tenses up) in almost any type of stressful situation. The vagina does this to protect the incredibly precious goods inside and this is a direct reflection of the fight or flight response.

Physical trauma: Constant physical stress (load bearing), repetitive pressures running, cycling, jumping can all cause an overworked hypertonic pelvic floor.

Tummy Sucking: Many of us have replaced deep, abdominal activity with “sucking our stomach in,” and think we are constantly using our muscles. In reality, the sucking in motion is a pressure that pulls the abdomen’s contents up (not in). You get a temporary flat stomach that looks fantastic on the beach, but you also get a tucked pelvis, no butt muscles used when walking, no real core engagement, and excessive friction in the lumbar spine, hips and knees…and a hypertonic pelvic floor.

So what’s a gal to do? First of all, get checked out by a physiotherapist to understand how your floor is functioning. The truth is, most of us only do kegels halfway (read: incorrectly). The “hold your pee mid flow” analogy we’ve been taught is crap. All you’re doing is lifting up, working in one direction. You need to practice “letting go” just as much as lifting. You need to do it full range! Any anyone who is hypertonic should just be practicing “letting go” and omitting the lift entirely.

And finally, another reason to perfect your pelvic floor muscle function is because properly contracting and releasing that area connects to your deepest layer of abdominal muscles…which means truly flat strong lower abs! Can I get a “hell yeah!”

Knowledge IS power ladies!

How to do Kegels properly

YES! We Pilates teachers love to talk about kegels. Like, all the time.  Every class. At dinner parties ( well maybe that’s just me). It’s for good reason: engaging your kegels works your pelvic floor. A strong pelvic floor keeps you from leaking urine,  holds your internal organs in place, supports your spine and pelvis and is needed for sexual function.  Yes to strong pelvic floors please!

Not all teachers say the word “kegels”. Here are some common terms – rest assured it all means pretty much the same thing when we say to engage or lift…

  • your power house
  • your TA
  • your zipper
  • your PC muscles
  • your elevator

It can get annoying if you don’t know whether you’re doing it correctly.  The truth is, most of us only do kegels halfway (read: incorrectly). The “hold your pee mid flow” analogy we’ve been taught is crap.  All you’re doing is lifting up, working in one direction. You need to practice “letting go” just as much as lifting. You need to do it full range!

My friend Kim Vopni of Pelvienne Wellness wrote a recent how-to piece about kegels in The Globe and Mail. “Most women focus solely on the contraction of the pelvic floor and forget about the need to relax. They also use the wrong muscles – typically the glutes and/or the inner thighs. They squeeze and clench while holding their breath in an attempt to do a Kegel when really they are holding their breath, clenching their glutes and bearing down…”  (Check out the full article here).

kegels

All women, whether you’ve had kids or not, benefit from understanding how to engage the pelvic floor. TIP: picture the pelvic floor as a sling connecting your public bone and tail bone. When you lift, be sure to lift not just the “front”, but the whole region: perineum and rectum too.

By the way, men can and should do kegels too.  The analogy that works well for men is…wait for it…”walk into a cold lake” ( yes I giggled too, but it truly works).  Strengthening those muscles helps prostrate health, maintain continence and improves sexual function.

And finally, another reason to perfect your kegels is because properly contracting and releasing that area connects to your deepest layer of abdominal muscles…which means flat strong lower abs! Can I get a hell yeah!

So… we’ll see you in class.