Steps You Can Take to Improve Your Symptoms of Incontinence Today

As a physical therapist and personal trainer, I am well aware of how daunting initiating a new exercise program can be. It is with this in mind that I wanted to break down incontinence control into some simple steps. Try these today and tomorrow—ease your way into a routine that will improve your incontinence symptoms.

Step 1: Find 5 minutes per day to lie on your stomach.

Step 2: While standing in the shower, work your full pelvic range of motion by placing your hands on your hips and rocking your pelvis through extreme flexion and extension. In simple terms, rock your pelvis, tucking your buns under and then sticking your buns out. Repeat 20 times every morning.

Step 3: Directly out of the shower, stand so that you have a side view of your midsection in the mirror and draw your belly button “up and in” and hold for a 5-count. Visualize a string attached from your belly button to your pelvic floor when you do this. Feel your entire pelvic basket draw up and in as you pull your belly button “up and in” 10 times. (Take care not to tuck your buns under on this one and don’t forget to breathe normally!)

Step 4: Sitting in a chair, activate your inner thighs by placing a towel roll between your knees and squeezing for a 3-count. Do 20 repetitions.

Step 5: Sitting in that same chair, directly activate your pelvic floor by performing a 2-step Kegel. This involves tightening your pelvic floor and drawing it up toward your belly button and holding for an 8-count. Repeat this pelvic floor tightening and elevation 8 times.

In the 5 steps that I have listed above, you have the goal of establishing a routine. Within these simple steps you begin to establish a healthy extension of your lower spine. You also begin to activate the muscles that will help to support your bladder control, including your lower back muscles (multifidi), your lower abdominals (transversus abdominus), your inner thighs, and your pelvic floor muscles (levator ani).
I encourage you to take these 5 steps toward better bladder control and allow yourself to establish a routine. If/when you feel you want more direction in an exercise routine, you can gather educational and exercise information at http://www.youtube.com/watch?v=4cEApK3Do2Q&feature=channel . Now is the time for you to take the next step!

Go Aneaerobic for Better Health!

I was re-watching the 2010 Hawaii Ironman yesterday morning and one story of an 80 year-old competing in his 20th ironman stuck with me. At 80 years old, to still be biking, swimming, and running…surely this competitor had something to share with all of us. His words of wisdom were to go anaerobic every day. He said, “It’s pretty simple, your body has a limit and you go until it stops you.”

This is some great advice for all of us. In order for your body to adapt, to get stronger, to resist aging, it has to be stressed. Reaching your anaerobic threshold during your daily exercise is a great way to stress your body. This means that you go to an effort level that can only be sustained for short amounts of time. It can typically be marked by a shortness of breath that will eventually cause you to stop or to reduce your effort level. When we are younger, we all go anaerobic without even thinking about it. This happens when we are playing tag, running to the top of the sledding hill, and playing organized sports (remember running lines at the end of practice?).

As we get older, our free spirit play is typically more limited so we need to push ourselves in our workouts to our anaerobic threshold. This can be achieved by increasing speed, by climbing hills, or working against increased resistance. A great lesson for us to learn is that a comfortable, sustained effort, although it may feel good, is not going to help our body adapt and achieve our training goals, whether that be weight loss, faster times, increased strength, or change in body shape.

So if you are the picture of consistency, always choosing the same form of exercise, the same route, and going for the same time…you may need to spice it up a bit. Go anaerobic two to three times per week and see and feel the change. Challenge yourself to be better, to be stronger, and to stay that way for years to come.

Questions from You to Me: The TA vs. the RA Muscles

Is there a difference (in terms of which muscles are activated) if you pull your belly up and in as opposed to just pulling it in? In other words does the “up” do something different?

I use “up and in” because these actions help coordinate the pelvic floor elevation along with the transverses abdomius (TA) which is what we are trying to get back, since this is how the muscles should fire normally but have often stopped doing so due to childbirth, poor posture, etc.

As far as our abdominal muscles go, there is a clear difference between the transversus abdominus and the rectus abdominus and their functions.

In a nut shell, contraction of the rectus abdominus does definitely increase our intra abdominal pressure and press down on the pelvic floor. The transversus abdominus, however, tightens around our thoracolumbar region acting more like a vacuum or a compression stocking. If you perform a 2-step Kegel and tighten your sphincter muscles and then elevate your pelvic floor, you will feel your TA draw in with the elevation of your pelvic floor. Put your hand on your belly button and you will feel it draw away from your hand when you do the lift and hold. Once you become proficient at contracting your TA before overhead lifting, reaching, etc, you will feel the same connection to your pelvic floor. It will elevate as you engage your TA muscle.

Bottom line, you never want to see your belly pooch out when you contract the muscles. If you do, it’s the rectus abdominus being engaged. Instead, you always want to see your belly draw in when you contract muscles. When you do, you will know that you have activated your transversus abdominus.

Work Extension as You Walk

Oh how I love to talk about extension! It is so important to maintain the natural extension of our spine that I can’t help but talk about it again.

What does extension do for us? It lifts our ribs allowing us to take in a deeper breath, it allows for better shock absorption throughout the length of our spine, it positions our muscles at the perfect length to contract, and more. It is our job to maintain our extension as we work against the many forces that are pulling us forward into a flexed position throughout our lives. The force of gravity pulls us forward, the endless daily activities that are performed out in front of our bodies pull us forward, and don’t forget how most of us sleep in a curled up flexed position as well.

I have written about how swimming is a great extension activity, I have encouraged you all to lie for 5 minutes on your stomach each and every day, and I have written extensively about postural awareness helping to extend your spine throughout your day in both sitting and standing positions.

Now I would like to talk about how to get more extension when you walk. This is one of those simple adjustments that you can add to your daily walk outside or even as you walk around the house. It is as simple as exaggerating the push off phase of your walk. “Popping off your toes”. More than likely this will be a change from your normal walk where your heel strike is the dominant force that occurs as your leg reaches out in front of your body. Now, I want you to focus on a strong push off from the ball of your foot, especially your big toe, as your leg is extended behind your body. This simple change in emphasis will automatically decrease the impact of your heel strike and increase the muscle activity on the back side of your body. The beneficial muscles that will be activated include your glutes, your back extensors, your hamstrings and of course your calf muscles.

Give it a try today. This is one of those activities I encourage everyone to do. The teenagers with slouched posture will benefit, the new mom who is always cuddling her newborn will benefit, and men and women working to maintain their posture later in life will benefit. Exaggerate your push off and feel the difference!

‘Tis The Season

The holiday season can lead us into some traps that can have a direct or indirect effect on our pelvic floor function. Let’s take a closer look at three things we want to avoid in the next month.

The first and the most important is to avoid over-eating. It begins with the Thanksgiving meal and continues through New Years. There are snacks out on every table and we are baking more. By the time lunch or dinner roll around, we are already “full” but we pack more in. Over-eating results in an expanded stomach, leaving us with less space within our intra-abdominal cavity. We have all been there…it becomes harder for our diaphragm to expand down and draw in a normal breath. All of this results in more pressure being placed on our pelvic floor and increasing our symptoms of incontinence or prolapse.

The easiest way to avoid over-eating at any time is to eat as if you are going to work out in one hour. If you eat with the thought of an upcoming run, walk, or hike in mind, you will eat to simply fuel your body instead of eating to “fill” your belly.

The second thing to avoid this holiday season is “lazy posture.” ‘Tis the season for lots of shopping, which translates into a lot of slow walking and lots of standing. The tendency for all of us, as we fatigue throughout a day of shopping, is to slip into poor postural habits such as locking our knees back and tucking our buns under. This poor posture places more pressure on our pelvic floor and effectively turns our pelvic floor muscles off, leaving us at risk for increased symptoms.

The best way to avoid poor posture any time we find ourselves in an activity requiring lots of time on our feet is to stand tall and to walk with a purpose. Remembering to stand tall and proud will lift your chest and help to extend your lower spine, putting you in a position closer to neutral spine with your tail bone lifted. Walking with a purpose will also result in better posture as this leads to less of a heel strike and more emphasis on the push-off phase of your gait, leading to more extension of your spine.

The third thing to avoid during the holiday season is getting sick. Of course no one wants to get sick, but for those of us with weak pelvic floors, the force of a cough or a sneeze, or just simply the body aches and muscle weakness associated with the flu, can lead to increased symptoms. The sudden increase in intra-abdominal pressure with coughing and sneezing is a challenge for an affected pelvic floor at any time, but when this coughing and sneezing continues repetitively throughout the day, it can prove to be too much even for a strong pelvic floor. Also, the muscle aches and weakness we experience with the flu will have the most dramatic effect on those muscles that are already challenged by previous injury or general weakness, which again is bad news for our pelvic floor.

So do your best to get plenty of rest, wash your hands, exercise regularly, and eat well to maximize your body’s defense system against any cold or flu bug that comes your way.

That’s it from me. Enjoy the holidays, but avoid the traps that may affect your pelvic floor!

Turning on the Muscles for Optimal Posture

I was just working with a patient, coaching her on posture, and found myself explaining how the multifidi and transversus abdominus muscles fight against one another. Our conversation went something like this:

She asked, “So you want me to exaggerate the curve of my lower back?”

I said: “That is just the first step. I don’t want you to stay there or you’ll come back to see me for low back pain! So if we take it in steps, Step 1 is to stick your buns out so that you are standing in a gymnast posture. Step 2 is to draw your belly button up and in, cinching up your midsection. If you watch in the mirror as you’re doing this you can see how pulling your belly button up and in draws you out of this extreme position and softens your lumbar curve by rocking your pelvis back ever so slightly. This natural, soft lumbar curve is your neutral spine and where you want to be.”

She said, “Am I supposed to stand like this all the time?”

I said, “Yes, but it’s not easy. Good posture requires your muscles to work. The positive side of this is that holding good posture burns calories throughout your day. The challenge is snapping yourself out of the bad habits of locking your knees back or tucking your buns under. As you train yourself to hold neutral spine throughout your day, you will have to set reminders or cues that will trigger you to check your knees, your hips, and your belly button.”

She asked, “Why do I feel a tightness in my low back?”

I replied, “Because you are working muscles that you don’t typically have engaged. This is good. Your multifidi muscles of your low back are working to give you an arch in your low back and your transversus abdominus muscle which draws your belly up and in like a corset, also attaches back there. These two muscles are fighting each other, the first wanting to arch your back and the second holding on tight so you don’t over do it!”

Questions from You to Me: What Does the Back Pain Mean?

I am in pain after doing just the first workout (my lower back is really achy). Does that mean I did something wrong?

Your back is likely aching because your TA (transversus abdominus) has not been activated much as of late or maybe ever. Your TA wraps around and attaches to the fascia of your low back. Therefore, it is not uncommon to feel achiness at the first sign of fatigue of this muscle.

Stress, Dietary Habits and Urge Incontinence: How to Calm the Urge

by guest blogger, Michelle Herbst, MPT, DPT

The holiday season is upon us.   Our to-do lists are getting longer.  School continues to be in session and parent-teacher conferences have been held or are scheduled.  Your child or possibly you are eagerly looking at the finish line – the conclusion of the fall semester.

My last two blogs focused on building up our knowledge base regarding incontinence and bladder habits.  My current topic moves us to the problem of urge incontinence.  The increased stress of managing work, kids, and the holidays can aggravate urge incontinence symptoms.  You may be asking “why?”  Good, I am glad you are scratching your head.  But first let’s revisit what urge incontinence is and what normal bladder habits are.

In Bladder 101, I shared definitions for both Urge Incontinence and Normal Bladder Habits.  As a refresher:

Urge Incontinence: the loss of urine in the presence of a strong urge to urinate.  Leakage usually occurs during moments of increased anxiety, stress or the presence of temperature changes.  Urge incontinence is sometimes called ‘Overactive Bladder’ which describes an increased activity of the detrusor muscle which causes the bladder to empty.  Persons demonstrating urge incontinence may urinate more frequently than every 2 hours.

Normal Bladder Habits: It is normal to urinate up to 7 to 9  times during the day or every 2 hours.  Waking up to urinate is considered normal only after the completion of  menopause.  Urinary Incontinence regardless of the amount is not considered normal.

The Mechanism for Urge Incontinence and its Influences

In the National Institutes of Health’s A.D.A.M. Medical Encyclopedia, Urge Incontinence is described as the bladder muscles contracting at the wrong time despite the  amount of urine being held in the bladder.   An untimely contraction or spasm of the detrusor muscle results in the  bladder emptying despite having the strong desire NOT to urinate.   Periods of prolonged stress can alter our “fight or flight” mechanism, also known as our autonomic nervous system (ANS), causing  an uptick in urinary frequency and the symptoms of urge incontinence.  What is the mechanism behind this?  Could it be from the high drive from our ANS  and/or change in dietary habits during bouts of stress?  Dehydration and consuming acidic and caffeinated beverages may act as bladder irritants resulting in unwanted spasm or contraction of the detrusor muscle.

Plan to Reduce Stress, Assess and Change Dietary Habits and Kegels (Contraction of the pelvic basket)

1) Stress Reduction

How do you effectively and in a healthy way diminish stress?  Do you walk, meditate, journal?  Are you a problem solver and combat stress through a task-oriented approach?  Or, do you need to release stress by seeing a ‘chick flick’ and laugh yourself to a  happier you?

Specifically, do you need to reframe your current stressors?  Meaning, do you have a warm home, food on the table and a reliable car.  Are your basic needs being met?  If so, breathe deeply, taking in a big belly breath at that.  Calm and slow yourself down. By turning your flight or fight mechanism down, or your ANS, you will slow down the nerve input to the bladder driving the urge.

2)  Dietary Influences on the Bladder

Just remember weak lemonade.  Yes, you heard me – weak lemonade.  When you urinate, the color of urine should be that of weak lemonade.  We all have heard that we should drink eight, 8 oz glasses of water to remain hydrated but this depends on what you are consuming and your activity level.   So, my recommendation is this – moderation.  Acidic and caffeine-filled beverages and foods are linked to increases in urge incontinence.

Now, I do not want you to eliminate all acidic and caffeine-filled foods or beverages.  I want you to seriously and objectively assess  your use of them.  Simply ask yourself, is your consumption average or moderate?  If not, I suggest you decrease your consumption to a moderate level and increase your water intake to achieve the desired concentration of urine to the color of weak lemonade.  Staying hydrated will keep your urine from more being too concentrated thereby decreasing the frequency and intensity of unwanted detrusor muscle contractions.

3)  Kegel – To Suppress and Control The Urge

Tasha and I have made multiple references to Dr. Kegel and Kegeling.  If you do not know what a Kegel is – now is the time to know.  A Kegel is contraction of the muscles located between the pubic bone and tail bone.  Contracting this group of muscles involves the sphincters and multiple layers of the lower pelvic basket.

A Kegel in the presences of an untimely and strong urge to urinate can calm down the detrusor muscle and close the urethral via use of the sphincter muscles.  Its successful use can buy you more time and delay the urge to urinate.  I recommend holding the Kegel at a strong intensity while deep breathing for as a long as you need or are able.

As a clinician, I have come to suspect and accept that there may be multiple inputs or sources contributing to the patient’s current situation.  This typically is the case with the diagnosis of urge incontinence.  Therefore, I recommend multiple strategies to attack the urge: stress reduction, dietary changes and Kegels.  A multi-pronged approach will calm the urge quickly and effectively within a few weeks.  If not, it is time to see the doc.

References:  National Center for Biotechnology Information.  Bethesda MD. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002250/. Accessed November 1, 2012.

Developing Pelvic Floor Endurance

I have been asked several times about the process of building up pelvic floor endurance, so I’ve decided to focus on this question in this blog entry.

Perhaps one of the most frustrating things we experience as our bodies work to gain better control of our pelvic basket is the increased symptoms with simple activities such as a walk around the block or a trip to the grocery store. Our first instinct may be to restrict activity. However, the reality is that doing so will only serve to further our deconditioning and exacerbate muscle weakness, thereby leading to increased symptoms with even easier activities. So, probably not surprisingly, my advice it to get out there and move! And, to help you do that, I want to share some of my favorite exercises that I remember doing.

However, before getting into the actual exercises, I want to briefly discuss the importance of giving our pelvic floor time to recover. Just like our bodies have to recover after a hard workout (e.g., with activities such as stretching, icing, rest, compression garments, and/or cross training), we have to be aware of what will help our pelvic floor recover following a long day on our feet or an exercise session that taxes our pelvic basket.

Some of us may have to give our pelvic floor opportunities to recoever several times a day, depending on our symptoms and how early we are in the process of regaining optimal pelvic floor control. For example, after my second and third deliveries, you could find me on the floor performing my multifidi extensions (described below) at least three times per day. I liked this exercise because it put me in a position of extension and, by lying down, it took gravity out of the equation. There was no pressure on the muscle fibers of my pelvic floor in this position and it allowed me to essentially re-set my pelvic floor support.

Some women note the same benefit from any exercise in the hands and knees position. Whatever your preferred position of recovery, it is important to recognize that your pelvic floor may need to re-set throughout your day. Get in a position that gives it some relief from the job of supporting your pelvic organs. This means that coming home from a long day on your feet and simply sitting on the couch with slouched posture is probably not your best option. Follow the instructions for my multifidi extensions as instructed below for a great approach to re-setting your pelvic floor.

Multifidi extensions (3 sets of 10 repetitions) – Position yourself on your stomach with your forehead on a towel roll to avoid having to turn your head to the side. In this position you will perform 10 contractions of your multifidi muscles (the very small muscles in between each segment of the spine that holds the natural curve or neutral spine). Simply rotate your pelvis, lifting our tail bone up toward the ceiling. The movement is very subtle so you shouldn’t see a big rotation of your pelvis. Remember to SLOW DOWN holding each lift for a count before relaxing and repeating.

I also wanted to include one of my favorite exercises that I often work into my daily strengthening routine that I feel has a similar benefit for me now that my pelvic floor is well past the early recovery phase. I call these standing hamstring extensions.

Standing Hamstring Extensions (3 sets of 10 repetitions) – To begin, stand with your feet approximately 6 inches apart with a slight bend in your knees. From this position, hinge at the hips tilting your upper body forward. Take care to keep the arch or “lordosis” in your lower back as you tilt your upper body forward. It may help to think of sticking your buns out. When you reach a point of hamstring tension, stop your forward lean and begin a set of 10 knee extensions, straightening your knees followed by small knee bends. Three sets of 10 repetitions will produce good passive tension in your pelvic floor as well as a good hamstring stretch.

I also want to refer you to Edgar Caycee’s site http://www.choosing-natural-health.com/hemorrhoids-cure.html which presents exercises aimed at controlling symptoms from hemorrhoids. I do like the exercise he demonstrates, reaching for the sky and then grabbing air as he bend from the waist and allows his arms to fall to the ground. It is due to my hamstring tightness that I altered this exercise and came up with my standing hamstring extensions as described above.

Good luck to everyone “re-setting” your pelvic floor!

Bladder 101: What is normal? What is not normal? What to do?

by guest blogger, Michelle Herbst, MPT, DPT

In my last blog, Schooling Up On Pelvic Floor Dysfunction, the characteristics of a healthy pelvic floor were presented:  “…a healthy pelvic floor includes the normal placement of pelvic structures and normal functioning of the pelvic muscles, bladder and bowel.”  Bladder 101 covers normal functioning of the bladder, diagnoses that may be positively impacted by pelvic floor rehabilitation, and how bladder function may change across a woman’s lifespan.  Knowledge is power.  So, let’s get started!

Normal Adult Bladder Habits

It is normal to urinate up to 7 to 9 times during the day or every 2 hours.  Waking up to urinate is considered normal only after the completion of menopause.  Urinary Incontinence regardless of the amount is not considered normal.

Urinary Incontinence Diagnoses Related to Pelvic Floor Dysfunctions

There are several different types of incontinence:

Stress Incontinence:  The loss of urine when an increase in intra-abdominal pressure exceeds the closing pressure of the urethra, which is the tube that empties the bladder.  Leakage typically occurs when the individual changes position or when laughing, coughing, sneezing, jumping, or running.  The likelihood of leakage increases as the bladder volume increases and when weak pelvic basket muscles are fatigued.  Bladder habits may be varied with stress incontinence.

Urge Incontinence: The loss of urine in the presence of a strong urge to urinate.  Leakage usually occurs during moments of increased anxiety, stress, or the presence of temperature changes.  Urge incontinence is sometimes referred to as ‘Overactive Bladder’ which describes an increased activity of the detrusor muscle which causes the bladder to empty.  Those who have urge incontinence may urinate more frequently than every 2 hours.

Mixed Incontinence: The presence of both stress and urge incontinence.

How pregnancy may affect the bladder

Hormonal changes during the first trimester may prompt an uptick in the urge and frequency of urination.  As the baby grows and the uterus expands there is more pressure on the bladder and decreased bladder capacity.  Loosening of ligaments may predispose a woman to changes in her pelvic alignment which may negatively impact how the pelvic basket works resulting in leakage with quick movements and sneezes.

Post-partum changes to bladder function

After a vaginal delivery, the bladder and pelvic basket muscles may seem sluggish to respond and simply very weak.  This may be caused by swelling at the perineum and overstretching or compression of the pelvic nerves and muscles during delivery.

But, do not fear!  The body is wonderful at healing itself after injury.  As the swelling decreases and the muscles and nerves begin to heal, normal bladder function should return in a few weeks.  Bladder control will further improve as the sphincter muscles of the pelvic basket heal and become stronger, allowing for initiation, control and completion of urination.

Menopause and bladder function

Hormonal changes during peri-menopause cause thinning of the mucosal lining of the urethra, which is the tube that empties the bladder.  Normally when the bladder is filling the urethra is kept closed by the adhering or sticking together of the walls of the  urethra and the external compression force from the pelvic sphincter muscles.  However, as the mucosal lining of the urethra  thins, the walls of this tube do not stick together as well leaving the tube partially or fully open.  The result is an increased reliance on sphincters to close or ‘shut off’ the urethra during bladder filling.  In the presence of weak sphincter muscles, the leakage will be further be compounded with increased urge and during position changes such as lifting, sneezing, pushing, pulling, or jumping.

When to seek help for incontinence?  And, what type of help? 

Please do not delay getting help for incontinence.  All too often patients suffer with incontinence because they think nothing can be done or that it is normal.  This simply isn’t the case.  In fact, there are many things that can be done!

My recommendation is to contact a primary care provider to determine the origin of the onset of incontinence or worsening of symptoms.  The source may be due to urinary tract infection, underlying medical, psychological issues, or the symptoms might even have a pharmaceutical origin.

Prior to making an appointment with a primary care provider, you should consider recording/journaling bladder habits and how incontinence is negatively impacting your life.  Examples may be avoiding physical activities/exercise or socialization due to fears of leakage or avoiding intercourse with your significant other.  This subjective information may help the primary care provider in recommending viable treatment options such as dietary changes, pelvic rehabilitation, and medication or prompt a referral to a specialist.

I hope Bladder 101 helps you describe your leakage problem to others so you can seek out appropriate resources and support.  But most importantly, I hope you may begin realize that some phases in a women’s lifespan are simplys a phase.  Most bladder control issues during pregnancy, post-partum and menopausal periods can be positively impacted by lifestyle changes.  Pelvic floor rehabilitation/strengthening may be just the lifestyle change you need.

Please, make Hab-it your HABIT!