Body Perception Distortions

Why is it that, after extensive Physiotherapy, massage therapy, chiropractic, osteopathy and other forms of treatment people still experience pain? Research studies are still working on getting to the bottom of persistent pain, why some have it and others don’t.

The answer to the question is that pain and our experience of pain is complex. For this article I want to focus on body perception disturbance.

In order to have a better understanding of what we are talking about, I need to talk a bit about the brain, anatomy and physiology. My plan is not to go into great depths because that would turn this blog into a series of novels. So a brief overview and if this sparks your interest then I encourage you to research and learn more.

Let’s start with the sensory-motor cortex in the brain. The sensory cortex is the part of the outer brain that receives signals from the body regarding sounds, sights, smells, touch, vibration and where our body is located in space (1). It is also involved in planning movement.

The Motor Cortex is also located on the outer part of the brain, right beside the sensory cortex and its involved in planning, controlling and executing movement (2).

Another component of the brain involved in body perception is the cortical homunculus, which is a distorted representation of the body and its parts based on use and need for accurate sensation and movement. For example on the picture you will notice the representation of the hands is much later than the lower back. One reason for this is that the hands need to be able to perform fine coordinated movements and we use our hands very frequently where as we don’t need as much attention to move our lower back.

Some individuals with persistent pain have a distortion of their body perception which is defined as the feelings of one’s own body (3). Studies have found that some individuals have re-organization of their sensory-motor communication within the brain making it difficult to make sense of the sensation and movements of a particular body part.

An analogy I like to use is imagine you had a clear google map of where you were going and then all of a sudden that google map went all blurry. How difficult would it be for you to move around and sense where you are in the world? Now imagine it’s the map of your hand. Would your hand move coordinated? Would your hand experience sensations in the same way it did before? Likely not, and that why some individuals develop what is called complex regional pain syndrome or CRPS in their arm/hand following an injury. CRPS is characterized by a disproportionate experience of pain, unexplained swelling and discolouration of the skin and an inability to even be touched lightly due to pain.

When researchers discovered this reorganization in individuals with CRPS they began to wonder if the same could happen to low back pain sufferers. Can the brain change in individuals with chronic or persistent low back pain? The answer is yes. Studies have found that some individuals with low back pain have reduced accuracy of touch (3), meaning when the therapist touches their back they cannot correctly identify where they were touched or if the therapist draws letters on their back they cannot correctly identify the letters.

Individuals with back pain also cannot sense their back very well (either it feels bigger, smaller or swollen) and they have difficulty coordinating movement between the upper and lower part of the spine (3). Individuals might describe that they have to think really hard about making their back move the way they want it to or the right and left side feels lopsided. These reports are indications that changes may have occurred in the sensory-motor cortex and the homunculus map has “smudged” or gone “blurry.” (3)

So how might a therapist know if your body-perception has changed? Well we don’t have access to functional MRI’s and other expensive equipment so researchers have worked on creating a short questionnaire that can screen clients for body perceptions changes. The questionnaire is called the Fremantle Back Awareness Questionnaire or the FreBAQ. I have now implemented this questionnaire in my practice not just for low back pain but other types of pain so that I might be better able to direct treatment. Some other ways we can test for changes includes having the person identify where we are touching with their eyes closed, what letters we are drawing on the skin and/or 2-point discrimination. I also like to use other questionnaires to help support the overall picture of why a person is having pain.

Going back to the initial question at the beginning of this blog. Why do some people not get better after extensive treatment and exercise? While treatment and exercise are key components in rehabilitation if someone has body perception distortion this requires a different approach to help that individual essentially “refresh” their google map. There are a variety of ways to do this using sensation and movement strategies that are new and interesting. It is about increasing body awareness and bringing mindfulness to movement and sensation.

So if you’re an individual who’s completed extensive treatment perhaps body perception is a problem and finding a therapist that has an understanding of this might be helpful in your healing journey.

References:

1. Wikipedia https://en.wikipedia.org/wiki/Sensory_cortex
2. Wikipedia https://en.wikipedia.org/wiki/Motor_cortex
3. Wand et al. Assessing self-perception in patients with chronic low back pain: Development of a back-specific body-perception questionnaire.

Expectations

I was at a course and we did this experiment on expectations. I want you to try it too. I want you think about your hips and walk up and down your hallway like the Queen of England. What would that walk look like? How would your hips/pelvis move? Next, I want you to walk up and down like you are a famous rock star. What would that walk look like? Next I want you to walk like a sumo wrestler and lastly I want you to walk like a 90 year old.

Let me ask you a question. Now be honest. How many of you, when asked to walk like a 90 year old hunched over and walked with short careful steps?

Its interesting because when I was in the class amongst my peers, I also hunched over and walked as if I was in pain or immobile, while one or two people in the class walked normally.

This speaks a lot to our expectations. When they said 90 years old I just expected that I would be fragile and hunched over. But is that really what awaits us? Or do we set ourselves up because of our expectations?

How many of you have seen videos on Facebook of elderly dancing or doing parallel bars at 80, 90 years old? I’ve seen a few. I wonder what mindset or expectations those individuals have about their life and health. I’m suspecting they have a strong mindset around being healthy and completely capable of participating in the activities they enjoy.

The reason I bring up expectations is to also highlight how our expectations may influence the treatment we are seeking. When you go to see a healthcare provider for a problem, what are your preconceived thoughts about that provider? The type of treatment they might provide? What the outcomes will be and how it will be achieved? Are you coming open-minded? Resistant? Uncertain? Empowered? Are you coming with the expectation of being cured or being an active participant in your health?

Your mindset towards health and your expectations often play a part in dictating how the treatment will go/work and what the outcome will be. If we expect the treatment to hurt, in all likelihood it will hurt. If we expect it to fail, there is a high chance it will. If we expect it to work, in all likelihood it will work.

If we expect others to take our own health into their hands without participation, results may not be what you expected. In this case our expectations don’t meet what is required to achieve that goal/expectation. I encourage a dialogue about goals and expectations so that everyone can start with a clear understanding at the beginning of treatment.

I also encourage you to think about what do you expect to look like when you’re 50, 60, 70, 80, 90? And are your actions today helping you get closer to this vision? Or further away?

Thanks for reading,

The Pelvic Health Lady

There’s Physiotherapy for that? Constipation edition

Constipation is a common thing pelvic health physiotherapists try to address. Firstly, because the person suffering from it is uncomfortable, possibly bloated and in pain. It’s an unpleasant sensation when you need to go to the bathroom but can’t or it’s very difficult to do so. Secondly, constipation puts pressure on the pelvic floor muscles.

When someone suffers from chronic constipation, not only are they high risk for pelvic floor dysfunction, but are higher risk for hemorrhoids, rectal bleeding or mega colon. A mega colon is when the walls of the rectum stretch causing you to store more stool and can lead to an inability to detect that you need to go to the bathroom.

Whether it’s an occasional occurrence or chronic, constipation is not good, period.

Let’s talk about tips to keep constipation away.

One. Never ignore the “Call to Stool”

                I’ll use a story I learned on one of my courses. Think of the sensation of needing to go  as a butler tapping you on the shoulder. The butler walks up to you, gently touches you on the shoulder and says, “dinner is ready.” You decide, no this is not a good time, I’m busy. The butler goes away. He comes back later and says, “dinner is ready” and again its not a good time and you ignore him. If this happens over and over again, eventually the butler will stop coming to tell you, “You need to go to the bathroom.”

So when the butler comes, it’s okay if obviously you are not in a place where you can go to the bathroom but you really don’t want to wait too long before you go. Every time you ignore the butler the stool goes back into the rectum and more water is drawn out. The more water that is drawn out of the stool, the harder it gets.

Two. Hydrate well. 

As I mentioned if too much water is pulled out of the stool it becomes hard. If you are not hydrated well, then you already have very little water. Then if you delay going to the washroom, it can really make pooping difficult.

Three. Eat Enough Fiber

It is recommended that we eat anywhere between 25-40 grams of fiber daily. I often times give my clients a fiber chart that provides a long list of foods, serving sizes and approx amount of fiber so they can make different food choices and track their fiber intake. Veggies, whole grains, fruits, nuts are all foods high in fiber excellent choices.

Not only is fiber good for constipation but making healthier choices can benefit digestion, reducing the risks of heart disease, diabetes, cholesterol and cancer.

This is important to note that when you increase your fiber, you need to increase your water intake. The two work hand in hand.

Four. Get physically active

30 minutes of physical activity daily can help to keep your bowels happy. This could be walking, dancing, weight training, zumba, spinning.

Five: Mindset

Focusing your attention to mindset is an important key to making changes. What is your mindset towards getting healthy? How do you think about it? How do you feel about it? Why do you want to get healthy? For whom do you want to get healthy? Having a positive attitude towards health and setting your mind to the task will help you achieve your goals. Also surrounding yourself around others who have a similar mindset towards health will help you.

So where does physiotherapy come in?

Well, the tips I just provided you are things I go over with my clients. Lots of education on healthy lifestyle changes and why addressing this issue will help with addressing other symptoms that may be a result of the constipation. I teach toilet exercises, positions and abdominal massage techniques to improve bowel movements. If needed I also use manual therapy techniques to stimulate the intestines, reduce tension around the intestines and tension around the pelvic floor.

Some individuals with mega colon or reduced sensations to go to the bathroom may benefit from rectal balloon therapy techniques. While other clients have trouble relaxing their pelvic floor when it comes time to have a bowel movement and these individuals may benefit from biofeedback therapy.

So there are many different techniques a pelvic health physiotherapist can utilize to treat bowel dysfunction but you want to make sure your therapist has taken the training to treat bowel dysfunction.

So yes, there is physiotherapy for constipation J

The Pelvic Health Lady

There's Physiotherapy For That? ED edition

There is an ever growing market for erectile dysfunction (ED) treatment, some legitimate and others not so much. More men are experiencing difficulties and may not be aware of the variety of treatment options available to them. The purpose of this blog is to overview erectile dysfunction, causes/risk factors, the role of physical therapy and other treatment options.

Erectile dysfunction (ED) is defined as a persistent inability to achieve an erection or maintain the rigidity required for sexual intercourse (1). A complete examination should be completed by your medical provider to look at hormones, nerves, circulation and psychological status. The reason for a full work up is so that appropriate treatment is provided (1).

How do erections happen? Well you start off by thinking, smelling, seeing, touching or imaging something arousing. That signals the brain to send chemical messages to the blood vessels in the penis. These messages tell the arteries in the penis to open and relax so blood can freely enter into 2 long chambers within the penis. The veins in the penis close, allowing the penis to become rigid as blood flows in (2). This mark the first phase of getting an erection: the Vascular Phase (3).

The second phase is marked by the muscular phase. Once the pressure in the penis reaches a certain point, it triggers a contraction of the ischiocavernosus muscles (3) which is located in the first layer of the pelvic floor muscles. The contraction of this muscle maintains rigidity and plays a role in ejaculation (3). The bulbospongiosus muscle also located in the first layer of the pelvic floor muscles and it compresses the deep dorsal vein of the penis to prevent the outflow of blood from the engorged penis (4).

To summarize. Blood flows in after the brain signals the arteries to open. As blood fills in, it creates pressure on the veins so blood cannot escape. The muscles in the first layer of the pelvic floor contract to support and ensure blood stays in the penis.

Causes/Risk Factors for ED (1)

• ·         Alcohol and/or nicotine abuse
• ·         Drug use
• ·         Diabetes
• ·         Arteriosclerosis
• ·         Hypertension (Blood pressure)
• ·         Renal Failure (kidney failure)
• ·         Hyperlipemia (Cholesterol)
• ·         Nerve Damage
• ·         Psychological factors

Physiotherapy Treatment

Physiotherapy treatment should be considered as part of first line treatment along with medications and hormone therapy (5). It is non-invasive, painless, easy to do and inexpensive form of therapy (1).

Physiotherapy treatment focuses on teaching a variety of exercises targeting the pelvic floor muscles and training them in various positions. The client will be sent home with an exercise program to do between treatment sessions.

If the exercises alone do not improving symptoms of ED, the therapist may supplement exercise by using biofeedback. This is when a probe is inserted into the rectum and hooked up to a computer that will graph and track the strength, endurance and speed of muscle contraction. The visual cue often times helps individuals connect more effectively with the contraction. Patients will sometimes say, “I don’t know if I am doing the exercises correctly.” The biofeedback will show if what you are doing is actually registering as a pelvic floor contraction.

In line with biofeedback, the therapist may also supplement biofeedback training with an electrical stimulation that further aids in the muscles contracting. In cases where a probe may not be indicated electrical stimulation can be done through pads that are placed externally.

Typical treatment protocols as seen in various clinical studies includes treatment for 12-15 weeks, with in-clinic visits, once a week  (1, 3, 4, 5).

In addition to exercises, I often work with my clients to implement lifestyle changes. If we can also address the risk factors that will certainly impact the experience of erectile dysfunction. A few key areas for change may include; diet, aerobic exercise, weight loss, sleep hygiene, smoking cessation, alcohol intake and psychological factors. Typically this is achieved through a multi-disciplinary approach.

Physiotherapy does not replace other forms of treatment.

Other therapies

Other forms of therapy may include: medications, vacuum devices, constriction bands (cock rings), counseling/sex therapy, intracavernosus injections, intra-urethral medications, topical therapy. If these fail to produce results the third line of treatment may include: vascular surgery or prosthetic implant. Of course, speak with your health care provider when considering which route to go.

If you are having problems in this area or know someone who is, please share.

The Pelvic Health Lady

References:

1.  Van Kampen et al. 2003. Treatment of erectile dysfunction by perineal exercise, electromyographic biofeedback, and electrical stimulation. Physical Therapy 83L6): 536-542.
2. WebMD. 2017. How the Penis Works: Erection and Ejaculation. Accessed on Oct 29, 2017 from https://www.webmd.com/erectile-dysfunction/how-an-erection-occurs.
3. Lavoisier et al. 2014. Pelvic floor muscle rehabilitation in erectile dysfunction and premature ejaculation. Physical Therapy 94(12): 1731-1743.
4. Dorey et al. 2004. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. British Journal of General Practice 54: 819-825.
5. Dorey et al. 2005. BJU International 96: 595-597.

Did I just pee during sex? Or is this fluid something else?

For this blog I want to talk about a topic many women are curious about but very few talk about, female ejaculation. In our urban culture we don’t refer to female ejaculation by this name. 

If you have heard of it, usually its in the context of “squirting.”  I don’t really like this urban term because I don’t think it encompasses the variety of presentations female ejaculation can have.

Perhaps I also dislike this term because of the context in which it is used. It is often not used in a way that is a sacred experience for women and is almost made to sound dirty or something to laugh about. My goal with this blog is to introduce women back to the beauty of orgasms and female ejaculation as sacred and a wonderful experience.

I will start with a quick history lesson.

In Ancient spiritual sexual traditions the fluid from female ejaculation was considered a sacred medicine (1). In Ayurveda and tantra traditions the fluid was called “Amrita” which means the nectar of life (1). In Traditional Chinese healing, the fluid was known as the white moon flower medicine (1). What a beautiful way to describe it. Trying saying the word “Amrita” out loud.

It has a soft, sensual and romantic tone to it, way better than squirting or even the medicalized term, female ejaculation. Those do not sound romantic at all.

I do want to talk about the anatomy briefly just so women have a bit more background to what this fluid is. In some cases when a female is about to orgasm and release “Amrita” it can feel like she needs to pee and might mistake the fluid for urine and feel all embarrassed. Or stop the experience from going further because she thinks she will pee.

There are 2 sets of glands in the female genitalia.

The first is called vestibular glands or “Bartholins” glands. These glands are located at the bottom of the vaginal opening at approximately 5 and 7 o’clock. These glands secrete a very small amount of fluid during arousal (1). It is believed that this fluid is to help maintain the vaginal ecology and pH (1).

The second set of glands are called paraurethral glands or “Skene’s” glands. These glands are made up of a network of tiny tubules and are enmeshed in the erectile tissues that surrounds the urethra. This network of tubules has about 30 ducts or openings along the urethra and 2 main ducts that open inside or outside the urethral opening (1). It is from these glands that a clear watery fluid is produced.

This fluid can have a faint musky odour. The fluid can trickle, can have a small gush or as put in the book, be a “great geyser of liquid” (1).

It is believed that this fluid plays an immune function to prevent infection and maintain the vaginal environment but more medical research is needed.

Okay so…does every woman orgasm with “Amrita”?

Not all women orgasm with ejaculation. In fact it is a small minority of women that do and they don’t experience it every time they orgasm. There seems to be a small amount of women that are natural ejaculators (1). Now that doesn’t mean just because you don’t orgasm with “Amrita” that you never can.

Women have the equipment and therefore there is always potential.

So then you might be wondering…well how do I do that? Well I am no expert on this subject so what I do recommend is getting a copy of “Women’s Anatomy of Arousal” by Sheri Winston or researching into tantra for answers.

Happy Exploring,

The Pelvic Health Lady

Reference:

1. Winston, Sheri. 2010. Women’s Anatomy of Arousal. Secret maps to buried pleasure. New York: Mango Garden Press.

How many ladies out there have had a LEEP?

A LEEP procedure stands for Loop Electrosurgical Excision Procedure and is used to remove abnormal tissue from the cervix.

I am curious about how many experience painful intercourse after the LEEP. I tried searching for scientific research on the matter and I couldn’t find any information. All I could find was information on the effectiveness of the LEEP in removing abnormal tissue.

I wonder why there is no research on this matter? Likely because women are not reporting it. I know I didn’t report it to my doctor, because I didn’t know there was a connection and it didn’t start till a few months after the surgery.

My surgery was in 2008 and it wasn’t like I had painful intercourse all the time. It would show up here and there and then slowly became more frequent. It wasn’t until 2011 when I was on placement for school that I was introduced to pelvic floor physiotherapy and made the connection.

Trauma, like a surgery causes scar tissue. Scar tissue is typically tenser than regular tissue and when the penis touches that tense spot it causes pain. When the sharp pain started happening more often, that caused me to tense in preparation that it was going to be painful. Not only was it painful but it was more painful.

I tried changing positions. Then I tried just “dealing” with it. Slowly over time this made sex less enjoyable (obviously). 

So in 2011 when I started learning about pelvic floor physio, I would talk with my instructor in vague terms (cause I didn’t want her to know) on she deals with these kinds of situations and she stated explaining the concept of a tight pelvic floor and how that could lead to pelvic pain.

I knew right away that I needed to know more and I needed to find a way to overcome my pain. I started reading on my own and figured out how to relax my pelvic floor and over time my symptoms improved. What a change! That made me think of the women and men that are impacted by pelvic floor problems and how I could make an impact on the world.

So 2014 I officially started my courses in pelvic health for this reason. If you read my first blog post, I talked about this, if not feel free to have a read J

So I wanted to bring up the conversation about LEEP’s because I sat wondering today, how many others are struggling with this? How many others are going in for this procedure and have no idea this might be a side effect? How many will experience painful intercourse and not know there is treatment?

I felt compelled to write about this, just in case someone reads this and is experiencing this, they will know that they can seek a pelvic health physiotherapist for help. They will know they are not alone.

The Pelvic Health Lady

Let's talk Pelvic Organ Prolapse

Let's talk Pelvic Organ Prolapse

What is it?

The bladder, uterus and rectum are held in place inside the pelvic cavity by ligaments and an extensive network of fascia (also known as connective tissue because it connects things). A pelvic organ prolapse occurs when the ligaments and connective tissue are stretched or disturbed and the pelvic floor muscles are not supportive enough to hold the organs in place.

Essentially, either the bladder and/or rectum pushes into the vaginal wall and toward the vaginal opening. In the case of the uterus, the organ itself comes down into the vaginal canal and can push past the vaginal opening.

Grades of Prolapse:

0 no prolapsed present

1 slight downward movement but not to the vaginal opening

2 Downward movement of the organ up to the vaginal opening

3 Downward movement of the organ past the vaginal opening

4 Most often used to describe uterine prolapse where the uterus exits the vagina almost entirely.

Risk factors:

Body Mass Index: when there is extra weight on the body that puts extra pressure on the pelvic floor muscles, ligaments and fascia. Overtime these structures weaken allowing the organ to move down in the pelvis.

A body mass index of 25-30 was found to increase the occurance of uterine prolapsed by 31%, rectal prolapsed by 38% and bladder prolapsed by 39%.

A body mass index of greater than 30 increased the risk of uterine prolapsed 40%, rectal by 75% and bladder by 57%.

Having children: One study of 2600 women who never had children 19% had prolapse. 14.9 % had bladder, 6.3% uterus and 6.5% rectal. The risk of prolapse increases significantly with the first baby, with minor increases with each consecutive baby.

Constipation: Chronic constipation can increase the risk of prolapse due to the prolonged straining/pushing on the toilet. Its the pushing and straining that can stretch the ligaments and strain the muscles.

What can be done?

Pelvic floor physiotherapy has been shown to be effective in treating pelvic organ prolapse in grades 1-2. In the case of grade 3-4 there are several different options such as a pessary, which is a device that is inserted inside the vagina to hold the organ in place. Pelvic floor muscle training is still important if opting for a pessary because the muscles need to be strong enough to hold the pessary in place so it doesn’t fall out.

There is also surgical repair as an option. After a surgery, therapy might be required to deal with any pain, scar tissue formation and in some cases the muscles still need to be strengthened to reduce the risk of the prolapse happening again even after repair.

The Pelvic Health Lady

References:

Hendrix et al. 2002. Pelvic Organ prolapse in Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 186:1160-6.

Bø, Kari. 2012. Pelvic floor muscle training in the treatment of female stress urinary incontinence, pelvic organ prolapsed and sexual dysfunction. World journal of urology. 30:437-443.

What are orgasms?

Most of us understand orgasms to be the finale to sex or foreplay, however an orgasm is so much more than you probably think.

Let’s have some fun exploring this more deeply. So the word orgasm in Greek means, “excitement, swelling.” It is the sudden release of accumulated energy during a sexual experience, which results in muscular contractions in the pelvic region. With orgasms you typically experience a sense of euphoria, a variety of body movements and sounds (1).

An orgasm does not have to end as a single moment. Individuals have the ability to stay in a state of orgasm that can last many minutes, usually experienced as a rising and falling of pleasurable energy (2). For example, some individuals can have multiple orgasms or “aftershocks” which I sometimes refer to as the pleasure shivers.

An orgasm can be experienced in many different parts of the body or chakras (energy centers). They are not only reserved for the genitals (2). Remember an orgasm is a release of energy, a series of muscle contractions, bodily movement and noise in various combinations.

Even within the genital region you can experience orgasms in different places, such as, just in the clitoral region, perineum or entire vulva. Not sure what a vulva is, make sure to check out my previous blog on, “where is my vagina” for the answer.

Do people experience the same type of orgasms? Is there more than one kind of orgasm?

I came across a great list in a book called, Women’s Anatomy of Arousal. Here are some different types of orgasms.

Little sneeze like orgasms

Big, Bigger, Biggest orgasms

Full-body orgasms

Projectile, squirting orgasms

Surprise orgasms

Small orgasms with aftershocks

Love-gasms

Laugh-gasms

Sob-ogasms

Mutually timed orgasms

Clutching orgasms

Flowing wave orgasms

Energy orgasms

This list is not exhaustive. There is so much variety in the physical, emotional, mental and spiritual experience of orgasms.

Do not limit your orgasms. Open yourself up to new possibilities. You can begin to explore alone or with your partner. Just be safe and respectful with yourself and/or with your partner.

So what is your next orgasm going to look like?

The Pelvic Health Lady

References: 

1. Wikipedia. https://en.wikipedia.org/wiki/Orgasm

2. Winston, Sheri. Women's Anatomy of Arousal: Secret Maps to Buried Pleasure. 2010. Mango Garden Press: New York.

Kegels Vs. Reverse Kegels

KEGELS VS. REVERSE KEGELS

The term kegel was first coined by Arnold Kegel in 1948 (1). Although it seems like Kegels are relatively new, kegels were an important part of Chinese Toaist exercise programs for the last 6000 years (2). Kegel exercises are best described as, squeeze like you are stopping the flow of urine.

These exercises were found to be helpful in reducing urinary symptoms, pelvic organ prolapse symptoms and in some cases improving sexual function. Studies have found that more than 30% of women with pelvic floor problems are unable to contract the pelvic floor muscles correctly on their first consultation (3). So 3 out of every 10 ladies who are performing kegels are doing them incorrectly.

Women after childbirth are typically told to perform kegels daily, some might be provided a sheet with instructions but it is not common practice to actually check if this exercise is being performed correctly.

The Kegel itself is an inward lift and squeeze that occurs around the urethra, vagina and anus (3). The pelvic floor muscles contract as a whole but attention can be given to focus awareness to different parts of the pelvic floor.

When I assess the pelvic floor muscles I am looking to see the quality of contraction from left to right and from the front, middle and back muscles. I test for endurance to determine how long you can contract and how many times you can contract to 10 seconds before your muscles get tired. I also test for speed.

The 30% of women that do not perform kegels correctly are usually squeezing around the abdomen, butt muscles or inner thighs. These muscles are around the pelvis but play no part in preventing urine leakage. Another thing I often see is a lack of coordination between the pelvic floor muscles and the diaphragm (our breathing muscle).

You may be wondering why that’s even important. Well, because the diaphragm and pelvic floor move together firstly. Secondly they both are part of the “core” muscles. But let’s look at the first part. When you inhale, the diaphragm muscle flattens downward creating pressure on your abdomen and intestines. To release this pressure generated by the diaphragm and lungs the pelvic floor relaxes so the intestines have more space and therefore less pressure. When you exhale, the lungs deflate and the diaphragm moves upwards allowing the pelvic floor to lift back up.

In the beginning just performing kegels without breathing is fine, but then it needs to be coordinated with breathing. We need to train the “brain” that on exhale the pelvic floor needs to contract. What is a cough or a sneeze? Well it’s a high pressure exhale! What do we need the pelvic floor to do during an exhale? We need it to contract and lift up so we don’t leak.

For those ladies looking to get back into fitness and high impact exercise: regular kegel practice may not be enough for that. With exercise the kegels need to be coordinated with the rest of the core which is made up of the diaphragm, pelvic floor, transverse abdominis (TA) and multifidus a deep back muscle. These muscles turn “on” before movement occurs. They need to contract before a jump, contract before a dead lift, etc.

Ok, so let’s say you’ve been practicing your kegels, but they don’t seem to be helping. What might be some of the reasons.

• Performing them incorrectly
• Exercise program not specific enough for your needs.
• What I mean by this is that the intensity, frequency and duration of your kegel training may not be enough. Exercise programs can vary from 30-360 contractions daily. Length of the hold can vary from 5-30 seconds and programs can run from 6 weeks to 6 months (2). Also the coordination thing I mentioned above, may apply here too. 
• The pelvic floor is too tight!   

I have been talking a lot about kegels and they are important, BUT, they are NOT for EVERYONE. In some cases kegels can actually make your symptoms worse. Researchers were curious why in some cases women got worse with kegels. They had weak pelvic floors, so naturally kegel training would help. What they found was that women can have “short” pelvic floor muscles which can make them weak and painful (4). By “short” we mean tight/tense.

So why would that matter? If the pelvic floor muscles are tight they will have limited ability to move. If the muscles cannot move through the full range of motion, the muscles cannot generate enough force a) to stop the activity/contraction of the bladder b) generate enough contraction to close the urethra during a cough or sneeze and c) if the muscles cannot move well, you can’t strengthen them well.

Kegels should never be painful when you are performing them. This may be an indication that you are tight and should stop kegels and seek help. If you have to pee a lot and feel that urge to go all the time, you may be too tight. If you are doing kegels and are not getting better you may need to learn the REVERSE kegel.

In some cases, once you learn to relax the muscles properly, strength and endurance comes back on its own. If not, then kegels may need to be re-visited.

To find a therapist local to you for assessment and advice, go to www.pelvichealthsolutions.ca

Thanks,

The Pelvic Health Lady

References:

1.        Wikipedia. 2017. Kegel exercise. Accessed on August 10, 2017 from https://en.m.wikipedia.org/wiki/Kegel_exercise.

2.        Bø, Kari. 2004. Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Int Urogynecol J, 15: 76-84.

3.        Bø, Kari. 2012. Pelvic floor muscle training in the treatment of female stress urinary incontinence, pelvic organ prolapsed and sexual dysfunction. World journal of urology. 30:437-443).

4.        Fitzgerald, MP and Kotarinos, R. 2003. Rehabilitation of the short pelvic floor. I: background and patient evaluation. Int Urogynecol J. 14: 261-268.

Have You Heard of the DivaCup?

Have you heard about the DivaCup?

The DivaCup is an alternative menstrual product to tampons and pads. It is a silicone cup that you insert into the vagina that collects blood. The DivaCup is 100% plastic-free, BPH free and odorless. It comes in two sizes; one for women who had children and/or are older than 30 years old and a smaller size for women who have not had children or are under 30 years old. It is a product you can use on land, air or sea, meaning anywhere.

This is a product that I use and I will share my reasons for using it but will also present the cons.

1. I use this product for its eco-friendly nature. You use it, wash it, and re-use it. There are no plastic wrappers to dispose of and no waste is produced other than the original packaging.
2. It is cost effective. It is a one time purchase, or you may by a 2^nd size after a baby.
3. I can wear for a longer period of time, especially during a busy day with clients up to 12 hours.
4. It increases confidence in the water.
5. It is great for travel: less to pack, don’t have to worry about running out of products.

Here are some cons:

1. It can be messy when removing to clean. If you are more sensitive to handling blood, this product may not be for you
2. It can be finicky getting the diva cup in. I recommend this instructional video to help (see below) 
3. Pain, if you find tampons uncomfortable, the diva cup may be uncomfortable for you. You have to fold it to get it inside and then it expands open once inside.
4. Trouble pulling it out. I have read/heard some women find it difficult to pull out because the tab is small to pull on. I don’t find the diva cup difficult to remove, but others do.
5. Diva cup falls out. This could be a sign of pelvic floor weakness and I would suggest a consult/assessment with a pelvic floor physio close to you. Find one in Canada @ www.pelvichealthsolutions.ca

I find it important to state now… you cannot lose the diva cup in your vagina!.

These are the main pros and cons I know and heard of. I would love to hear what you think of this product simply out of curiosity. If you want to get one, I have seen them at some Shoppers Drug Mart or www.well.ca.

Thanks,

The Pelvic Health Lady 

Tampons and Sex. What Do They Have To Do With Each Other?

Your first menstruation is a rite of passage that can come with unexpected experiences. Some girls may experience mood changes, breast tenderness, cramping or pain. It is a time of unknowns, in terms of what is the best way to take care of yourself and what products are best to use.

It is in these early years that girls may first try using a tampon with some reservations on how to use it. Thankfully, girls now have a variety of ways to access information about the use of tampons. These include parents, friends, internet, you tubes, books, etc.

For a select group of girls, the first few attempts at using a tampon doesn’t go well. There could be one of two reasons for this. First, the young girl may get the tampon inside but is so uncomfortable she has to take it out. The second is that she tries to insert the tampon despite discomfort but, simply cannot physically get it in. This is when she may abandon the idea of using tampons.

Most young girls do not think to seek medical advice as to why tampons are a problem to use, likely due to embarrassment or not knowing this can be an early sign of pelvic floor dysfunction.

The next life event that these girls encounter a potential problem with is intercourse. In many cases these girls don’t link their discomfort with tampons to their current pain with intercourse. A majority of ladies I see, simply avoid the pain by avoided tampons and intercourse.

It is not until they get married, meet someone special or want to have children that they start to seek answers to their problem. Most often these girls start their journey by talking to their family doctors. I have noticed in the past couple years more doctors are aware of this problem and can recommend appropriate treatment but not every doctor is familiar with the following diagnoses and treatment options available.

So let’s dive into the two more common diagnoses. Just before, I wanted to explain the reason I started with tampons rather than sex is because problems with using a tampon can be a risk factor for problems with intercourse.

So let's talk diagnoses, the first possible diagnosis is called dyspareunia, which is recurrent or persistent discomfort with attempts at or during intercourse/penetration. There are 2 subcategories of dyspareunia.

a)      Primary: meaning this pain/discomfort is present at the first attempt at penetration/intercourse

b)      Secondary: pain with intercourse/penetration develops after a trauma, such as tearing from childbirth or surgery.

The second diagnosis is called vaginismus. This is a term used by Dr. Marion Sims in 1862 to describe a reflex-like contraction of the muscles around the vagina and perineum. Simply put, penetration/intercourse is not possible because the muscles around the entrance of the vagina spasm, closing the opening. Partners will often note, “It’s like hitting a wall.”

Either of these two situations can be very concerning for a young woman. Often times these women think there is something wrong with them and that somehow this is their fault. This simply is not true. There are many different reasons this can happen.

Finding a physician who is familiar with dyspareunia and vaginismus is helpful to rule out other causes for the pain/discomfort but also important in making sure you are given the right diagnosis. This article is not intended to diagnose you but to give you awareness of possibilities so that you can have a more informed discussion with your healthcare provider.

Finding a pelvic health physiotherapist is an important addition to your recovery. They will help you understand your condition and will provide treatment/resources to put you on the path of a fulfilling sex life.

Having a sex therapist/sexologist can also be very helpful on this healing journey. It is usually a multidisciplinary approach to make sure the physical and mental/emotional aspects are addressed.

WE ARE LOOKING FOR FEEDBACK REGARDING PAINFUL SEXUAL EXPERIENCES. TOTALLY ANONYMOUS. PLEASE CONSIDER OUR SURVEY www.ecophysio.com/survey

Thanks for reading,
The Pelvic Health Lady

Reference: Lamont, J. 2011. Dyspareunia and Vaginismus. Glob.libr.women’s med. www.glowm.com, accessed on July 3, 2017.

I Love My Pelvic Floor and I Want You To Loves Yours Too

Ladies and gentleman, I love my pelvic floor and I hope this will inspire you to loves yours too.

My pelvic floor works so hard for me, all day everyday. Here are 5 amazing things the pelvic floor does for us. It makes sure blood and lymph pumps through the pelvis. It supports the organs inside the pelvis such as the bladder, uterus, rectum and then the digestive system on top of that. The pelvic floor is part of the core system that works hard to provide support to the back, pelvis and hips before and during movement. The pelvic floor keeps urine and stool inside, so we don’t have to wear pads or diapers and lastly it plays an important role in sexual function.

The pelvic floor is amazing! When you stop to think about what it does, I hope it gives you a sense of appreciation of the hard work these muscles do for us and inspiration to give it the attention it deserves. Taking a proactive approach to the pelvic floor really has lifelong benefits and can be protective against developing pelvic floor dysfunction. For the ladies, getting in tune with the pelvic floor prior to pregnancy or even during pregnancy can have positive effects for labour and delivery, as well as recovery.

Now we cannot control everything that happens to our pelvic floor, for example, during birth or after a surgery or a fall, etc. However should a situation arise, having good body awareness and connection can really help in overcoming challenging situations. For example, a gentleman who needs to have prostate surgery. That gentleman could gain great benefits in having a pelvic floor assessment prior to surgery.

Why? Because the therapist can provide great advice on protecting the pelvic floor after surgery, can teach you how to exercise your pelvic floor so that right after the catheter is removed, he can start practicing his exercises. This can have positive effects on regaining control over urination sooner than the gentleman that doesn’t know how to perform these exercises. The same is true for women having gynecological surgery such as a hysterectomy or prolapse repair. Knowing in advance what exercises to perform can speed up recovery and reduce side effects of surgery.

Taking care of pelvic floor is not just about kegels. It’s about creating an awareness and connection to the muscles so that you can take care of them better. We live in a go, go, go society. We are often running from activity to another. There are so many distractions and demands on us. What I tend to find a lot of is tension in the pelvic floor region. The pelvic floor needs to move through its full range of motion to be most effective and healthy. So not only is it important to use the muscles in exercise, but equally important is learning how to relax them and give them a break from their long shifts.

So I thought I would create my own little pelvic floor relaxation exercise routine that you can do with me at home.

Hope you enjoyed this article. Stay up to date with new posts by liking our Facebook Page.

Thanks,

The Pelvic Health Lady

To use soap or not use soap? That is the question.

Let’s Talk about Hygiene

There are many misconceptions and misleading information available online and through social media when it comes to personal hygiene.

I remember a saying from one of my instructors, “The vagina is supposed to smell like a vagina, not like flowers.” Another important saying I want you to remember is, “the vagina is a self-cleaning oven.”

So let’s start off with some don’ts when it comes to personal hygiene.

1. No douching
2. No putting anything inside the vagina such as yoni pearls or other “detox” products. It is not necessary
3. No using soap on the inner lips or vaginal opening
4. No perfume, deodorant, anti-bacterial down there

Just WATER is all you need.

When it comes to partners, everyone has a personal preference. Some men like women freshly showered and some men prefer when you have a little of your own personal scent. Make sure to find out what your partner likes/prefers. Notice how I said, your own personal scent? Just your body’s natural odour.

There are very good reasons why you don’t want to use products. Firstly the area around the vaginal opening is very sensitive. Soaps and chemicals can dry and irritate the mucous membrane. This can lead to burning, itching and above all, is the leading cause of infections. Products and soaps can change the natural balance of pH and the ecology of the vagina (1). The vagina has a very delicate balance of its own bacteria and fluids that we don’t want to disturb.

The vagina cleans itself by naturally producing and releasing vaginal discharge. This is normal. The amount of discharge will vary among women. What I will say is if you have concerns about your vulvar area or changes in your discharge, see your Doctor.

Now lets look at some specific tips to keep the vulvar area clean and happy.

1. Use warm water to wash area and dry thoroughly with towel or if sensitive/irritated you can blow dry on cool setting. Make sure to pat dry.
2. Wearing 100% cotton underwear
3. Avoid thongs
4. Ensuring good rinse cycle when doing laundry, avoiding harsh soaps
5. Use soft toilet paper, no perfume
6. Avoid nylon pantyhose
7. Don’t scratch the area
8. Wash new underwear before wearing
9. Sleeping in the nude
10. Wiping front to back
11. Removing wet clothing, especially after swimming
12. If you sweat in the vulvar region you can use cornstarch to keep area dry

I hope you found this blog helpful and if you have any questions or suggestions, please feel free to comment or send me an e-mail maddy@thepelvichealthlady.com

Thanks,

The Pelvic Health Lady

References:

1. Winston, Sheri. 2010. Women’s Anatomy of Arousal. Mango Garden Press: New York.
2.  Cleveland Clinic. 2013. https://my.clevelandclinic.org/health/articles/vulvar-care
3.  Pelvic Health Solutions. 2017. http://pelvichealthsolutions.ca/for-the-patient/what-is-vulvodynia/vulvar-skin-care/

What? There are 3 different ways I can wet my plants?

            I saw a saying on a billboard somewhere that said, “I laughed so hard I wet my plants.” Although it was meant in a humourous way, individuals whom experience incontinence do not find it to be a laughing matter in most cases. Why is incontinence not a laughing matter? Because incontinence is the involuntary loss of urine, meaning you had no control.

          In Canada based on the Canadian Continence Foundation numbers, approximately 3.3 million Canadians have incontinence (1). I’ve read estimates in various studies saying 1 in 3 or 1 in 4 women will experience incontinence in their lifetime and 1 in 9 men. If it is so common, why aren’t more people talking about it and most importantly seeking treatment for it?

         I believe it is because media and even some healthcare providers have normalized incontinence as normal after giving birth and something that comes with age. Just because something is common, does not mean it is normal. There is a shift happening currently where more celebrities and healthcare providers are working really hard to spread the word about pelvic health. I am just one of those people trying to educate others.

Okay so, what’s this about 3 different ways I can lose urine?

            Well, there are 3 types of incontinence that are the most common, stress incontinence, urge incontinence and mixed incontinence.

Stress incontinence: the loss of urine associated with increases in abdominal pressure, such as coughing, sneezing, laughing, lifting, running and high impact exercises.

Urge incontinence: is when you get the sudden urge to go pee and you rush to the bathroom but don’t make it.

Mixed Incontinence is a combination of stress and urge incontinence.

What can I do about it?

Very good question. Most women are familiar with the term “kegels” which are basically pelvic floor contractions. But are they enough? And are they right? I want to take the time now to clear up a few things.

            Yes Kegels can be helpful if they are performed correctly. Many women “think” they are performing them correctly but I often see in my practice that they are also contracting compensatory muscles such as the abs, inner thighs or buttock. I also see clients whom are contracting more strongly around the anus, which is great for keeping control of stool but are under-utilizing the muscles around the urethra where the urine comes out. So if you are thinking about trying kegels at home, I strongly encourage you to find a pelvic health physiotherapist near you to ensure kegels are right for you and that you are performing them correctly.

           Now, its important for me to note that “kegels” are not for everyone! In some cases can make your symptoms worse. I see more often than not pelvic floor tightness that leads to weakness. In these cases learning to relax the pelvic floor muscles helps to optimize strength because the muscles can actually move through their full range of motion. So if you are performing kegels and are not getting better it can be because a) you’re not doing them correctly b) you actually have tightness in the pelvic floor or c) lack of coordination with other muscles.

           Lastly I wanted to clear up that incontinence is not just something pregnant women get. Several studies have been conducted showing young female athletes get incontinence too. One study found the highest percentage of incontinence among young women is in gymnastics and track and field (2, 3). This is another discussion that healthcare providers are trying to educate coaches, parents and athletes about, incontinence in sports. It is more common than previously thought and again common but not normal.

           Other risk factors aside from pregnancy for developing incontinence are obesity, surgery, strenuous work or exercise, constipation, straining with bowel movements, chronic coughing and older age (4).

           What about age? A large study of 34,815 women out of Norway found, 10% of women had incontinence between the ages 20-24, 14% 25-29, 18% 30-34, 21% 35-39, 24% 40-44, 28% 45-49 and 30% 50-54 years old (5). Although the percentage of women experiencing incontinence does increase with age, younger women experience it too.

           I hope you found this article informative about incontinence and that it cleared up some misconceptions. So ladies and gentleman if you have incontinence, please find a therapist whom is trained in pelvic health and can perform internal exams so that they can help you. To find a therapist close to you, visit www.pelvichealthsolutions.ca

Don't forget to follow me on Facebook.

The Pelvic Health Lady

References:

1.        Canadian Continence Foundation, accessed n Feb 4, 2017 from http://www.canadiancontinence.ca/EN/what-is-urinary-incontinence.php

2.        Nygaard et al. 1994. Urinary incontinence in elite nulliparous athletes. Obstet Gynecol 84: 183-187.

3.        Nygaard, IE. Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective cohort study of female Olympians. Obstet Gynecol 90: 718-722.

4.        Bø, Kari. 2004. Urinary Incontinence, pelvic floor dysfunction, exercise and sport. Sports Med 34(7): 451-464.

5.        Hannestad et al. 2000. A community based epidemiological survey of female urinary incontinence: The Norwegian EPINCONT Study. Jorunal of Clinical Epidemiology 53: 1150-1157.