Ladies and Gentlemen, it is finally time to go for this blog and go on a deep dive to discuss at length (pun not intended), the physiology, health, and function of an amazing organ, the penis! A couple years ago we talked about testicles in our blog, All About Testicles, which remains one of our most popular blogs. Now it is time to travel north and talk about how people with penises can best care for them and how to address things that may go wrong from time to time. This blog will periodically cover different issues that can (ahem) arise with penises. Today we will go over premature ejaculation. But before we can do all that, lets review how the penis works.
As an organ, a healthy penis is an amazingly complex organ despite it’s seemingly simple exterior. It is the tail end of the urinary system, provides amazing sensation, carries sperm to the outside world, delivers a substance that can neutralize the acidity of the vagina in order to make it more hospitable to sperm, and is able to use the muscles around it to raise the blood pressure in the penis higher than that of the outside body, in order to maintain erection.
The penis is not one tissue all the way through. It has what’s called the tunica albuginea which is the wrapping for the erectile parts of the penis. This guy is really important because it closes off the vein returning blood flow from the penis to keep the penis erect during arousal. Inside the tunica albuginea is the corpus carvernosum and corpus spongiosum. No, these two tissues are not Harry Potter spells, but critical parts of penile infrastructure. The corpus cavernosum fills with blood during erection and helps make the penis hard. The corpus spongiosum keeps the urethra from getting clamped shut during erection so the sperm can get out.
How Does The Penis Get Hard?
Usually, in response to sexual stimulation, the smooth muscles (the involuntary ones, not the pelvic floor) will relax allowing the small blood vessels within the penis to fill with blood, the result is the tunica albuginea ( the wrapping of the erectile parts of the penis) will compress on the veins of the penis, thus preventing the blood returning back to the body. The trapped blood in the penis will cause the penis to get hard and stand up. The lovely muscles of the pelvic floor, specifically the ischiocavernosus will contract to further increase the blood pressure within the penis and keep the penis erect.
What Happens with Ejaculation?
Ejaculation occurs with orgasm. It is possible to have an orgasm without ejaculation if you have had a procedure like a prostatectomy. For a normally functioning penis, ejaculation occurs with orgasm and is what carries the sperm and other fluids to the outside world. The contractions felt in orgasm are what propel the sperm through the penis and to the outside world. The bulbospongiosus is responsible for these contractions and is part of the pelvic floor.
Premature Ejaculation
Here is where I would normally supply you a pithy little statistic like “ 1 in 4 men will experience premature ejaculation in their lifetime”. Unfortunately, I cannot provide any such statistic for this subject because so few people talk about this problem. The clinical definition of premature ejaculation is a little wonky too, and has not consistently been used in research, therefore prevalence data are likely inaccurate. The International Society for Sexual Medicine (ISSM) , in an attempt to improve the medical definition of premature ejaculation defines it as:
Ejaculation that always or nearly always occurs within about 1 minute of vaginal penetration from the first sexual experience (Defined as lifelong premature ejaculation)
OR
A clinically significant reduction in latency time, often to about 3 minutes or less (defined as acquired premature ejaculation)
Inability to delay ejaculation on all or nearly all vaginal penetrations; and
Negative personal consequences, such as distress, bother, frustration, and/or avoidance of sexual intimacy (Althof 2014)
If you are a gay or bi-man, or a man who does not have vaginal intercourse you are probably well aware how problematic this definition is. Currently, it is the ISSM’s stance that there is insufficient evidence to draw up criteria for men who have sex in ways other than vaginal intercourse.
As you can tell by the definition, premature ejaculation is divided up into 2 subgroups, lifelong and acquired. The distinction is relatively new in the research and can help patients find better ways to treat their premature ejaculation.
Potential causes of premature ejaculation include:
Hypersensitivity of the glans( head) of the penis
Issues with serotonin
Erectile dysfunction*
Either stopping or starting drugs
Chronic pelvic pain syndrome*
History of rushing early sexual encounters
Prostatitis*
*These are conditions treated at Beyond Basics Physical Therapy
What to do about premature ejaculation?
Don’t ignore it. Performance anxiety and premature ejaculation can often become a vicious cycle, where one will promote the other. Regardless of how your symptoms started, there is a lot that can be done to improve your sex life.
If you have prostatitis or chronic pelvic pain come to physical therapy. Did you know 90-95 percent of cases of “prostatitis”/chronic pelvic pain are musculoskeletal in nature… ahem… this is one of the most common conditions we treat at Beyond Basics. Overactive muscles, those in the abdomen, legs and pelvis can contribute to symptoms of prostatitis/chronic pelvic pain, (i.e. burning urination, painful ejaculation, sitting pain, genital pain, defecatory pain, urinary or bowel frequency, urgency, retention, incomplete emptying, etc.,.). Physical therapy can go a long way to treating and curing these symptoms by relaxing and lengthening your overactive muscles and strengthening weaker muscles. Prostatitis is a vast subject that requires its own blog. Luckily for you, I already wrote one. Check it out here.
If you are experiencing erectile dysfunction along with premature ejaculation, get thee to a doctor. I already explained to you how amazing the penis is as an organ. Its function is reliant on blood flow, thus problems with erection, especially in younger people may be an early sign that something may be up with your vascular system. Once systemic causes have been ruled out, get thee to physical therapy. We spoke earlier about how the penis requires blood flow and muscles to work properly; pelvic floor physical therapy can restore the function and improve the vascular health of the muscles vital to erection. Erectile dysfunction is yet another subject that could use its own blog. Again, luckily for you, I already wrote one. Check it out here.
If you don’t think erectile dysfunction, prostatitis or chronic pelvic pain is causing your premature ejaculation, there is still a lot you and your urologist can do. There is new work revealing that certain medications and psychotherapy can really help reduce premature ejaculation. You are not alone in this and you deserve to start feeling better.
Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!
Fiona McMahon PT, DPT is currently practicing from our midtown location
Althof S, McMahon C, Waldinger M, et al. An Update of the International Society of Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE). Sex Med. 2014; 2(2) 60-90
Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8
Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60
Summer holidays are approaching. You’re lounging at the beach and feeling quite proud of the ruffled swimsuit that guards the battle marks of the mom bod—the wrinkly and poochy belly. On the horizon, a woman in string bikini framing her flat tummy joins the four children sitting next to you. She must be their nanny, or maybe the children were adopted, or she probably had a surrogate. But after a short conversation, she reveals that in fact is the biological mother of these children and that she carried to full term. And when you awkwardly compliment her on the restoration of her college-era body, she nonchalantly shrugs and says, “Genetics? Maybe the coconut oil that we brought back from Bali?”
As the power of airbrushed social media images expand, the Cinderella stories of mummy tummy to model abs give hope to the many moms scrolling mindlessly on our phones passing the wee hours of childcare. These stories are powerful and inspiring, but do not reflect most of our situations, nor answer many elusive questions about diastasis recti abdominus.
What is Diastasis recti abdominis and why do we care?
Diastais recti abominis (DRA) is the excessive separation between the two sides of the rectus abdominis (the six pack muscle), which creates a pooching of the belly, particularly with difficult tasks. For this blog, the background information focuses on pregnancy related DRA while the application of the information can be used for any one with DRA. During the third trimester 100% of women have a DRA, defined as a separation >2 cm below the umbilicus (1). One answer to why we care about DRA is that we want our stomachs to look normal if not flat. The wrinkly skin stomach has not reached mass popularity on the runways. Another reason we care is because DRA has been assumed to predispose a long term sequelae of breakdown in the body. The cosmetic appearance associated with DRA improves as the inter-recti distance (IRD), the width between the bellies of the rectus abdominis, decreases.
As physical therapists, we screen for DRA in order to gain a larger understanding of how the body is working together. Many of us assume that the lack of stability in the front of the body will lead to compensations in other parts of the body—primarily the diaphragm, pelvic floor, and back. Dysfunction in these areas have been documented to be higher during pregnancy and the post-partum period (2). Physical therapists regularly address DRA when patients present with low back pain (LBP), pelvic floor dysfunction, pelvic pain, and urinary incontinence (3). A couple of studies looking at post-partum women seeking medical care for abdominal pain and pelvic floor dysfunction show a higher incidence of DRA in this populations (4,5). However, this is not to say that the DRA causes or predicts these conditions.
In recent prospective studies using ultrasound assessment, the assumption that DRA correlates to pelvic floor dysfunction and low back pain (LBP) is challenged. The findings suggest no relationship but even a possible protective mechanism of DRA during pregnancy, with no difference in LBP symptoms at one year postpartum regardless of DRA status. Of course, this is a statement of generalization to a study population and does not reflect the outliers, individual predispositions and presentation.
DRA During Pregnancy
No differences were found in pelvic floor function or in urinary incontinence between women regardless of DRA status, during or after pregnancy. Women presenting with DRA in their 2nd trimester were more likely to have higher vaginal resting pressures, strong pelvic floor muscles strength, and better endurance of pelvic floor muscles. The set of women with 2nd trimester DRA had lower BMI before pregnancy and during pregnancy with trend increased general physical activity (6)
DRA Post-Partum
Interestingly, women who at 6 weeks postpartum did not have aDRA were more likely to have a pelvic organ prolapse > Stage 2 (6). DRA status (none or mild) had no relationship with low back pain at 6 months (1) and 12 months postpartum (7). This corroborates another study showing no difference for DRA in women reporting LBP and that severity of DRA does not predict intensity of LBP when present (5). Heavy lifting >20x/week was shown to be a risk factor for postpartum DRA, but not age, pre-pregnancy BMI, 2nd trimester BMI, weight gain, caesarean or vaginal delivery, abdominal circumference at 35 weeks, hypermobility (p – 0.06), cardio and strength exercise, general abdominal and pelvic floor exercise (1). From the research available, we cannot predict from a group of postpartum women with DRA who will have symptoms that affect their daily living.
Looking a Little Deeper at Diastasis Recti Abdominis
As assumptions about DRA and its relationship to long term dysfunction start to shift, what is important to identify in a DRA presentation is also changing. The literature and clinical practice related to DRA mainly looks at the IRD, or the separation between the right and left muscle bellies of the rectus abdominis However, the focus on the widening of the linea alba may be less important than the ability of the linea alba to transfer forces and contribute to the stability of the abdominal muscles (8). A wide linea alba that holds tension and stabilizes the front of the abdomen with increased intra-abdominal pressures through functional task may be more desirable than a narrow linea alba with distortions that loses force and allows abdominal pressure to push forward through functional task. A pulled-apart and taut rubber band hold tension better than a relaxed and crumpled band. The width and depth of the linea alba need to be contextualized within the individual’s posture, daily movement, and functional core adaptability. The literature has yet to identify subgroups that would likely explain why some people have DRA that self-resolve and among those who don’t, why it impacts cosmetics and function in some people and not in others, why it seems to be a protective mechanism for some pelvic floor and low back conditions and exacerbating in others.
The linea alba is often connected to the rectus abdominis because of the focus of the IRD as a marker of DRA. However, the linea alba actually is the anatomical and functional intersection of all the abdominal muscles—the rectus abdominis, the internal and external obliques, and transverse abdominis, which is seen at a microscopic level with different angles of fibers in the linea alba. In a cadaver study looking at the collagen of the linea alba without DRA, previously pregnant women had thinner linea alba, but greater widths. Females who were previously pregnant had higher ratio transverse to oblique fibers—60% for females and 37.5% for males. The female cadaver that had never been pregnant had infraumbilical fibers more similar to males (9). The small size of this study limits its application, but perhaps an increase of transverse abdominis muscle activity in the lower abdominals is represented in the higher number fibers, and that this adapted activity resolved the DRA for these women.
Hormones may possibly play a role of the development of DRA for some women, but because DRA persist well after post-partum hormones return to normal. In men, hormones are unlikely to be the primary driving cause of persistent DRAs. Women who are breastfeeding do have a higher relationship with unresolved DRA until breastfeeding is concluded (5). However, no research has been conducted on this relationship and may add to another subgroup to explain the variance of women who spontaneously resolve and others who never resolved their DRAs.
Joanna is a treating therapist at our downtown location. Stay tuned for the next installment on this topic, Mind the Gap Part II: Diastasis Recti Abdominis: What we Can do About it.
To call and make an appointment with our expert PTs call:
212- 354- 2622 (Midtown)
212-267-0240 ( Downtown)
References:
1. da Mota PG, Pascoal AG, Carita AI, Bø K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Manual therapy. 2015 Feb 1; 20(1):200-5.
2. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of bodywork and movement therapies. 2008 Oct 1; 12(4):333-48.
3. Keeler J, Albrecht M, Eberhardt L, Horn L, Donnelly C, Lowe D. Diastasis recti abdominis: a survey of women’s health specialists for current physical therapy clinical practice for postpartum women. Journal of Women’s Health Physical Therapy. 2012 Sep 1; 36
4. Spitznagle TM, Leong FC, Van Dillen LR. Prevalence of diastasis recti abdominis in a urogynecological patient population. International Urogynecology Journal. 2007 Mar 1; 18(3):321-8
5. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy. 2009 Jul 1; 33(2):15-22.
7. Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016 Jun 20:bjsports-2016.
8. Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. journal of orthopaedic & sports physical therapy. 2016 Jul; 46(7):580-9.
9. Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths: II. Variability and biomechanical aspects. Journal of Surgical Research. 2001 Apr 1; 96(2):239-45.
10. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. journal of orthopaedic & sports physical therapy. 2011 July.
11. Coldron Y, Stokes MJ, Newham DJ, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Manual therapy. 2008 Apr 1;13(2):112-21.
12. Boissonnault JS, Blaschak MJ. Incidence of diastasis recti abdominis during the childbearing year. Physical therapy. 1988; 68(7):1082-6
13. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy. 2005 Apr 1; 29(1):11-6.
14. Benjamin DR, Van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar 1; 100(1):1-8.
15. Pascoal AG, Dionisio S, Cordeiro F, Mota P. Inter-rectus distance in postpartum women can be reduced by isometric contraction of the abdominal muscles: a preliminary case–control study. Physiotherapy. 2014 Dec 1; 100(4):344-8.
16. Sancho MF, Pascoal AG, Mota P, Bø K. Abdominal exercises affect inter-rectus distance in postpartum women: a two-dimensional ultrasound study. Physiotherapy. 2015 Sep 1; 101(3):286-91.
17. Litos K. Progressive therapeutic exercise program for successful treatment of a postpartum woman with a severe diastasis recti abdominis. Journal of Women’s Health Physical Therapy. 2014; 38(2):58-73.
18. Gillard S, Ryan CG, Stokes M, Warner M, Dixon J. Effects of posture and anatomical location on inter-recti distance measured using ultrasound imaging in parous women. Musculoskeletal Science and Practice. 2018 Apr 1; 34:1-7.
19. Kirk B, Elliott-Burke T. The Effect of Visceral Manipulation on Diastasis Recti Abdominis (DRA): A Case Series.
By Amy, a former patient at Beyond Basics Physical Therapy
I just completed a prenatal yoga teacher training. During the closing circle, we passed around a foam pelvic floor and when we wanted to share the speaker took it as though it were a “talking stick”. As I held on to the foam model, I told the rest of the women in my training how this past year my pelvic floor had caused a lot of joy in bringing my daughter into this world, but also more pain than I could have imagined.
I had complications from the delivery of my daughter that left me in terrible pain for months. Granulation tissue (excess scar tissue) grew from my vaginal tear that the doctors were unable to treat because they did not detect I had an infection until four months postpartum. I felt physically broken. A complete failure as a mother, as all the procedures caused my pelvic floor muscles to go into spasm that it was often unbearable to walk or even sit to nurse my daughter. I was in constant pain but felt like I couldn’t share it with anyone because the pain was in my “privates”.
Pain is pain no matter where it is in your body, and I wish I had lived in a world where I could’ve been honest about my traumatic recovery without having to say “sorry if it’s TMI.” If that were the case, I hope I would have recovered faster. Even my doctors (which I saw at least half a dozen different ones to seek treatment) made me feel like this pain is private. When I asked one doctor if I could speak to another patient about the surgery she told me I needed, her response was “I don’t think she would be so open.” I hate to tell you but vaginas are not just sexual organs — at least mine created a human, oh and also, they’re pretty important if you like sitting and walking.
I felt completely alone seeing other moms six weeks postpartum already being told they can exercise and have sex when I wasn’t even there at six months. When I started going to Fiona at Beyond Basics Physical Therapy, I learned that pelvic pain was not at all uncommon and that helped me open up more to others about my experiences. Then something amazing happened, the more I opened up the less alone I felt as others felt more comfortable to share with me. As I heard more stories like mine of women suffering but not knowing how to seek treatment, I asked Fiona to come speak to at my yoga studio in Brooklyn.
To spread the word about the event, I swallowed my pride and posted on my Brooklyn new mom’s group – “I had a terrible recovery from childbirth that I wouldn’t wish on my worst enemy. It landed me in pelvic floor physical therapy. Whenever I share my recovery story the line “no one ever tells you these things” kept coming up. I asked my amazing physical therapist if she would come to Brooklyn to teach others about the pelvic floor (“these things”) and she agreed.” Within a few days the session was completely booked and I even received messages from complete strangers in the group wanting to share their story and get advice from me!
At the session I shared my story and am lucky that it does have a happy ending. I finally was properly diagnosed and treated after seeing a doctor Fiona had recommended. The day after the info session in Brooklyn, almost poetically, I graduated from physical therapy. Through the relaxation exercises and sessions, I no longer was in pain and was able to reclaim my life as a new mom.
I asked Fiona if I could blog since when I was going through my recovery these types of entries always comforted and encouraged me. I hope in sharing my story of my recovery with Beyond Basics it can help comfort someone in their own journey towards recovery.
Breath. Breath is the common denominator for understanding how pilates can enhance the pelvic floor’s function. Reciprocally, using your pelvic floor correctly can deepen your connection to your pilates practice.
Let’s take a look at how to optimize your breath in the first place. A deep, three dimensional breath utilizes your diaphragm to its fullest extent. When you inhale, your diaphragm contracts forming a dome shape under the rib cage while simultaneously lengthening the pelvic floor creating a cylindrical shape within your torso.
There are two options for the rib cage while you take this inhale. Option one involves flaring the ribs outward during the breath. Option two involves narrowing the ribs slightly down towards your ASIS (hip bones). When we breathe with a more neutral, tapered rib cage, we utilize the second option for rib placement, thus finding our Zone of Apposition (ZOA). Breathing within the ZOA provides us with the most efficient breath we can take. Once the ribs are placed properly over the pelvis, we’re able to create the cylindrical shape within the torso and the relationship between the diaphragm and the pelvic floor is optimized!
Pilates is rooted in core strengthening principles that directly correlate to breath and the ZOA. In order to keep your ribs from flaring, ultimately keeping you from finding the ZOA, you need to have a sense of abdominal control. There are a handful of ways to find the ZOA, but one of my favorite cues to use with clients is to “narrow your ribs toward your naval.” Try this on your own either lying down, sitting, or standing, and notice what happens to your abs as soon as you taper, or narrow, your ribs toward your naval. You should feel some muscle tone over your stomach. AKA your abs kicking in!
Once you’ve achieved proper rib placement, ab engagement, and optimal breath, layering various exercises into your program will be much more attainable. It requires a good amount of body awareness to be able to coordinate these three major concepts before advancing through your pilates practice. It’s also important to concentrate on how your pelvic floor is reacting to your breath and movement. In footwork, for example, you start in neutral spine and exhale as you press the carriage out feeling a slight contraction in the pelvic floor. On the inhale, knees bend pulling the carriage back to it’s starting position while the tailbone drops slightly and the sits bones widen allowing you to lengthen the pelvic floor. (Prime example of moving within your ZOA).
As you can see, the pelvic floor plays a huge role in breath and core activation which is the root foundation of all your pilates and basic core exercises! If this interests you, or utterly confuses you, schedule a pilates session with me at Beyond Basics!
Exercise in ever tightening spandex while making frequent public toilet stops, or binge on Netflix and cronuts? Pregnancy is a great equalizer. Not even Kate Middleton can escape the hormones that can cause pregnant women to suffer from mood swings, fatigue, nausea, and achiness. Those symptoms—and modern culture—frequently encourage pregnant women to decrease movement and everyday activities. However, there is resounding support in academic literature that recreational physical activity during pregnancy is beneficial to both mother and baby.
While the pregnant woman is best suited to monitor what is beneficial for her body and baby during pregnancy, adequate information to make that decision is not always readily available. Yet around 600 studies published between the mid-1980s and mid-1990s corroborate that exercise during pregnancy is not harmful by measure of fetal birth weight, mode of delivery, preterm delivery, Apgar scores, and acute fetal well-being (1-3). What’s more, the American College of Obstetricians and Gynecologists (4) removed the limitations for intense exercises back in 1985 (5) and a literature review showed that bed rest was not beneficial for pregnancy complications. Still, 95% of ob-gyns continue to prescribe activity restrictions to certain pregnant mothers (6).
Clearer guidelines are needed for how pregnant women can decrease injury while maintaining performance and the well-being of mother and baby. While running is only one mode of boosting fetal and maternal health, many women, especially here in New York, embrace it as a key part of their overall wellness. As a recreational runner myself, I was disappointed during my first pregnancy with the foggy information regarding how to run safely during pregnancy. I found myself as a self-case study, correlating the physiological and biomechanical pregnancy changes with a shift in running mechanics. At the third trimester, I had a suspicion that I should replace running with the elliptical and restorative yoga.
The scientific literature specific to running during pregnancy is extremely limited, and in its absence, I’ve used findings for “moderate to strenuous” physical activity, in addition to clinical knowledge of pregnancy related changes in the body and running patterns to develop the recommendations below. Recently, a group of researchers published a series of five papers and combined recent literature about higher level physical activity during pregnancy for application in appropriate populations (7-8).
Pregnancy and exercise:
Pregnancy may seem like a counter-intuitive time to start an exercise program. However, research shows that 150 minutes/week of moderate exercise (9) for inactive and relatively sedentary women, and moderate to strenuous exercise for active women, has strong health benefits for both fetus and mother. Moderate exercise is recognized as 5-6 on the Rate of Perceived Exertion (RPE), 40-59% HRR (Heart Rate Reserve = Heart rate max – Heart rate resting). Moderate to strenuous is described as 7-8 RPE, 60-84% HRR (1). So while growing a baby is not a good time to start a running program, it is a good time to increase an appropriate level of physical activity or continue an established running program. Some of the benefits of appropriately prescribed exercise are correlated to (10-16):
· Healthier gestational weight gain, which protects against complications like cesarean delivery, hypertension, preeclampsia, and gestational diabetes
· Improved general healthy behaviors
· Improved psychological wellbeing – reduction in depression and anxiety, improved self-esteem, particularly for women who were previously inactive
· Improved ability of the placenta to deliver oxygen
· Increased amniotic fluid
· Healthier fetal birth weights that correlate to changes in leptin levels that continue to correlate with a healthier body fat and muscle ratio at the age of 5
· Increased gestational age
· Decreased rate of pregnancy complications, although one study showed higher use of physician assisted delivery (10)
· Faster delivery and decreased chance of Cesarean delivery in a setting that supports natural birth (11)
· Higher Apgar scores
· Lower fetal heart rate and increased fetal heart-rate variability
· Improved neonatal orientation
· Higher general intelligence and oral language skills at the age of 5
· Improved ability of baby to self-soothe after birth, (i.e. longer stretches of night sleep)
Precautions:
Strenuous activity is correlated to a higher rate of miscarriage during the implantation phase of pregnancy—about 20-23 days after the last menstrual cycle. Elevated body core temperature (above 103 degrees Fahrenheit), which can be caused by strenuous activities like marathon running or exercising in hot and humid weather, can increase the risk of fetal neural tube abnormalities during its development, 35-42 days after last menstrual period. Exercising for 60 minutes in a comfortable environment will not raise core temperature above 100 degrees Fahrenheit.
The pregnant woman’s heart rate should not exceed 90% of her maximal heart rate. Because of physiological changes, the pregnant runner will underestimate her heart rate based on the typical rate of perceived exertion or talk test. For this reason, the pregnant runner should modify the run intensity knowing that her heart is working harder than she perceives or wear a heart rate monitor using the HRmax = 220-age, unless she has access to laboratory equipment that can calculate HRmax without full exhaustion.
The American College of Obstetrics and Gynecology, (ACOG) has set absolute and relative contraindications to aerobic exercise during pregnancy (4).
Absolute contraindications:
· Hemodynamically significant heart disease
· Restrictive lung disease
· Incompetent cervix or cerclage
· Multiple gestation at risk of premature labor
· Persistent second or third trimester bleeding
· Placenta previa after 26 weeks of gestation
· Premature labor during the current pregnancy
· Ruptured membranes
· Preeclampsia or pregnancy-induced hypertension
· Severe anemia (different than mild anemia)
Relative contraindications:
· Anemia
· Unevaluated maternal cardiac arrhythmia
· Chronic bronchitis
· Poorly controlled type 1 diabetes
· Extreme morbid obesity
· Extreme underweight (BMI <12)
· History of extremely sedentary lifestyle
· Intrauterine growth restriction in current pregnancy
· Poorly controlled hypertension
· Orthopedic limitations
· Poorly controlled seizure disorder
· Poorly controlled hyperthyroidism
· Heavy smoker
Warning signs:
Low back and pelvic girdle pain/instability, knee/hip pain, pelvic heaviness, sharp pains in the pelvic floor, urinary leakage, and regular ankle sprains are all signs that it may be time to modify running as exercise. In the clinic, I am often asked about pelvic floor symptoms, particularly urinary leakage during pregnancy, and specifically with running.
I like to think of these warning signs as a force transfer problem—something in the system is not working well. For stress incontinence and pelvic heaviness, it’s the inability of the pelvic floor to generate enough force to keep things up against the up-chain forces of running (2.5x while accepting weight after the flight phase) and down-chain forces of steadily increasing body weight + baby’s weight (around 20% of pre-pregnancy weight). But post-partum is not as simple as the forces that are generated from running or the ability to do a Kegel. Elite athletes and non-exercisers have about the same rate of post-partum incontinence. However, postpartum symptoms are more likely if exercise also caused urinary leakage during pregnancy (16).
The pregnant body is a little more complicated:
It needs to taken into account, that the 10-fold increase of relaxin and progesterone that might be responsible for more instability as forces from the ground traveling up into the falling arches of the feet, adduction of the knee, internal rotation of the hip, through the pelvic floor and gapping of the sacroiliac joint. As the fetus and breasts grow, the body’s center of gravity shifts forward, the ribs flare, and the pelvis tilts forward. While the gluteus maximus and calf muscles are getting stronger to propel the pregnant body forward, the front of the body gains significantly more mass. When this happens, the front of the diaphragm and the front of the pelvic floor are positioned so more forces are going through the front of the pelvic floor than the back. This requires more support of the bladder through the pelvic floor. As the pelvis widens, foot step width increases in walking (17), but decreases in running during the single stance phase, requiring more pelvic control. In other words, the pregnant runner’s leg strength, particularly the hip stabilizing muscles, gluteus medius and minimus, need to be exponentially stronger than in the non-pregnant runner to account for additional weight, forward weight shift, and ligamentous laxity. I primarily talk about the deficit of the gluteus group because of what I see clinically, but depending on when the woman is experiencing pain or pelvic floor instability symptoms, other muscles may also need attention.
The usual period of pain experienced by pregnant runner’s initial strike to single stance, corresponds with the biomechanical gapping of the sacroiliac joint. Alleviating such issues will require force absorption and muscle activation through the quadriceps, medial hamstrings, calf muscles, tibialis anterior, TFL, adductor magnus, iliopsoas, and gluteus medius/minimus. Symptoms of lower extremity and lumbopelvic pain, pelvic heaviness, or sharp pains in the pelvic floor have similar biomechanical and physiological causes as urinary leakage. They should be treated in a similar manner whether controlling the upward and downward loads by:
· decreasing speed of running – correlated to double flight phase, which increases upward pressures
· decreasing vertical displacement
· landing with a midfoot strike to increase shock absorption (18)
· increasing arm swing/thoracic movement – dispersing upward forces and facilitating the respiratory and pelvic floor piston
· decreasing daily physical exertion that causes increased abdominal pressure
· increasing external support with (sacroiliac joint) SIJ belts or foot orthotics – decreasing the body’s instability
· improving dynamic single leg pelvic stability – star excursion
· maintaining hip flexor mobility – controlling forward pelvic tilt, movement throughout the day out of sitting posture, hip flexor stretches, shifting weight back through heels, diaphragmatic vs. back breathing
An orthopedic physical therapist specializing in pelvic floor dysfunction and in prenatal and postpartum care will be able to give more specific recommendations, since each woman’s symptoms are a little different.
Expected running changes in pregnancy:
For previous recreational to elite runners, about 70% will continue to run at some point in the pregnancy with only 1/3 continuing into the third trimester. They usually cut the running volume and intensity by 50% compared to non-pregnancy training. For those who stopped running during pregnancy, over half elected to do so because of self-monitoring symptoms of wellness, about one quarter stopped due to physician’s advice, and the remainder stopped for fear of a miscarriage. Whether choosing to continue or stop running during pregnancy, most women had returned to running by 2 months postpartum, and without negative impact on breastfeeding (19).
Speed will decline as instability increases, so that the body has less time with both feet off the ground. Ankle sprains may happen intermittently because of changes in foot position, possible increased swelling, and laxity in the ankle ligaments. Resting heart rate increases 15-20%. Breathing might be more labored during running because of increased sensitivity to carbon dioxide (particularly in early pregnancy) and decreased lung capacity/rib excursion (in late pregnancy). Pregnancy-related mild anemia, which decreases available blood oxygen, affects more than 40% of pregnant women and may show up as accelerated fatigue and increased respiratory rate during running. Be sure that fatigue is not related to severe anemia or hypothyroidism, particularly in persistent symptoms. The pregnant body will improve its ability to thermoregulate with increased sweating to dissipate more heat.
Clothes won’t fit like they once did, especially the spandex. Find some appropriately fitting, breathable, loose exercise clothing that does not excessively compress around the stomach. Urinary urgency and frequency are common limitations in running as the pregnancy progresses, which requires some planning and increased water intake.
Running during pregnancy presents an opportunity to do something overwhelmingly beneficial for both mother and baby, with the added incentive of tuning into the body’s remarkable capacities. While physical activity, running or otherwise, will look different during pregnancy, the goals are similar for a healthy lifestyle. Be kind to yourself—body, mind, and spirit. You and your baby will be thankful. Happy trails. Please leave any comments or questions here!
Joanna is currently taking new patients at our downtown office.
Joanna keeping fit with personal trainer, Irene Donahue at our Downtown location
Phone: (212)- 267- 0240
1. Szymanski LM, Satin AJ. Exercise during pregnancy: fetal responses to current public health guidelines. Obstetrics and gynecology. 2012 Mar;119(3):603.
2. Physical Activity Guidelines Advisory Committee. Physical Guidelines Advisory Committee Report, 2008. Wasington, DC: U.S. Department of Health and Human Services: 2008.
3. Barakat R, Stirling JR, Lucia A. Does exercise training during pregnancy affect gestational age? A randomised controlled trial. British Journal of Sports Medicine. 2008 Aug 1;42(8):674-8.
4. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol. 2015;126(6):e135-142.
5. Artal R, O’toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British journal of sports medicine. 2003 Feb 1;37(1):6-12.
6. Bigelow C, Stone J. Bed rest in pregnancy. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011 Mar 1;78(2):291-302.
7. Bø K, Artal R, Barakat R, Brown W, Davies GA, Dooley M, Evenson KR, Haakstad LA, Henriksson-Larsen K, Kayser B, Kinnunen TI. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant. Br J Sports Med. 2016 May 1;50(10):571-89.
8. Bø K, Artal R, Barakat R, Brown W, Dooley M, Evenson KR, Haakstad LA, Larsen K, Kayser B, Kinnunen TI, Mottola MF. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2—the effect of exercise on the fetus, labour and birth. Br J Sports Med. 2016 Sep 22:bjsports-2016.
9. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Department of Health and Human Services. Washington, DC: 2008.
10. Kuhrt K, Harmon M, Hezelgrave NL, Seed PT, Shennan AH. Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy. BMJ open sport & exercise medicine. 2018 Mar 1;4(1):e000296.
11. Erdelyi GJ. Gynecology survey of female atheletes. J Sports Med Phys Fitness. 1962;2:174-179.
12. Prather H, Spitznagle T, Hunt D. Benefits of exercise during pregnancy. PM&R. 2012 Nov 1;4(11):845-50.[Ine
14. Clapp JH, Capeless E. The VO2max of recreational atheletes before and after pregnancy. Med Sci Sports Exerci. 1991;23:1128-33
15. Gjestland K, 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. 2012 Aug 1:bjsports-2012.
16. Bø K, Sundgot‐Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life than non‐athletes?. Scandinavian journal of medicine & science in sports. 2010 Feb 1;20(1):100-4.
17. Gilleard WL. Trunk motion and gait characteristics of pregnant women when walking: report of a longitudinal study with a control group. BMC pregnancy and childbirth. 2013 Dec;13(1):71.
18. Nicola TL, Jewison DJ. The anatomy and biomechanics of running. Clinics in sports medicine. 2012 Apr 1;31(2):187-201.
19. Tenforde AS, Toth KE, Langen E, Fredericson M, Sainani KL. Running habits of competitive runners during pregnancy and breastfeeding. Sports health. 2015 Mar;7(2):172-6.
You’ve probably heard of SI pain, but what is the SIJ and what can we do if something goes wrong?
The sacroiliac joint (SIJ) connects the sacrum, the wedge-shaped bone at the bottom of the spine, to the ilium, which is one of three bones that make up each half of the pelvis. (1) The sacroiliac joint is designated as a diarthrodial joint, which means it is a moveable joint that is surrounded by connective tissue. (2,3) Each joint is supported mainly by ligaments that lie in front and behind it, that are made up of strong, threadlike types of connective tissue. Stability is also enhanced through ligaments that connect between the spine and the sacrum (sacrospinous ligament), and the sit bone and the sacrum (sacrotuberous ligament). (2)
The SIJ helps us to walk and change positions by being stable enough to move weight from the spine to the legs, while allowing for a small amount of movement between the spine and the pelvis. This small amount of movement between the spine and the pelvis is also important as it allows for the pelvis to expand to make childbirth easier. (2,4) These functions can occur due to the unique design of the SIJ.
According to a well-known researcher named Andry Vleeming, the SIJ gains its stability in one of two ways: through form closure or force closure. Form closure refers to the stability provided by the bony surfaces of the sacrum and ilium, which fit together like a puzzle. You may use this type of stability, for instance, when you are lifting a heavy box, or pushing a very full cart of groceries; you want your SIJ to be as immobile as possible so your trunk can be stiff and rigid, allowing you to move a heavy load without overstressing any muscles in your back. Force closure describes stability occurring through the ligaments and muscles around the joint; this allows for more movement to occur. For this type of stability, think salsa dancing. In salsa dancing you need a great deal of hip and pelvic movement; however, you need those movements to be in control so you can move with precision along with the quick beat of the music. (5-7)
What is sacroiliac joint dysfunction?
Sacroiliac joint dysfunction (SIJD) is a common cause of low back pain, accounting for up to 40% of cases of nonspecific low back pain. (4,8) It can occur in any population: males and females; those with a sedentary lifestyle and those who are athletes. However, there seems to be a slightly greater occurrence in women, with the theory being that since the joint surface in women is smaller and less curved, the SIJ may become dislodged more easily. (2,4) SIJD can have a negative impact on quality of life, from being less active to having a financial impact. For instance, indirect health-care costs associated with low back pain range from $7-$28 billion per year, and individuals lose an estimated 5.2 hours of work time per week. (4)
The origin of SIJ pain is unknown; however, factors that may contribute include fractures, ligamentous injuries, or inflammation that occur with excessive stress to the SIJ. (8) Risk factors for developing SIJD include abnormal walking patterns, differences in leg length, scoliosis (abnormal curvature of the spine), heavy physical exertion, trauma, pregnancy, and back surgery. (8) Presentation of symptoms can vary quite a bit; however, individuals with SIJD often present with achy low back pain that can make it difficult to find a comfortable position. Pain may worsen with running, climbing stairs, or standing from a seated position. Also, if pain is truly coming from the SIJ, a person will not experience symptoms down into the leg, as is seen with sciatic nerve involvement. (4)
How is SIJD diagnosed?
SIJD can be very challenging to diagnose due to the complexity of the joint itself, as well as the variation in pain patterns that can be seen; thus, if you visit a healthcare provider, you may find he or she performs an array of components in an examination. Many individuals have tenderness with touch over the joint; this can help a healthcare provider rule in SIJD. (2,8). Also, various orthopedic tests can be performed that put stress on this joint, such as by putting a person’s trunk or leg in a certain position to see if it recreates symptoms. (2) Imaging can be performed in this area, but it rarely provides clear information that can help make a diagnosis; however, a doctor might recommend it if there is a concern for infection, inflammation, fracture, or other more serious conditions. (2) Injections into the SIJ itself can also be used to help diagnosis this condition, and are shown to be one of the single-most definitive diagnostic tools available. (2) Overall, effective diagnosis for dysfunction at the SIJ requires the use of multiple tools to help increase the accuracy of the condition being ruled in or out.
How can this impact function? Why does it matter?
It is hypothesized that SIJD can have such a significant impact on quality of life because it results in inadequate stability at the joint during movement. If the SIJ is unable to maintain an optimal level of stability, then excessive stresses will likely be placed on surrounding structures and tissues when each leg has body weight going through it. This can lead to other areas of pain, and potentially start the process of degeneration. (4) A recent research group looked at the impact of SIJD on a simple, but common functional task of rising from a chair. They found that in individuals with SIJD, there were significant differences in the amount of weight a person was putting through the leg on the painful side, as well as in the amount of bend at the hips when sitting. They also found that when individuals began to rise from a chair, muscles on the side of SIJ did not turn on right away, which means the muscles were not helping to keep the SIJ from moving too much. (4) Thus, this condition can make it challenging to use the body efficiently due to pain and weakness, which can negatively impact function throughout a given day.
What can physical therapy do?
Once a person is diagnosed with SIJD, what can be done? Research has shown that non-surgical treatment, such as physical therapy, can be very beneficial for someone with SIJD. If you see a physical therapist, you will likely receive some variation of joint mobilization and exercise, which is shown to help achieve significant improvements in pain, function, alignment, and muscle control. Exercise programs that emphasized pelvic stability through core, pelvic floor, and gluteus (hip and buttock) exercises, as well as increasing the strength of hip rotator muscles, decreased pain and decreased reported disability after a range of 8-12 weeks. (8,9) In other studies, an exercise program that focused mostly on gluteus maximus strengthening was utilized, since this muscle is considered one of the primary stabilizers of the SIJ. The exercises in these programs included bridging, single leg bridging, hip extension on hands and knees, fire hydrants, deadlifts, and single-leg squatting. In these studies, participants reported less pain after the course of treatment, demonstrated increased muscle strength, and returned to normal daily activities. (10,11) While there is no set exercise protocol established at this point, a strengthening program, with or without a home program, is a mainstay for treating this condition, and results in improved function.
Are there other treatments?
In some cases, physical therapy alone is unable to resolve the issue. In these situations, a patient may be given an injection of corticosteroids to decrease inflammation, in or around the SIJ. Prolotherapy is also sometimes used in this population to help reconstruct or regenerate damaged or weakened connective tissue. While it is helpful to know what other options are out there, it is important to note that the research in these areas is continuing to develop, and there is no consensus on dosage or who is the optimal candidate. (2)
Conclusion
The sacroiliac joint is a complex joint between the back and the pelvis, that allows for minimal mobility, and is required to maintain stability between the trunk and the legs. It can become painful due to direct or indirect trauma, which can have a significant impact on function and quality of life. While diagnosis can be tricky due to the wide variety of symptoms, research is finding that conservative care through physical therapy can make a significant difference by promoting optimal alignment and stability. If you or someone you know is struggling with sacroiliac joint dysfunction, make an appointment with a physical therapist today to help improve function. Feel free to contact our office at 212-354-2622, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!
2. Peebles R, Jonas CE. Sacroiliac joint dysfunction in the athlete: diagnosis and management. Current Sports Medicine Reports, vol. 16, no. 5, 2017, pp. 336-342.
4. Capobianco RA, Feeney DF, Jeffers JR, et al. Sacroiliac joint dysfunction patients exhibit altered movement strategies when performing a sit-to-stand task. The Spine Journal, 2018, DOI: https://doiorg/10.1016/j.spinee.2018.03.008.
5. Vleeming A, Stoeckart R, Volkers AC, et al. Relation between form and function in the sacroiliac joint. Part I: Clinical anatomical aspects. Spine, vol 15, 1990, pp. 130-132.
6. Vleeming A, Volkers AC, Snijders CJ, et al. Relation between form and function in the sacroiliac jt. Part II: Biomechanical aspects. Spine, vol 15, 1990, pp. 133-136.
7. Vleeming A, Schuenke MD, Masi AT, et al. The sacroiliac joint: an overview of its anatomy, function, and potential clinical implications. J Anat, vol 221, 2012, pp. 537-567.
8. Al-Subahi M, Alayat M, Alshehri MA, et al. The effectiveness of physiotherapy interventions for the sacroiliac joint dysfunction: a systematic review. J Phys Ther Sci, vol 29, 2017, pp. 1689-1694.
9. Albright J, Allman R, Bonfiglio RP, et al. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain, Physical Therapy, vol 81, n 10, 2001, pp. 1641–1674.
10. Added MAN, de Freitas DG, Kasawara KT, et al. Strengthening the gluteus maximus in subjects with sacroiliac dysfunction. International Journal of Sports Phys Ther, vol 13, n 1, 2018, pp. 114-120.
11. Yoo WG. Effect of the single-leg, lateral oblique, decline squat exercise on sacroiliac joint pain with knee pain. J Phys Ther Sci, vol 28, 2016, pp. 2688-2689.
We are reposting an old post broadly discussing the LGBTQ+ community, with special focus on transgender individuals. Please keep checking back as we continue to discuss specific issues relating to the care of the LGBTQ+ community.
Amy Stein PT, DPT and Fiona McMahon PT, DPT
Who are LGBTQ+ individuals?
At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc. They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.
Never Assume. Listen, Ask.
We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community. First rule of thumb: with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.
As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us. Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.
We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in trans care. Hormones, either testosterone, estrogen, lupron, puberty blocking, testosterone suppressing can be used in many patients, but are also used specifically to aid in transition in transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options. There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration. Endometriosis can be worsened with testosterone hormones. Hormones can be administered via injection, pellets, patches, creams, gels, and pill form. It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc. Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals. Progression of hormones can be monitored for each patient and according to patients wants and needs.
For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs. Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.
How is care for the LGBTQ+ community funded and regulated?
Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.
How can physical therapy help?
At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction. We also specialize in orthopedics and functional manual therapy. We treat the LGBTQ+ community and we welcome any questions at desk@beyondbasicspt.com or call 212-354-2622. We are happy to help and look forward to hearing from you! Resources: Center of excellence for transgender health.
Kierstin Elliott, Pilates Instructor at BBPT
Joanna Hess PT, DPT, PRC, WCS
