Ever hear about "The 5 Love Languages" book? Dr. Gary Chapman discusses in his book the different ways to express and receive love, specifically through: acts of service, receiving gifts, physical touch, words of affirmation, and quality time. I’m always asking my husband for more quality time! That’s how I connect best to him.
Our bodies have their own language, and they’re speaking to us all the time. One of my body's love languages is physical touch with loved ones--hugs with friends and family, giving or receiving a hand on the shoulder for assurance, tucking my kids in at night.
When we feel good, our bodies tell us what we’re doing right – that we’re going to bed on time, eating the right food, surrounding ourselves with the right people. When we don’t feel well, our bodies are telling us – and sometimes screaming at us – to tell us that something isn’t right. These signs can come in the form of pain or muscle aches, and even fatigue, or anxiety.
Take a moment to listen to your body and learn your body's love language. Below are some examples of the love languages our therapists have with their bodies!
Being active, especially biking and climbing. -Bryn Zolty, PT
Spending time being outside and exploring. -Katelyn Sheehan, PT
Yoga, being in the woods, and walking barefoot directly on the Earth. -Marzena Bard, PTA
By Donna Zamost, PTA
Even wide shoes tend to be too narrow in the toe box. Shoes need to be wide across the balls of the feet for a proper fit, but they also need to be wide across the toes. Shoes that have a narrow toe box will squish the toes together. Take your shoes off and notice that your toes are the same width as your metatarsal bones. (Or should be!) Therefore, doesn’t it make sense the toe box should also be as wide as the ball of your foot?
The natural spread of your toes is known as toe splay.
It is an important part of how a foot functions. Toe splay is necessary for ankle stability and arch support, as well as activation of the intrinsic foot muscles (muscles within the feet). Allowing the toes to maintain their natural spread promotes a good base of support. This not only helps with balance, but it helps to reduce stress at the front of the foot when pushing off during walking and running. In shoes with a tapered or narrow toe box, the big toe angles in and all the toes are squished together, reducing the base of support. Over time, this can cause painful issues, such as bunions, hammer toes and ingrown toenails.
After years of dancing in this type of shoe, when I would take my shoes off, my toes would stay squished together. Over time, this unnatural position of my toes led to bunions and arthritis. I even required surgery in one of my big toes to restore a normal range of motion and allow me to walk without pain. Understandably, I am now very careful with my choice of shoes.
If your toes feel a bit squished together, there are things you can do to help restore your natural toe splay: While sitting, cross your ankle onto your opposite thigh and interlace your fingers between your toes to help spread them out. You can use your fingers to help stretch the toes and then when comfortable, use your fingers to move your toes up and down and in circles.
Another great tool that is becoming popular is something called toe spacers. These are made of soft silicone and help to spread the toes apart, allowing them to go back into their proper alignment. Toe spacers are available on the internet. I have a pair from a company called Correct Toes and I often wear them around my house while bare foot. I’ll even wear them in my athletic shoes during my power walks. I can definitely feel the difference in my body when my toes and feet are in the correct alignment.
So, if you are guilty of wearing shoes that have reduced your proper toe splay, switch your shoes to a pair with a wider toe box and try the above suggestions. Or come see us at Connect PT. We’ll have you back on your toes in no time!
by Karen Bruno, PT
Sometimes we're looking for something easy and quick to help us regain balance during our busy day. Here is a quick vagus nerve-regulating exercise that can be done daily. It will help to:
by Bryn Zolty, PT
Rib pain during pregnancy and postpartum can make everything difficult. Taking care of kids, lifting, carrying, rolling over in bed, getting out of a chair, and even breathing can hurt.
In many cases, this is due to musculoskeletal changes that occur during pregnancy. Your ribs start changing position even before your uterus is large enough to push pressure up into the diaphragm and rib cage. Therefore, it is thought to be hormonal changes that may play a large role in the alteration of the rib cage.
Rare Musculoskeletal Pain Cause
In rare cases, women will experience transient osteoporosis during their pregnancy. Throughout your pregnancy the amount of calcium transferred from you to the baby increases drastically. It starts at about 2 mg/day and by the 3rd trimester it could be as much as 250mg/day (1)! As with anyone with osteoporosis or osteopenia, there is an increased risk for fracture in your bones including the ribs. A weakened bone can fracture under normal forces, and if you suspect this you should contact your doctor.
Muscle dysfunction, painful joints, stiffness, and trouble with normal daily activities can be treated by a physical therapist. If you are pregnant or postpartum and have a pelvic therapist nearby, contact them and make an appointment. They have additional training to help a woman during and after her pregnancy.
When Rib Pain Is Not Musculoskeletal
There are many causes of chest pain that can occur during pregnancy. These include cardiac causes, clots, pneumonia, heartburn, peptic ulcers, shingles, and more. Your physician will help order any tests needed.
Get Started Before You Make An Appointment
For some women, the musculoskeletal changes that occur during pregnancy do not go away on their own. Here are some ideas to get started in case you are not ready to start physical therapy.
For getting your abdominal muscles fully back on-line immediately postpartum
How to help your abdominal muscles immediately after delivery (connectpt.org)
Improve Mobility During Normal Tasks
If you feel it is difficult to find time to exercise and stretch, start with incorporating lots of movement into your day. Add trunk rotation and side bending into your normal tasks. This will help mobilize the ribs and the spine. It can also help encourage the obliques to mobilize the ribs as well.
If your ribs feel wide and “stuck out’, focus on a long, full exhale. And absolutely work this breathing pattern into all kinds of stretches and yoga poses.
If you are pregnant and past your first trimester, it is important to monitor how you feel when laying on your back and limit this position. This breathing exercise can be done in sidelying, sitting, standing, reclined, or any other comfortable position.
If you feel like getting up and moving, some of these yoga poses may help. Combine them with your 360 breathing. Note she is twisting away from her bent knee in many poses to avoid compression in the groin and maintain open space for your baby.
Make an Appointment
Rib flare left untreated can cause altered function of your core muscles. When you feel ready to attend therapy, your therapist will help customize a stretching, breathing, and strengthening program specific to your body.
1 Women's Health in Physical Therapy. Jean and Glenn Irion.Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, ©2010
By Shraddha Wagh, PT
Everyone’s heard the saying “sit up straight” or “stand up with good posture” at some point in his/her lives - but what is good posture, and why is it important?
There is no such thing as one “perfect posture,” and it is unrealistic to try to maintain one specific posture when performing various activities throughout the day. Each individual has varying body types, muscle flexibility, and muscle tone that can contribute to poor posture. Although there is no ONE perfect posture, good posture is important for multiple reasons.
As more and more jobs are transitioning to remote or involve sitting for extended periods of the day, sitting posture is one of the biggest things to address to prevent future injury and or pain.
Tip when working from home or in the office:
Place a post-it note with “posture” written on it somewhere on your desk around eye level. Every time you see that note, it will remind you to be more mindful of your posture and adjust it if needed- this improved awareness over time will allow you to remain in a better posture for longer periods of time and with less thinking as it will become more subconscious.
See a physical therapist to receive individualized recommendations and exercises for postural corrections and improvements!
By Becca Ironside, PT
In February of this year, I moved from New Jersey to Florida. I was excited about this new chapter in my life, and received a farewell gift from the daughter of Michelle Dela Rosa. Elise is 9 years old (such a fabulous age of wonder and creativity) and she created a hobo bag with a long stick, a piece of yarn and ball of tissue paper dangling from it. I was tickled at how Elise imagined me striding towards my next adventure with a hobo bag over my shoulder. But deep down, I was quite scared about leaving everything and everyone that I loved in NJ. I was also well aware that such a big relocation would put my nervous system into overdrive and that my sympathetic nervous system would react and play a dominant role in the next few months.
So, I decided to take action. I put a plan into place to help support my parasympathetic (calming) system during a time when I knew that it needed bolstering. There is significant research supporting ways to allow the parasympathetic system to have its voice during times of duress. I discovered some on my own, and needed to ask for help for the others. Here is what worked and what you can do to prepare when you know that hardship or major life changes are coming:
That is how, four months after moving, I came to coax my body back into a state of calm. I didn’t have to be a slave to a racing heartbeat, shallow breathing, and worrisome thoughts. It is important to remember that when the next big change is coming your way, you can try exercise, breathing, time in nature, believing in something bigger than yourself and viewing life as a child does. And don’t forget to ask for help! Tell others that you need them, until you are ready to pick up your hobo bag and walk bravely towards your new adventure.
Becca Ironside, PT continues to work at Connect PT from sunny Florida. She does Wellness Visits, where you can have an appointment online and ask questions about how your pelvic health is related to your other bodily systems. You can discuss how various pieces of your medical history gleaned from other medical practitioners can be peeled back for a comprehensive look at what might be driving pelvic floor issues, including bladder, bowel and sexual concerns. Becca also writes articles for Health Union, an online organization which supports those with chronic health conditions like multiple sclerosis, prostate cancer and endometriosis. She has been nominated for an award for Revolutionary Research by this company for her ability to take scientific studies and make them easy to digest with humor, compassion and simplicity.
by Katelyn Sheehan, PT
Have you ever experienced any of these symptoms?
If you answered yes, then splinting may be a useful tool for you. Splinting is a technique often used by patients with pelvic organ prolapse to help them fully empty their bowels or bladder. Splinting is primarily suggested for helping with constipation, but certain splinting techniques can also help with urinary symptoms. Typically, splinting is performed by inserting a clean finger into the vagina to help hold, or splint, the pelvic organs and stabilize them in a more optimal position while using the bathroom. This can help hold the bowels or bladder in a more upright position to allow for full emptying when you go to the bathroom. You may also find that splinting externally can also help; this involves applying some gentle upward pressure to the perineum (see pictures and video below).
Internal splinting for the bladder/urethra
Begin by sitting on the toilet. Then use a clean finger with or without some toilet paper around it. Insert the tip of your finger into the vagina and gently apply some pressure forward, away from your spine.
INTERNAL splinting for the bowels
Begin by sitting on the toilet. Then use a clean finger with or without some toilet paper around it. Insert the tip of your finger into the vagina and gently apply some pressure backward, toward your spine.
EXTERNAL splinting for bowels
During pregnancy, your abdominal wall lengthens. The muscles have been working because even though they were stretched, the baby kept them on tension. Remember feeling like your abdominal wall was so tight? How could it stretch any more?! Picture a long string from the bottom of your sternum to your pelvis over your pregnant belly. Now the baby is delivered and suddenly the tension on the long rope is gone. The abdominal muscles are now hanging down, feeling loose, almost like they aren’t even yours. So many women are told to start working on their abdominal muscles lying flat. But, when you lie flat, picture the string again as your muscles. It is loose, and we cannot contract our muscles in their full length. We need to flip over, so the muscles can be all the way long. We also need to get the ribs moving. Rib motion will help the abdominal muscles, the diaphragm, and other core muscles working sooner!
You can try it in a few positions - pick the one most comfortable for you. Remember that you should be facing down, since we want the belly to be able to fall down:
Start with your belly relaxed, hanging down, no tension in the muscles. Inhale and feel your ribs expand wide, but gently. Then start your exhale with a gentle “shhhh” sound, like you are calming your baby to sleep. The “shhhhh” sound should start to create some tightening in your abdominal muscles. The loudness of the “shhh” may affect the amount of tightening you feel.
Once you feel the abdominal muscles tightening, gently help them draw in. Can you feel the tension start lower, above the pubic bone, and then the middle and upper abdomen tightens? As you start to reach the end of your exhale, can you feel the ribs tightening in as well?
Now inhale. Feel the ribs move wide and back, opening like an umbrella. Now, we use the muscles in reverse by slowly lowering the abdominal muscles back down. Slow down. We need to use our muscles to control this without dropping them. They are still strengthening even though they are getting longer.
Repeat these steps. This is a gentle exercise, so you can do it throughout the day. Be mindful of how you feel to judge how much you should do this. I would recommend at least 3 times a day for 10 reps minimum. This can be done if you had a vaginal delivery or a c-section. It is just breathing and gentle tension as you are just following your breath. Pick the position that best suits how you feel.
By Karen Bruno, PT
Ever get queasy from a shot or the site of blood? Or experience something and feel like fainting? Sometimes, those feelings are due to the overstimulation of the vagus nerve. And on the other end, the vagus nerve can also initiate relaxation after stress. So it makes sense that when we’re in fight or flight mode, the vagus nerve comes into play.
Fun fact: the vagus nerve is responsible for our “gut feelings”.
So how can we use the vagus nerve to our benefit? Well, once we understand what it is, we can control it to breathe more easily, and control our heart rate when we’re in tense conversations or high-pressured situations at the office.
What is the Vagus Nerve?
The vagus nerve is part of our central nervous system, which is made up of our brain and spinal cord. The central nervous system communicates with the body and processes information. The vagus nerve, also known as the tenth cranial nerve, starts in the brainstem and travels into the neck, trunk and abdomen. Having extensive reach and influence, the vagus nerve is responsible for the functioning of our internal organs and processes such as:
In short, our vagus nerve has a central role in every aspect of our lives. Our well-being is dependent upon our ability to adapt and on our nervous system’s capacity to function properly. Vagus nerve exercises help us get out of the stress related fight, flight and freeze response and move us into a calmer state of rest, restore, relax and digest. So, whether you have pain, a bowel, bladder or sexual condition, an issue with digestion, anxiety, trauma, or any combination these, your vagus nerve could use a boost.
There are numerous ways to support optimal function of your vagus nerve. Here is a simple, 2-step exercise you can perform. This technique comes from Stanley Rosenberg’s "Accessing the Power of the Vagus Nerve, Self-Help for Anxiety, Depression, Trauma and Autism."
Step 1 - Place both hands behind your head, right at the bump behind your head.
Here are some practical application suggestions to use the simple vagus nerve exercise.
Practice it daily and as often as needed throughout the day.
By Bryn Zolty, PT
One treatment we consider for our patients is a stimulation known as interferential current. The use of electrical stimulation for reducing pain and muscle strengthening is well known. But this special current can help your GI tract move a little faster. For our patients, it's 2 electrodes on your abdomen and 2 placed on your back. It feels like a tingling sensation.
Studies on interferential current for slow transit show it increases colonic activity. Beyond that, there are some theories on the mechanism of action. A few of these theories include: it affects the pacemaker cells of the GI tract, stimulates the enteric nervous system to the GI tract, or it stimulates the cells that are responsible for peristalsis.
What we do know is that it is non-invasive, cost-effective, and can be done at home. Many patients that we talk to are on an endless search for supplements. Slow transit constipation typically does not respond to laxatives and fiber. Therefore, this may be a good option to reduce over the counter supplements and improve your transit time.
Our pelvic therapists would be happy to discuss this type of stimulation with you and determine if this should be a part of your treatment.
J Neurogastroenterol Motil. 2018 Jan; 24(1): 19–29. Published online 2018 Jan 1. doi: 10.5056/jnm17071
By Bryn Zolty, PT
Pelvic organ prolapse is experienced by many women as heaviness in the vagina. For some women this experience is painful, dull, aching. For others it feels as if there is something in the vagina or sliding out. This can occur when a woman has pelvic floor muscle injury and in the presence of increased tissue mobility such as hypermobility disorders. It is commonly seen after a vaginal delivery.
Different images of two different pessary shapes used with permission from Pelvic Guru®, LLC | www.pelvicglobal.com
Although these conditions all sound like weakness and lengthened muscles, as clinicians we often see an increase in pelvic muscle tension and activity. What appears to happen is when a woman stands up, the feeling of heaviness and falling out increases, and either knowingly or unknowingly, she increases the pelvic floor muscle that tries to hold the organs in. This can be seen on biofeedback as pelvic muscle overactivity.
A pessary is a device fitted for a woman that helps reduce the symptoms of heaviness by insertion into the vagina and providing support that your body is not able to provide. New research suggests it may also improve muscle function. One hypothesis is that the muscle will stop contracting all day in attempts to decrease the symptoms of the pelvic organ prolapse. This hypothesis states that the muscles, specifically the puborectalis, will now assume a more normal resting position/tension and therefore allow for better muscle function.
If you are experiencing symptoms of pelvic organ prolapse and other pelvic muscle dysfunctions, talk to your providers about the use of pessaries to not only improve the symptoms of the heaviness, but improve the way the muscles work. These muscles have important functions for urination, defecation, continence, movement, core strength, and sexual function.
By Jennifer Watt, PT
This time of year for Crossfitters is the CrossFit Games season, where it starts with a worldwide event called the CrossFit Open. Hundreds of thousands of people all over the world and of all ages and physical abilities compete in three workouts given across the timespan of three weeks. As someone who has been doing CrossFit since 2018, this will be my fourth CrossFit Open season that I have competed in. CrossFit has become my passion.
Now as a pelvic floor physical therapist, I have run into a common situation at my gym. We look up on the white board that has the WOD (workout of the day) and I would see the term “double unders.” Double unders is a form of jump roping where your jump rope must go under you twice. As soon as I see that, I see many of both my female and male buddies head to the bathroom, and in many cases multiple times before the workout starts.
There is a well known video clip from CrossFit titled “Do You Pee During Workouts?” And when I watched it I got some interesting topics from the CrossFit community. Some say they definitely leak urine during double unders and box jumps. Many basically said it was a part of life as a CrossFitter and simply manage with pads. But is it okay?
As a pelvic floor physical therapist, I would say it is not okay. Peeing when exercising is telling us that there is a problem with our pelvic floor. A normal pelvic floor is simply one that can do all its functions – maintain continence, support the pelvic contents and contribute towards optimal movement during functional tasks. Now there are several reasons why it may not be normal or that there is pelvic floor muscle dysfunction.
What is pelvic floor dysfunction exactly? Pelvic floor dysfunction is simply where your pelvic floor is not doing its job properly. The pelvic floor is designed to provide support for your pelvic organs, help control intra abdominal pressure, control your urine and bowel movements, and help provide pleasure during sexual intercourse. One form of dysfunction could be that you have a weak pelvic floor. Common reasons why it is weak are: pregnancy and childbirth, surgery or other medical procedures, posture and behavioral habits, and lack of exercise. Another could be an overactive pelvic floor which is a condition where there may be increased pelvic floor muscle tension at rest, increased voluntary or involuntary contractile activity, or a decreased ability to fully relax the pelvic floor muscles. You could also have a damaged pelvic floor. Your pelvic floor might have been through a lot. Childbirth, cancer and radiotherapy, and other conditions can contribute to tearing, scarring and damage to the pelvic floor muscles. The nerves to the area can be damaged, the muscles themselves can become detached from the pubic bone, scarring from surgery and childbirth can cause asymmetrical contractions.
So what are some things to help? First and foremost, like I said before peeing when working out is NOT normal and should be addressed. Seeing your primary care physician, urologist, gynecologist, and to get a referral for pelvic floor physical therapy. These are health care providers who have taken extensive coursework, some even board certified, on the pelvic floor muscle anatomy and will be able to properly assess your own situation and create a plan specifically for you. Other things to consider, particularly in the realm of CrossFit. Try not to rely on items like lifting belts, braces, wraps, and other means of support. This allows you to really be aware of your physical limitations and hopefully will keep you from moving or lifting something you shouldn’t. Rely on good technique with all movements. Sometimes during these WODs, we push ourselves so much that technique goes out the window. And lastly what ties both the supports and technique is straight ego. Focus and train on your weaknesses and build upon them. If we’re leaking when we hit a certain amount of double unders or box jumps, then make that your target and to slowly build upon that. As I said, leaking during workouts is not normal and one should address it and not let it go.
Pelvic floor symptoms can be the reason that women stop exercising and end up living a more sedentary lifestyle. Don’t let this be you!
People need tune-ups, just like cars do. Many of our patients understand that coming back in for physical therapy is a healthy decision to make before and after they deliver their baby, before going back to work/school, or when they start to feel a twinge or ache somewhere. The single most common theme I hear upon return to therapy is, “I stopped doing my exercises.” Maybe there’s no more time with the baby. Or major life changes got in the way. I get that.
So I took a small poll with our patients that seem to have found a rhythm in doing their exercises not only consistently, but with ease! Here are the top 3 things they said helped them plug that time in for exercise:
[#3] Pair activities together. Similar to getting a workout buddy, pair exercise with another activity. My kids don't use this particular strategy, but I know I do! It could be as simple as, I tied my exercise band to the bottom of the stairs (maybe not if you have little ones at home!), so every time I go up the stairs I do a set of exercises. When my kids still napped, I always did exercises while they fell asleep, then creeped back in to put a little blanket on them.
For example, drive the route that ensures you pass the gym. Finish the online yoga class as a reward before you normally read your book or watch your favorite TV show.
Cement in new habits by choosing one of these strategies, or develop something else that works for you. Make exercise a part of your daily routine, instead of something extra.
By Becca Ironside, PT
Your urologist has likely performed a digital exam (meaning they inserted a finger) to assess the size of your prostate. It is the test that NOBODY wants from their doctors. But the test is valuable because it can determine if your prostate is enlarged. And you are in good company, Sam, because the chances of having an enlarged prostate are as high as 50% in guys over the age of fifty. This condition is referred to as BPH, or benign prostatic hypertrophy, in the medical world. 
As a pelvic floor physical therapist, I have treated many men with enlarged prostates, or BPH. Their complaints range from difficulty peeing (hesitation, weak stream or dribbling) to the sensation of sitting on a golf ball (or a ping pong ball, if you prefer this sport over golf)! Furthermore, erectile dysfunction can also result from having an enlarged prostate.
While pelvic floor physical therapists cannot shrink enlarged prostates (we are not magicians), we can help with techniques to improve urinary flow, educate on the mechanics of urination to maximize that stream, and even teach men how to perform Kegel exercises to strengthen their pelvic floor muscles. Stronger muscles in the saddle region can lead to better erections.
In response to your question, Sam, having an enlarged prostate is not a huge cause for concern. Remind yourself that roughly half of the guys from your graduating high school class now have the same condition. And if you want to refine what your pelvic floor muscles are doing for you, pelvic floor physical therapy is a nice option to take control of your symptoms and improve the quality of your life.
Question from Lars: I had my appendix removed over 6 months ago. I have noticed that my erections are not the same since my surgery. I spoke about it with my surgeon, who prescribed Cialis. Why is this happening? Is this normal?
Answer from Becca: This is such an interesting question, Lars. Erections are obviously governed by blood flow, which is likely why your doctor prescribed the Cialis. But there is also more involved with arousal than meets the naked eye (please excuse the pun. I just get so enthused when talking about this, I cannot help myself!)
The beginnings of an erection start with blood flow that is shunted to the groin. What makes erections so complex is that once the blood gets into the penis and testicles, it needs to remain there during the arousal process. In order for the blood to remain there, the pelvic floor muscles are required to lengthen to accommodate this new influx of pressure.
If the muscles responsible for containing this blood are too tight, they won’t be able to do their job, which is to act as a water balloon that expands to take in more water. With tight pelvic floor muscles, guys are left with a water balloon with a much smaller reservoir and volume capacity.
Now, let’s add another factor into your specific situation, Lars. The muscles of the core, specifically a deep abdominal muscle known as the transversus abdominus, have a very close relationship with the pelvic floor muscles. When the pelvic floor muscles contract in ejaculation, so does the transversus abdominus; conversely, when the pelvic floor muscles lengthen to accommodate blood in the penis and testicles, the transversus abdominus follows in suit.
Given the location of your appendix and the scar tissue incurred from its removal, there may have been a disruption in the coordination of your pelvic floor and core muscles. Decreased erectile function can certainly happen if these two muscle groups are not communicating in the exquisite and refined manner which they once did.
Pelvic floor physical therapists often hear of decreased quality of sex after abdominal surgeries in their patients. It is often one of the first questions I ask people who report a change in sexual habits. Lucky for you, Lars, and so many others, is that seeing a professional to manually release the scars of your surgical incisions and learning how to breathe properly during very basic life activities can reunite these muscle groups who have parted ways.
As a review, the appendix removal might have caused the abdominal muscles to become bound down and unable to expand. As a result, the pelvic floor muscles might have shortened and less blood was then allowed into the penis and testicles for Lars. There are so many people for whom this is the case. And there is help in pelvic floor physical therapy!
By Karen Bruno, PT
Create an intention for yourself. You might see yourself in vibrant health, strong and prosperous. You may imagine yourself in healthy personal and work relationships, with plenty of leisure time. There are no limits to imagining your heart's desires. Use positive imagery as you create. Allow yourself to envision your life any way you’d like it. See, sense and feel this intention and your life however you would like to experience it. Infuse this with feeling really good, really excited, really optimistic, really grateful, and really glad. Have joyful expectations and exuberance. Feel the energy in your body and see, sense and feel your life any way you would like it to be. You are joyful and exuberant, filled with glad expectation, optimism and inspiration. These are infusing in, through and around you and your entire experience. Take a few moments to amplify this and let it expand. Amplify and accelerate it into your experience. Love every aspect of your creation, blessing every aspect, consciously aware and consciously participating. Feel yourself become that which you imagine.
By Marzena Bard, PTA
Downward-facing dog offers many benefits:
By Bryn Zolty, PT
As she described her urinary symptoms to me, I decided to check the fascia located near the urethra for any restrictions or asymmetries. There I palpated a very large round dense mass. It was on the right side and felt as if it was altering the position of the bladder. The most likely cause was a fibroid, and the patient did then confirm that she had a history of a small fibroid. I had concerns that this fibroid had grown and might have been the cause of the urinary symptoms. It was certainly large, and very close to the urethra and bladder. I referred her back to her physician to have the dense mass evaluated. The physician confirmed it was a fibroid and immediately ordered a surgical consult. The fibroid was removed.
We have all been through such moments of anguish where symptoms don't add up. This patient is a reminder that we are not alone in our fear and confusion. She had a fibroid that had been driving many of her symptoms all along. It was through her persistence in getting the right care and her practitioners actually communicating with each other that a solution was found. She was her own advocate with a powerful alliance of team members to help her find an answer. She is an example of how sometimes we have to fight through the anguish and fear to find true healing.
I am so thankful that this patient was kind enough to share her story to help other women continue to search even when they feel at a loss as to where to turn for answers. A pelvic physical therapist is one of the few practitioners that spends each session one-on-one for at least 45 minutes. As a result, we are able to re-evaluate and treat each session. Consider a physical therapist on your treatment team.
Dr. Greenleaf: You know, this is very interesting and is becoming a very big topic of discussion, not just the vaginal microbiome but microbiomes in general. So the terminology “microbiome”: a biome is basically a little environment. So it’s all the organisms that live in and around an area. So we think of the Amazon rainforest; that’s its own biome. But on a microscopic level, we have the microbiome.
Ironside: What is an example of a microbiome in humans?
Dr. Greenleaf: So there’s different areas of our body such as our mouth, our intestines, the vagina; each one of those areas has its own bacteria, yeasts, and organisms that live in balance. The vaginal microbiome is so important for women and it can get out of whack. The first thing you may notice is that you may develop an itch or a burn or an odor. And for people who study and treat the microbiome we know that’s a sign the microbiome is out of balance. And so there are healthy bacteria that live in the vagina that basically, they’re called lactobacillus, and the lactobacillus is what keeps our vagina in balance. And so things like stress or diets high in sugars or being on antibiotics or changes in hormones from pregnancy or menopause, these things can affect the healthy lactobacillus’ ability to fight off “the bad guys”.
Ironside: What can a person do when the “bad guys" get the best of the healthy lactobacillus?
Dr. Greenleaf: when the lactobacillus is no longer there because it’s been affected that’s when we’re at much higher risk for vaginal itching, burning, odor, which may be termed a “vaginitis,” an inflammation of the vagina, and that can happen from an overgrowth of bacteria or an overgrowth of yeast. So it’s really that we want our biomes to be in balance. So it’s really this whole fascinating area of study now and even with some of the laboratory tests that are coming out we’re discovering more and more about what is a healthy microbiome. They’re discovering bacteria that lives in the vagina that nobody knew existed because of some of these advances in the testing that is out there.
Ironside: That’s awesome. Can you explain how you test this vaginal microbiome?
Dr. Greenleaf: Sure! So it’s still interesting because the standard of care for testing for vaginitis is really still stuck in the 1950s. Unfortunately the standard of care for when you go to the doctor for itching and burning is they will test your vaginal pH. That’s actually a nice, easy way for people to know and can actually do it yourself at home. There’s a lot of different type of pH paper that you can find on Amazon. So the normal range of pH for the vagina should be between 3.5 and 4.5, which is very acidic.
Ironside: Is it enough to have a vagina that is acidic to maintain good vaginal health?
Dr. Greenleaf: The pH level alone is not all that you need to know. Like I said, this was considered standardized testing and what we’re taught in medical school, and a lot of doctors are still doing as a standard of care. It’s still kind of antiquated and other than pH, there’s ways for us to look under the microscope and see inflammatory cells or there’s something called a “whiff test” where we apply a bit of a base to a slide. If there’s an odor associated with this base with the vaginal secretions, then we know there’s bacterial vaginosis. So really that’s what’s considered standard of care and doesn’t actually test the microbiome. It wasn’t until about 15 years ago that laboratories started developing more advanced testing that looks at the DNA presence of what’s in the vagina looking at the vaginal secretions. A lot of time this can be done with just a simple Q-tip like swab that’s sent off to a specialty lab to look at exactly what type of bacteria is there. There’s two (2) kinds of tests.
Ironside: Can you describe these tests?
Dr. Greenleaf: The first one came out initially called a “PCR” test. The PCR test looks at the DNA presence of bacteria and yeast and tests to see if there’s any kind of healthy bacteria. That can be done in a doctor’s office. Now, I have to say, there’s still not a lot of doctors that are doing that because it’s still not considered 100% standard of care. So unfortunately, I hope we’re moving in that direction because I find that in general when it comes to advances in medicine that insurance or the general medical population lags about 10-15 years behind the technology. Nowadays, they’ve gone on to not only look at the DNA presence of the bacteria but there’s another type of test called “Next Generation Testing.” The Next Generation test actually is able to test and identify even more types of bacteria and microbiome that’s there. There are some commercial companies that are developing tests where patients can go directly to their websites and actually order these microbiome tests. The only thing I caution you with some of the Next Generation Testing is it’s really for information purposes only and not used to diagnose or treat because we’re finding out so much more bacteria that exists that we never knew was there so clinically they’re not 100% sure what to do with this knowledge. There are some laboratories out there that are doing major research on discovering what is “normal,” what is “not normal” when it comes to vaginal health, so I think in the next 5-10 years we’ll see a big shift in the ability to test for this and also to help women balance out their microbiome so they don’t ever have to deal with itching, burning and odor ever again.
Ironside: It’s so wonderful, this kind of pioneering work that you’re doing and we just love hearing about this. So the next question that I wanted to ask you is about the use of lasers for vaginal health. Can you delve into that for us please?
Dr. Greenleaf: Sure! And this is also connected with the vaginal microbiome, so we’re gonna take a step back and people might say, “Why do I need to care about my microbiome?” and you know, “why does it really matter?” If you’re treating itching, burning, odor that’s one thing; but there’s actually some bigger problems that can happen when the microbiome is thrown off. Number one, like we were talking about, you’re at much higher risk for recurrent vaginitis but you can actually have recurrent issues with urinary tract infections, and it can actually cause infertility if the microbiome is not off. So this is something where if a patient is struggling with infertility, maybe balancing out the microbiome will help. And now they’re even doing research into sex drive and microbiome. I’ll connect this with lasers in just a minute but – the thought is that there may be this vagina-brain connection. Once you explain it, it kind of makes sense, but scientists are now currently trying to prove this: if the microbiome is off in the vagina, that might not ideally be the best time to reproduce and this feedback signaling to the brain to shut down sex drive; so that’s something that we’re looking at.
Ironside: Interesting. How does this connect with the use of lasers for better vaginal balance?
Dr. Greenleaf: So how to connect it to vaginal lasers, this is where it gets really interesting: when a woman is menstruating and the vaginal tissue is being exposed to hormones like estrogen, the tissue is going to be nice and thick and healthy, that’s gonna help with moisture in the vagina and help with comfort. The other thing is with that healthy tissue, the tissue is going to constantly be growing and the old cells are going to be sloughed off. Those sloughed off cells make up a chemical called glycogen; that’s the food source of the lactobacillus. As long as there's a food source for the lactobacillus, the lactobacillus will be there and will fight off all these other bad guys and keep the microbiome in balance. There are a number of conditions where that tissue in the vagina starts to really thin down, and when it thins, it stops sloughing off, and the food source of the lactobacillus disappears and the lactobacillus starves and dies and now you have all these other conditions. The biggest time that this happens in a woman’s life tends to be in menopause when the estrogen levels get low and the ovaries are stopping to produce as much estrogen and women are complaining of vaginal dryness or pain with intercourse. Especially during this time period we see increased risks of vaginitis and recurrent urinary tract infections. This can also happen in times after childbirth or breastfeeding those hormones are low, or even in women who are on birth control. So even though taking birth control, the body perceives the estrogen levels as being much lower and the vaginal tissue can be affected.
Ironside:What about the use of estrogen creams to address these concerns?
Dr. Greenleaf: Traditionally, the way we were able to treat this in women was using estrogen cream in the vagina. But, not that it’s a bad option – for some women it’s wonderful option and are very happy with it, the downside of using estrogen creams in the vagina is from a comfort level it may be slimy, some people don’t like that slimy sensation or don’t like having to put in creams every night or a couple of times a week. Some people are just nervous using hormones or exposing their bodies to hormones, such as women who have had breast cancer. So there’s a number of reasons – some people just can’t tolerate it. A lot of the prescription options contain something called propylene glycol as a filler that can be very irritating to the vaginal mucosa. So there’s a number of reasons why women would choose not to use estrogen vaginally. So if you’re reading or listening to this and you are choosing it it’s not a bad option, it’s just for a long time it was the only option. So what I think is really fascinating in the world of vaginas is that since about 2016 here in the United States, there’s been more focus on how we can help women with dryness, with pain with intercourse due to dryness, or microbiome problems without using hormones.
Ironside: When did lasers start to come into focus for vaginal health?
Dr. Greenleaf: In Europe prior to 2016 they really started looking at lasers for tissue regeneration. The funny thing about lasers is lasers have been used since probably the 1980’s for tissue regeneration when it comes to cosmetics. They use it for facial rejuvenation, for skin anti-aging, for skin tightening, and then all of a sudden somebody – and I wish it was me, but it wasn’t – somebody decided “if this works so well on the face and other areas cosmetically, why don’t we use it for the vagina?” And starting in Europe and prior to 2016 is being used for vaginal rejuvenation. And lasers are just light energy, and they used the light energy applied to the vaginal tissue and it actually will trigger the body to produce it’s own growth factors and can actually cause the vaginal tissue to re-grow without being exposed to hormones. So, we’ve been able to use that technology in the United States since 2016. It started out with a product called the “Mona Lisa Touch,” which is a laser that I’ve loved to use, but there are a number of different companies that are now employing their own use of lasers so there’s a lot of different laser products that being used for the vagina. I think what happened with laser vaginal rejuvenation it really kicked off this industry of “wait a minute, there’s a lot of things that we use for regenerative purposes cosmetically, let’s now apply this to the vagina.” So lasers were the first option and now we’re starting to see things like red light therapy, which they know is great for the skin, being applied to the vagina; and something called “Carboxytherapy'' where you use a gelled carbon dioxide that they use – once again it was taken from the cosmetic world and they do still put it on people’s face to rejuvenate the skin – but there are now options out there to be applied to the vagina. So I think we’re see in the next couple of years more and more of these products coming out to help women, and more options without having to use hormone creams.
Ironside: That is fantastic, and what I really admire about your practice is how you continue to experiment with these lasers on your own and also with fellow professionals. You spend your weekends, I know this, doing all manner of experimentation with lasers and I’m a huge fan of what you’re doing. So finally I’d like to ask you about something called a “pessary.” I think the average person does not know what this is, and if they do know, they might be a little hesitant to try it. My hope is that you can dispel this anxiety surrounding the use of pessaries.
Dr. Greenleaf: So the unfortunate thing is that 50% of women will experience or develop a prolapse, and then we have to take a step back and go, “what is a prolapse?” So prolapse is when things are drooping and dropping. So you may have heard about people talking about their bladder drop or their uterus drop, rectum drop. Unfortunately not enough people are talking about it because it’s happening in 50% of women. So it happens often because the ligaments in the pelvis have been damaged either childbirth is the most common reason, but heavy lifting or some sort of trauma to the pelvis, or severe constipation, sometimes people with really hard coughing or vomiting can put a lot of pressure on the pelvis and damage the ligaments.
Ironside: What is a person's response when this happens, what reactions have you seen??
Dr. Greenleaf: So what happens especially when the bladder drops, a woman may not know that is happening right away but they may all the sudden have problems emptying their bladder all the way, urinary tract infections, some women will actually feel something bulging out of the vagina. A lot of women's first reaction to it is, “Oh goodness I have a tumor!” and so they come into the office and we can say, “no, it’s not a tumor, it’s just that you’ve lost some of the support.” There’s a whole range of things that can be done for this. I think in general we sometimes overlook the simplest and easiest thing that can be done, which is a pessary. A pessary is a support device that is fitted for your vagina and basically is worn inside the vagina and just wedges in there and can hold up the bladder, the uterus, the rectum.
Ironside: When did pessaries come into fashion?
Dr. Greenleaf: The interesting history about pessaries is that they’ve been in use since ancient Egypt. Women used to use pomegranates, which I don’t advise, but women used to use pomegranates or rocks and place them in the vagina – something to wedge in there to prevent things from falling out. In Rome they used to do the same thing – rocks or potatoes have been reported in literature, which I don’t advise. But the simple idea of a pessary is something that has been in existence for hundreds and hundreds of years. What’s nice about it is that you can be fitted for them. They can be easily taken care of by yourself or a doctor. They should be comfortable when they’re in place, they should never cause pain. Some people think it’s something they can do temporarily and that it’s not something that can be left or something they can use long-term. But I have many patients that are very happy with their pessaries and it helps their quality of life, and you can basically have a pessary for the rest of your life. It doesn’t necessarily mean that you have to have surgery.
Ironside: What do pessaries look like?
Dr. Greenleaf: They do come in all sorts of shapes and sizes, just like the vagina comes in all sorts of shapes and sizes. The shape is determined by how well it wedges in the vagina. Some of them look just like a little Frisbee, some look like doughnuts, the more extreme ones look a little bit like a cube. So there’s different shapes and your healthcare practitioner can help determine which shape and size is the best for you. Some people feel comfortable and can be easily taught to take them in and out themselves and we may have people take them out every day and wash them; they can come out once a week. Interestingly enough, there’s no standard of care for how long they can be left in. Usually the recommendation is not to have them in place for longer than 6 months at a time. The longer they’re left in, the body will produce a heavy discharge in response to the foreign body. But a lot of times patients will ask, “will this cause an infection? Can I get injured from these things?” Very, very rare that that happens. This is a simple, easy, non-surgical way to manage a prolapse. So some people surgery is just not the answer if they have health conditions and not wanting to undergo surgery, or some people are just not mentally ready to undergo surgery. So this is something great that can kind of bridge that gap so you can decide if you eventually want to have a surgery.
Ironside: As a surgeon who has performed many surgeries to correct prolapse, what have you seen regarding long term results?
Dr. Greenleaf: The unfortunate thing about pelvic surgeries for a dropped bladder, or uterus, or rectum was that we used to believe that you got surgery and that was great, and you’d be good for the rest of your life. Unfortunately none of those surgeries are considered permanent and a certain portion of patients once they have surgery are at higher risk for things drooping and dropping again. It would be nice to be like your appendix, if your appendix is out it’s out it’s not like prolapse surgery and never going to happen again. Pessaries just may be a great option for somebody who’s a little nervous about the idea of surgery or just not ready for it yet. Sometimes we even use it to try out how a patient is going to feel once the bladder and uterus is put back where it’s supposed to be. It can be used as a diagnostic way to evaluate a patient’s condition. But once again, they’re really easy to manage. Depending on the shape and size you can still engage in sexual activity with them. Some people think you can’t have sex with them in place, certain shapes and sizes you can. They don’t necessarily need to be taken out. Just when it comes to care for them, they can easily be taken out and cleaned with soap and water and then put back. Some people can take them out themselves, others will go to their health practitioner to be cleaned. But sometimes, we’re talking about bladder and uterus, but if the rectum is falling these pessaries can also hold up the rectal side of the pelvis and they may help people who are getting constipation from the rectum drooping and dropping. That’s another advantage of the pessary. It’s fun when you use something that really hasn’t changed in technology in hundreds of years and I think that we as healthcare practitioners forget to go back to the basics, so this is a great option for people.
Ironside: I love how when you treat you’re able to cover this gamut of treating the person with these very modern approaches such as lasers, looking into the vaginal microbiome, but as you said that sometimes going back to the basics of the most simple things can prevent people from undergoing surgeries that may or may not help them and also offer a comfort level about something a pessary. You’re giving them this option of something very, very basic that they can manage themselves and they’re not going to be afraid that it’s unsexy or unappealing; they’re just going to feel more like themselves without any surgical intervention. I want to thank you so very much for joining us today Dr. Greenleaf. It has been outstanding talking to you.
Dr. Greenleaf: Thank you so much. I am very passionate about these things and have such a great time talking about this stuff, so if you guys are on social media follow me. If you look for Dr. Betsy Greenleaf you can find me pretty much anywhere; I’m all over social media. I have a podcast called “Some of Your Parts” and we have another podcast called “Body Mind Spirit.” Last but not least, I have a website called “The Pelvic Floor Store” that we’re constantly trying to put out new and improved information. Thank you once again for having me.
Ironside: Thanks so much.
Dr. Betsy A.B. Greenleaf DO, FACOOG (Distinguished), FACOG, FAAOPM, FPMRS, MBA
America's "Down There" DoctorTM,
First Board Certified Female Urogynecologist in the United States
Board Certified in Obstetrics/Gynecology
Board Certified in Female Pelvic Medicine and Reconstructive Surgery
Board Certified in Procedural Medicine and Aesthetics
Masters of Business in Strategic Management and Innovation
Follow her at:
by Katelyn Sheehan, PT
Do you have low back pain? Is the pain mostly on one side? Do you sometimes feel it move into your hip or groin? If so, dysfunction in your SI joint may be driving your pain.
What is the SI joint?
The SI joint, or sacroiliac joint, is the joint where your low back (the sacrum (S)) meets your pelvis (the iliac (I) bone). There are SI joints on both right and left sides of your back, directly next to the dimples in your low back. If you have pain on one side around the dimple of your low back, you should check in with a physical therapist to evaluate your SI joint.
Why is the SI joint important?
The SI joint is an extremely stiff and complex joint that helps with shock absorption through the spine and pelvis. If the SI joint becomes inflamed or fails to move properly, it can cause pain to the low back, hip, and groin on the affected side.
Both of our SI joints work together to dissipate shock, so dysfunction in one SI joint can cause dysfunction and pain in the other. Most people with SI dysfunction complain of discomfort on one side; however, the cause of dysfunction may actually originate from the other side! A thorough evaluation can help determine which side might be the real problem.
How can the SI joint become inflamed?
The SI joint frequently becomes symptomatic if it has either too much movement or too little movement. Here are some examples:
Too much movement
Too little movement
How can Physical Therapy help?
First, your physical therapist will examine you for any structural impairments and risk factors for SI joint dysfunction. Then, they will examine how you move and what movements may be causing your pain. After this examination the physical therapist will give you a specific treatment program designed to help either stabilize or mobilize the SI joint depending on your specific impairments, and ultimately help to relieve your pain!
Benefits of Cross Body Hip Stretching include:
How to perform the stretch:
What you should feel: A comfortable stretch in the back of your hip.
Please note: if one side is easy and the other side is painful, uncomfortable and/or moderately harder, only exercise on the side that feels good. Let your physical therapist know so personalized instructions can be given to you. There are techniques you can be taught to address pain, tightness and weakness without creating further discomfort. Do not do an exercise that feels painful or uncomfortable.
Tips for success:
✓ Breathe deeply and rhythmically so that you do not hold your breath.
✓ Stretch comfortably; do not push the stretch to the point of pain or discomfort.
✓ Stretch on a consistent basis; stretch throughout the day and do it daily, if possible.