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.
by Bryn Zolty, PT
Rib flare refers to an altered ribcage position. This means the rib cage is tipped up/forward, flattened and wide, or both. Rib flare has many potential causes. For this article, we will focus on the postpartum individuals.
Ribs Tipped Up Flare
First, let's look at the rib cage position from the side to identify the ribs tipped up flare. Ideally, the rib cage would line up over the pelvis and the curve in your lower back is greatest in your lower back. You can feel the top of your hips and walk your hands around to your back, this is where your lower back curve should be located. See the arrow from her hips to her lower back.
The first picture (left) demonstrates fairly neutral (good) posture. Notice the horizontal arrow from the top of the hip bone to the low back showing the curve. Also, note the vertical line running through the middle of the shoulder, trunk, and hip. The line is fairly centered in these locations. The ribs below her bra line are tucked in the abdomen.
The second picture demonstrates the tipped up rib flare. Notice the curve in the spine compared to the first. The curve in the back is higher. It continues throughout the middle back and her shoulder blades sit further back. The ribs are tipped upwards and stick out further than her abdomen. Also, note the vertical line running through the shoulders, trunk, and hip. The trunk is more forward and not centered as in the first picture.
This rib tipped up position, the second picture, in a postpartum population is common. Later in pregnancy as the baby grows, the ribs tip up to make room. Women may lean back to maintain balance as their weight has increased forward. Next, women carry around a growing baby and continue to lean back. After standing in this position for months, your body begins to recognize this posture as straight.
Postpartum, the front abdominal muscles are stretched and weakened. The muscles in the lower back have been in a shortened position and can become painful and overworked as their counter parts in the front need time to regain strength. However, to do that, we need to restore posture. It is difficult to strengthen abs that are lengthened if the ribs stay tipped up! When this position is maintained for a long period of time, the back muscles can become tight and even maintain the tipped ribs when laying down.
Note in the picture the space between the floor and the back. The left rib cage here is sticking up. This individual will require some release work and stretching in addition to posture modifications.
Infrasternal Rib Flare
Another type of rib flare is seen in a front view. This is the infrasternal angle, the angle formed by the ribs coming together under the breastbone. A normal angle is 90 degrees. Place your thumbs together in this space and see if they form a 90 degree angle. When this angle is greater than 90 degrees, there is a rib flare.
Commonly with a rib flare, the internal oblique muscles tend to be dominant, creating muscle imbalance. The internal oblique muscles flare the ribs wide.
Here is the same individual lying flat looking at the front view to check for infrasternal rib flare. Now you can see the left rib is more pronounced and wider than the right. This angle is greater than 90, and is asymmetrical.
In the picture below, she was asked to start to curl up her shoulders off the ground. Note the ribs pulling wide and as her internal oblique muscles contract strongly demonstrating her muscle imbalance.
Rib flare does not get better on its own and needs individualized care to improve posture and muscle recruitment. So many functions in the body rely on the diaphragm and rib position. Dysfunction can alter digestion, create back pain, increase your sympathetic nervous system, and decrease pelvic floor muscle flexibility. Muscle imbalance can create compensatory patterns and resulting pain and/or weakness. Many women tell us they want their core back and their stomach to look pre-baby. Rib flare can prevent abdominal muscles from contracting well and even push(pooch) out the lower abdomen if muscle imbalances exist.
The key to treating rib flare is improving alignment and muscle balance. And not just muscle imbalance in your back and abdomen, but also shoulders, legs, feet, and pelvis. How you stand, sit, carry your kids, and exercise at the gym can all be part of improving rib flare.
At Connect PT we are happy to help evaluate and treat your posture, muscle coordination, and improve your strength!
We loved reading about all the dog-walking, trail hiking, and playing with kids and grandkids that helped to keep people moving this past year. Here are more ideas from the community board:
As the spring weather allows, we encourage you to grab a friend, get outside, and soak up some vitamin D!
by Becca Ironside, PT
Here is how it works: The patient lies on their side and the PT inserts a deflated lubricated balloon into the rectum. The PT then begins to pump small amounts of air into the balloon to inflate it. This mimics the sensation of having a full bowel and “needing to go” for the patient. Small sensors which line the bowel walls are being trained with the presence of the expanding balloon that it is time to void; this unique sensation is historically ignored or suppressed by the brains of people with chronic constipation. Yet with the use of rectal balloon training, such people are afforded the opportunity to show their colons who is truly in charge of having healthy, soft and regular bowel movements (their own brains are!).
The use of rectal balloons might sound weird and like the stuff of science fiction. But once patients experience this treatment in the relaxing and supportive environment of a pelvic floor clinic, they often discover how they might have been contributing to their own unconscious tension which leads to a lifetime of constipation. Rectal balloon therapy has also proven to be effective for the management of people with chronic diarrhea and poor stool quality. In short, it is a wonderful adjunct to a balanced pelvic floor treatment plan aimed at improving bowel health. If you have bowel concerns, please ask us at Connect PT about rectal balloon training.
Barthelemy, Anne1; Shifferd, Jennifer1; Erickson, Kim1 Balloon Training for Bowel Dysfunctions, Journal of Women's Health Physical Therapy: Spring 2009 - Volume 33 - Issue 1 - p 18
If you are experiencing chronic pain, stiffness or discomfort, what is your body trying to tell you? Here is a short, fun practice to begin dialogue and partnership with your body.
This may seem awkward or strange at first; it may seem silly or even uncomfortable, but if you do this more and more, you shall receive the answers and your body begins to trust you and you begin to trust your body, thereby creating a partnership for health. Through practicing this over and over you may notice that the pain begins to subside and may eventually be gone.
You may choose to combine this with a very clear intention that it is your intention to 100% enjoy your body fully, and that your body enjoys you inside of it fully and completely. This supports your collaboration with your body for a maximum amount of enjoyment.
Although the pain may not leave immediately, recognize that the physical form takes longer to change, but the change starts once you make a connection and change your thoughts. It is new energy; it is new consciousness; it is new awareness. Your job now is to stay in a mode of receiving and know that you have started the process of feeling better, and while it might not be an overnight healing, it will be steadfast and continuous, and with ease and grace. We want this with ease and grace in the most gentle way for you.
According to Dr. John Sarno, in his book, Healing Back Pain, for a condition like chronic back pain, once you call out the emotion that your body is repressing, there is no longer any need for the pain and the body will no longer need to generate tension. (2)
All of us here at Connect Physical Therapy are here to support you to feel your best.
by Bryn Zolty, PT
I hear this constantly. “Check my muscles, are they on?” The struggle is real. I’ve been there postpartum. Women feel hopeless at times trying to reconnect with muscles that have stretched or torn. The deep core muscles, including the transversus abdominis (TA) is one of them.
The TA muscle is part of the deep core muscles. It wraps around your trunk like a girdle. If a girdle sounds supportive to you, you are right. One of the main functions of this muscle is trunk and pelvic stability.
The TA was a big part of my postpartum rehabilitation and I would like to share some of that journey in case any part of it could help another woman find her way. My daughter was born via c-section. I knew at that time my abdomen felt weak and the middle of my muscles felt different. I waited for physician clearance and began exercising, slowly building strength and intensity. I noticed my side abdominal muscles, the obliques, looked chiseled! I was proud. However, I realized after having my c-section that a muscle tore in that area and soon found out that it had led to an inguinal hernia. I needed another open abdominal surgery. I again waited for clearance and started back up exercise and had the same results.
I noticed that I had very little strength or tension in the middle of my abdomen again. This time the separation (diastasis) was more obvious. Like many of my patients, I was guided to start trying to “find my TA.” This made me very sympathetic to my patients trying to tension their TA. It took me forever to activate it despite being a physical therapist. Two open abdominal surgeries left me with poor ability to connect to the lower deep abdominal muscles.
I tried feeling for the muscle. I tried laying on my back, side, and cat/cow. I tried using sheets, taping and bracing. I used all the breathing techniques. I also knew that a c-section doesn’t mean you can’t have pelvic organ prolapse (pelvic laxity). I was relying heavily on other muscles to compensate for my abdominal muscle weakness and it was becoming painful in my hips and tailbone. I finally found it! It took a long time. But I had motivation, not just for how the abdomen looks. I wanted to be strong.
I share this story because now there are more tools to help our patients and postpartum women learn how to start using those deep core muscles. Ultrasound imaging makes it easier for women and men to connect to the deeper muscles. We use this at Connect PT as a type of biofeedback for turning on muscles and coordinating functional movement. Being able to see the muscles while you try different breathing patterns of movement can help you see what works for you!
Below is an ultrasound of my abdomen during a sit up/curl up. The TA should turn on for this movement. But there is no widening, nothing like the image above. The internal oblique, D2, does start to widen. The obliques help with side bending and rotating; the next picture on the right shows me doing those movements. My obliques are really widening and working now!
Finally, in this last image below, I exhale and gently start the TA turning on and do a sit up. I let my body start to take over with how much intensity is needed. I provide a gentle reminder to my deep core to turn on. D1, the TA, is widening and turning downwards.
There are many online postpartum and mommy fitness programs now. Many of them are great, but for some women, you need help knowing you are doing the techniques correctly. Are you doing a TA workout and not actually turning on the TA? Are you bearing down when supposed to be pulling up/in? I recommend a visit to a pelvic physical therapist, even if it’s just a few times to make sure you are on the right track. We want you back to running, back to lifting weights, and back to the activities that make you feel good. Let us help you get your confidence back.
Beat those winter blues by getting up to stretch with Marzena Bard, PTA. When you can't get to the gym, these easy stretches are great to begin and end the day or to break up sitting all day at the computer.
Watch the video tutorial below.