Pelvic Health Blog

The return to running after delivery

7/5/2019

By Bryn Zolty, PT, DPT

*This article is based on Return to running postnatal-guidelines for medical, health and fitness professionals managing this population. Tom Groom, Grainne Donnelly and Emma Brockwell

Taking time off from running, crossfit, or high impact sports for pregnancy and postpartum can be very difficult for a woman. The 6-week postpartum visit is highly anticipated by many women so that they may be cleared to return to running or the gym. Is a woman ready at just 6 weeks after having a baby to run and jump? A recent article published in March 2019, Returning to running postnatal-guidelines for medical, health and fitness professionals managing this population, outlines the current evidence in return to sport.

Most orthopedic injuries have protocols after surgery for rehabilitation prior to returning to sport. However, there is not a set protocol for women after giving birth to return to their prior level of activity safely. Many women have very limited knowledge of their pelvic floor or ability to strengthen the muscles to support their organs and keep them from leaking urine or bowel movements. Very frequently, women are not even aware of pelvic organ prolapse (POP). POP occurs when the pelvic floor muscles are weakened and the bladder, uterus, or rectum can start to press into or drop out of the vagina.

The research shows that women should wait until 3-6 months postpartum to return to running. For women anxious to return to running, that seems forever! The reason to wait is based on healing time. For vaginal births, the pelvic floor muscles are stretched greatly, and the levator hiatus (pictured below) can take as long as 12 months to become closer to baseline. In addition, the pelvic floor muscles, connective tissue and nerve healing is maximized by 4-6 months (Staer-Jensen et al. 2015). That means that women should seek a pelvic floor physical therapist after vaginal births as soon as they are cleared in order to maximize their ability to heal these tissues.

After a cesarean birth, the research shows that the abdominal fascia has around half of its original tensile strength at 6 weeks, and 73-93% at 6-7 months (Ceydeli et al 2005). This means after c-section, the abdominal wall is still undergoing significant healing and low impact exercise is recommended for the first 3 months.

In both cases, vaginal or cesarean, the recommendation is to have a pelvic health physical therapist evaluate the pelvic floor and abdomen prior to returning to high impact exercise. High impact exercise in female athletes was found to have a 4.59 fold increase in risk of developing pelvic floor dysfunction compared to low impact (De Mattos Lorenco et al 2018). Running has been associated with a rise in intra-abdominal pressure and increased ground reaction force between 1.6 and 2.5 times bodyweight when running at a moderate pace (Gottschall and Kram 2005). These statistics are not to show that women should avoid high impact exercise, but should make sure women are physically prepared to return to sport.

The article concluded that return to running should occur 3-6 months postpartum in the absence of the following symptoms:

Urinary and/or fecal incontinence prior to or during commencement of running
Pressure/bulge/dragging in the vagina prior to or during commencement of running
Ongoing or onset of vaginal bleeding, not related to menstrual cycle, during or after attempted low impact or high impact exercise
Musculoskeletal pain e.g. pelvic pain prior to or during commencement of running

Other symptoms in addition to those listed above, that if experienced a woman should seek out a physical therapist include:

Urinary and/or fecal urgency that is difficult to defer
Pain with intercourse
Pendular abdomen, separated abdominal muscles and/or decreased abdominal strength and function

In addition, there are recommendations on the amount of strength and endurance in the pelvic floor and fascial support that should be present for running to prevent pelvic floor dysfunction. These measurements can be evaluated by a pelvic floor physical therapist.

The full article can be found for free here.
Goom, Tom & Donnelly, Grainne & Brockwell, Emma. (2019). Returning to running postnatal – guideline for medical, health and fitness professionals managing this population. 

What the research says: mindfulness for bowel health

6/12/2019

Recent studies support the benefits of mindfulness for bowel health. A 2014 study of 53 patients reported that mindfulness-based stress reduction (MBSR) “had a significant positive impact on the quality of life…” on people diagnosed with ulcerative colitis compared to a control group (1).

Another study the same year examined 24 people with irritable bowel syndrome (IBS) and compared them to a control group. Authors concluded that mindfulness-based therapy was more effective than cognitive behavioral therapy (CBT) to decrease symptoms in those with IBS at a 2-month follow-up. (2)

(1) Jedel, S., Hoffman, A., Merriman, P., Swanson, B., Voigt, R., Rajan, K. B., & Keshavarzian, A. (2014). A randomized controlled trial of mindfulness-based stress reduction to prevent flare-up in patients with inactive ulcerative colitis. Digestion, 89(2), 142-155.

(2) Zomorodi, S., Abdi, S., & Tabatabaee, S. K. R. (2014). Comparison of long-term effects of cognitive-behavioral therapy versus mindfulness-based therapy on reduction of symptoms among patients suffering from irritable bowel syndrome. Gastroenterology and Hepatology from bed to bench, 7(2), 118.

Nutrition strategies to relieve pelvic and chronic pain

6/12/2019

strategies for pelvic and chronic relief

By Karen Bruno, PT, DPT

Proper nutrition and knowing what you should eat and what you should avoid can assist to reduce the contributors to pelvic pain and chronic pain. This is done by addressing inflammation.

Is what you are eating contributing to your pain? Can the choice of food you eat actually help to relieve pain? Can nutritional interventions ease your pain? The answer is that nutritional interventions are often effective in reversing chronic pain. Simple dietary changes that remove inflammatory foods and replace it with better choices can help to reverse chronic pain conditions. Pain conditions are often due to an imbalance in the body’s chemistry. This can be due to many factors, such as a lack of nutrients in your diet, stress overload, lack of exercise, increased inflammation, insulin resistance and environmental factors. Nutritional interventions can be one element for shifting the chronic pain response.

In the links below, Joe Tatta, PT, DPT, addresses components of various anti-inflammatory diets and their benefits. Dr. Tatta is a physical therapist and Founder of the Integrative Pain Science Institute, an education company that supports practitioners as they explore integrative models for pain. In these blogs, there is a review of the current literature of the types of foods and diet that can ease the pain associated with various health conditions.

The Basics:

Eat clean food. This means food that is unprocessed. Eat meats and poultry that are organic when possible, and fish that is wild caught. Eat plenty of fresh vegetables and fruits, and consume grains that are in their purest form.
Avoid the trap of “organic” and “gluten- free”. Creative marketing is trying to convince us that these foods are healthy. Check the ingredient list. These often consist of low quality, highly processed ingredients. Also. beware of “natural flavors”. That can be a way to hide MSG, yeast, sugar and non-vegetarian based products. Look at the nutrition facts label for additional information.
Natural fats and oils are good for you. These include olive oil, ghee, butter, coconut oil and avocados/avocado oil.
Some people benefit from the reduction or elimination of dairy milk products from their diet. This may only be needed as a temporary change. Great substitutes include butter, milk and cheese made from nuts and seeds. Once again, make them yourself to avoid the highly processed, less nutritional commercial items. It is very easy and there are plenty of recipes on the internet. The recipes can often be found by looking up the vegan and/or paleo versions of a recipe.
Eat whole grains and legumes. Whole grains include quinoa, brown rice, buckwheat, millet, barley and whole wheat. Consider using sprouted wheat flour or any other sprouted grain when you bake and cook. Sprouted grains are easy to digest, contain more fiber, and have more available nutrients. Ezekial 4.9 bread is an easily digestible sprouted grain bread and can be easily found in grocery stores, health food stores and Trader Joe’s. Trader Joe’s aldo has a few varieties of sprouted grain bread. Also, consider sprouting legumes to receive similar benefits. Check out these links for tips to sprout your legumes or just do a Google search.

For more on this, visit Sprout People.

Avoid refined and highly processed grains. If you do go “gluten-free,” be aware to avoid the refined and highly processed grain substitutes.
Use natural sweeteners like stevia, which is an herb, monk fruit, raw honey, date sugar and maple syrup. Avoid refined sugars and artificial sweeteners.
Drink hydrating liquids like water, broths, fresh juices and herbal teas. Carbonated beverages, alcohol and caffeine are bladder irritants that can trigger inflammation.
For the more sensitive beings, (and we know who we are), it may be beneficial to avoid one or more of the following: eggs, peanuts, corn and alcohol.
Enjoy liberally seasoning your food with plenty of herbs and spices to enhance the flavors.

These are some general guidelines. There is not a “one-size fits all” eating plan as you are unique and complex. Start by making a few changes in your diet and notice how you feel. For example, you can eliminate sugar and processed foods. Making limited changes will assist in recognizing how those particular foods impact you. Is there a relationship between food and pain? Going slowly and changing one or two things at a time is recommended so that you can identify whether a particular modification had an effect.
What happens if you eat a dessert or two, have some alcohol or coffee, or eat some other food that is generally considered inflammation provoking? By all means - enjoy it and savor the experience! There will be more on that in an upcoming blog. Resume the low inflammation regimen when you can and just move forward.

What you choose to eat has an influence on your overall health and resolving pain. Nutrition and diet affect both the physical and psychological processes that impact chronic pain, and good nutrition can be a pivotal component to attain and sustain optimal function and quality of life.

Making delicious and nutritious meals and desserts can be simple. Here is a simple 3 ingredient treat to get you started.

Blueberry Banana Muffins
Ingredients:

5 very ripe bananas
1 cup nut butter
1.5 cups of blueberries

Preparation:

Preheat oven to 350 degrees.
In a bowl, mash the bananas with a fork. Add the nut butter and mix until combined.
Add the blueberries and mix well.
Use muffin cups or prepare the muffin tin by rubbing/spraying it with oil.
Add the batter to the muffin tin.
Bake for 18-20 minutes.
Let the muffins cool. Enjoy!
Makes 12 muffins.

For reference, check out the Integrative Pain Science Institute.

Q&A for men: second edition

6/4/2019

While drawing from her clinical experience, Becca Ironside, PT answers specific questions from men about their urinary, bowel, and sexual concerns.

This is Connect PT's second edition of the Question and Answer series.

Question from Marc: I have premature ejaculation. It has been part of my life since I was sexually active at 16 years old and I am now 33. Is this something that can be helped by pelvic floor physical therapy?

Answer from Becca: Marc, I would imagine that you may have been treated by psychotherapists for your issue. In the last century, many specialists have placed premature ejaculation into the category of a problem of the brain. However, pelvic floor physical therapists now treat your particular diagnosis in an entirely different manner. What we have discovered in treating men like you, is that those who experience early climax often have tight musculature in their saddle muscles (the muscles of your body that would be in contact with the saddle of a horse, were you seated upon one). In the ideal situation of arousal, these saddle muscles should expand and allow blood to flow into the penis and testicles. This blood should be retained in this saddle area to allow for an adequate time span during arousal and penetrative sex before ejaculation. In the case of premature ejaculation, the muscles of this saddle region are taut and cannot allow accumulation of blood to pool in the testicles and penis, which then creates an emergency expulsion of the seminal fluid from the penis.

This condition of premature ejaculation is treated in pelvic floor physical therapy. We assist men in reaching longer time durations of their erections by teaching them to lengthen their pelvic floor (saddle) muscles. We also instruct patients and their partners to increase the time of arousal and defer climax, thereby encouraging the blood flow necessary to prolong the sexual experience. In answer to your question, Marc, you can find help with a pelvic floor physical therapist.

Question from Steve: I suffer from chronic constipation. While that is terrible by itself, I also find that I cannot get fully hard during sex when I am constipated. Am I imagining this, or is there a correlation between constipation and erectile dysfunction?

Answer from Becca: Steve, I wish that more of our patients made this connection between the bowel and sexual function. The organs that sit within the relatively small cavern of the bony pelvis in men are the bladder, prostate, and the end of the colon (rectum). These organs are crammed into a very tight space. Which means that when one of these organ systems is a little bit off, the other systems invariably feel askew as well!

When the bowel is impacted with stool, as it is with constipation, this organ presses on the prostate and then the bladder. Also, the pressure on the perineum (the saddle region we discussed in Marc’s case), is created by too much fecal matter accumulating in the bowel. This excess pressure inhibits a full sexual response and limits full erections in men. The long-term discomfort associated in prolonged constipation can also distance a man from wanting to engage in sex.

The solution: pelvic floor physical therapists treat bowel dysfunction. We educate our patients in how to improve bowel regularity with stretches, exercise and lengthening of the pelvic floor muscles. What we find in treating patients like Steve is that when regular bowel movements are achieved, more satisfactory sex follows!

Question from Chen: I have trouble urinating from time to time. Sometimes, I think I am done peeing, I pull up my pants, and then I dribble urine. I am only 25 years old. Why is this happening and what can help?

Answer from Becca: Chen, I wish that you would start an online social media feed about your problem! Because it is so common and so very easily addressed. Many men come to pelvic floor physical therapy with complaints of leaking after peeing, or what we refer to in our line of work as “the post-void dribble.” Guys think there is something terribly wrong when this occurs, and because they won’t talk about it, they don’t know that many other guys have exactly the same problem!

Many men stand up to pee in urinals. This is the cultural norm in our society. But for men with tight pelvic floor muscles, or even men with moderate anxiety in a public restroom, the bladder cannot completely empty when a guy is in a standing position or when there are other men around him. What happens in this case is that the bladder cannot fully relax and the urine within it will not completely drain from the pelvis. Many guys shake their penises to try to get excess pee out of it. But this technique doesn’t always work to sufficiently drain the bladder. Hence, the dribble occurs after you think you are done peeing, Chen, and so many other men like you leave the bathroom to return to the tavern or sports arena, because they never allowed their bladders to fully empty.

Here is what a pelvic floor physical therapist may tell you, Chen.

Sit down when you pee. Go into a stall and don’t worry about what your friends think. This will allow your bladder to fully relax and empty, which might prevent the post-void dribble entirely.
Instead of shaking your penis when you think you are done peeing, take your fingers and press up into the space between your anus and your scrotum. Swipe your fingers towards the front of your penis. This will get that lingering pee out before you pull your pants back up.
Don’t wear tight pants or boxer briefs. If you have this condition, skinny jeans may not be for you. This type of clothing creates tension in the pelvic floor and prevents the penis from fully draining pee.
While these suggestions sound ridiculous, they are extremely effective. Moreover, wouldn’t you rather get back to your game? Because you will get back to that game, and you won’t leak urine anymore!

Finally, for Chen and the vast number of guys like him, view this PDF for the technique on how to avoid the post-void dribble.

Pelvic floor Q&A for men: first edition

5/21/2019

Introducing a new quarterly segment of Connect PT devoted to the pelvic health of men!

While drawing from her hands-on experience as a Pelvic Floor Physical Therapist, Becca Ironside will answer specific questions from men about their urinary, bowel and sexual concerns. This is an arena for men to ask their most personal matters with candor.

Question from Don:
“I am 32 years old and have no difficulty with sex. I do find that it is hard for me to pee after ejaculation. Is this normal? And should I be forcing out pee after sex?”

Answer from Becca:
“What you are describing is very normal. The muscles of your pelvic floor that allow you to maintain an erection and expel semen during ejaculation are in a shortened position during sex. These same muscles must be completely relaxed and elongated to allow urine to exit the urethra. Asking your body to pee immediately after having sex is like decelerating a car from 90 mph to a full stop. The pelvic floor muscles are too revved up after climax to stretch and relax. Instead of ‘forcing out pee after sex’, try sitting on the toilet and taking some deep breaths. This will allow whatever is within the bladder to naturally come out of your penis. And if you do not have the urge to pee after sex, you needn’t try this at all.”

Question from Gary:
“I am 53 years old and in pretty good shape. I have diabetes and my erections are not as strong as they used to be. My doctor has tried to give me Cialis; it works only some of the time, and it is very expensive. Are there any tips that you could offer as a pelvic floor physical therapist to improve my erections?”

Answer from Becca:
“Erectile dysfunction and diabetes are often linked. This is because having high blood sugar in the body alters circulation of blood and leads to nerve damage over time. The good news is that this type of erectile dysfunction can be reversed with good lifestyle choices. Maintaining a good diet for stable blood sugar, regular exercise and stress reduction can all help to improve your sexual response. From a physical therapy perspective, we can teach you how to isolate and contract your pelvic floor muscles during sex (also known as Kegel exercises), and improve your core strength. This will allow for increased rigidity of erections. You are one of so many men with exactly the same problem; there is help in pelvic floor physical therapy for a better sex life.”

Question from Pedro:
“I am 28 and began having groin pain over one year ago. I have penile pain along my shaft and up towards the tip, both during and after sex. It helps when I masturbate versus have sex with someone else, because I can avoid the tip of my penis and ejaculate with much less pain. I am not having sex with anyone at the moment, but I am worried because I used to get morning erections and now I don’t. Is this normal? I can’t exactly ask my friends.”

Answer from Becca:
“This is a multi-pronged question, so I want to be careful that I address each part of it. First, a great place for you to start if you have penile pain would be to go to a physician. There may be an infection under your foreskin (known as Balanitis), certain cancers or scar tissue development within the penis (also named Peyronie’s disease. You may have seen commercials on television about this diagnosis). Once your physician has ruled out any medical cause for the pain in your penis, a pelvic floor physical therapist can assess the musculature of your pelvis to determine if there are any imbalances or muscle tension that may be driving your pain.

“Second, having pain in the penis is one of the symptoms of Chronic Male Pelvic Pain Syndrome. That is not to say you have this diagnosis, Pedro. But this description of your problem is more common than you know. In pelvic floor physical therapy, we treat many men with penile, testicular, perineal and rectal pain. The causation of this pain is often tight musculature in the saddle area. Relaxation of these muscles can do wonders, but it is often difficult for guys to learn how to relax this region of the body without some guidance.

“Thirdly, many men with such symptoms tend to prefer masturbation to sex with a partner, especially when they are having a flare-up of pain. This is because, just as you mentioned, only you know what hurts and how to avoid pain during sex. Your partner will have a more challenging time working around your specific pain. That said, once your symptoms are decreasing in severity, the reintroduction of sex with a partner can be a creative and exciting learning curve. Physical therapists can help with this area of problem-solving with both partners.

“Lastly, morning erections are the body’s natural response from overflow of the parasympathetic nerves in your spine. In other words, the nerves are sending calming signals to the pelvis during sleep. This explains why having erections in the middle of the night or first thing in the morning is not a result of having erotic dreams or a person feeling aroused, per se; rather, the body is in a calm state and the testicles and penis become engorged with blood during sleep. Your lack of morning erections is consistent with your penile pain. This is because your pelvis is not relaxing appropriately during the sleep cycle to facilitate those erections. Many men with pelvic pain find that their morning erections return once their symptoms of pain are better managed. This is a good sign that the muscles of the pelvis are relaxing and allowing the return of painfree arousal and improved sex.”

Male pelvic pain video from Becca Ironside

Recommended resources: VMagic

5/2/2019

Connect PT loves VMagic for vulvar care.

Our therapists have seen significant benefits for women with itching and burning when used externally. Many with chemical sensitivities have been able to tolerate the honey and propolis, and organic extra virgin olive oil, among other natural ingredients in the cream.

Spring into detoxification

4/18/2019

by Karen Bruno, PT, DPT

Detoxification can be one way to heal your body and set the stage for sustainable weight loss and pain management because it assists in decreasing inflammation. It helps to reboot your hormonal system, cleanse your liver, cleanse your intestines of unfriendly bacteria, reduce chronic inflammation, and all of that helps with weight reduction and minimizing the inflammatory response that creates pain.

There are many different cleanses out there, and you may or may not choose to do one, however, here is a short visualization to pave the way for creating a healthier you and rejuvenate your body. Visualization can be used to communicate with your body and put it in a calm, relaxed state so it can rebalance itself and become healthy. It is a gentle and natural approach to allow your body to restore and repair itself.

Find a quiet place and sit or lie down in a relaxed, comfortable posture.
Begin by taking a deep breath in and then breathe out, allowing tension to release. Repeat this 2 more times.
Imagine a beautiful ball of bright, white light in your navel.
Imagine this light circulating inside and around you, getting bigger and brighter.
Imagine yourself in an infinite ocean of beautiful, bright, white, healing light.
Allow all of the pores of your skin to open up to allow this beautiful, bright, white, healing light to come in from all directions.
Feel the light in your chest, lungs, heart, stomach, intestines, pelvis, back, arms, legs, neck and head.
Let every cell in your body be filled with this beautiful, bright, white, healing light.
Everywhere this bright light touches, it cleanses your body, nourishes your body and heals your body. You feel every cell in your body saying “cleanse”. All 70 trillion cells are saying at the same time, “cleanse”.
Feel all the cells in your body starting to cleanse and getting ready to let go of any excess weight and any excess toxins. These are all being flushed out of your body, illuminated and evaporated into that infinite ocean of white light.
Imagine every cell of your body feeling clean and light.
Feel yourself and your system going into a better state. You are filling yourself with health and vibrancy, feeling purified, healthy, light and clean. You are feeling calm, centered and relaxed. This is easy and effortless for you.
Enjoy this feeling of well being for as long as you would like.
When you are ready, take a final deep breathe and know that your body has switched into a detoxification mode and you can lose weight easily and effortlessly, and eliminate excess toxins to bring more comfort to your muscles and joints.

Adapted from The Gabriel Method.

Sleep solutions

3/7/2019

By Karen Bruno, PT, DPT

Many of our patients report that they have difficulty getting a restorative night’s rest and they are not alone. In the United States, 50-70 million adults have a sleep disorder (1). Insomnia is one of the most common sleep disorders, with short term issues reported by about 30% of adults and chronic insomnia reported by 10%. 3–5% of the overall proportion of obesity in adults could be attributable to short sleep (1). Sleep disorders are a common complaint among people with pelvic pain and chronic diseases (2).

According to a recent article published in the American Journal of Physical Therapy, “Research continues to reveal that sleep is not a period of physiologic inactivity; rather, it represents a critical period of recovery that supports cardiovascular, neurologic, and other life functions. Sleep is a basic human need, and recent attention on sleep by researchers and media are changing sleep attitudes and behaviors. Sufficient sleep was often viewed as a luxury, and reduced sleep time was often equated with increased productivity; however, attitudes are shifting to prioritize sufficient quality sleep. Quality sleep is recognized as a positive health behavior, and it has been recommended to consider sleep as another vital sign, as sleep can give insight into the functioning and health of the body (3)."

You may have noticed that getting a good night’s sleep helps you to feel better both physically and mentally and this helps you function better during your waking hours. Basically, getting a good night’s sleep is a game changer that enhances the quality of your life. “Sleep is critical for the proper functioning of the body, including immune function, tissue healing, pain modulation, cardiovascular health, cognitive function, and learning and memory. Impaired sleep can lead to obesity, mood disorders, constipation and heart disease” (3).

https://www.sleepassociation.org/about-sleep/sleep-statistics/
https://academic.oup.com/ptj/article/97/8/826/3831304
Siengsukon CF, Al-dughmi M, Stevens S. Sleep health promotion: practical information for physical therapists. Phys Ther. 2017;97(8):826-836.

Tips for Healthy Sleep
There is good news! There are many natural ways to improve the quality of your sleep and restore your sleep health. Scroll through the list below and try one or more of the tips, and see how they work for you.

Decrease stress - Try diaphragmatic breathing to help you wind down and de-stress. Breathing full breaths in through your nose for 4 seconds and exhaling through your mouth or nose for 8 seconds is calming to the nervous system.
Create your bedroom space as a peaceful sanctuary - remove electronics, TV’s, exercise equipment and anything that may remind you of any form of work. Reserve your bed for sleeping and intimacy.
Get to bed in enough time to enable you to get 7+ hours of sleep. Create a relaxing bedtime routine. Read a book or take a bath to help wind down.
Establish regular sleeping and waking hours
Avoid light-emitting electronic devices at least 30 minutes to 2 hours before bedtime; use amber glasses at night when watching TV or working on a laptop.
Find the right temperature for your bedroom. The general recommendation is to keep the bedroom temperature between 60-70 degrees.
Sleep in complete darkness. Use of an eye mask may be beneficial to keep light out. Use earplugs or a white noise machine to block out noises.
Consider applying a hot pack to your abdomen. This can be very calming. Keep the hot pack on for no more than 20 minutes. If you tend to have cold feet, wrapping a hot pack around your feet for 10-20 minutes can be warming and relaxing.
Consider using essential oils. Lavender, Roman Chamomile and Vetiver provide relaxing effects and calm the nervous system. You can diffuse them, put the oils on your pulse point, rub them on the bottom of your feet, lightly spray them on your pillowcase or add them to an Epsom Salt bath and take the bath before bedtime.
Find a comfortable, supportive, neutral sleep positions. Use of a neck roll or a lumbar roll, or a pillow between your knees when you are on your side as positioning supports.
Avoid taking naps to catch up on sleep.
Exercise can have a positive effect on deep sleep. Find the time of day that works best for you. Stretching, strengthening, yoga, aerobics or a combination of activities may be right for you.
Avoid alcohol, caffeine and other inflammation-causing foods, like sugary snacks, refined carbohydrates, or processed meats, late at night.
Support through vitamins and supplements may be useful. Please check with your doctor, nutritionist, pharmacist or herbal practitioner for what may be right for you. Some common sleep nutrients include ashwagandha, valerian, chamomile, passion flower, lemon balm, melatonin, L-theanine and 5-HTP or Tryptophan. GABA is helpful if sleep is disturbed by anxiety. Taurine and phosphatidylserine help to lower cortisol. Magnesium and magnesium glycinate are helpful in insomnia.
Move your energy through easy Energy Medicine exercises.

Energy medicine is a safe and natural way to manage your energies to meet the stresses and anxieties in your life by optimizing your energies to help your body and mind function at their best. This approach acknowledges your unique complex nature and how your whole body is connected. From the energy medicine perspective, sleep problems are seen as an energetic imbalance that can be resolved by activating the body’s natural healing ability to restore balance.

I hope you will join me on Wednesday, March 20, 2019 at 6 pm in our Hamilton office to learn some of these easy and gentle self-care Energy Medicine techniques. Get a jump start and sign-up by calling 609-584-4770 for this free presentation.

Kegels for pelvic pain?

2/5/2019

By Bryn Zolty, PT, DPT

High muscle tone pelvic floor
Increased muscle tension in the pelvis
Levator ani Spasm
Hypertonic pelvic floor

If you have been told you have one of these in your pelvic floor, you were hopefully also educated on pelvic floor releases. That means letting go of tension in the pelvic floor. Releases along with diaphragmatic breathing, meditation, stretching, and pelvic floor glides are an excellent way to lower muscle tension in the pelvis. All of these are the opposite of Kegels - which are contracting and squeezing the pelvic muscles strongly.

However, there is research that suggests that women who have painful penetration and have not yet had children, three maximum Kegels can significantly lower vaginal resting pressure and surface EMG(1). Lower resting pressure and surface EMG, or biofeedback, translates to lower muscle tension, improved function, and less pain.

Biofeedback can be a very helpful tool to determine if this type of treatment is right for you. Small electrodes (stickers) are placed on either side of the anus. These electrodes connect to a computer that measures the muscle activity in the pelvic floor. As you watch the computer, a therapist will guide you through how to contract and relax your pelvic floor and try the three maximal contractions. If the tension in the pelvis is reduced, the therapist will provide you with your home exercise program that includes the three maximal contractions.

Can maximal voluntary pelvic floor muscle contraction reduce vaginal resting pressure and resting EMG activity? Naess, I. & Bø, K. Int Urogynecol J (2018) 29: 1623.

Patient cheat sheet of our most common exercises

1/7/2019

Our dedicated team of therapists are constantly creating ways for patients to stay compliant with their home program. Many people are confident in their exercise form at the office, but sometimes the knowledge seeps out after they walk out the door…

Check out our refresher videos on our patient's section (scroll down to the bottom). Marzena Bard, PTA, CYT, demonstrates your favorite exercises like “cat-cow” and “thread the needle”--you won’t forget them again!

A physiatrist's view on pelvic pain: an interview with Allyson Shrikande, MD

12/11/2018

By Michelle Dela Rosa, PT

Connect PT has the privilege of working with smart clinicians who are passionate about pelvic health. Meet Dr. Allyson Shrikande, an expert in treating pelvic pain.

Michelle: I'm here with Dr. Allyson Shrikande, founder of Pelvic Rehabilitation Medicine in New York and recently Hoboken, NJ. Thank you for speaking with me.

A lot of people ask us about the practice of physiatry. Some people know how it's pain management, but they don't really know how it's different than seeing their gynecologist or their urologist in the way they would treat their pelvic pain. So, can you give me a general overview to describe physiatry and how it treats pelvic pain differently than their gynecologist or their urologist.

Dr. Shrikande: Sure, thank you so much for having me, Michelle, this is great. For a physiatrist treating pelvic pain, we help the other doctors treat the muscles, the nerves, and the joints of the pelvis in a non-operative approach.

Michelle: How would that be different--can you give me examples of treatments that people may not see with their doctor that they're already seeing?

Dr. Shrikande: Essentially, we want to look at it from more of a sports medicine approach, seeing if the pelvic pain is coming from the pelvic floor musculature. Are the muscles in spasm and potentially irritating the nerves of the pelvis, causing some pain? So that's where we would come in when we're evaluating patients. Is there a pelvic floor muscle spasm, which we call pelvic floor hypertonia and can cause pain in patients. And we're really trying to evaluate why this is happening and is there anything from the sports medicine standpoint where we can identify a cause and help to find a proper diagnosis and treatment.

Michelle: I was lucky enough to be able to shadow you for an afternoon and I noticed that while you were treating patients, you were interested in not just recognizing that there was spasm, but like you said, what else could be contributing to it. So what other things do you look for that could be contributing to pelvic spasm?

Dr. Shrikande: From the musculoskeletal or the sports medicine standpoint, you want to see if there's anything going on in the lumbar spine that can cause pelvic floor dysfunction. Or is there anything going on in the sacroiliac joint? Or you want to consider the hips--are the hips working, functioning well? And is there any underlying pathology in the hips as well as what we call the pubic symphysis, which is the joint in the anterior aspect of the pelvis. In addition, is there anything going on from the other specialties as well that could be causing this secondary guarding of the pelvic floor muscles? So is there a gynecological reason if it's a female, or urological reason if you're male or female, or maybe from the GI system, etc? But you really want to say, 'Is there anything else going on here that's causing these muscles to go into this guarding state where it's really not letting go very well?'

Michelle: This is interesting because so many of my patients say they've gotten a diagnosis of pelvic spasm, but they didn't really get checked out. As a physiatrist, you are doing a pelvic exam?

Dr. Shrikande: When you see us, we would do a full exam--again looking at your back, your hips, etc--but we do end the exam evaluating your pelvic floor both externally and internally. So we do an internal exam. I always tell our patients that we're not gynecologists, so we're really looking at the muscles and distribution of the nerves internally. But we would do an internal exam and it does not require a speculum. It would be similar to an internal exam of a pelvic floor physical therapist--we really look at the tone of the muscles, the strength, and the lift of the pelvic floor, and follow the nerve distribution internally to see if there's any increased sensitivity or pain internally.

Michelle: Wonderful, we have such a growing population of men coming to see us for pelvic pain as well. And they're always curious how your exam would be different or how you would be able to help them because they're hearing that a lot of these treatments are for women. Would they be able to access you and what would you be able to offer them?

Dr. Shrikande: We see a lot of men here at Pelvic Rehabilitation Medicine, about equal amounts of men and women. From the muscle, nerve and joint standpoint, the anatomy is actually the same. For us, evaluating men and women, it is a similar approach. For the men, we do look at your lumbar spine, hips, and abdomen, any concern for underlying hernias that could have been missed. But then we do an internal pelvic floor exam as well--it would be internal rectally, also evaluating the muscle's tone and lift and any nerve tenderness internally. With men it would be a similar approach trying to see if there is any possible underlying cause for pelvic floor guarding. And then it's a full body treatment approach where we really can--we call it down-regulate--or calm down the nerves, of both the central and peripheral nervous system and increase blood flow to your muscles, and get the muscles longer and stronger to rehabilitate the pelvic floor.

Michelle: Many of our patients have been seeing multiple providers. And I noticed that in your practice, you seem to be a gateway to many of the other providers, sort of--coordinating care. Is that part of your model of care and how would you say your practice runs differently than other practices that treat pelvic pain?

Dr. Shrikande: Definitely. We see ourselves as the quarterback here, because as rehabilitation doctors, we really are trained from the beginning to look at the whole body and the interplay between multiple organ systems. So quite often, we are talking to a patient, and in our minds, thinking if there's any other specialist that we would need to bring into the picture to help us get this patient better. We work closely with specialists who are excellent in treating the pelvic pain from their angle. But we do see ourselves as the quarterback kind of sending as needed, as well as working closely with pelvic floor physical therapy, to figure out how to get our patients better and what other specialty is needed to calm down their muscles and their nerves.

Michelle: Some of our patients have been getting injections for their pelvic floor and they've been given an option for steroid. I know that you have other options, and also, can you touch upon the imaging that you use to guide you through the injections--if injections are necessary.

Dr. Shrikande: The way we do our injections, or treatments as we like to say…everything is external, nothing is internal. So it's all external, along the sling of the pelvic floor, and they're ultrasound guided. Patients call them their butt injections, that's kind of what it feels like--it's not internal, it's external. The idea behind the guidance is like internal eyes so you can see where you're going. And in addition, it allows us to do a hydrodissection technique, where we can really open up the fascial planes and create space where there is restriction, particularly where the nerves want to flow. What we're using to supplement for a steroid, is something called Traumeel, which is a homeopathic medicine, so it's derived from plants. The main ingredient is arnica--a lot of people have heard of arnica cream like topical arnica--but this is an injectable form of arnica and in combination with echinacea. So it's a nice way to promote healing in addition to decreasing inflammation, which is why we love it. I really used it more in my plastic surgery rotation. Post-operatively we would give it out after a surgery so that patients wouldn't become as bruised and swollen. It would decrease inflammation and promote a faster healing topically. So that's where the idea kind of came from.

Michelle: I know that one of the positions that you hold is that you're the Chair of the Medical Education Committee for the International Pelvic Pain Society. How do you feel that the position helps to shape what you do in your practice and helps shape how pelvic medicine is moving for the future?

Dr. Shrikande: We're actually lucky enough to be surrounded by amazing, intelligent, pelvic health practitioners who constantly push me to really think about things and learn more. The mission of what we do is educate the future of pelvic health from the medical practitioner standpoint--from both the residency program and urology, as well as gynecology and physiatry and any pelvic floor physical therapist who's had training there--just to try and increase awareness for the people who are training, that the pelvic floor itself is its own distinct entity. And although it does not show up in imaging, we really should not ignore it, particularly when the workup is normal and the patient symptoms persist. So we're really trying to raise awareness and at an earlier stage in physician's medical careers, in hopes of getting all our patients recognition earlier and treatment earlier. Because we really believe that is the key--early recognition and early treatment, to squashing it early and getting patients better.

Michelle: What's the range of people that you see in terms of how long patients have had pelvic pain for prior to seeing you? Is there a range?

Dr. Shrikande: It's getting better by the day. But still at this point, the average is six months to 25/30 years worth of symptoms. Even six months is rarest. It's really along the lines of 1.5 years to 25 years.

Michelle: Hmm, yeah. So, both of us are working on that.

Dr. Shrikande: We have to work together.

The Self-Care Corner

11/18/2018

By Karen Bruno, PT

The old healer to the soul:
It's not your back that hurts, but the burden.
It's not your eyes that hurt, but injustice.
It's not your head that hurts, it's your thoughts.
Not the throat, but what you don't express or say with anger.
Not the stomach hurts, but what the soul does not digest.
It's not the liver that hurts, it's the anger.
It's not your heart that hurts, but love.
And it is love itself that contains the most powerful medicine.
Author: Ada Luz Marquez

As we sink deeper into autumn, the leaves are changing colors, the daytime light is decreasing and the temperature is getting cooler. This can be a difficult time for many people. In addition, there is much to do in preparation for the upcoming holidays. Here is a quick "go to" exercise to restore coherence and calm.

Place one or both hands over your heart.
Begin to take some deep breaths in and out through your nose. One to three breaths is sufficient.
Shift your attention to your heart. Imagine breathing in and out through your heart.
Imagine breathing in love, and as you exhale, let that love expand in, through and around you. Surround yourself in a field of loving and compassionate, heart-centered energy. Take it in. Allow yourself to receive this gift.

For extra-credit: put a smile on your face.
For double extra credit: Smile into your heart.

Use this exercise anytime you want! Here are some suggestions for convenient uses:
As you awaken in the morning.
When you to go to bed.
Anytime you need or want a boost of energy, nourishment or connection to yourself or others.
When you are driving.
Anytime you are feeling upset or stress.
Anytime!

The overarching benefit of heart-centered practice is to live a fuller, healthier and happier life, even in the midst of the day to day demands.

My intention for each of you is to have a happy, peaceful, joyful and healthy holiday season.

After Prostatectomy: Kegels and Clamps

11/17/2018

By Bryn Zolty, PT

Kegels
Yes, men do Kegels too! In fact, you can start Kegels as soon as your doctor clears you to begin contracting your pelvic floor. After a prostatectomy, physical therapy can help educate men on how to reduce pelvic dysfunction and urine leakage. Some of this education can include: reducing excessive pressure on pelvic muscles, improving tissue mobility, re-educating deep core muscles, and strengthening pelvic floor muscles. A pelvic health physical therapist can tailor a program for you, as there isn’t a one-size-fits-all treatment.

How do men Kegel? In the literature, the phrase that was found to be most associated with stopping urine leakage was, “Shorten the penis.” This simple cueing creates the greatest displacement of the muscles that close the urethra. Other cues like “lift the bladder” were not as effective and increased pressure in the abdomen and pushed down on the pelvic floor. (1) It is important to be aware that you are not contracting other muscles in the legs, buttocks, and abdomen when isolating the pelvic muscles.

Every Kegel or pelvic floor strengthening program should be customized to each person. In the clinic, we work on endurance and quick contractions. For example, a home exercise program may include:

Endurance contractions: Shorten the penis and hold that contraction for 10 seconds. Release the contraction and rest for 10 seconds. Perform 10 times in a row. Do this set 3 times a day.
Quick contractions: Shorten the penis and hold that contraction for 2 seconds. Release the contraction and rest for 5 seconds. Perform 10 times in a row. Do this set 3 times a day.
For everyday activities that cause urine leakage, perform a Kegel simultaneously. For example, if standing up from a chair causes leakage, take a deep breath first and allow your abdomen to expand. Next, exhale and perform a Kegel prior to standing. Hold the Kegel while getting up to stand. Did you leak less?

Clamps
Some men lose large amounts of urine after prostate surgery, which can have a huge impact on normal daily activities. It may take time for kegels to make a difference in symptoms. A penis clamp may be an appropriate option to stop large leaks. The clamp places gentle pressure on the urethra to block urine loss. It may not stop all leakage but can significantly reduce it. When the clamp is removed, the release of pressure allows for normal urination. The amount of time recommended for wearing the clamp is variable between different devices. If you have any interest in a using a clamp, contact your physician or pelvic physical therapist to see if you are a good candidate.

According to the Journal of Neurourology and Urodynamics, men " found the device easy to use, felt more confident wearing the device, and had increased levels of physical activity with device in situ." They had significantly improved urinary incontinence symptoms per the Incontinence Impact Questionnaire. (2)

If you are going to have a prostatectomy or already have, ask your physician for a referral to a pelvic physical therapist. They can guide you through your pre- and post-surgical rehabilitation and reduce urinary incontinence.

(1) Stafford, R. E., Ashton‐Miller, J. A., Constantinou, C. , Coughlin, G. , Lutton, N. J. and Hodges, P. W. (2016), Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourol. Urodynam., 35: 457-463.

(2) Barnard, J. and Westenberg, A. M. (2015), The penile clamp: Medieval pain or makeshift gain? Neurourol. Urodynam., 34: 115-116.

Cable television discovers the pelvic floor

11/14/2018

By Becca Ironside, PT

I have been working as a pelvic floor physical therapist for a few years now. As with many people with hold this job title, we were often met with confused looks, raised eyebrows and a generalized misunderstanding as to what physical therapy of the pelvic floor could possibly entail. This is entirely understandable, as I had been a physical therapist for sixteen years before taking the dive into getting my pelvic floor specialty.

Why did I change paths and redirect my craft towards the pelvis? In part, because I had become a little bored with the other facets of physical therapy I had worked within and wanted a new challenge. But the larger reason why I felt compelled to undergo this very specific training for the pelvic floor is because I suffered from pelvic pain. It was unpredictable pain, which manifested itself in odd and various ways. I went to so many different physicians, yet none of these specialists I went to for treatment could help me with my symptoms.

Fast forward, five years later: I have a very gratifying job treating the pelvic floor muscles of both women and men. The demand for this work is enormous, as there are not enough pelvic floor therapists to treat the vast number of people who have discovered its importance. Women come to our clinic and the ability to help others who have the nebulous and seemingly inexplicable symptoms that I once did is a splendid feeling. Secondly, I no longer experience pelvic pain. This is because I can utilize the techniques and knowledge that I use with my patients on myself; I also have a great bunch of coworkers who can treat me when I cannot fix the problem and need another mind or another set of eyes and hands to brainstorm and palpate the causation of it. Lastly, there is a show featured on HBO which is all about a woman with pelvic floor dysfunction. Finally, the world is being educated on a grand scale about the importance of pelvic health! The show is entitled Camping.

In this show, a woman named Kathryn plans a camping trip to celebrate her husband’s 45th birthday. Kathryn invites other friends. She has a binder of scheduled events for her guests. Within the first few minutes of the show, it becomes very clear that Kathryn (played by Jennifer Garner) has some major control issues, coupled with a pelvic floor problem.

In watching the show Camping, we learn that Kathryn has undergone a hysterectomy. The loss of her uterus and ovaries has led to other losses. For instance, Kathryn and her husband have not had sex in two years. We are led to the conclusion, by her husband’s discussion with his fishing buddies, and Kathryn’s own overt disgust and refusal of sex, that it is chronic pelvic pain that seems to be driving the boat in their marriage.

Let’s go back to what pelvic floor dysfunction really means. Some women, like Kathryn, have had pelvic surgeries which can lead to scar tissue formation. Other women have constant burning and discomfort with urination, all due to muscular imbalances. What will that lead to? Sex can often become painful and many women brace themselves before each sexual encounter, in fear of the discomfort that will ensue.

The show Camping does a fair job in unveiling how a relationship can be eroded by pelvic pain and the lack of intimacy that often accompanies it. This is a finding often seen in the pelvic pain population. Pain alters how the brain processes information. It effects our ability to be active listeners, to take care of others, either in the bedroom or out of it. But when the pain is so directed in the perineum, sex is often one of the first leisure activities to take a backseat in the relationship. That makes sense, right?

There are other manifestations to having this condition. Many people with chronic pain find themselves more withdrawn than they might have been without it and more apt to find solitude. Their threshold for chaos can often run thin. And because women are often called upon in society to act “motherly” and to be “nurturers”, many of them living with chronic pain will simply put their chins up and bear it. Even though depression and anxiety might be creeping up their backs like a snake. Lots of them soldier on, push down the pain and are reluctant to make their diagnosis public.

Obviously, this does not represent all women with chronic pelvic pain. When we are introduced to Kathryn, the main character in Camping, we get quite a different profile of how this pain can affect people. The actress Jennifer Garner plays the role of Kathryn, and Ms.Garner uses her elan in this performance to show us a woman who is highly obsessive, erratic in thought and speech and has great difficulty maintaining relationships with others. Kathryn is described as “bitter” and “angry” behind her back and she hits her husband when he attempts to initiate sex.

This characterization of a woman with pelvic pain may be what the writer of the series felt if she had similar pain. Or the character may be based on a Type A Helicopter Mom to make the series more amusing, as this series is a sitcom. But the reality of this portrayal of Kathryn as a woman suffering from pelvic floor dysfunction is that she does not represent the typical sufferer. Because this is the first exposure that the general public has had in mainstream television to the pelvic floor, it may render women less willing to acknowledge or seek help for their diagnosis, as they may not want to align themselves with the behaviors of Kathryn.

In fact, the portrayal of women in this light can seem reminiscent of the 1950’s. The term “hysterical” was used in the past as an actual psychiatric diagnosis used to label women for being overly dramatic and prone to bouts of insane behavior. The medical operation known as a hysterectomy was named because it was believed that if a physician removed a woman’s female parts, he would eradicate her insanity.

I am reluctant to bring these facts from the past for women into the cold light of today. This is what the world of pelvic floor physical therapy is trying to reverse – the notion that women with feminine troubles are irrational and unable to be around without great unpleasantness. While it is encouraging that a cable network has named pelvic floor dysfunction, it would be far more helpful in the future if women were represented as emboldened by the power to take back their own pelvic health. Because that is precisely the image of the women who come to us: bold, unashamed and ready to use available resources to uproot outmoded theories of how they should feel and who they should be.

So, where do we go from here?

If you have seen Camping, and feel that you may have something going on in your pelvic floor, you can locate a physical therapy practice which specializes in this diagnosis. To find a pelvic floor physical therapist near you, visit https://pelvicrehab.com/.
If you feel unhinged because of your pain, and other irritating symptoms associated with pelvic floor problems, you may be told that this is “all in your head”. Yes, you might have some depression and anxiety surrounding what your body is doing, but there are actual anatomic and physiologic problems for which there is now treatment available. Remember, this is not 1952 and you are not “hysterical.”
Finally, rediscovery of your own pelvic health is exciting! You can return to many painfree activities. Your goals are your own and you will set them yourself. In this way, you will become your own healer, with some other minds, eyes and hands to assist you along the way. To quote the motto of the Pelvic Floor Physical Therapy clinic wherein I work: “It’s time to own your body” Connect PT.

Mini-relaxation exercises for everyday use

10/8/2018

By Karen Bruno, PT

Mini-relaxation exercises are focused breathing techniques which help reduce anxiety and tension immediately. You can informally cultivate mindfulness by focusing your attention on the moment to moment sensation during ordinary activities. You can simply do this by single tasking - the art of doing one thing at a time and giving it your full attention. As you wash your hands, pet the dog or eat a meal, slow down the process and be fully present, using all of your senses.

As you awaken, bring your awareness to your breathing. Take a few deep, mindful breaths, sensing the effects in your body. You should feel your belly rising about an inch as you breathe in, and falling about an inch as you breath out.
Instead of hurrying into your usual routine, slow down and enjoy something special about the morning: a flower that bloomed, the sounds of the birds, the face of a friend or family member.
Give yourself 10-20 minutes to elicit the relaxation response through meditation, stretching, or your favorite way.
On your way to work, attend to how you walk, drive, or ride. Breathe mindfully, relaxing throughout your body. Perhaps you would benefit from listening to soothing music.

When stopped in traffic, check your body for signs of physical tension. Drop your shoulders, release your hands on the wheel, soften your facial muscles. Can you break the cycle of running yellow lights and passing cars?
Look for people, places and things which remind you to relax. Use the repetitive events of the day--the ringing telephone, a knock on the door, walking down the hall--as cues for mini relaxations. Can the clock on your watch or phone remind you to take a deep, easy breath and let go?
Practice “news and goods” together. A pleasant experience, no matter how small, can be a stepping stone to feeling better. Have a buddy system and practice focusing on things you like about each other. Reward each other with well-deserved appreciation we so rarely get during our work day. Notice how good it feels to empower another with your appreciation.
When you start a project or feel overwhelmed by what you need to accomplish in the near future, take a few moments to orient yourself, breathe consciously and calmly, relax and then begin. Organize your work. Set priorities. Be realistic with your goals.
Find a few moments during the day to take a break. Breathe consciously, meditate, listen to something relaxing, go out for some fresh air or take a walk.
Whenever you eat, listen to the wisdom of your body. Begin to choose healthier alternatives to quick-fix items like caffeine, sugar and prepared foods.
Acknowledge that you don’t have to remember to do this all the time or be a perfect stress manager. Notice the temptation to turn even stress management into a way to set up unreasonable expectations. Instead appreciate yourself for your successes. Forgive any relapse, laugh, and enjoy this moment. The past is gone; the future is not here; this is your moment. Savor it.
Walk mindfully to your car, bus, train or vehicle of transportation, coordinating your breathing with your steps. Can you see something new in the environment? Can you enjoy walking without rushing?
Use the time in commuting, when waiting in lines or when put on hold during a phone call to turn your awareness within. Breathe deeply, calmly, consciously; release tension. Enjoy the moment.
As you return home, can you consciously make the transition from work to home? If possible, give yourself a few minutes alone to ease the transition.
As you go to sleep, let go of today and tomorrow and take some slow, calming, mindful breaths. Place one hand on your abdomen and one hand over your heart to deepen the relaxation.

Mini Version 1: count very slowly to yourself from ten to zero, one number for each breath. With the first breath you say “ten” to yourself, with the next breath, you say “nine, etc.

Mini version 2: as you inhale, count very slowly up to four; as you exhale, count slowly back down to one.

Mini version 3: after each inhalation, pause for a few seconds; after each exhalation, pause again for a few seconds. Do this for several breaths.

Matt and the hockey puck

9/6/2018

By Becca Ironside, PT

Matt was a regular guy. At 36 years old, he had a successful career in IT and was newly married. Matt had been playing ice hockey from the time he was in grade school and had no intention of stopping in adulthood. Every Tuesday and Thursday night, Matt went to a local ice rink and laced up his skates to play with a men’s league. This was the release from the grind of his job and he felt like a young kid as the blade of his stick hit the puck away from the opponent’s net.

Matt always wore a mouth guard and a jock strap. They were as necessary as the shoulder pads under the jersey. Anything could happen on the ice, and Matt was taking every precaution necessary, while having the best release of adrenaline he ever felt during the workweek. Until one day when all of this hockey armor failed to protect Matt. He will never forget it, he said. How could he? One evening, as Matt was playing defense, the puck flew into the air and hit him just to the left of his groin. The trajectory of the puck was like a sharp-shooter, it got that very tender spot between his jock strap and
testicle. The pain was excruciating.

Matt took a few deep breaths. He sat on the bench for about four minutes, then resumed playing and felt almost no pain at all. It was not until he arrived at home and took a hot shower that the secondary shock wore off and he had no choice but to go to the Emergency Room. A prominent urologist just happened to be on call, luckily for Matt, who informed him that his left testicle had been fractured. This meant that the casing of the testicle was damaged and that the contents therein were
extruding out of it into the space of the scrotum.

The only choice was surgery. The urologist made an incision down the seam in the middle of the scrotum and removed the damaged tissue. There was pain after the surgery, Matt said, but nothing as severe as the pain which brought him to the hospital after the puck’s errant contact with his groin. This surgical pain settled down, healing took place, and all seemed to return to normal.

It was not until three months later when Matt noticed that he was having difficulty with sex. He had developed premature ejaculation. There was also a strange sensation of fullness and tenderness in his testicles after climax. How had this happened, Matt wondered? And what could be done? Was there treatment for this?

It was Matt’s wife who found our clinic. This was not surprising, as women typically have a more visceral connection with their pelvic floors; we have periods as teenagers, we get examined internally when most men do not until later years and we often have pregnancies which put this area of our bodies in the spotlight. Matt came to Pelvic Floor physical therapy with his wife, Maria.

Maria explained that she was concerned about her husband’s premature ejaculation and discomfort after sex. Not only did Maria and Matt want to return to their very robust sex life, they also wanted to conceive a child. It was helpful to have both partners attend this initial session.

Matt returned for several physical therapy appointments by himself after that first evaluation. He learned methods to relax the muscles of his perineum. It was the scar adhesions of his testicular surgery that caused his muscles to go into spasm; this was driving the premature ejaculation and pain after intercourse he was experiencing. He learned techniques to release the scarring and relax his muscles and taught his wife how to help him. Together, this couple worked to recover Matt’s sexual and
pelvic health.

It was nothing short of wonderful to get a letter from Matt a few months after he stopped attending PT. The letter read as follows:

“It was not easy to come to a physical therapy office and talk about erections. But I am so glad that I did it. Since then, Maria and I are able to have the kind of sex that we did before the injury. I am also back to playing hockey, but only one night a week. This is because we are expecting a baby girl in a few months and I need to be at home more to get ready for the baby.”

What was so successful about the outcome of this story, you might ask? Firstly, Matt had a traumatic injury to his groin and developed symptoms immediately thereafter, so the causation of the problem was easy to determine. Secondly, Matt was open to this type of therapy and it was readily available to him in the area in which he lived. Finally, and what is most important about this story, is that Matt and his wife Maria tackled the problem together. They both had to adjust their expectations, lifestyles and learn to overcome something which might have driven them apart. Instead, it brought them closer together.

Pelvic Floor physical therapy helped to make this happen. With a baby girl to reinforce the story! There is great power in looking at life’s problems and seeking help. It requires staring down our opponent on the ice. We need the shoulder pads and the mouth guards, but the puck might still hit us in the worst possible spot. With a team approach, we can recover. We cannot allow the fear of the puck to keep us out of the ice rink. Just like Matt and Maria, we have to keep skating.

"The foot bone’s connected to the…pelvic bone"

8/6/2018

Many patients have visited their pelvic floor physical therapist and wondered, “Why are you looking at my feet when I’m here for pelvic pain?” The answer is the alignment in your feet, and how you walk affects the muscles, joints, ligaments, and bones in your pelvis.

The foot is complicated. It contains 26 bones, 33 joints, and over 100 muscles, tendons and ligaments. But let’s keep this explanation simple. Its main functions are to soften, absorb shock and accommodate to the surface on which your foot lands, then become rigid to help you push off and take a step.

The foot bone’s connected to the…pelvic bone. pronation supination

The softening of the middle of the foot to absorb shock is also known as pronation. You can have too much pronation. This looks like flat feet or collapsed arches. Alternatively when your foot becomes rigid to push off, this is known as supination. You can also have too much supination. This looks like very high arches.

Both motions are important for movement. Each in excess can lead to pain and dysfunction. Every time you step, the alignment of your foot affects the way your whole body moves. Your therapist looks at how you stand, step, walk, how your shoes are worn and your foot structure, and puts the pieces together. In standing, the therapist can see if you excessively pronate or supinate.

Here are two examples of how your foot alignment can affect your pelvis:

When a person has too much pronation, or collapsed arches, this causes the leg to turn in. The hip and pelvic joints absorb the extra rotation leading to strain on muscles that rotate the hip. One of those muscles, the obturator internus, is a common source of pelvic pain and dysfunction.
Alternatively, when a person has too much supination, or a high arch, this is a rigid position. It has a decreased ability to soften and absorb shock. This increases the demand on ligaments in the pelvis and can lead to too much motion in the sacroiliac joint, or the lower end of the spine. This can also cause too much outward rotation at the knee and hip.

There are many more considerations in evaluating the foot than the two examples provided, but they all have a profound effect on the rest of the body. They can cause instability at joints, pain, strained muscles, overworked muscles, and much more. In pelvic health physical therapy, your therapist is not only treating the symptoms in the pelvis, but always looking for possible causes of the symptoms such as your feet!

What the research says: abdominal adhesions in gynecologic surgery

8/1/2018

By Michelle Dela Rosa, PT

A longitudinal study published in the International Journal of Obstetrics and Gynecology discusses how the presence of adhesions in abdominal gynecological surgery is associated with cesarean delivery (n = 15,479). Repeat cesarean, age, obesity, and infection increased the risk of pelvic adhesions after cesarean section. Pelvic physical therapy after cesarean section can teach women how to mobilize scars effectively to minimize the potential for adhesions in the future.

Hesselman S, Högberg U, Råssjö E‐B, Schytt E, Löfgren M, Jonsson M. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population‐based register study. BJOG 2018; 125:597–603.

Testimonial corner: Eva

7/11/2018

I have been to 4 different practitioners for different reasons, from pelvic floor therapy to orthopedic therapy for my back and I can't sing their praises enough. This is the only truly holistic physical therapy center I have ever attended. The work they do is based on scientific medical practice but feels more like a nurturing yoga based treatment. I have learned so much about the connections between different body systems and how stress affects everything. Using what I have been taught and implementing it in everyday life has helped me maintain my well-being. Thanks guys! -Eva

What's new: cupping therapy

6/22/2018

By Bryn Zolty, PT

Cupping therapy has added another element of therapeutic release for our patients at Connect PT. Cupping has been around for over 3500 years in ancient Egyptian and Chinese Medical texts. It is a method of placing or sliding cups on various body parts using heat or suction to create a negative pressure to mobilize the tissue.

Its proposed treatments include a wide range of ailments, such as improving lymph drainage, improving blood flow, decreasing pain, and even drawing out infections.

Our therapists use one of the more gentle methods, gliding cupping, as a way of decompressing the soft tissues with lotion/oil to increase motion and decrease pain. A patient can feel gentle suction, stretching, or slow gliding of the cup. This is unlike the prolonged, static placement of the cups, as performed on some Olympic athletes. Our patients benefit by: increasing blood flow and removal of stagnant blood, softening/releasing scar tissue and adhesions, releasing trigger points and "muscle knots", improving tissue mobility/flexibility, and relaxing muscles. We have had success using cupping therapy with many conditions, like low back pain, pelvic pain, hip pain, stuck scars, constipation, and much more!

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