A wonderful resource for those with GI issues…

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Treating pelvic floor dysfunction has given me the opportunity to work with some wonderful people who are suffering from some very serious ailments. Whether that is the embarrassment they feel from leaking urine or feces, or the pain they feel on a daily basis during the most basic activities of daily living. Several months ago I began working with an amazing young lady who suffered from severe constipation and abdominal/pelvic pain. She has been through more in the past few years than the average adult has in their entire life. Check out my friend, Jenna’s, blog on her journey with pelvic pain and living with an ostomy.

http://jennaleesjourney.weebly.com/

Written by: Jenna Sires PT, DPT

Your Friday Amusement– Pelvic HUMOR!

Happy Friday! Here’s a little humor to get your weekend started off right… Enjoy! – Jessica Reale, PT, DPT, WCS

teachjunkie.com

teachjunkie.com

quickmeme.com

quickmeme.com

Managing a Holiday Flare-Up

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First, and foremost, a very HAPPY THANKSGIVING! from all of us at Proaxis Pelvic PT! We are so thankful to you–our patients, readers, and friends for all you do to support the work we do, and for allowing us to be a part of your health journey. We are very grateful to be a part of your life.

Now, every year around the holidays, an interesting scenario happens. Many patients come in worried, stressed, and often disappointed as their symptoms tend to go a little “backwards” through the holiday buzz. Often times, they don’t necessarily connect the two together, but instead, come in to their appointment frustrated that things are not going well. And it could be anything– people struggling with bladder control may be leaking more, people with constipation may be having more difficulty, and people experiencing pain may see their pain spike. But, why does this happen? Sometimes, we can’t identify a cause—it just does But during the holidays, there are often a few key things that I find will contribute to a change in symptoms:

  • Stress: Holidays are wonderful, awesome times to be with those we love and celebrate together. However, it is very common for this wonderful season to be accompanied by stress– planning, cooking, eating–spending lots of time with family, etc. Stress is often accompanied by increased muscle activity, increased sympathetic nervous system output, and thus can lead to a spike in pain or changes in bowel and bladder.
  • Diet: I shouldn’t need to explain this (we LOVE eating over the holidays), but many people will change their diets significantly throughout the months of November and December. We eat more rich foods, change our eating routines, and very likely consume slightly different fluids than we typically do. As you may remember from previous posts, the bowels love routine and changing this will likely impact the system.  In addition, both our bowel sand bladder are influenced by the fluids we take in and may become irritated if we are consuming fluids that are acidic, carbonated, caffeinated, artificially sweetened or containing alcohol (Jenna wrote a great post about that last year)
  • Inconsistency in Routine: Even the most compliant and consistent person may have difficulty staying in a healthy routine over the holidays. Often times, people will find it difficult to get in their recommended exercises, and may find themselves slipping from the habits recommended to them by their healthcare team. This can often lead to a worsening of symptoms (bladder, bowel and pain).

So, what to do when this happens?

  • First, do your best to stay calm and stay positive. I know it can be very frustrating when you are hurting/leaking/etc, but realize that this is likely just a small “hiccup” in your progress. Try not to let stress take over (see above), and instead, try to take a proactive approach to calming down the “flare,” whether it be bowel, bladder or pain problems. Check out this great post from Pelvic Health & Rehabilitation Institute for more great info on “How to not freak out during a flare”.
  • Next, evaluate the previous few days and take note of any of the items mentioned above. Did you have a few glasses of wine with dinner last night? Did you skip the fiber for the potatoes and turkey at Thanksgiving? Did that one relative show up at dinner and make you crazy? Have you forgotten to drink your normal water amount with all that Black Friday shopping?
  • Finally, make a plan to get back on track. Fill up that water bottle and start getting fluid. Skip the leftovers for a big salad for lunch. Spend some time doing a guided meditation or breathing routine to calm your body. Take a few minutes to do your exercises. Use an icepack to calm down painful areas.

Most importantly, remember to keep positive. It is easy to go down a negative road when symptoms seem to worsen suddenly, but remember that your journey to better health is in fact a journey. There will be ups and downs, but you are not alone. E-mail your PT if you need to for a little encouragement. Take a deep breath, and enjoy this holiday season.

Have a very Happy Thanksgiving!

Jessica Powley Reale, PT, DPT, WCS

Potty Yoga

As many of you know, I am very nerdy–in a great way, I believe. And this nerdiness especially comes out when you take a look at my leisure reading material. Recently, I began reading a new book that came to me in a package of promotional materials from the awesome website, Potty MD. Potty MD offers excellent products and books–including my reading of choice, Overcoming Bladder & Bowel Problems in Children by Dr. D. Preston Smith. This $8 book is a jewel and is full of great recommendations–including an appendix full of kid-friendly fiber recipes! I have loved reading it, and I especially loved his idea of practicing “Potty Yoga.”

Now, for those of you who have done yoga in the past, I’m sure you are wondering how the two words “Potty” and “Yoga” can possibly be paired together. But actually, I think the ideas work very well and that both children and adults can truly benefit from the idea of “Potty Yoga.”

Spending time on the toilet is something both children and adults often tend to avoid. We feed into this mindset for ourselves, even referring to bathroom stops as “Pit Stops” comparing our urination to that of a racecar stopping mid-course. The unfortunate side effect of this is that many adults develop poor voiding patterns with bad habits and our children develop frequent urinary tract infections and experience accidents.

Normal emptying of the bladder occurs with a coordinated relaxation of the pelvic floor muscles and a contraction of the detrusor muscle of the bladder to empty urine. This actually involves very little work on our part. Our job is simply to breathe and relax and allow our bladder to empty itself. When we try to speed up this process by pushing or straining, we often negatively impact the bladders function and can develop dysfunctional voiding patterns, difficulty emptying our bladder and pelvic floor muscle incoordination.

For children, dysfunctional voiding patterns often develop from chronically trying to hold urine for longer periods of time. Often times children become involved in playing and do not wish to stop their activities to use the potty. Abnormal habits can often make it more difficult to start a urine stream, which can cause a child to become frustrated and cause unnecessary straining/pushing to empty. Often children are also thinking of other things on the toilet which worsens the difficulty in emptying.

Parents can feed into this process without meaning to by urging the child to “hurry up” or distracting the child by games/playing on the toilet. This unfortunately only makes it more difficult for the child to relax his/her muscles to properly allow the bladder to empty.

Instead, both adults and children should practice, “Potty Yoga.” Yoga focuses on mindfulness, allowing the mind to stay on task, breathing and allowing the body to fully relax. Children and adults should use proper posturing on the toilet as well to allow muscles to fully relax, and should spend 2-3 minutes uninterrupted in order to get positive results. Dr. Smith encourages children to sit in a relaxed position, quiet and comfortable, with eyes closed and slow breathing to avoid being distracted and to allow focus to stay on the bladder.

This same habit should be used for bowel movements to allow muscles to relax and improve ability to empty. So, take a deep breath and get into the habit of practicing potty yoga. The results for your body could be wonderful.

Namaste!

Written by Jessica Powley Reale, PT, DPT, WCS

Is Running Bad for a Woman’s Pelvic Floor?

As some of you may know, I recently completed my second half-marathon. To make it even better, I completed it with my amazing and wonderful husband Andrew:

4 miles in to our first half marathon!

4 miles in, and feeling great!

This was my second half marathon in 1 year, and my third *big* athletic event—the other two being the Disney Princess Half Marathon and the Ramblin’ Rose Sprint Triathlon. I started out 2013 with the goal of being healthier and developing strategies for life-long fitness, and I really am proud to say that as I approach the end of 2014, I am well on my way to better fitness.

Disney princess half

Disney Princess Half Marathon with my awesome sister, Tara and wonderful colleague, Jenna

After completing my last half-marathon, I received the following question from a previous patient of mine,

“Ok, I have to ask, after seeing your race pictures,

isn’t running bad for a woman’s internal organs??”

My initial thought was to respond quickly with a, “Not always, but sometimes…” type of response. But then it got me thinking, and inspired me to really delve into the issue with a little more science to back my thought—although honestly, the gist will stay the same.

So… Is running bad for the pelvic floor? Let’s take a look.

When someone initially looks at the issue, there may be the temptation to respond with a resounding, “YES!” We initially think of running and think of “pounding the pavement,” identifying large increases in intra-abdominal pressure and assuming that this pressure must make a woman more likely to experience urinary incontinence and/or pelvic organ prolapse.

But, what does the research really show?

1. Urinary incontinence during exercise is common and unfortunate.

  • Jacome 2011 identified that in a group of 106 female athletes, 41% experienced urinary incontinence. However, they also found that UI in those athletes seemed to correlate with low body mass index.

2. High impact athletes often may require more pelvic floor strength than non-athletes.

  • Borin 2013 found that female volleyball and basketball players had decreased perineal pressure when activating their pelvic floor muscles compared to nonathletes which they concluded placed these women at an increased risk for pelvic floor disorders and especially UI.

3. Over time, physically active people are not more likely to have urinary incontinence or pelvic organ prolapse that non-active individuals.

  • Bo 2010 found that former elite athletes did not have an increased risk for UI later in life compared to non-athletes (although she did find that women who experienced UI when they were younger were more likely to experience UI later on in life).
  • In another study, Bo (2007) found that elite athletes were no more likely to experience pelvic girdle pain, low back pain or pelvic floor problems during pregnancy or in the postpartum period compared to non-athletes.
  • An additional study by Braekken et. al. 2009 also did not find a link between physical activity level and pelvic organ prolapse. However, they did find that Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP.

Is your head spinning yet?? Let’s make some sense of this research…

First, it does seem like UI is a common problem in athletes—the cross-fit video that had all of my colleagues up in arms identified this problem really well—and honestly, runners are no exception to this. Every week, I work with women who experience urinary leakage when they run or may have even stopped running due to leakage, and I can assure you this causes a huge impact to these women’s lives. I also can assure you that there are many women out there dealing with leakage during running or other exercises who suffer in silence, too embarrassed to get help or somehow under the impression that leakage with exercise is normal.

With that being said, I am not ready to throw away running or really any other form of exercise all together (other than sit-ups…let’s never do those again). Running has amazing benefits—weight control, cardiovascular improvements, psychological improvements/stress reduction—and these should not be cast aside due to a fear that running could cause a pelvic floor problem.

As a pelvic floor physical therapist working in a predominantly orthopedic setting, I see many men and women enter our clinics with aches and pains—and injuries—that began while starting or progressing a running program. Often times, our amazing PTs identify running gait abnormalities, areas of weakness, or biomechanical abnormalities which can be contributing to hip/knee/foot/etc. pain with running. Improving those movement patterns and improving those individual’s dynamic stability seems to make a huge difference in allowing the client to participate in running again without difficulty.

To be honest with you, I see pelvic floor problems in runners the exact same way. When a woman comes into my office complaining of urinary leakage during running, I look to identify running gait abnormalities, areas of weakness or biomechanical abnormalities which are impacting her body’s ability to manage intra-abdominal pressure during running. I also make sure I am managing other things—identifying pelvic organ prolapse when it may be occurring and helping the woman with utilizing a supportive device (tampon, pessary—with collaboration with her physician, or supportive garment), managing co-existing bowel dysfunction or sexual dysfunction, and making sure the patient has seen her physician recently to ensure she is not having hormonal difficulties or medication side effects which could worsen her problems.

We know that intra-abdominal pressure is higher when running. A poster presentation at the International Continence Society in 2012 identified that running does in fact increase intra-abdominal pressure compared to walking—but not as much as jumping, coughing or straining (Valsalva). And not as much as sit-ups…which I hate.

Kruger et. al. ICS Poster Presentation, "Intra-abdominal pressure increase in women during exercise: A preliminary study." 2012

Kruger et. al. ICS Poster Presentation, “Intra-abdominal pressure increase in women during exercise: A preliminary study.” 2012

As you know by now if you follow my blog posts, I do not believe that the pelvic floor is the only structure involved in controlling intra-abdominal pressure increases in the body. (This is why I get so annoyed with all of the studies trying to look at the effectiveness of pelvic floor muscle exercises used in isolation in treating pelvic floor dysfunction). The most current anatomical and biomechanical evidence supports the idea that the pelvic floor muscles work in coordination with the diaphragm, abdominals, low back muscles as well as even the posterior hip muscles to create central stability and modulate pressures within the pelvis. In order for a runner to not leak urine or not contribute to prolapse or pelvic floor dysfunction when she runs, she needs the following(well really, more than this…but let’s start here):

  • Properly timing, well-functioning, flexible pelvic floor muscle group.
  • Properly timing diaphragm—that is used appropriately as she runs so she is not participating in breath holding during her exercise
  • Strong and adequately timed abdominals and low back muscles to assist in stabilizing her spine/pelvis and assist in controlling IAP.
  • Flexible and appropriately firing gluteal muscles to support her pelvis during each step as she runs
  • Appropriate shoes to support her foot structure and transfer the loads through her legs
  • A great sports bra to help her use good posturing while running

Now, is there a time when a woman shouldn’t run?

Yes, I do actually think there are times when running does more harm than good and it may be advantageous for a woman to take some time off from running to restore the proper functioning of structures listed above.

  • If a woman has pelvic organ prolapse, for example, she may need to take some time off from running and participate in other exercises emphasizing functional stability with less of an increase in IAP prior to resuming an exercise program. Some women can return to running in the meantime using a supportive device like a pessary or tampon to help support her organs; however, this may not ultimately mitigate the harm if a person is not stabilizing properly as she runs.
  • I also recommending taking a break from running if a woman is leaking significantly during running or experiencing pain with running. I generally believe that once these structures are appropriately restored to function, women can return to running with less difficulty.
  • The other time I will often recommend waiting is when a woman is further along in her pregnancy or early post-partum. At this time, the increased weight on the pelvis as well as the loss of stability occurring due to hormonal changes places a woman at a higher risk for pelvic floor dysfunction. This, of course, varies based on the individual, but in many cases it may be helpful for these women to choose alternative exercises until after they deliver their children.
  • And lastly, I do recommend a woman holds off on running immediately after gynecological surgery (no-brainer here folks). The research does not indicate that said woman should never return to running—but again, I do think she should allow her body to heal and build up the appropriate strength and coordination needed to support her organs and her pelvis when running.

This post got a little longer than I originally anticipated… so to sum it up… is running bad for your female organs? Not always… but sometimes.

Many of my colleagues have some fantastic blog posts regarding exercise and pelvic floor dysfunction. Check out a few of them below:

Vlog by Julie Wiebe providing an alternative to running:

https://www.juliewiebept.com/video/integrative-programming-for-female-runners-with-incontinence/

Safe exercise for those with pelvic pain:

http://www.pelvicpainrehab.com/pelvic-floor-physical-therapy/2058/pelvic-pain-and-exercise-general-fitness-tips/

Tracy Sher, “Pelvic Guru” on Leaking during exercise:

http://pelvicguru.com/2013/06/22/dear-crossfit-and-crossfit-gynecologist-im-appalled-theres-help-for-peeing-during-workouts/

Seth Oberst’s 4-post series on the Diaphragm:

http://www.sethoberst.com/blog/category/breathing

What do you think? Let me know in the comments below!

Written by: Jessica Reale, PT, DPT, WCS

References:

Bo K, Backe-Hansen KL. Do elite athletes experience low back, pelvic girdle and pelvic floor complaints during and after pregnancy? Scand J Med Sci Sports. 2007 Oct;17(5):480-7. Epub 2006 Dec 20.

Bo K, Sundgot-Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life that non-athletes?

Borin L, Nunes F, Guirro, E. Assessment of pelvic floor muscle pressure in female athletes. PM R. 2013 Mar;5(3):189-93. Scand J Med Sci Sports. 2010 Feb;20(1):100-4

Jácome C, Oliveira D, Marques A, Sá-Couto P. Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet. 2011 Jul;114(1):60-3.

Persistent pelvic pain information in one location (at last)

Excellent post by Sue Croft giving lots of resources on understanding persistent pelvic pain! Read on for book recommendations, videos and blog posts!

sue croft physiotherapist blog

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My blog is a wonderful resource for me and my patients. It’s like having a great big library of all the things I want patients to read at my finger tips. When we physios teach a vast amount of seemingly complex medical information in an hour to an hour and a half- its pretty certain that most adult learners will take in about 20% of what you’ve said (at the time of the consult)- if you are lucky. That’s why every patient I see gets a 14 page handout plus some extra pages if there are specific tests I want them to undertake (for example- a simple corn or beetroot test to check their bowel transit time; or a handout on the causes of faecal incontinence- and if they have pelvic pain they get the normal pelvic floor dysfunction handout as well as a dedicated pain handout). They also get a copy…

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4 Children’s Books to Improve Your Child’s Bathroom Habits

As you know from my previous post, we are SUPER excited to be rolling out our Pediatric Pelvic Floor Program. With that being said, my next few posts are going to cater to this specific population–with this first being an introduction to a few books that I think are awesome for helping kids with bladder and/or bowel problems.

First, let me say that I LOVE children’s books. I love the photos, the stories, the fantasy–I have many wonderful memories of my mother and father reading classics like Goodnight, moon!, The Rainbow Fish, and  Alexander and the Terrible, Horrible, No Good, Very Bad Day. Maybe that’s why I loved seeing all of the children’s books specifically written to help kids with bathroom health. Regardless, here we go– 4 books to improve your child’s bathroom habits (in absolutely no particular order).

1.) Everyone Poops by Taro Gomi

Everyone Poops

What child doesn’t love a book with the word “poop” in the title? Everyone Poops is perfect for the child who is embarrassed of having to have a bowel movement. Although embarrassment may not seem like a big deal initially, it is important to recognize that for some children, embarrassment could be the start of a pretty big problem. Often children who are embarrassed to have a bowel movement will develop chronic holding patterns which can create painful hard stool, bowel leakage, and difficulty having bowel movements. I love Everyone Poops because it’s funny, fun, and normalizes having a bowel movement to take away the fear. Plus, it only costs $4.99 on Amazon.com–who can say no to that?

2. Look Inside: Your Body (Usborne Look Inside)

Look Inside

Ok, I will be honest with you– this may have recently become my most favorite children’s book ever! How could it not be? It literally has over 100 flaps to open inside! When this arrived to my clinic I forced my poor student to listen to all of the fun little facts under each flap in this book. It is filled to the brim with excellent information on the body and even has a beautiful 2-page spread on the digestive system. Plus, it’s interactive–your child can lift a flap and see how the bicep muscle works…lift another flap and see how our ears hear!  My only beef is that they really did not include much information on Urinary function…but other than that, it is amazing! It may have just become my book I give all of my pregnant friends for their new kiddos. Amazon.com $10.48 and worth every penny!

3. It Hurts When I Poop: a Story for Children Who Are Scared to Use the Potty, by Howard J. Bennett

Hurts to Poop

Back to the poop– Constipation is the worst! And fear related to using the bathroom can be equally as bad as embarrassment in creating holding patterns and constipation in children. This book was written by a physician who provides a relatable story for children fearful of using the bathroom. The story follows a young boy Ryan as he goes to see a doctor to help with his constipation. Dr. Bennett also does a great job at providing great recommendations for kids and parents to help improve bowel function! I especially love his page on “foods that make poop hard” and “foods that make poop soft.” This book is an absolute must for children dealing with constipation. The reviews on Amazon.com really say it all, and this book only costs $8.96.

4. Sammy the Elephant and Mr. Camel: a Story to Help Children Overcome Bedwetting, by Joyce Mills and Richard Crowley

Sammy and Camel

How could you not love the sweet story of an elephant who struggles with carrying water, is mentored by a camel, and goes on to save the town by putting out a fire? This wonderful story not only provides a powerful image for children having difficulty with enuresis (bedwetting), but it also is great for improving self-esteem in children and decreasing feelings of guilt or low self-worth. This book also includes information in the back for helping parents take the next steps to improve a child’s bladder function. An excellent read for kids and parents alike! And only $8.96 on Amazon.com!

I hope you will consider picking up some books if your child is having bowel or bladder problems! Do you have any other great books for this? Let us know in the comments!

By Jessica Powley Reale, PT, DPT, WCS

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