Educate Yourself about Incontinence, Prolapse, and General Health

Mis-Information About Kegels

I recently read through two different sites with the bloggers writing about how Kegels are worthless. If I could delete these entries just as quick as I read them, I would so that it didn’t cause any more confusion for all of you searching for answers. Do I agree that pelvic floor strengthening has been over-simplified – YES! But to say that you don’t have to do another Kegel is simply not correct. Our pelvic floor is a muscular area with the ability to tighten on the urethra (the pathway from the bladder to our urethral opening in our pelvic floor) and to support/cradle our pelvic organs. Not to mention the sphincter muscles of our pelvic floor which provide the second line of defense within our pelvic floor to control the passage of solids, liquids, and air from our bodies.

To say that we don’t have to and shouldn’t work this muscle makes no sense. It has a neuromuscular connection to our transverses abdominus and our multifidi, working as our three deepest core stabilizers. These muscles play a huge role in our posture and in maintaining stability of our lumbosacral spine, as well as controlling issues such as incontinence and prolapse. So how do I believe we should work our pelvic floor for optimal benefit?

It starts with the ability to find and contract each of these muscles individually and then progresses to exercises where they all three fire together. Let’s start with our transverses abdominus, then talk about our multifidi, and finish with our pelvic floor and the coordination of our deepest core stabilizers.

Our transverses abdominus (TA) wraps around us like a corset. This muscle is able to stretch lengthwise to accommodate a pregnancy belly and still work to support our low back and pelvic floor. Think of this muscle as the shrink wrap – the deepest abdominal layer that encircles your spine, extending down within your pelvis. To activate this muscle, work to pull your belly button up and in. The best exercise to start with to help find and activate your transverses begins on your hands and knees. In this position, relax your belly, allowing it to hang loose. When you contract your TA by drawing your belly button up and in, you will see your belly draw up from its relaxed position to a tighter position. Keep in mind that you want no rocking of your pelvis when you’re in this position on your hands and knees. If we rock our pelvis in order to hollow out our mid section, we will actually be activating our rectus abdominus which is not our goal. So take care to keep your pelvis and low back in a locked position as your draw your belly up and in.

To find and activate your multifidi muscles of your low back, stand by a mirror so that you have a side view of yourself. In this position, rotate your pelvis, giving a small lift to your tail bone. Your multifidi are small muscles in between each segment of your spine that help to extend each of these joints and can lock you in neutral spine when your pelvic floor needs to pull on a secure anchor that is your tail bone. You should see a slight lift of your buns in the mirror and a slight increase in the arch of your low back, but no other movement of your upper or lower body. Work to isolate these muscles with repetitive, small extensions of your lumbosacral spine.

Our next step is to contract and elevate your pelvic floor muscles. We have talked extensively throughout my blogs on how to activate every fiber of your pelvic floor muscles and we will review it all again now. Your initial contraction is to squeeze your muscles as if to stop the flow of urine or the passing of gas. The next step is to draw your pelvic floor up into your pelvic outlet as if there is a string attached from your belly button down to your pelvic floor and you are attempting to draw it up into a flattened, tighter position. It is during this step that you will feel your belly button draw in, as you co-contract your transverses abdominus with your pelvic floor in order to elevate the muscle fibers. It is these muscle fibers that tighten to elevate our pelvic floor that work as endurance muscles, cradling our pelvic organs and squeezing on the urethra before it reaches our urethral opening. Working longer holds is appropriate for these muscle fibers, so tightening and elevating your pelvic floor, and continuing to pull up on that string attached to your pelvic floor for a full 8-10 count is your goal. Then you can switch your focus to the sphincter muscles of your pelvic floor. Remember, they squeeze the three openings within the pelvic floor tight so we want these muscles to fire quickly if needed. To exercise these quick reacting muscle fibers, we can work them through “quick flicks” of our pelvic floor. Following a long hold with quick flicks that are performed repetitively to a rhythm of “contract, relax, contract, relax, contract, relax, contract, relax”, will work all the fibers of your pelvic floor. This combination of longer holds and quick flicks performed 8 times each day will keep your pelvic floor firing efficiently and effectively.

Finally, we change our focus to the coordination of firing our deepest core stabilizers (TA, pelvic floor, and multifidi) before every lift, every reach, every cheer, etc. We have just reviewed how to contract each of these muscles individually, but now the final step is to coordinate their actions. Contracting our multifidi muscles, giving a slight lift to our tail bone and locking it in this position is important as our pelvic floor attaches to our tail bone and will pull against it. If we don’t activate our multifidi muscles, our tailbone will move when we activate our pelvic floor, leaving us with a weak, ineffective pelvic floor and possible symptoms of incontinence and prolapse. By finding our neutral spine, which requires us to activate our multifidi muscles, we ensure that our pelvic floor is pulling against a solid tail bone or anchor. As we squeeze and elevate our pelvic floor by drawing it up into our pelvic outlet, we automatically activate our transverses abdominus. Our transverses abdominus co-contracts along with our pelvic floor, displacing pressure up under our ribs as it squeezes like a cone within our pelvis. This co-contraction of our TA and pelvic floor creates a stronger contraction of our pelvic floor muscles as it lifts the pressure off of the working muscle fibers.

So putting all of this together is the challenge that will lead you to optimal pelvic floor control. Working to find neutral spine and performing a pelvic floor strengthening sequence while lying down, while sitting, and while standing as instructed on our Hab It: Pelvic Floor DVD is functional training of the deepest core stabilizers. A progression of exercises as included on the DVD will train this firing pattern that will allow you to remain continent and in control throughout all of your daily activities!

Favorites Kegel Pelvic Basket Muscles May 24, 2010

Developing a Strategy to Manage Incontinence

It is important to develop a strategy to help you manage your incontinence. This may include special clothing or the use of devices that will allow you to continue with normal activities as well as any recreational activities you choose to participate in. We will review four strategies that can help you to manage your incontinence.

The first management strategy is use of a pessary device. A pessary is a small latex or silicone device, similar to a diaphragm, that you insert into your vaginal canal to give better support to your bladder and urethra. The goal is to hold your bladder and urethra in its appropriate position. This takes pressure off of your pelvic floor muscles, allowing these muscles to squeeze tight on the urethra, preventing urine leakage. Your healthcare provider can help fit you for a pessary device that is the right size and shape for optimal performance and comfort.

The second management strategy is use of a urethral plug. These plugs again can be rubber or silicone plugs that are designed to be inserted in and removed directly from your urethral opening. The goal of the many different types, sizes, and shapes of urethral plugs is the same: to temporarily block urine flow out of the urethra between bathroom breaks. You can talk to your healthcare provider to discuss different options available to you if this is a strategy you may want to use.

The third management strategy is the one most commonly used and that is absorbency products. The newest absorbency products, including absorbency pads and protective undergarments have essentially replaced the adult diaper. The newer products are more discreet because they are lower profile and are treated to control odor and minimize skin irritation. This allows more comfort for the user and greater confidence in continuing with an active lifestyle.

A fourth management strategy is wearing compression shorts, which I have mentioned in a prior blog entry. This strategy uses a common physical therapy rehabilitation principle called “proprioception.” Shorts that provide compression and support to our pelvic floor will enhance the proprioception of our pelvic floor muscles, which improves the efficiency with which the muscles will fire. Triathalon shorts are one example of compression shorts and the light biking pad in these shorts gives comfortable compression directly to the pelvic floor. These shorts can also hold an absorbency pad in place if extra protection is needed. Compression of your pelvic floor may be just what you need to get back on the hiking trail, the walking path, or back to whatever activity you love.

I recommend that you contact your healthcare provider or search the internet on “incontinence devices” for more information.

Understanding Incontinence May 16, 2010

Questions from You to Me: Kegel Positioning

After viewing your DVD, I know I was doing my Kegels correctly but I have been doing them lying in bed only. You have sitting and standing Kegels on the DVD but these are hard for me. Does it matter if I just do them lying on my back?

Glad you were doing your Kegels correctly! Progressing from supine to sitting to standing is a progression in difficulty as are the exercises in workouts 1 through 4, respectively. Progress only as you are able – meaning make sure you can do them correctly. Otherwise, you are not ready. The best part about mastering Kegels in the sitting position is that they become a car exercise. Every time I enter my car, I think of posture and Kegels. I usually do them while taking my son to preschool and back, which is great because it fits into my busy schedule! Then you will progress to mastering the standing Kegel, which is even more difficult, but the most functional. We have to be able to activate our pelvic floors in the standing because- this is the position we are in when we feel the prolapse the most.

Bottom line, give yourself a 2 week progression to master the standing Kegel. I have no doubt you will.

I have noticed that my legs shake a bit when I do the Kegels lying down.

This is OK. It means that your muscles/nerves are working so hard to find the right contraction or the right firing pattern. This will subside.

DVD Questions Kegel May 10, 2010

Vitamin D and Pelvic Floor Strength – Is There a Link?

Incontinence is not a disease. It is a symptom of pelvic floor and/or bladder dysfunction. The root of this dysfunction may be poor muscle strength or endurance of the pelvic floor. It may also be altered or blocked transmission of the nerves that communicate with the bladder or pelvic floor muscles.

There are many risk factors that can cause the altered nerve communication or poor pelvic floor muscle function. They include: smoking, obesity, pregnancy and childbirth, pelvic/abdominal surgery, neurogenic disease, chronic cough, repetitive heavy lifting, hormone changes, and more.

Researchers continue to discover new risk factors as they study incontinence and prolapse symptoms. A recent study on vitamin D deficiency showed a relationship between low vitamin D levels and pelvic floor muscle weakness. You can read more details on this study and the recommended levels of vitamin D we should all strive for at http://search.modernmedicine.com/search?qgeneral=vitamin+D+and+pelvic+floor&searchtype=defLink

This is one study and I am not one to jump on every new piece of research and take it for fact. Certainly, there needs to be a follow up, but doesn’t it make you wonder what your Vitamin D levels are?

General Health April 27, 2010

Healing after Baby: Incisions

by guest blogger, Michelle Herbst, MPT, DPT

Bringing a baby into this world can be hard work for some Moms. Pregnancy may be filled with aches, pains, nausea and moments of joy mixed with concerned anticipation. Motherhood is a wonderful time in a woman’s life and the sacrifices are worth the rewards. Caring for the baby and others is what we Moms do. As the focus shifts away from the pregnant mom to the newborn, how is Mom doing? Remember learning the terms episiotomy or C-section? If you’re an American Mom these words may be a reality.

Most new Moms heal well from episiotomy and C-section incisions but some mothers do not, and may ignore the problems they are having. Moms that aren’t healing well or haven’t healed well may not feel quite right. They may ask themselves, “Why does it hurt when I insert a tampon? Why can’t I unload the dishwasher without pain or stretching in my belly?” Intercourse likely isn’t on their radar any time soon and these Moms often continue to ignore their concerns and remain silent.

Don’t let this be you! Remember the scar that remains was once a surgical incision that was made to facilitate the delivery and improve the safety for the Mom and baby. Painful scars can occur after an episiotomy and C-section due to the adhering/ interweaving of the skin and muscle tissue during the healing process. The episiotomy was made by making a surgical cut through the skin, subcutuaneous (fat and connective tissue) and muscle layers. During a C-section the surgical incision further extends into the abdominal cavity and uterus. The incision may be closed with absorbable or nonabsorbable thread, staples or clips.

What can be done? Ideally, pain medication and routine use of ice can help as soon as the surgical procedures are complete. Staples are typically removed prior to discharge and within five to ten days the stitches will have dissolved. Once the stitches are absorbed incision or scar massage can begin. However, incision mobilization or scar massage can be done weeks, months and even years after the incision was made.

Incision or scar mobilization works by simply moving the skin along and against the grain of the incision. Incision or scar mobilization may be done one to two times per day until symptoms have resolved or improved and does not cause in redness or bruising.

Below is an outline of how to complete incision/scar mobilization to make it a more effective and pleasant experience:

You can warm the affected skin using a towel, wash cloth or soaking in a warm tub. This may help decrease sensitivity by increasing blood flow and promote relaxation and can help you get used to touching the area.
With two fingertips, gently make circles along the incision. When working on an episiotomy incision it may help to make gentle circles using a wash cloth. C-section incision may be touched directly. You may feel some initial discomfort but, if you do, simply let up on the pressure. It is normal to feel hesitant.
Lastly, when you can perform the gentle circles without pain, you can begin rolling the incision. C-section incision can be rolled by gently lifting the incision away from the abdominal wall and gently rolling the incision between the thumb and forefinger. Episiotomy incisions are more difficult to roll due to their smaller size and location. But, the technique is the same.

References: Simkin, P. et al. Pregnancy Childbirth and the Newborn The Complete Guide. 4^thed. New York. Meadowbrook Press; 2001; 291-293, 324.

Pregnancy/Post Partum April 22, 2010

Easing the Strain On Your Pelvic Floor: A Couple of Tips

I want to share a couple of tips that many of my patients have found helpful in their journey through pelvic floor rehabilitation and return to activity: triathalon shorts and a high fiber diet. The high fiber diet seems logical to reduce any added strain on our pelvic floor, but the triathalon shorts…pretty random right? I agree, but so many women have shared these tips with me that I must pass them on.

Let’s start with the tri short. The benefit of the tri short is two-fold. Number one, they hug tight to your hips and buns as any spandex short would, but the light pad included in the triathalon short provides a comfortable compression to your pelvic floor. Why is this helpful? There is something called proprioception that we work on a lot in the physical therapy clinic. It’s your body’s awareness of where it is in space. It has been shown that providing compression to a joint or muscle can improve the proprioception of stabilizing ligaments or tendons and the muscles, helping them to fire more efficiently and effectively. You see many athletes using the compression sleeves on knees or elbows to provide this effect to a joint that is weaker than its counterparts. The triathalon short provides this same proprioception to our pelvic floor muscles.

The second benefit of the triathalon short comes from the same light padding that improves our muscle firing with compression. The pad can also provide some absorption for minor leaking without having to wear a pad as you work to get your pelvic floor muscles strong enough to allow walking, running, or hiking symptom-free. And even if your leaking is a bit more than the pad can absorb, these shorts will hold any absorption product in place because of the tighter fit.

Although, the use of these compression shorts hasn’t been medically researched, enough of my patients swear by them that I don’t hesitate to recommend them. I personally like the low rise DeSoto triathalon short as I wore these first while I was pregnant and the low rise waist band was a perfect fit under my pregnant belly. To be honest, they continue to be my favorite to this day!

The second tip that I want to share that will ease the strain on your pelvic floor is a high fiber diet. This suggestion comes from the desire to alleviate all downward pressure on our pelvic floor muscles. A high fiber diet along with plenty of water will alleviate the tendency to breath-hold and push when voiding. The benefits of a high fiber diet include better motility through our bowel and may translate into lower LDL cholesterol levels. These benefits make a high fiber diet an easy recommendation.

When looking for high fiber food choices, keep in mind that fruits and vegetables are some of your best choices. Foods with oats, beans, and whole wheat will also increase your fiber intake. If you don’t see the benefit of easing your bowel movements with food choices alone, you may choose to add a daily spoonful of Metamucil or Benefiber to a glass of water for that extra burst of fiber in your diet. Remember, the potential benefits of a high fiber diet include lower risk of colon cancer, lower LDL cholesterol levels, typically more heart healthy food choices, and of course, easing the strain on your pelvic floor.

Good luck everyone. Hope these two tips help you on your path to better pelvic floor health. Any other tips out there are welcome. We will all benefit from the stories of what works for you!

General Health April 15, 2010

Questions from You to Me: Techniques During Pregnancy

I have a pregnancy class that I teach and I am unsure which position I should teach the pelvic floor lift and holds?

I would recommend your clients perform the pelvic floor lift and holds and quick flicks in a seated position. Coach them to find their “tripod” first and then perform the exercise. This is easiest on a Swiss ball but can be performed sitting anywhere once they master it. The sitting and standing positions are far more functional, as well as being more advanced. Teach the supine version to help them feel the muscles they are drawing up and then progress to sitting and standing contractions. No matter what trimester they are in, they will be okay on their back for short periods of time if this is the only position they feel they can get a strong pelvic floor contraction.

Also, the women I teach seem to take a breath in when they elevate their pelvic floor. Is this okay?

The tendency will be to breathe in as they draw the pelvic floor up and this is okay as long as they are continuing with a regular breathing pattern for the length of the hold. They are actually teaching themselves to expand their rib cage and chest by doing this, which is a positive. Anyone who is seeing expansion of their belly when breathing in is on the wrong track because this actually forces their pelvic floor down.

Breathing Pregnancy/Post Partum April 8, 2010

Questions from You to Me: Exaggerating the Curve of Your Spine – Good or Bad?

I have been told to exaggerate the curve of my lumbar spine, is this your neutral spine?

No. Neutral spine is a happy medium between the two extremes of the lumbar spine. It is a position that requires muscular control because we are not relying on bone-on-bone compression. Not to mention that if we exaggerate the lumbosacral curve, our spine has to balance out the curves which this leads to an exaggerated thoracic and/or cervical curve. To a physical therapist, this means that the shoulders are forward and there is decreased room for chest/lung expansion (this is bad for the displacement of that room the diaphragm takes up when we breathe in because it means more pressure on our pelvic floor or smaller more frequent breaths). Not to mention the forward head displacement wreaks havoc on our upper back and neck muscles and vertebrae. I believe that if you hold this posture consistently and we jump ahead 5-10 years and evaluate all of your pains/aches and pelvic floor symptoms due to this posture coaching, it wouldn’t be a pretty picture.

Posture April 5, 2010

The Who, What, and Why of Manual Therapy for the Pelvic Basket

by guest blogger, Michelle Herbst, MPT, DPT

The pelvic basket is an intricate weaving of muscles, tendons, and ligaments that support our pelvic and abdominal organs and assists in bowel and bladder control. As discussed in Tasha’s blog post, The Positive Side Effects of Pelvic Floor Muscle Weakness, “the pelvic basket incorporates the front, back, sides, and floor of your pelvis and lower spine that provide the deepest layer of stability to your body.” Muscle tissue is normally pliable but poor postural habits, trauma to the pelvic basket or chronic tension of the pelvic basket muscles may lead to the development of shortened tissues, scar tissue, and tender points. Normally the muscles of the pelvic basket contract and relax resulting in the basket moving up and down. However tissue changes within the pelvic basket may inhibit normal muscle function resulting is a pelvic basket that is less mobile.

So, what can be done to restore normal pelvic basket muscle function? One option is manual therapy. All tissues – including those of the pelvic basket – need hydration or fluid flow. The goal of manual therapy is to improve fluid flow, stimulate repair, and elongate tissues. Most tissue restrictions within the pelvic basket are related to poor postural habits or the result of poor tissue repair. In these types of cases there is a shortening of the muscle and connective tissue resulting in a loss of pliability or movement. Effective manual therapy techniques for pelvic basket conditions of involve techniques that stimulate fluid flow and provide for gentle stretching. Once the precise areas of shortened tissue, tender points, or scar tissue of the pelvic basket have been identified gentle manual forces can be used to stimulate healing.

The use of manual therapy is difficult and challenging. However, the rewards gained are well worth the effort. Manual therapy can be self-applied or performed by a skilled women’s health physical therapist. If seeing a women’s health physical therapist is not an option, it is a good idea to ask your family physician, OB/Gyn or midwife to assist you in identifying the precise location(s) of your muscle injury. Once that has been identified, one manual technique that may be used is a gentle press and manual stretch technique. The application of gentle pressure to the pelvic basket muscle tissues will stimulate fluid flow and begins the healing process. Yes, it is normal to be hesitant and feel initial embarrassment. But remember, these are muscles, muscles that need the gentle application of pressure to start fluid flow and healing.

Specifically, the gentle pressure and manual stretch technique uses a one to two fingertip pressure. The gentle fingertip pressure may be applied for 90 seconds or until the tissue softens or relaxes. Once the tissue has softened, maintain gentle pressure and follow that with a manual gentle stretch along the injured muscle. Manual therapy of the pelvic basket may be minimally to moderately painful but should be stopped if the pain is approaching severe. If the gentle pressure and stretch technique is applied externally, a water based lubricate can assist with the stretch or sliding on the skin surface. If you are using the gentle pressure and stretch technique internally to the pelvic basket, it is a good idea to use non-latex gloves. Repeated application of the gentle pressure and stretch may be applied to one area for up to 10 minutes, 1 to 2 times per week.

Who does manual therapy to the pelvic basket? Ideally, manual therapy should be performed by a physical therapist trained in women’s health physical therapy since this specialty involves further study in the evaluation and treatment of conditions affecting the pelvic region. Another option is to do it yourself although depending on the location of the tissue injury, the application of manual therapy to the pelvic basket may be too difficult to complete yourself. Spouses or significant others may also be able to apply the gentle pressure and manual stretch technique when they are educated on the location of injury and manual therapy techniques.

Reference: Lederman E. The Science and Practice of Manual Therapy. 2^nd ed. Edinburgh: Elsevier Churchill

General Health March 19, 2010

An Alternate Kegel Position During Pregnancy

I can confidently tell you that while pregnant, you can safely perform the series of Kegel exercises as coached on our Hab-It: Pelvic Floor DVD in any of the three positions demonstrated on the video. These positions include lying on your back, sitting, and standing. Although lying on your back can be contra-indicated during pregnancy due to pressure on your abdominal aorta, the two-minute segment of our Kegel sequence is sufficiently short to alleviate concern.

Today, however, I want to provide a 4th, alternate, position for those who want to avoid lying on their back altogether when doing exercises. This is a side-lying position in which we can perform our same Kegel sequence.

To begin, position yourself on your side with your head placed on a pillow or your hand. Bend your knees to 90 degrees, with one leg directly on top of the other. Your shoulders, hips, and ankles should all be in line, with your knees bent out in front.

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 visualize yourself elevating 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.

At the count of 8, release your hold, relaxing your pelvic floor down and allowing yourself to take in a deep breath and release.

Now, follow with 4 quick flicks or quick Kegel contractions. Keep in mind, with this action, you are 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. Remember, this exercise isolates 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.

A complete Kegel sequence consists of a pelvic floor elevation, followed by 4 quick flicks. I recommend you perform eight complete Kegel sequences each day to maintain good tone in your pelvic floor muscles. You do not have to perform all eight at once. You may find that your muscles fatigue too quickly to perform eight in a row, so you may benefit more from performing groups of Kegels throughout your day.

Remember, the key to successful rehabilitation of the pelvic floor is consistency!

Pregnancy/Post Partum March 11, 2010