Pelvic Health Blog

Postpartum rib flare

5/17/2021

by Bryn Zolty, PT

Rib Flare
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!

Am I even doing this right?

3/30/2021

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!

Here is an ultrasound image of my abdomen with me at rest.

D1 is the TA.
D2 is the internal oblique.
D3 is the external oblique.

The top of the picture is the surface of my abdomen. The TA is deeper than the obliques.

This is an ultrasound image of me turning on my TA. Compare it to the picture above. See the lower band, D1 which is the TA, widen and start to slope down, which is what we want to see.

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.

Dolphin on the table & skier stretches

1/14/2021

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.

"Dolphin on the table" is a feel-good stretch for anyone who has tightness in the back, shoulders, or hamstrings. It increases the length and blood flow of these muscles.
"Skier" stretch is helpful for those with pelvic tension and pain. It helps to stretch the inner thighs and the entire groin area, which also improves blood flow to the pelvis.

Watch the video tutorial below.

Taping for diastasis recti: criss-cross method

10/12/2020

Every pregnant woman has an abdominal diastasis, or diastasis recti, at the end of their pregnancy. It's a massive stretch on the abdominal wall that makes the connective tissue at the center very thin. Some heal in the first six weeks postpartum, but many need more time. We're here to help women that need help strengthening their belly after baby.

Watch Bryn Zolty, PT demonstrate the criss-cross method with kinesiotape to support the diastasis and help activate your abdominal muscles correctly.

Planks for prolapse

9/30/2020

By Bryn Zolty, PT

Planks are one of the most well-known core exercises. Doing a plank incorporates many muscles to make us strong and support our joints. Typically an individual starting off with planks would try a modified plank and build up to a full plank. A modified plank means less difficulty when you are starting out so you can maintain a nice neutral spine, avoid holding your breath, and build strength. Two common modifications would be starting on your knees or placing your elbows on a higher surface than your feet as seen below in the Common Progression. After this position becomes easier, you can hold longer or perform more repetitions. Next you could try a full plank. Planks can continue to be progressed to have your feet above your elbows, your elbows on exercise balls, use exercise bands and more.

Now let's add prolapse to the situation. Pelvic organ prolapse can feel like heaviness in the vagina and even progress to the organs (bladder, uterus, vagina, rectum) coming out of the body. These symptoms increase with gravity. The more upright you are, the more symptoms you may have. So with a prolapse, we may consider reversing the progression. We may start with your body inverted - check out the picture with the feet on a chair and elbows on the ground in step 1 of the Prolapse Progression. We also encourage you to monitor your breathing. Holding your breath can increase symptoms. Consider what happens when you breathe in and fill your system with air, and then hold your breath and strain in a position. This can push these organs down. In addition, you could consider adding a kegel, or pelvic floor squeeze, to help support the organs. Your progression might look like the reverse of the Common Progression! As you gain better control of the pelvic muscles and breathing, you may be able to progress to being more upright with less symptoms. Good Luck! Contact us if you need help modifying your exercises, breathing, or help with pelvic muscle strengthening so you can exercise with confidence.

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: 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.

Can I do a crunch?

4/3/2018

Written by Bryn Zolty, PT

If I just had a baby can I return to running? I’m leaking - can I do exercise that involves jumping? My doctor says I have a prolapse - can I lift weights at the gym? As pelvic physical therapists, we hear these questions every day. It is very common to wonder if after having a baby, a surgery, or if you have pain in the pelvis, if it is okay to engage in activities that can push pressure down into the pelvis.

While more research is needed to better answer these questions, there are a couple of studies available that have measured the pressure in the vagina with functional tasks, yoga poses, and other exercises in attempts to answer these questions. Here is a little of what they found with a group of women ranging in age from 20-51:

Crunch AVG pressure: 23.8, range 19-76, with an exhale AVG 12.4 range 8-75
Downward facing dog AVG pressure: 39.1 range 26-72
Exercise machines AVG 37 range 20.3-182.3
Jumping AVG 171 range 43-252
Coughing AVG 98 range 49-130
Bearing down with breath hold AVG 101.7 range 45-131

*Units of pressure used in the study are in cm of water. This is the height in cm of water displaced by pressure. (O’Dell et al.2007) (Cobb et al. 2005)

These numbers can surprise people. How can a crunch be so bad if the average pressure is 23.8 and a normal daily occurrence like coughing is 98? As a therapist, my focus is drawn to the large ranges within each activity. What is the woman doing differently to crunch at a pressure of 8 compared to the woman at a 75?

As therapists we evaluate how you move and conduct each of these activities. As pelvic physical therapists we look closer at your movement, alignment, breathing, coordination, and muscle tone in relation to the pelvis. All these factors play a role in the pressure your body places on the pelvic floor. This pressure is known as the intra-abdominal pressure. This is how one woman can have very low pressure on her pelvic floor while another woman has high pressure during the same activity. The key is how they complete the task.

Back to the question, can I do a crunch? Can I return to strenuous exercise? Our goal is to teach you how to do movements or activities properly while minimizing the negative impact on the pelvic muscles. A pelvic physical therapist’s job is to evaluate the movement or activity that gives you pain or makes you leak and improve it.

How do we do this? Let’s take a squat for example. If a patient comes in because she leaks urine while squatting, we would explore all the possibilities.

If a weak pelvic floor is causing your leaking, we would teach you techniques to strengthen/engage your pelvic floor and prevent leaking. This could be done by performing a pelvic contraction, a breathing pattern to encourage activation, or even using a high tone phonation!
Conversely, leaking can also be caused by a tight/tense pelvic floor. In this situation, we could trial lengthening/releasing the pelvic floor during the squat.
Alternatively, leaking could be caused by too much pressure on the pelvic floor and not necessarily lack of strength. It is possible that a change in alignment of the head/neck, ribs, or pelvis could increase pressure higher than the pelvic floor can support. According to the study holding your breath and bearing down causes an average pressure of 101.7. It may be your breathing pattern might need to be adjusted!

After having babies, surgeries, or injuries our bodies change. Some of these changes can lead to incontinence or pain. A pelvic physical therapist is a great clinician to discuss these changes along with your goals for fitness or everyday activities. Whether it’s cueing on alignment or movement strategies, breathing, releasing or strengthening, it is our goal to help you reach yours.

References/Citations

From the Glottis to the Pelvic Floor: Making Clinical Connections. Julie Wiebe, PT, MPT,BSc, and Susan Clinton, PT,DScPT,OCS,WCS,FAAOMPT.

Cobb WS, Burns JM,Kercher KW, Matthews BD, Norton HJ,Heniford BT. Normal Intra-abdominal Pressure in Healthy Adults. 2005; Journal of Surgical Research 2005; (129):231-235.

O’Dell KK, Morse AN,Crawford SL, Howard A. Vaginal Pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines. International Urogyneocology Journal, 2007;18: 1481-1489.

Infertility is on the Rise

12/18/2017

Written by former staff physical therapist, Aisling Linehan, PT

Infertility is on the rise and as pelvic floor physical therapists we want to do our part to help our patients get pregnant. According to this study, 15% of couples will struggle with infertility. Reasons for infertility can be broken down to ovulation disorders (27%), male factors (25%), tubal disorders (22%), unexplained factors (17%), endometriosis (7%); and “other factors” (4%). Pelvic floor physical therapists specialize in manual & movement therapy. It makes sense that the type of infertility that we can help with is “mechanical”.

The study also states: Many of the issues that cause a woman to have difficulty with conception can be traced to scar tissue, fascial restriction, and congested lymphatics. The manual and movement work we do with our patients can help with scar tissue, fascial dysfunction and poor lymphatic drainage. The body gets tight and stale with our everyday routine and mundane movement patterns. These changes in physiology require manual work and movement therapy.

Release of fascial and ligamentous restrictions can decrease pressure on blood vessels, thereby optimizing the vascular phase and improving the efficacy of the lymphatic system. Better blood flow basically means better “detox” and waste management by the body. The body, in turn, is better able to perform important processes such as reproduction. It is also important to note that reproduction is not essential in keeping a person alive; thus, if the body feels under threat in any way reproduction is not a priority. Check out the study to see how pelvic floor PT can help you get pregnant.

Not sure if you want to try pelvic floor PT yet? Stop by on Thursday night to try our gentle relax and renew yoga class. Getting your body in a more parasympathetic state can help you mentally and physically prepare for bringing new life into this world.

Yoga During and After Pregnancy

11/8/2017

Written by Michelle Dela Rosa, PT

Anxiety and depression in women can be common before or after giving birth, with rates around 10% and 20% respectively. These disorders can make it hard to care for yourself or your new baby.

Medications, while sometimes effective, have the risk of side effects for you and/or developing baby. Why not try an alternative treatment, like yoga, which has been shown in the general population to help mental health and well-being?

A 2015 systematic literature review showed that yoga was not only effective in decreasing depression and anxiety in perinatal women, but also improved: pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, optimism, and well-being. If you are pregnant or just had a baby and are unsure how to progress with exercise, our therapists who are also certified yoga instructors can help you make the leap into fitness.

Sheffield KM, Woods-Giscombé CL. Efficacy, Feasibility, and Acceptability of Perinatal Yoga on Women's Mental Health and Well-Being: A Systematic Literature Review. Journal of Holistic Nursing 2015:34(1)64-79.

What the research says: does mode of delivery affect perineal trauma and painful intercourse?

10/12/2017

Written by Michelle Dela Rosa, PT

1500 women who had never given birth were recruited during their first and second trimesters of pregnancy from six maternity hospitals in Australia. Researchers studied data from baseline and postpartum questionnaires about pain with intercourse (dyspareunia). 98% resumed intercourse by 18 months and 24% reported dyspareunia. Women who had an emergency cesarean section, vacuum extraction, or elective cesarean had an increased risk of reporting dyspareunia at 18 months postpartum, compared to women who had a spontaneous vaginal delivery with an intact perineum or unsutured tear.

McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015;122:672-679.

Recommended Resource: BabyBod

10/6/2017

Connect PT likes BabyBod, written by Marianne Ryan, PT. The book details how to stay fit during pregnancy and get back into shape after delivery with the guidance of an experienced pelvic physical therapist. Moms will benefit whether they gave birth yesterday or many years ago.

Recommended Resources: reviving your sex life after childbirth

1/11/2016

Connect PT likes Reviving Your Sex Life After Childbirth, by Kathe Wallace, PT.

This book offers women physical therapy techniques and other tips to return to pain-free, pleasurable intercourse after childbirth.

What the Research Says: Predictors of Pregnancy-related Pelvic Pain

5/1/2014

Written by Michelle Dela Rosa, PT.

Pregnancy-related pelvic girdle pain (PPGP) can significantly limit movement both during and after pregnancy.

The International Association for the Study of Pain researched predictors of pelvic girdle pain in the working mother.

In 548 Dutch working women, almost half reported pelvic girdle pain at 12 weeks postpartum. Pregnancy-related predictors for pain included: history of low back pain, elevated somatization, 8 or more hours of sleep/rest per day, and uncomfortable postures at work. Pregnancy and postpartum-related predictors for pain included: disability and pelvic girdle pain at 6 weeks, elevated somatization, higher birth weight of the baby, uncomfortable postures at work, and number of days on bed rest. The authors discussed that a woman with PPGP should be cared for to prevent more serious postpartum disability (Stomp-van den Berg et al, 2012).

Another study looked at the type of delivery and pelvic girdle pain in 10,400 women with singleton pregnancies. A planned cesarean section was associated with 2-3x the rate of pelvic girdle pain at 6 months postpartum. The authors recommended vaginal birth for women with PPGP, unless there is a serious medical reason (Bjelland et al, 2013). In a study done by the same lead author, postpartum women had high recovery rates from pelvic girdle pain, but those who reported significant emotional stress during pregnancy had an independent correlation with continued pelvic girdle pain (Bjelland et al, 2013).

A final study looked at the relationship between exercise and PPGP. Pregnant women who exercised more than 2x per week reported a lower rate of pelvic girdle pain, and those who exercised 1-2x per week reported less low back pain and depression. The authors concluded that exercise during pregnancy could lower the risk for pelvic and low back pain (Gjestland et al, 2013).

Bjelland EK1, Stuge B, Engdahl B, Eberhard-Gran M. The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study. BJOG. 2013 Jan;120(1):32-40.

Bjelland EK1, Stuge B, Vangen S, Stray-Pedersen B, Eberhard-Gran M. Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum. Am J Obstet Gynecol. 2013 Apr;208(4):298.e1-7.

Gjestland K1, Bø K, Owe KM, Eberhard-Gran M. Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med. 2013 May;47(8):515-20.

Stomp-van den Berg SG1, Hendriksen IJ, Bruinvels DJ, Twisk JW, van Mechelen W, van Poppel MN. Predictors for postpartum pelvic girdle pain in working women: the Mom@Work cohort study. Pain. 2012 Dec;153(12):2370-9.

What the Research Says: Pregnancy and Delivery is Not Always the Culprit for UI

11/18/2012

Written by Michelle Dela Rosa, PT.

Pregnancy and delivery is not always the culprit for urinary incontinence (UI).

An article on the MONASH University website concludes that “up to 1 out of every 8 healthy women who have not carried or birthed children have urinary incontinence”, which significantly affects quality of life.

1000 healthy, young women (age 16-30 in Melbourne, Australia were surveyed about continence. 6.2% of women reported urinary leakage with stress, 4.5% with urge, and 1.9% with both stress and urge. Women were also more prone to UI if they reported a history of bedwetting beyond 5 years of age.

Case Study: Constipation

10/22/2012

Patient: 40-year-old female with 8 year history of constipation.

Chief Complaint: Difficulty with bowel evacuation, normal stool consistency. Patient leans back and presses on stomach to evacuate.

Past Medical History: 2 vaginal births, insomnia since last birth 3 years ago.

Physical Therapy Treatment: Manual therapy to pelvic floor and abdomen; review of proper bowel evacuation and stool formation; breathing mechanics; postural education and exercise; LE stretching; core strengthening exercises; HEP.

Results: Complete bowel evacuation 1-2x per day without straining or altered mechanics after 8 visits.

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