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 inquire 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 it occurred. 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, they will be provided  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: Adding Pelvic Floor Relaxation to Deep Breathing

Amy Stein DPT, PT and Fiona McMahon DPT, PT

 

bookhppThis blog contains information adapted from Heal Pelvic Pain by Amy Stein. If you are interested in learning more about pelvic floor exercises you can do on your own, please visit http://www.healpelvicpain.com/ , http://amzn.to/2ioSz2J, or visit us at Beyond Basics Physical Therapy in New York City to get your copy today.

 

In an earlier post we discussed the positive benefits of adding diaphragmatic breathing to your routine to reduce stress. If you missed it, check it out here .

But why not go a step further. Did you know that you can add pelvic floor drops to your breathing routine to help relax a tight and painful pelvic floor.

 

What is a pelvic floor drop?

A pelvic floor drop is the relaxation of the muscles of the pelvic floor. It is like that feeling you have when you can finally relax the muscle in between your legs after holding urine in for a long time. It’s a great feeling of relaxation and here’s how you can mimic it when you don’t have to go.

 

But How do I do it?

 

  • Step 1: Get comfortable. Sit, stand, lay down, whatever suits you, relax your body and close your eyes
  • Step 2: Breathe deep. Inhale between 3 and 5 seconds
  • Step 3: Exhale. Exhale slowly, 5-6 seconds. As you exhale imagine your breath gently placing pressure on your pelvic floor into relaxation. Don’t push or strain.

Like diaphragmatic breathing, you can use this technique throughout the day to help reduce stress and pain in the pelvic floor. Happy breathing!

An Unnecessary Hysterectomy

According to an article in The Huffington Post, a new study performed by the University of Michigan and Wayne State University suggests one in five women undergoing hysterectomy surgery never needed the procedure. In fact, the article states, hysterectomy “is the second most common surgery performed on reproductive-age women in the United States, after the cesarean section. An estimated 1 in 3 women in this country will have had their uterus removed by age 60.” This is a scary thought, especially from the point of view of a pelvic floor physical therapist because our primary defense against musculoskeletal causes of abdomino-pelvic pain is, of course, physical therapy. The article states that one doctor, Dr. Lauren Streicher of Northwestern University’s Obstetrics and Gynecology department, said it’s possible the women recorded in the study were offered other treatments and then refused them, which wouldn’t have shown up in the medical charts evaluated for the study. Even so, she was still surprised other non-invasive treatment options like pelvic floor physical therapies were so underutilized. Like Dr. Streicher, we hope women are being given all of their options before making a choice–and that they are also given the opportunity to make the choice to begin with. A hysterectomy should not be the only option in treating pelvic pain, be it endometriosis, abnormal bleeding, or what have you. Instead, other, more benign therapies like some mentioned in the article –IUD, birth control pills, (i.e…hormonal therapy), NSAIDs (non-sterioidal anti-inflammatories), pelvic floor and abdominal physical therapy–should be first line of treatment for certain conditions, like endometriosis, painful periods, and any other abdomino-pelvic pain conditions. Obviously any underlying serious gynecological pathology should be addressed appropriately, but if nothing is found, then hormonal therapy should be questioned, and perhaps pelvic floor physical therapy used instead. Within this realm, there are a variety of treatments and exercises one can perform to relieve much of this pain before surgery of any kind is necessary. In Amy’s book, Heal Pelvic Pain, she reviews ways to treat pelvic pain without undergoing surgery of any kind, let alone one so major as a hysterectomy. We encourage you to pick up her book or her DVD, Healing Pelvic and Abdominal Pain, before considering a more drastic choice like surgery.

Kegels for Men?!

While Kegel exercises have typically been prescribed for women’s health, men richly benefit from them as well. Just as with women, the muscles in a man’s pelvic floor are the foundations of urinary and sexual health. As author Roni Carin Rabin writes in an article in this week’s New York Times, “Like all muscles, these weaken with age, doctors say. In order to strengthen them, men are told to tighten the muscles they might normally use to cut off the flow of urine midstream or prevent passing gas in a closed space. The contractions are held for a few seconds, then released, with the motion repeated 10 to 15 times for each workout.”

Amy discusses this phenomenon in her book, Heal Pelvic Pain. As she writes:

Men typically suffer the same two basic categories of [pelvic] disorder that women suffer—namely, those that result from muscles that are too tight and/or nerves that are irritated, and those resulting from muscles that are too weak. Not surprisingly, the disorders derive from the same basic causes as well:

Maybe it was too many Saturday afternoons at the stadium sitting too long on a hard surface. Or too many long, fast bike rides on that narrow, high-tech, Italian bicycle saddle. Maybe it was the heavy lifting you did when you helped out on your neighbor’s house renovation, or decided you’d like to split the firewood logs yourself, or hauled the summer deck furniture back into the garage in the autumn, or took up weight training at the gym and did it to excess.  The irritation and discomfort that ensue from acute prostatitis can lead to a habitual holding and tightening of the pelvic floor muscles resulting in pelvic floor dysfunction. A simple fall, especially if you landed on the tailbone, or that old sports injury from when you slid into third base last summer and hammered your sacroiliac: any and all of these can result, sooner or later, in a pelvic floor disorder.

One other cause that happens to men only is a prostatectomy—that is, the removal of the prostate—or radiation treatment for prostate cancer or any reproductive cancers. As any prostate cancer patient knows, these therapies for the disease can result in problems of incontinence and erectile dysfunction. In such cases, your oncologist may only be able to promise you that function will come back “within a year or so,” not a terribly cheerful prognosis. What your doctor may not tell you is that a specialist in pelvic floor dysfunction may be able to help.

She prescribes a variety of exercises to perform if you or someone you know is suffering from male pelvic pain, so pick up a copy of Heal Pelvic Pain today to learn more!

 

In Case You Missed Them: Great Health Resources!

In case you missed them, here are a few great resources and insights about pelvic health from the last few weeks.

Sex Therapist Talli Rosenbaum on The Pelvic Messenger, Interviewed by Alexandra Milspaw, PhD, LPC
On The Pelvic Messenger radio show, internationally renowned sex therapist Talli Rosenbaum spoke with healthcare educator Alexandra Milspaw about using mindfulness techniques to help treat pelvic pain. Check it out here.

Invitation to Dialogue: Alternative Therapies by Dr. James Gordon, The New York Times
With rising healthcare costs, Dr. James Gordon has sought to open a dialogue about the benefits of alternative medicine in place of costly medications and surgeries. Do you think it’s a valuable option? Check out the article in the New York Times here.

Interview with Amy Stein–Author of Heal Pelvic Pain by Sara K. Sauder, DPT
Amy was interviewed by Sara K. Sauder, DPT of Sullivan Physical Therapy! Check out the link to the interview here, and read Amy’s insights into physical therapy’s role in pelvic pain.

Love Your Colon: Part II

by Riva Preil

I know you have been waiting patiently for more details about the I Love You massage.  Well, today is your lucky day, because you are about to discover a wonderful way relax your core and help promote colonic motility.

Here’s how to do it:

Lie on your back- preferably on your bed, but a firm sofa or other comfortable surface will do. You might want to wedge a couple of pillows under your knees. Use your hand in the most comfortable way possible- either as a fist, using your fingers, or using the edge of the palm. Begin on the left side of the body- think of the belly button as the center- just beneath the left rib cage, and massage down toward the pubic bone in a straight line. In other words, draw the letter “I” from the bottom of your rib cage downward. In doing so, you are massaging your descending colon. Repeat 15x.

Now for the L: This time, start on the right side of your body, just under the rib cage to the right of the belly button.  Massage from right to left, then down toward the pubic bone: across, then down, as in the letter “L”.  This also massages both the descending and the transverse colon.  Repeat 15x.

Finally, draw the “U”: Start to the right of the belly button, but this time, begin at the top edge of the pelvic bone, and massage up toward the right wide of the rib cage, then across to the left, then down to the top of the pelvic bone. Repeat 15x. This massages all the portions of the colon- ascending, transverse, and descending.  Good luck, and feel great!

Adapted from Amy Stein’s Heal Pelvic Pain. Refer to healpelvicpain.com for details.

Update: Beyond Basics Presents at NY Cornell!

Yesterday morning, Dania and ImageAmy made grand rounds at Cornell with the pediatric GI department. It went very well, and was well received. There were about 15 people there: physicians, nurse practitioners, fellows and attendees. They liked the non-invasive approach that Dania and Amy have and that they try to make the treatment educational and fun for the kids. Amy gave out her book, Heal Pelvic Pain, to a couple of the physicians there, which has a chapter specific to pediatric pelvic floor dysfunction.