Educate Yourself about Incontinence, Prolapse, and General Health

Questions from You to Me: How the DVD Workouts Fit Together

I have a 2nd degree uterine prolapse at 24, after my 2nd 10lb+ baby. I am not petite, but no one expected me to have such large babies.

I was extremely athletic before and during my pregnancies, even biking several miles the day before I gave birth. I felt beautiful while pregnant, and strong.

I pushed for over an hour and a half with both my baby’s completely natural births and then…BOOM…I feel my uterus nearly coming out! I felt broken, nonsexual, and depressed after being on such a high. I couldn’t believe my body that could do such awesome work, failed.

I LOVE being a mother, and my husband and I would desperately like to have more children without further damage to my body. So…I have been doing the DVD three times a week, for 3 weeks and I have already seen improvement!! This has given me great hope. I also saw a physical therapist early on, just once, as I could not afford to continue, even with insurance. I now recommend to clients, family, and friends that EVERY woman make that visit at least once. Well, I just wanted to say Thank you!

My only question is this…Do the workouts build on each other or should I vary them? How do I know when to move on to the next work out? Also, should I plan on always doing these workouts 3 times a week for the rest of my life because of my weakness? Or will there be a point that I can stop?

Thank you for your story and for your questions. It is good for all of us to know that there are healthy, strong, women out there who experience prolapse at various stages of their life. It is not a life sentence – as many of us have proved that we can develop better muscular control and adopt a posture that gets us out of the comfortable, “buns tucked under” position, and go on to have more children and return to the activities we love, all with control of our prolapse symptoms.

That being said, we will always have this structural change of our bodies that we will ALWAYS have to work to control. The work may be very conscious now, but it will eventually become routine or habit. So the answer is YES, you will always have to exercise to maintain control of your prolapse, but if I was your physical therapist, I would stress to you that we all HAVE TO exercise daily in order to maintain our posture, in order to maintain our level of fitness, and in order to maintain our overall health. So this is just another benefit of consistent exercise. Continue to follow my blogs since I plan on adding more advanced exercise instruction in the months to come.

Keep up the good work 3 times per week – eventually you won’t have to follow the DVD as you will have the exercises in your head. As for the workouts 1-4, each does build upon the previous workout, but I do like to go back to work out 1 and 2 from time to time since they make me slow down and go “back to the basics” of my pelvic basket control.

Hope I provided clear explanation on this. I am so happy that your body is responding – you will continue to see improvement and increased body awareness for years to come!

DVD Questions October 14, 2010

Still Seeing Progress Years After Delivering My Third!

I noticed something awesome last night at my 4 year-old’s soccer game. I have blogged in the past that I continue to experience prolapse symptoms when I yell or cheer at my son’s soccer games, after eating too much (every once in awhile I do this), and after being sick.

Well, I still feel symptoms after meals that are too big and, for a day or so when I’m sick, BUT I no longer have symptoms when I cheer at my daughter’s soccer games or at my son’s football games! Is this because my prolapse has magically disappeared or have I trained my body – my pelvic basket – to contract before I cheer? What once was a conscious effort to draw my transversus abdominus muscle up and in before I would yell is now an automatic firing pattern of my deepest core stabilizers. They have the ability to displace the intra-abdominal pressure upward, lifting my chest and expanding my lower rib cage and I can hold this lift as I yell. In the past, the force of yelling, pushed a lot of pressure down on my pelvic floor and would increase my symptoms, but I have changed this pressure displacement by activating the right muscles.

It is this same training process that has allowed me to return to running, dancing, hiking, snowboarding, carrying my children, and now cheering for them too — all symptom-free! What a great example of how the human body can do what we train it to do! It may require a conscious effort in the beginning but, with consistent effort, it eventually becomes a natural firing pattern that we don’t even have to think about.

Understanding Prolapse October 12, 2010

Activity is the Best Medicine You Can Give Yourself

I just returned from a continuing education course in which the primary message delivered was that the human body is driven by activity. It is our activity level throughout our day that dictates the health of our bones, our muscles, our nerves, our brain, and more. Without activity, our bodies begin to degrade. That’s right, degrade!

Research has shown that our bones begin to break down if they aren’t stressed and we also begin to lose muscle tissue quite rapidly with lack of use. Even more intense, recent studies have shown that this phenomenon of healthy tissue breakdown doesn’t just occur in individuals over the age of 50 or 60, but affects everyone, including young people in their 20’s and 30’s, and it even affects our children. What the research is showing is that no matter what your age, your cells are susceptible to breakdown if they are not being used or stressed. As our healthy bone cells and muscle cells break down, they are often converted into fat cells. So not only do we lose healthy bone and muscle tissue if we don’t exercise, but that healthy tissue is replaced with fat that takes up residence within our bones and our muscles. This increase in overall body fat is directly linked to an increase in chronic disease, including an increase in incidence of diabetes, MS, Parkinsons, cancer, Alzheimers, stroke and more. This inactivity and increased amount of body fat is also linked to an increase in symptoms such as poor balance, incontinence, prolapse, decreased lung volume, arthritis and more. Quite simply, all of these symptoms are directly linked to the amount of time spent sitting throughout your day.

Don’t be intimidated by the word exercise. Simply being active and staying off the couch will stress your bones and muscles and prevent healthy tissue breakdown. Researchers stress that we don’t have to go for a 30 minute run every day to have a positive impact on our health. Simply 10 minutes of brisk walking in the morning, afternoon, and evening is a great goal. This can include: climbing stairs instead of taking the escalator, working in some lunges when you push the vacuum, having a couple of favorite exercises you like to do in the shower, performing 8 squats every time you stand up from your desk. All of these activities contribute to a more active lifestyle that can have significant effects on your health.

Keep in mind that you are the best example for your children that sit along with you watching TV, working on the computer, etc. When they get home from school, do you get outside in the yard, walk the dog, ride your bike, or rake the leaves? Our children are affected just like us and the more they sit, the more their muscle and bone tissue is replaced by fat at a young age. This is why the epidemic of childhood obesity is so high as there is less time for gym activities during their school week and they come home to TV and video games. You can teach your children at a young age the importance of activity. You are the example, so work to set a good one!

Certainly, as we age, it is the norm to become even more sedentary than we were in our younger years. We adapt to postures that are comfortable and require less muscle activation and energy to hold. Most of the activities that we perform throughout our day work the muscles on the front side of our bodies since most of what we do draws our bodies forward and very little we do requires us to extend back behind our bodies. This means that the muscles that are used the least are those extensors including the glutes, lats, lower traps, and external rotators that work to hold us all upright. Also, we allow our bodies to slink forward into a lazy posture that has us relying on the tension of our ligaments and tendons instead of our muscles to hold us upright (i.e. locking our knees back, thrusting our hips forward, rounding our shoulders forward). All of these postural habits, or tendencies, lead to disuse of important muscles such as the transversus abdominus, multfidi, and our pelvic floor which are important for controlling continence and back pain. We also have decreased muscle activation in our legs, leading to muscle breakdown and an increase in adipose or fat tissue that is linked to increased arthritis symptoms. The final postural mistake that we all make is to round our shoulders forward, stretching out the weakened muscles of our mid and upper back. This leads to changes within our spine, giving our upper back a hump, limiting the amount of air we can take into our lungs, and pulling our head forward, stressing our neck.

We can take all the pills we want to control many of these symptoms, but the honest answer is that increasing our activity level is the best medicine for our bodies. Be conscious of the amount of time you spend sitting and begin to perform strengthening exercises for those muscles that aren’t used as much throughout our daily activities. Also be aware of the posture you hold and work to recruit those muscles that hold us in a healthy neutral spine posture (see Give Your Tail Bone a Lift). All of these efforts will help to prevent muscle breakdown and the subsequent symptoms that come along with decreased muscle activation.

Below, I have included some simple exercises to work the back sides of our bodies. They are a great starting point for all of us!

2-Step Kegel Sequence (8 repetitions): To perform a 2-step Kegel sequence, begin on your back with your knees bent. In this position, first perform a Kegel contraction by tightening your pelvic floor as if to stop the flow of urine or the passing of gas. Hold this Kegel contraction as you begin to elevate your pelvic floor up into your pelvic outlet. Imagine there is a string attached from your belly button down to your pelvic floor and you are attempting to pull it up. Keep pulling that “string” up for a full 8-count. (You will feel your belly button draw in as you work to pull your pelvic floor higher and that is okay. This is your transversus abdominus coordinating with your pelvic floor)

At the count of 8, release your hold, relaxing your pelvic floor down, allowing yourself to take in a deep breath and release, relieving all muscle tension. Now, follow with 4 quick flicks or quick Kegel contractions. With this action, you are only tightening the muscles around the openings of your pelvic floor as if you don’t want to pass any urine or gas. These are quick contractions with a quick release to a rhythm of “tighten, relax, tighten, relax” and so on for four quick flicks. These quick flicks isolate the sphincter muscles of your pelvic floor so your back shouldn’t move and your legs should remain in the same position (bent at 90 degrees) as when you started the exercise. At the end of your 4 quick flicks, reset, and perform a 8 second pelvic floor elevation once again. Repeat this entire sequence 8 times.

Bridge with adductor squeeze (3 sets of 8 repetitions): To begin, position yourself on your back with your knees bent, squeeze your buns tight, press through your heels, lifting your buns up off the floor (to the point that your thighs and hips make a straight line) for a 3-count before slowly lowering. Continue to a rhythm of “bridge up 2, 3, and down, bridge it up 2, 3, and down…and so on for 8 repetitions.

Standing multifidi extension (3 sets of 10 repetitions): Standing so that you have a side view of your body in a mirror will give you the best visual feedback for this exercise. Place your hands on your hips, so that you can feel the subtle movement of this exercise. As you activate your multifidi muscles of your low back, you will tilt your tail bone “up.” The view that you would see in the mirror would be the motion of being in neutral spine, moving to more of a gymnast posture when you activate your multifidi muscles. Make sure the movement is at the level of your pelvis only and there is no movement of your legs, upper back or shoulders. Repeat this multifidi extension for 10 repetitions. Remember that your pelvic floor muscles attach to your tail bone, so with each extension you are increasing the tension in your pelvic floor muscles and then relaxing them repetitively throughout the reps.

Prone W’s – (3 sets of 10 repetitions): Lie on your stomach, with your palms flat on the floor, making a “W” position with your arms (i.e., elbows bent, palms down, with your finger tips aligning approximately with the top of your head). Lift both arms slightly off the ground, squeezing your shoulder blades down and in. Remember to pull your elbows down so you feel it between your shoulder blades and not in your neck.

General Health Posture September 27, 2010

Questions from You to Me: What You Recommend vs. What Whole Woman Recommends

I have performed Kegel exercises off and on in the past then I read on “WholeWoman.com“, Christine Kent wrote that Kegel exercises can actually worsen a prolapse and cause further prolapse. I know you and her both prescribe the same posture, but why do you think she says that about Kegels?

I want to make a very strong point. Christine Kent of Whole Woman and I DO NOT agree on posture, Kegels, breathing, muscle activation, and more. The path she prescribes is very specific, which simply does not work for a physical therapist who is always evaluating various treatment paths, depending on the patient’s symptoms, lifestyle, activity level, etc. In other words, I believe it’s important to recognize that there are a lot of different paths available to get to the same point.

To address my approach to Kegel exercises: I believe it is naive to think that Kegels are all one has to do to control incontinence or prolapse symptoms. But, Kegel exercises are certainly a very important piece of the puzzle. An appropriate Kegel sequence, as I teach and as Brianne Grogan at www.pelvichealthplus.com teaches, includes both squeezing the muscles and elevating the muscles. This 2-step process is necessary to activate all of the fibers of the pelvic floor. It is this pelvic floor that is the soft tissue barrier closing off our pelvic outlet. Our pelvic floor lends support to our rectum, vaginal canal, our bladder, our uterus, and urethra. These are not passive muscles…they actively contract in a healthy body and when we lose the ability to contract these muscles efficiently and effectively, we begin to see symptoms of incontinence and/or prolapse. So Kegel exercises are one of the main components of an effective rehabilitation program.

To address my approach to posture: Christine Kent and I strongly disagree on posture. I teach a neutral spine which is a natural, subtle lumbar curve that requires activation of both the multifidi muscles of the low back and the transversus abdominus (lower abdominals). Co-contraction of these two muscles will automatically turn your pelvic floor “on” so that you naturally hold a healthy tone in your pelvic floor throughout your daily activities. This neutral spine position gives a slight lift to your tail bone, putting your pelvic floor muscles at the perfect length/tension to contract efficiently and effectively. I teach posture that requires muscle activation to hold and support our body in its optimal position. This same posture has a positive impact on bone health, breathing, and muscle function throughout our bodies. Christine’s posture instruction puts clients in an extreme position of extension in their low back and asks women to simply let their belly hang out and fall forward. I don’t think there is a physical therapist that would support this instruction and I would be willing to say that every woman adapting this posture will suffer from mechanical low back pain, if not immediately, then down the road at some point.

I hope I have not spoken too strongly, but I definitely wanted to draw a clear line between programs I would refer you to such as www.pelvichealthplus.com and www.prolapsehealth.com, versus others that I would avoid. Let me know of any other questions you have.

Kegel Posture September 24, 2010

Questions from You to Me: Hypertone of the Pelvic Floor

My sister has been diagnosed with a pelvic floor that is always contracting. Will your DVD help her?”

If your sister’s diagnosis is hypertone of her pelvic floor, then she really needs to concentrate on the relaxation phase of pelvic floor exercises. I still believe patients with hypertone benefit from strengthening exercises as long as they prolong the relaxation phase and allow their pelvic floor to completely let go.

I often describe this like when we make a tight fist and our knuckles turn white – that is what a pelvic floor that never relaxes can look like – unhealthy, lacks blood flow, and dysfunctional. Exercising these muscles, allowing a lengthened relaxation phase, allows for an influx of healthy blood flow similar to opening and closing your fist.

Often, to recognize how to relax the pelvic floor, manual feedback from a physical therapist is required. You can find a women’s health physical therapist in your area at www.apta.org under “find a PT.”

Pelvic Floor Muscle Spasms September 11, 2010

Schooling Up on Pelvic Floor Dysfunction: How Working Knowledge Can Drive Positive Changes

by guest blogger, Michelle Herbst, MPT, DPT

As a young lady, I loved the start of a new school year. When I heard the late summer locusts calling, my eager anticipation began of meeting my teacher and, yes, learning new things. My love for learning has continued into adulthood and has made it easy, as a clinician, to embrace the time commitment of delivering comprehensive and quality patient education. I love the light bulb moment of seeing the patient’s face light up when they begin to have a working knowledge of their diagnosis. The light bulb moment often allows the patient to become more accepting of their current limitations and have a renewed sense of commitment to and respect for the healing process. In order words, expanding a patient’s knowledge base allows her to realize just how awesome the healing process can be and often spurs long-term positive changes. So, now that school is in session let’s turn our attention to what pelvic floor dysfunctions (PFD) is. My hope is that the information presented may create a light bulb moment for you as you improve your working knowledge about PFD.

Before we go further, let’s define what a healthy pelvic floor is. What are the characteristics of a healthy pelvic floor? Per Wang et al, a healthy pelvic floor includes the normal placement of pelvic structures and normal functioning of the pelvic muscles, bladder, and bowel. By contrast, those individuals with PFD have abnormal placement of pelvic organs or structures, and/or impaired functioning of the bladder or bowel.

What diagnosis or diagnoses are associated with PFD and what causes PFD? PFD is a set of clinical disorders which generally includes urinary and fecal incontinence, pelvic organ prolapse, impaired emptying of the urinary tract and bowel, sexual dysfunctions, and pelvic pain. PFD affects millions of women and, early research suggests, four percent of men. The cause or etiology of PFD is not clear-cut, black or white. Rather, it results in varying shades of gray and is typically related to injury to pelvic muscles, nerves and connective tissues. Risk factors for PFD include being female, aging, pregnancy, interstitial cystitis, obesity, and low back pain.

How is PFD diagnosed? Urologists and OB/Gyns are trained in examining and diagnosing PFD by observing and palpating pelvic structures and by collecting and evaluating objective data such as voiding data and diaries. Additionally, nurse practitioners and women’s health physical therapists can collect additional quantitative data confirming the diagnosis of PFD by using electromyographics (EMG), which measure the activation and relaxation patterns of pelvic floor muscles.

PFD includes a range of diagnoses that relate to how your pelvic floor or basket works. As clinicians, our goal is to improve the patient’s working knowledge of something specific which includes simply knowing how to do something. Specific to pelvic rehabilitation, working knowledge is the ‘how to’ for improving the function of your pelvic basket.

OK – so here is your test:

What is your working knowledge for PFD diagnosis?
Have you been properly diagnosed by a qualified health care provider and what is your diagnosis?
Do you have risk factors that you could change, such as obesity and low back pain that you may be able to address to improve your pelvic floor health?
Do you have a treatment plan that is being administered by a qualified provider? If not, what are your options?
Have you used Hab-It: Pelvic Floor or thought about using the Hab-It program?

Our commitment at Hab-It is to provide you the tools and resources for successfully managing and rehabilitating PFD. As your knowledge base grows, so will your commitment to positively impact your pelvic floor function. This may occur through the use of the guided Hab-It workouts, posting your questions to “Ask Tasha,” or working with your local women’s health physical therapist in conjunction with the Hab-It program.

Knowledge is power. Now that you identified a way to improve your pelvic floor function, I challenge you to learn it, do it, live it. You will be grateful you did.

References: Wang Y-C, Hart DL, Miodusk JE. Characteristics of Patients Seeking Outpatient Rehabilitation for Pelvic Floor dysfunctions. Physical Therapy. 2012; 92(9): 1160-1173.

General Health September 5, 2010

Deciding What Is Right for You To Treat Symptoms

Making your own individual treatment decision on how to treat your pelvic floor dysfunction will depend on your symptoms, what you have already tried, and what you have researched. There is no doubt that there are success stories out there for all the treatment options available, including exercise-based rehabilitation of the pelvic floor, medication for symptom management, pessary use, and various surgical procedures. It is not my job to speak out against any decision that you may choose, but it is my job to help make you more informed so that you can make a decision that is well thought out.

Of all the treatment options listed, there is only one option that can cause permanent damage and that treatment is surgery. The “quick fix” may sound perfect to just take care of your symptoms, but there is no going back after you attempt surgery. I have included a study below that highlights many of the concerns associated with surgery. My recommendation is that you thoroughly research all of your options (read through my previous blog, “Finding your options and knowing your risks,” before making a decision so that you are confident you gave yourself every opportunity to heal naturally and without risk.

From Reuters Health Information
Mesh Support for Vaginal Prolapse Repair Prone to Erosion

NEW YORK (Reuters Health) Jul 28 – Polypropylene mesh placement during vaginal reconstructive surgery for pelvic organ prolapse appears to do more harm than good, according to a small randomized trial in the August issue of Obstetrics and Gynecology.

The investigators stopped study recruitment early when five of 32 women experienced mesh erosion.

According to the American Urogynecologic Society, about half of all women between the ages of 50 and 79 have some form of prolapse, and about 11% in the U.S. will have it surgically treated. Approximately 200,000 procedures for correction of pelvic organ prolapse are performed each year in the United States.

Physicians at three academic centers in the U.S., led by Dr. Cheryl B. Iglesia at Washington Hospital Center, Washington, DC, treated 65 women (mean age 65) with uterovaginal or vaginal prolapse. They randomly assigned 32 women to colpopexy with Prolift mesh (Ethicon Women’s Health & Urology) and 33 to vaginal colpopexy without mesh. Women with a uterus also underwent vaginal hysterectomy.

Patients were blinded as to group assignment, as were evaluators at months 3 and 12.

The women in both groups reported very high subjective satisfaction with their procedures, with no significant differences in scores on quality-of-life questionnaires at 3 months.

During median follow-up of 9.7 months, 59% of women in the mesh group and 73% in the no-mesh group had recurrence of their prolapse, a nonsignificant difference.

Erosion of mesh support developed in 15.6% of patients within 2.1 months of surgery. Three erosions required surgical removal.

“This study questions the value of additive synthetic polypropylene mesh for prolapse repairs considering that there are no statistically significant differences in subjective or objective cure rates,” the investigators conclude.

The authors note that in 2008, the US Food and Drug Administration reported on complications from mesh use, such as erosions, infection, pain, incontinence and rare but serious visceral injury. In response, manufacturers have developed lighter weight and mixed composite meshes, including the next generation Prolift +M, but they have no long-term data for the new products.

SOURCE: Abstract

Obstet Gynecol 2010;116:293-303.

Understanding Prolapse August 29, 2010

Question from You to Me: Exercises When Short on Time

Once you work through all of the workouts featured on our DVD, you will likely find a few that will be your “favorites” and that’s okay. The exercises we like best are the exercises we are most likely to stick with during our busy schedules.

My routine is doing my Kegels in the car while driving. I tend to do my Samuri Squats while in the shower, a balance exercise while brushing my teeth, and then I can usually get a bridging and plank exercise in when I am playing with the kids. Nevertheless, I recommend really learning the exercises thoroughly that are featured on the DVD, making sure to really understand the instructions. Then you’ll find your own way, and some you will “feel” more than others.

I think the key for me is that I know all the exercises so well, that they almost pop into my head when I find myself lying on my stomach, or on my side, etc., and that’s when I get in a few repetitions. The exercises are great not only for your prolapse issues, but also for posture. This is key because, as mothers, we spend a lot of time bending over, hugging, and carrying our little ones which doesn’t bode well for us if the years go by and we do nothing to fight against the effects of gravity.

So here are my personal favorites to squeeze in on a very busy day:

I love multifidi extensions alternated with a glute/heel squeeze
I always get in a bridge with adductor squeeze or bridge with alternate leg extension.
I alternate the bridge exercise with an advanced plank exercise.

DVD Questions August 16, 2010

Aging and Incontinence

A common thought is that incontinence, or occasional urine leakage , is a normal part of aging. Although it is true that the prevalence of incontinence increases with age, it is not considered normal to leak urine at any point in our lives.

It is important that we recognize incontinence as a symptom and not as a disease. It is a symptom of bladder and/or pelvic floor muscle dysfunction. There are many risk factors associated with this dysfunction including a history of smoking, pregnancy and childbirth, pelvic surgery, obesity, chronic cough, repetitive heavy lifting, neurogenic disease, hormone changes and more.

Certainly as we age, we may recognize one or more of these risk factors in our own personal history that will put us at higher risk to experience incontinence symptoms.

Also with age, we all experience a gradual loss of muscle tissue throughout our body. This is a natural process that occurs with age along with a decline in our cardiovascular and respiratory systems and a decline in our bone density as other examples of this natural process. As we age, we will all experience a loss of muscle strength and endurance throughout our bodies including our pelvic floor muscles.

It is important to recognize that we can slow the loss of muscle tissue with appropriate strengthening exercises for our pelvic floor and surrounding muscles of our pelvis and abdomen. Working strength and endurance of our muscles as well as recognizing postural changes that may be taking place as we age are important steps to keeping our pelvic floor muscles working efficiently and effectively.

Understanding Incontinence August 10, 2010

Why Choose a Women’s Health Physical Therapist?

Did you know that no matter what treatment option you choose for your pelvic floor dysfunction, it is always recommended that you follow up that treatment with an exercise program to strengthen your pelvic floor muscles.

If you choose surgery, it is important to strengthen your pelvic floor muscles following the procedure to support the work that was done and, hopefully, increase the length of time the sling or mesh may be effective.

If you choose a pessary device, you want to continue to strengthen your pelvic floor muscles and monitor your posture to decrease your dependence on the device. You may also have the goal of eliminating the need for a pessary device in the future, so a consistent pelvic floor program is highly recommended.

If your treatment choice is to take medication to control you incontinence symptoms, again, exercise is also recommended. Studies have shown that taking medication in conjunction with a regular pelvic floor exercise program to treat incontinence symptoms is much more effective than taking medication alone.

Exercise is consistently recommended, no matter what treatment option you choose to control your incontinence or prolapse symptoms. The best place to receive exercise advice for muscle groups that are no longer working as they used to, is from a Physical Therapist. Physical Therapists are trained through post graduate work to treat muscle and joint dysfunction. More specifically, a women’s health Physical Therapist has thoroughly studied the pelvic floor and the supporting muscles of the pelvic and abdominal basket.

Women’s health Physical Therapists are the professionals that teach pelvic floor rehabilitation on a daily basis, taking the latest research available and applying it to each patient according to their symptoms and goals. In a visit to a women’s health Physical Therapist, you would receive thorough patient education on the anatomy of your pelvis and the muscles that support it, hands-on posture education to give your body the best opportunity for optimal function, and thorough coaching through an exercise program. You will be getting one-on-one, hands-on guidance, from a professional trained specifically in pelvic floor rehabilitation.

So why a women’s health Physical Therapist? Because you give yourself the best chance to completely resolve your symptoms with a combination of treatment options or an exercise-based program alone. You can find a women’s health Physical Therapist in your area at www.apta.org under “Find a PT”.

Understanding Incontinence Understanding Prolapse July 31, 2010