What is Pelvic Floor Physical Therapy

marigold-2117436_960_720By Amy Stein, DPT and Fiona McMahon, DPT

As physical therapists who specialize in abdomino-pelvic pain disorders, one of the toughest parts of the job is meeting men and women who have suffered with pelvic pain for years, only to be told by their doctors/healthcare providers that there is no help for them. It is not uncommon to meet a patient who has suffered for 5- 10 years without help before finding us. Musculoskeletal causes of abdomino-pelvic pain are treatable conditions and often times we can start to improve a patient’s symptoms within just a few visits. Please read on to see how we can help you with your pain.

What do pelvic floor physical therapists actually do? Why do they do what they do? What can you expect from your first physical therapy visit?

Physical therapists (PTs) are experts in movement and function, which sounds like a pretty broad topic to be an expert in, and it is. After physical therapists graduate PT school (now-a-days at the doctoral level), they find their niche and specialize. You can find PTs working with high-level athletes, children, infants, people who are recovering from injuries, people with neurological conditions and many other types of clients.

Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but don’t have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to enquire about the experience and level of training your potential physical therapist has had in this specialty.

What is the pelvic floor and what is pelvic floor dysfunction?

Who needs pelvic floor PT? The pelvis performs many important functions of the body. The muscles, nerves, connective tissues and skeletal structures of the pelvic floor help to keep us continent, aid in sexual performance and function, and assist in core stability.

When some or all of these structures of the pelvic floor are not functioning properly, they can cause a multitude of different symptoms. People who are suffering from bowel, bladder, and or sexual problems, as well as those who are suffering from pain in the pelvis, upper legs, abdomen or buttocks most likely have pelvic floor impairments contributing to their pain.

Issues with the pelvic floor can arise from a multitude of reasons. Infections, previous surgeries, childbirth, postural and lifting problems, and trips and falls can all bring on pelvic floor dysfunction. Pelvic floor pain can persist well after the cause of it has been removed. So it is entirely possible to feel the effects of an old infection, surgery or injury, days to years after they occur. Anyone who has had long standing abdomino-pelvic pain, or pain that they can’t seem to get rid of after seeking the help of medical doctors or other healthcare providers is a good candidate for a pelvic floor physical therapy evaluation and possible curative treatment.

What is Pelvic Floor Physical therapy?

Physical therapy is a practice of healing that restores function and reduces pain through the use of techniques to improve bony alignment, reduce trigger points, and improve muscle coordination and strength. Pelvic floor physical therapy is a branch of physical therapy and is built upon these same principles.

What sets pelvic floor physical therapists apart is their in depth understanding of the muscles and surrounding structures of the pelvic floor, beyond what was taught in physical therapy graduate school. What that means for a patient who is seeking the help of a pelvic floor physical therapist, is that his or her pelvic floor issues will be examined and treated comprehensively with both internal and external treatment, provide them with lifestyle modifications to help remove any triggers, and receive specific exercises and treatment to help prevent the reoccurrence of pain once he or she has been successfully treated.

What exactly do Pelvic Floor Physical Therapists Do?

The elephant in the room with pelvic floor physical therapy is the internal exam/ treatment. It can seem a little daunting, especially if you have pelvic floor pain, but pelvic floor therapists are trained to be as thorough as possible while minimizing discomfort.

During the internal exam, your physical therapist will place a gloved finger into your vagina or rectum to assess the tone, strength, and irritability of your pelvic floor muscles and tissues. Internal exams and internal treatment are invaluable tools that are taught to pelvic floor physical therapists. It can tell us if there are trigger points (painful spots, with a referral pattern or local); muscle/tissue shortening; nerve irritation and/or bony malalignment that could be causing your pain directly or inhibiting the full function of your pelvic floor muscles. We can also determine if your pelvic floor has good coordination during the exam. A pelvic floor without good coordination, may not open and close appropriately for activities such as going to the bathroom, supporting our pelvis and trunk, sexual activity, and keeping us continent.

It is essential that we, as pelvic floor physical therapists, also include other assessments when we are examining our patients for the very first time. We employ the tried and true physical therapy exam practices to determine if there is an underlying condition elsewhere in your body, such as a strength deficit or alignment issue that could be affecting your pelvic floor. It’s wild to think of it, but something as seemingly unrelated as a flat foot or a hip injury can be enough to set off pelvic and abdominal pain!

Some pelvic floor physical therapists may have the opportunity of getting a lot of time to speak one-on-one with a patient to determine possible causes of his or her symptoms, educate the patient and to guide them to other practitioners who may optimize their physical therapy results if necessary. We truly can find out so much by just listening to what our patients have to say. A fall, or infection can be significant as well as a patient’s feelings and knowledge about their current condition.

Once we determine the cause of our patient’s pelvic floor dysfunction, we design a plan tailored to the patient’s needs. At Beyond Basics, we have a diverse crew of physical therapists who bring their own training and background into each treatment. What is really beautiful about that, is that all teach and help each other grow as practitioners. It will be difficult to go over every single type of treatment in one blog post, but we will review some of the main staples of pelvic floor rehab.

Manual Techniques

As physical therapists, are our hands are amazing gifts and phenomenal diagnostic tools that we can use to assess restrictions, tender points, swelling, muscle guarding, atrophy, nerve irritation and skeletal malalignment. We also use our hands to treat out these problems, provide feedback to the muscles, and facilitate the activation of certain muscle groups. There have been a great number of manual techniques that have evolved over the course of physical therapy’s history. Let’s go over a few.

Myofascial Release

Myofascial release was developed by John Barnes to evaluate and treat the myo-fascia throughout the body. The myofascial system is the connective tissue that coats our muscles, nerves, blood vessels, and bones, and runs throughout our bodies. Any tightness or dysfunction in the myofascial system can affect the aforementioned structures and result in pain and or movement dysfunction. By treating the fascia directly, therapists can improve their patient’s range of motion, reduce pain, and improve a patient’s structure and movement patterns.

Myofascial release is a more gentle technique that can be useful in cases where a patient is already experiencing a great deal of pain. The therapist will hold gentle pressure at the barrier of the tissue (the point where resistance is felt) for a short period of time, usually less than 2 minutes until the therapist feels the tissue release on its own. The therapist does not force the barrier.

Scar Tissue Manipulation

Scars are almost always a fact of life. From surgeries, to accidents, to conditions like endometriosis, or certain STI’s, almost everybody has one. What doesn’t have to be a fact of life are the muscle, nerve and skin restrictions and overactivity that they can cause. By releasing scar tissue in physical therapy, it has been shown that the surrounding restrictions also decrease their resistance and adherence to the deeper tissues and surrounding organs.

Myofascial Trigger Point Release

Discussed extensively in Travel and Simon’s two volume series, trigger points are taut (firm) points in the muscle that have a consistent referral pattern (they transmit pain to the another part of the body). Trigger points are not only important because they cause pain, they also can affect how the muscle works. This is one of the main reasons our therapists at Beyond Basics are fastidious about ensuring all trigger points are released in the abdomen, back, legs and pelvic floor before transitioning to any core stabiltiy or strengthening exercises that can re activate a trigger point.

People with trigger points in their pelvic floor and surrounding areas can experience pain in the rectum, anus, coccyx, sacrum, abdomen, groin and back and can cause bladder, bowel, and sexual dysfunction. When physical therapists find a trigger point they work to eliminate it and lengthen it through a myriad of techniques. Recent literature has found that trigger point release alone can achieve an 83% reduction in symptoms.

Connective Tissue Manipulation

Skin rolling, ie. rolling of the skin over another layer helps to improve the movement of those two layers and reduce the tension and pulling between them. It feels like a scratch or ‘nails’, and in cases where a patient has more restrictions, the sensation may be more amplified.

One of the great benefits to skin rolling is it increases the circulation in the area to which it was applied. Often times, areas that are tight or restricted are receiving reduced blood flow and oxygen. By bringing blood flow to the area, toxins can be cleared and the healing contents of the blood are brought to the injured area. Skin rolling can also restore the mobility of surrounding joints and nerves, which can help to restore normal function. By allowing the skin to move more freely, pelvic congestion, heaviness and aching can be effectively treated.

Neural, Visceral, and Joint Mobilization

Nerves, organs, and joints can lose their natural mobility over time and cause a whole host of symptoms from pain, to loss of range of motion, and poor functioning of the bodily symptoms. Skilled and specialized therapists can use a variety of active techniques (patient assisted) and passive techniques to free up restrictions in these tissues and organs and improve overall function.

Neural mobilization as the name implies, involves the restoration of neural structures back to their normal mobility: to glide and slide. Neural structures that cannot move properly can cause pain that can radiate down an extremity or into the trunk and can give the sensation of burning, zinging, and stabbing. Some orthopedic therapists practice this type of mobilization; common examples include the sciatic nerve in the leg and the ulnar nerve in the arm. Pelvic floor PTs focus on these nerves when they cause issues, but they also pay attention to nerves that innervate the perineum and genital region (bicycle seat area), such as the pudendal, iliohypogastric, obturator, ilioinguinal, genitofemoral and the femoral cutaneous nerves. By allowing these nerves to move freely, symptoms such as vulvovaginal, penile, rectal, clitoral and testicular pain, itching and burning can be greatly improved.

Visceral mobilization restores movement to the viscera or organs. As elucidated earlier in our blog, the viscera can affect a host of things even including how well the abdominal muscles reunite following pregnancy or any abdominal surgery. Visceral mobilization aids in relieving constipation/IBS symptoms, bladder symptoms, digestive issues like reflux, as well as sexual pain. Visceral mobilization can facilitate blood supply to aid in their function, allow organs to do their job by ensuring they have the mobility to move in the way they are required to perform their function, and to allow them to reside in the correct place in their body cavity. Evidence is beginning to emerge to demonstrate how visceral mobilization can even aid in fertility problems.

Joint mobilization is a common and favorite tool of most orthopedic physical therapists. We love it so much because it can have so many different benefits depending on the type of technique used. Maitland describes types of joint mobilization on a scale between 1 and 5. Grade 1 and 2 mobilizations are applied to a joint to help to lessen pain and spasm. These types of mobilizations are typically used when a patient is in a lot of pain and to help break the pain cycle. On a non-painful joint, grade 3, 4, and 5 (grade 5 requires post graduate training) mobilizations can be used to help restore full range of motion. By restoring full range of motion within a restricted joint, it is possible to lessen the burden on that and surrounding joints, thereby alleviating pain and improving function.

Neuro-education of the Pelvic Floor and Surrounding Structures

The muscles of the pelvic floor must work together and in coordination to perform specific tasks. The pelvic floor has to contract, elongate and relax in very precise ways to perform basic functions like urination, defecation, support the pelvis and organs, and sexual function and pleasure. If your pelvic floor muscles and/or nerves fail to do what they are supposed to do at the right time, problems like painful sex, erectile dysfunction, constipation, and incontinence can occur.

Biofeedback is a modality that allows you to learn how to better control your muscles for optimal function. Biofeedback shows you what your muscles are doing in-real time. It is helpful to teach patients to lengthen and relax the pelvic floor for issues like general pelvic pain, painful sexual activity and constipation or to contract the pelvic floor in order to prevent leakage with activities like coughing, laughing, lifting, running or moving heavy objects. However, biofeedback does not demonstrate shortened muscles and tissues; therefore, in certain cases the biofeedback may seem to be within normal limits but yet the patient has 10/10 pain. In these incidences, manual palpation is more appropriate to identify restricted and shortened tissues and muscles, and myofascial trigger points.

HEP: Home Exercise Program

 

Home exercise programs are essential for each patient. In the case of weakness, a patient will require more pelvic floor, core and functional strengthening and stability exercises. For overactive and pain conditions, the HEP typically consists of relaxation techniques, self-massages (both external and internal), gentle stretching, cardiovascular fitness as tolerated, and eventually pain-free core stability exercises. Both require postural and behavioral modifications and self-care strategies. For more information and detail, check out the book: Heal Pelvic Pain, by Amy Stein or her DVD: Healing Pelvic and Abdominal Pain here.

Conclusion

As you can now see, there is so much out there that can be done for people suffering with pelvic floor dysfunction. This blog is by no means extensive, and there are even more options you and your physical therapist can explore to help manage your pain or other pelvic issues. Pelvic floor dysfunction requires a multidisciplinary approach for most of our patients. Hopefully, this blog helped to paint a picture of what you will experience with a pelvic floor physical therapist. We advise that you seek out an expert and experienced pelvic floor physical therapist in order to help better your life and improve your function.

Sources

FitzGerald M, Kotarinos R. Rehabilitation of the short pelvic floor I. Background and patient evaluation.

Padoa A, Rosenbaum T. The Overactive Pelvic Floor. Springer. 2016

Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1 Upper Half of Body. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999.

Stein, Amy. Heal Pelvic Pain. McGraw-Hill. 2008

Stein, Amy. Healing Pelvic and Abdominal Pain. Video: www.healingpelvicandabdominalpain.com 2013

Travell, Janet G. and Simons, David G., MYOFASCIAL PAIN AND DYSFUNCTION. THE TRIGGER POINT MANUAL, Volume 2, The Lower Extremities, Williams & Wilkins, Baltimore, 1992.

Valovska A. Pelvic Pain Management. Oxford University Press. 2016

Weiss J. Chronic pelvic pain and myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001; 166(6) 2226-31

BBPT Health Tip: How Not to Mess Up Your Back this Holiday Season

Fiona McMahon DPT

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Photo by Ana Paula Nardini on Pexels.com

Chances are doing some traveling over the coming months. The holidays are a time when we haul luggage through airports, Christmas trees and boxes of decorations through your house, or load massive turkeys into the oven. With all this lifting on the docket, I have a pretty good hunch you don’t want to start the new year with a heating pad and lying down in bed, so I am going to share with you, some of my favorite lifting tips.

Get close to what you are lifting:

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I mean really close. Maybe hug it if you can. The reason why we should get close to what we are lifting calls back to high school physics. The force on the spine equals the weight of the object being lifted by the distance it is away from the spine. Therefore, the farther an object is away from you, the harder it is on the spine to lift. My co-workers use the term “T-Rex arms” to describe how close they want their patients to be holding what they are lifting.

 

Squat

Don’t lift with your back. You have all heard it a million times, but if you bend forward with your back to pick up what you are lifting, you will end up placing a tremendous strain on the muscles and bones of your spine. Just don’t do it. Instead, bend with your knees to get to what you want to lift, and push through your legs to stand back up.

Don’t be a Hero

Ask for help if something seems too heavy to lift. In the long run, everyone will be better off. Knowing when to ask for help is sometimes the most challenging part of safe lifting practices.  If you feel you are asking for more help than you would like or you have back pain that is not resolving, come see us at Beyond Basics to help you get back into lifting shape.  The sooner, the better.  You don’t want it to become a chronic problem.  

Fiona McMahon PT, DPT practices at our Midtown location

fiona2018

PH101: I’m Pregnant – Help!

 

Having a baby is exciting, fascinating, and nerve-wracking. If you have never been through the process before, chances are you have a lot of questions and concerns about what changes your body will go through during your pregnancy, what the birthing process entails, and how your recovery will go once you’ve had your baby.

Join us and childbirth specialist, Ashley Brichter, in our Pelvic Health class to discuss the ins and outs of having a child.

Register at pelvichealth101.eventbrite.com   today.

Location:

110 East 42nd Street, Suite 1504

New York, NY

10017

Time: 7pm on  November 6th , 2019

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How to Start a New Exercise Program When You’re Feeling Intimidated

How to Start a New Exercise Program When You’re Feeling Intimidated

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Kierstin Elliott

Maybe you were an avid gym-goer, cross fitter, or yogi and then you got injured. Or maybe fitness has never been a part of your life, but now your doctor or PT has told you that a fitness regimen is necessary in order to help you feel like yourself again. Whatever the case may be, you just don’t know where to start, or you feel intimidated to return to what you were doing in the past because that is how you got injured in the first place. My advice is to start slowly. Educate yourself on how and why you got injured and what the next steps are on your road to recovery. Set goals on what you need to accomplish and build a plan to achieve them. Last but not least, train smartly. If you follow this check list, then you should definitely feel more confident moving forward!

It is imperative when you are transitioning from injury rehab to the fitness world, or starting a new exercise program for the first time, that you build a foundation. It is so crucial you stay true to your journey and not compare yourself to others. Trust that progress takes time. Resist the urge to jump right into something new if you’re unsure about form, alignment, and technique.

The first step would be to invest in private sessions. Educate yourself on what you’re getting into and find an expert in what you want to master. Having a coach who devotes the entire hour to your body and your needs will help you garner a deeper understanding of how your breath, body, and mind connect. Learning the proper form with a watchful eye on alignment, will ensure you have a strong foundation to move forward or join group classes.

Once you’ve gained confidence with your new (or old) exercise program, set some fitness goals. You’ve laid a strong foundation and now it’s time to build a skyscraper! Do you want to improve strength, flexibility, endurance? Once you have clear goals set, create a timeline. Establishing a realistic timeline will hold you accountable to sticking with your exercise program and crushing your goals!

The point I’ll end with is to train smartly. No matter what discipline you train in, if you are not focused on form, alignment, and breath control, you are only setting yourself up for future injuries. If you are in a group class, don’t be afraid to ask questions if something is unclear, doesn’t feel quite right, or if you know you need a modification. If you are doing an at home workout on your own, try to do it in front of a mirror to check out your form. If there’s no mirror accessible, simply take it slow and use the knowledge you’ve acquired from a trainer, coach, or PT. Take notes. Practice. Your exercises won’t be perfect the first time you attempt them. Be patient and mindful. It’s all about the journey 🙂

PH101: Ladies Session

By: Fiona McMahon, DPT
Hey Ladies!!! In the next installment of our Pelvic Health 101 course, we are hosting a ladies’ session to allow for a safe and non-threatening place to discuss many issues that can affect the health of your pelvic floor. This class one of Stephanie Stamas’s (the founder of PH101’s ) favorites and is definitely not to be missed. Hear more about it in her video below! Join us at 7pm on October 30th . Please register at pelvichealth101.eventbrite.com

 

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

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How Exercise Can Help Your Recovery From Breast Cancer

awareness cancer design pink
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Fiona McMahon PT, DPT

Have you noticed it yet? Everything is pink. Pink cups, pink pens, pink stickers, pink ribbons, pink everything. The flood of pink that happens every October and reminds us it is Breast Cancer Awareness Month. If you are someone you love has or has had breast cancer, chances are you don’t need any reminding. At Beyond Basics Physical Therapy we have spent a good deal of our blogs discussing the ins and outs of how PT can help with the symptoms following treatment for breast cancer. But what can you do right now to help your health? Emerging research is pointing to the profound importance of exercise on so many facets of well being for individuals with breast cancer. In this blog we will discuss some of the newest findings as well as practical ways to apply these findings in your own life. I hope you choose to read on and please share this with family and friends.

What the researchers are finding:

We know that to say breast cancer treatment can be hard is an understatement. The risk of symptoms like fatigue, sarcopenia (muscle loss), osteoporosis, cardiovascular disease, and cognitive impairments are all elevated in individuals who are undergoing or have undergone treatment for breast cancer. These symptoms can have a profound impact on quality of life, which breast cancer survivors should not have to accept. Luckily in researching this blog, I found so many studies examining how to improve the quality of life of people going through breast cancer treatment. As a physical therapist, the studies on activity naturally piqued my interest.

Three of the studies I looked at examined how structured and monitored physical activity helped out people undergoing breast cancer treatment and those who had already undergone it. The studies included workout programs consisting of cardio, resistance training, or a combination of both. The studies showed improvements in fatigue, depression, physical fitness, and quality of life immediately following the exercise program. In one of the studies that look at how long these effects lasted, the positive benefits were lost 36 weeks after completing the exercise program.

How to use these findings:

It’s probably not groundbreaking journalism on my part to tell you that exercise is good for you. But what I do find compelling is the amount that good exercise can do, even during treatment. So the question is how to make exercise work for you. First get your doctor’s clearance for exercise, because there may be some exercises to avoid, especially if you have had a mastectomy. Most of the studies I looked at examined structured and monitored programs run by a physical therapist or other healthcare professional, which I would highly recommend especially if you are not used to exercising. A skilled physical fitness professional, like a physical therapist or Pilates instructor can not only help you progress safely through different exercises, but they can also introduce you to fun exercises you may have never thought of. That said, the best exercise is the one you will actually do. Remember, the benefits of exercise will be lost if you aren’t consistent. Cancer treatment can often feel like a full time job and adding another appointment into the mix is often not very practical. The good news is that in the study by Gokal and colleagues, walking independently for 30 minutes 5 times a week reduced self reported cognitive failures in participants. So even if you can’t make it out to see someone, there still is a lot of good you can do for yourself on your own.

Practical tips:

  1. Start slow: be kind to you body and ease yourself back into exercise. “Chunking” or breaking exercise into smaller sessions is a great way to start
  2. Spark Joy: (Shout out to Marie Kondo) but exercise should not be something you dread the thought of. If yoga, or walking makes you wanna crawl under a rock and hide, it’s not for you and that’s okay. Approach exercise curiously and you will find one you love, or at the very least, don’t hate.
  3. Buddy up: in the spirit of sparking joy, having an exercise buddy will not only help you remain accountable, it will probably make the experience a heck of a lot more fun.
  4. Get help when you need it: If you are a brand new exerciser, are in pain, or just feel like your routine is getting stale, see a fitness professional. It’s a short term investment that will pay dividends in the future by making exercise more comfortable and fun.

Keep positive, keep moving and if you have any questions, give us a call!

Dieli- Conwright C, Courneya K, Demark-Wahnefried W, et al. Aerobic and resistance exercise improves physical fitness, bone health, and quality of life in overweight and obese breast cancer survivors: a randomized controlled trial. Breast Cancer Research. 2018; 20 1:24

Gokal K, Munir F, Ahmed S, et al. Does walking protect against decline in cognitive function among breast cancer patients undergoing chemotherapy? Results from a small randomised controlled trial. PLOS ONE. 2018

Penttinen H, Utriainen M, Kellokumpu-Lehtinen P, et al. Effectiveness of a 12 – month Exercise Intervention on Physical Activity and Quality of Life of Breast Cancer Survivors; Five- year Results of the Brex- study. In Vivo. 2019. 33:881-888

Witlox L, Hiensch A, Velthuis M, et al. Four -year effects of exercise on fatigue and physical activity in patients with cancer. BMC Medicine. 2018; 16:86

Ph101 Men’s Only Seminar

Fiona McMahon PT, DPT

On October 23rd at 7pm we will be hosting our  “Men’s Only Seminar”. Join us as we discuss how pelvic floor dysfunction affects the male pelvic floor. Learn how your sex life can be improved by pelvic floor treatment, how to regain function after prostatectomy, and how to rid yourself of the pain of prostatitis, and avoid antibiotics for the most common type of prostatitis. This seminar is not to be missed!

For more reading on male pelvic health topics, check out:

All About Testicles

Navigating Life with Chronic Pain: Part 1

Navigating Life with Chronic Pain: Part II

Prostatitis What it is and What to do About it

Location:

110 East 42nd Street

Suite 1504

NY NY

10017

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