Lace up or Feet up? Running During Pregnancy

Running and exerciseJoanna Hess PT, DPT, PRC, WCS

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):

· Improved cardiovascular function

· Lower risk for gestational diabetes

· Improved strength and lean muscle mass

· Improved sense of wellbeing

· Improved sleep

· Decreased bone density loss

· Decreased physical discomfort – low back pain, pelvic girdle pain

· 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 glute strength in functional positions – tandem lunges, close chained glute isometrics

· 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.

Irene &amp; Joanna treatment 4
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

13. Hoeg TB. Baby on Board: Long Distance Running During Pregnancy – iRunFar.com [Internet]. iRunFar.com. 2017 [cited 2018May7]. Available from: https://www.irunfar.com/2017/12/baby-on-board-long-distance-running-during-pregnancy.html

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.

The Special Care Needs of the LGBTQ+ Community

Happy Pride Month!!!!

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

rainbow flag

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.

WPATH center for care Endocrine Society

  • speaks on hormone therapy (however some information may be out of date).

 Adolescent Health Center

Joint Changes in Arthritis are Permanent, but Pain Does Not Have to Be

stick man

Fiona McMahon PT, DPT

May is arthritis awareness month. Arthritis can come in many different forms. It can be a result of wear and tear or it can be a response to an autoimmune condition. There are many different types of arthritis, but the fact remains that in all of these different types of arthritis, once the damage to the joint is done, it is done. Currently, we have no way of repairing the joint outside of joint replacement. You may be thinking, if the damage is done, why bother spending my precious time and money in physical therapy? The reason is that physical therapy and lifestyle management can make a huge difference towards reducing your pain, improving your function, and even preventing the progression of joint break down. Physical therapy has been proven to help reduce pain and increase function, and in many cases, avoid surgery.

Physical therapists are movement experts. It seems obvious that they should be the providers directly involved in restoring function to individuals with diseases of the joints. For both rheumatoid conditions as well as osteoarthritis, physical activity is considered the first line intervention for improving pain and function. This is not to say that exercise will replace disease modifying arthritis drugs (DMARDs) in cases of rheumatoid arthritis. It is saying treatment is not complete until you address the strength, pain, and range of motion problems that occur with arthritis.

Physical therapy will not change the conditions of joints that have been damaged by arthritis; however, physical therapy is paramount to improving the prognosis of arthritis by helping to improve the strength around the joint, range of motion, and stability of the joint to prevent further cartilage and joint break down. Physical therapy can also have a marked effect on the pain and function, and can open up your world to things that were once too painful. In a meta-analysis study conducted by Sampath and colleagues, two common physical therapy techniques, manual therapy (work on the joints) and exercise therapy were examined to assess the efficacy of these techniques on pain and function in individuals with arthritis. The study found strong evidence that exercise therapy and manual therapy were good at reducing pain and improving function in people with arthritis.

Physical therapy is so worth the investment. It is an investment in your comfort, the ability to do the things you love, and commonly helps people stave off needing a joint replacement. Full disclosure, I’m partial to our clinic, Beyond Basics Physical Therapy (understatement of the year, I know). What makes us so special is that we have the manual therapy, exercise and orthopedic experts. We all come from various orthopedic (joint and muscle PT) backgrounds including the Postural Restoration Institute (PRI) and the Institute of Physical Art (IPA) and many of us have earned advance orthopedic certifications such as the Certified Functional Manual Therapist (CFMT), Certified Orthopedic Specialist (OCS), and Postural Restoration Certification (PRC) distinctions. What this means is our therapists have the knowledge and skill set to go above and beyond the basics in our hour long treatments to treat you head to toe, improving the way your body moves and more importantly, how it feels. Click here to read more about the ins and outs of the CFMT certification and how it can take you to the a place of less pain and more function here.

Another thing to keep in mind is your weight. When it comes to management of arthritic conditions, additional pounds put additional stress on your joints and can hasten the progression of joint break down. Losing pounds can be a big task when your joints are not feeling their best. Your physical therapist can guide you through exercises that are efficient for weight loss and do not exacerbate your symptoms. We also can provide a valuable link to get you set up with proper nutritional support to help manage weight.

Once the damage is done by arthritis it is done; however, that does not mean you are condemned to pain, decrease function and continued deterioration. Get physical therapy today for pain relief and to get moving again!

We have two clinics. One in Midtown Manhattan and one Downtown. We also offer Pilates and personal training at our clinics, which can help get you back into an exercise routine.

Give us a call today to find out more:

212-354-2622 (Midtown)

212- 267-0240 (Downtown)

Heidari B, Rheumatoid Arthritis: Early diagnosis and treatment outcomes. J Capsian Internal Med. 2011: 2(1) 161-70

Hootman J, Murphy L, Omura J, et Al. Health care provider counselling for physical activity among adults with arthritis. Morbidity and Mortality Weekly Report. 2018; 66(51-52) 1398-1401

Sampath K, Mani R, Miyamori T, et al. The effect of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clinical Rehab. 2016; 3-(12) 1141-55

Wang Y, Lombard C, Hussain S, et al.Effect of a low-intensity, self-management lifestyle intervention on knee pain in community- based young to middle-aged rural women: a cluster randomised controlled trial. Arthritis Research & Therapy. 2018; 20(74)

Building a strong foundation – Treating the pelvic floor in individuals with multiple sclerosis

By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT

MS

What is Multiple Sclerosis?

Multiple Sclerosis (MS) is an “immune-mediated” disease, in which the body’s immune system attacks the central nervous system (1).  The cause is unknown. MS is characterized by injuries (plaques) of the myelin, which is a fatty substance that surrounds and insulates the nerve fibers; nerve fibers themselves may also be attacked. The damaged myelin forms scar tissue that is called “sclerosis,” which is how the disease was named (1,2).  When the myelin, or nerve fibers, are damaged or destroyed at any point on the neural pathway, nerve impulses that are traveling between the brain, spinal cord and the body are interrupted, and as a result, can create a variety of symptoms.(1)

Symptoms:

The more common symptoms seen in individuals with MS are:

  • Fatigue
  • Numbness or tingling
  • Weakness
  • Dizziness or Vertigo
  • Sexual Problems
  • Pain
  • Emotional changes
  • Walking difficulties
  • Spasticity
  • Vision problems
  • Bladder problems
  • Bowel problems
  • Cognitive changes
  • Depression(1)

Types of MS:

There are four disease courses that have been identified in multiple sclerosis:

  • Clinically Isolated Syndrome (CIS) – a first episode of neurologic symptoms in the central nervous system, which lasts at least 24 hours.(1)
  • Relapsing-remitting MS (RMSS) – the most common form of the disease, that is characterized by clearly defined episodes of new or increasing neurologic symptoms (relapses), followed by periods of partial or complete recovery (remissions).(1)
  • Primary progressive MS (PPMS) – characterized by a gradual worsening of neurologic function, from the onset of symptoms, without any relapses or remissions.(1)
  • Secondary progressive MS (SPMS) – follows a course of MS that is initially relapsing-remitting. Most people with RMSS will eventually transition into a secondary progressive course, which is when their neurologic function will gradually worsen over time.(1)

Treatment of MS:

Because of the complex nature of this condition, and because it is not a curable disease, the management of MS requires comprehensive care. One component of that care is physical therapy. A physical therapist will evaluate and address the body’s ability to move and function. Common physical therapy interventions frequently address walking and mobility, strength, balance, posture, fatigue, and pain. However, did you know that physical therapy can also treat issues with bowel, bladder, and sexual dysfunction(1)? These dysfunctions are addressed through treating the pelvic floor musculature and surrounding tissues, which is performed by specially trained clinicians, such as the physical therapists at Beyond Basics Physical Therapy.

 

Bowel Dysfunction:

As previously noted, patients with MS can have various symptoms, including symptoms related to pelvic floor dysfunction, such as bladder, bowel, and/or sexual dysfunction. According to one study from 2016, individuals with MS can have lower anal sphincter pressure (which limits their ability to control stool flow), as well as higher rectal sensitivity (which makes it more difficult for a person to appropriately recognize when they need to defecate). These can increase the occurrence of fecal incontinence (involuntary leakage of stool), as adequate muscle strength and tone are needed to prevent leakage, and appropriate urge is required to ensure a person can get to the bathroom when they actually need to go (3) Even in the constipated individual with MS, there is a decrease in anal sphincter tone, which results in poor muscle coordination, making the release of stool more challenging (3) With these individuals, pelvic floor relaxation is typically needed to allow for easier and complete emptying and to decrease symptoms of bowel urgency.

Several studies from the late 1990s and early 2000s have looked at using biofeedback to help retrain muscle coordination. Biofeedback was applied in two ways: through stick-on electrodes that measured the response of muscles surrounding the anus, and with feedback applied internally in the rectum, with a finger, rental sensor or balloon. With stick-on electrodes, individuals are typically connected to a machine that allows them to see the electrical activity of their muscles, so they can work on controlling them (contract or relax). With internal feedback through a therapist’s gloved finger, with a rectal sensor or balloon, individuals can improve muscle control through gaining better awareness of their pelvic floor muscles. Researchers found that the use of biofeedback yielded some improvement in patient reported disability for those experiencing either constipation or fecal incontinence (4,5).  Physical therapy treatments to address muscle coordination and sensitivity can be helpful to treat those experiencing constipation or fecal incontinence related to MS; however, more research is needed to help enhance care.

Urinary Dysfunction:

As MS impacts the nerve signal transmission along nerve channels, urinary dysfunction frequently occurs (6) The most common urinary disorder seen in this population is urinary incontinence, which is involuntary leakage of urine. Urinary incontinence is related to fatigue and uncoordinated muscle recruitment, which are characteristic of MS, and can have a significant impact on an individual’s quality of life(2) Another common diagnosis is overactive bladder, which interrupts bladder function and causes a sudden need to urinate(6). This may occur, at least in part, due to hyperactive muscles in the pelvic floor that have become too short and tight over time.

Many groups have looked at the impact of physical therapy to directly address weaknesses that develop in the pelvic floor, and are related to urinary dysfunction (6,7) Two separate articles published in 2016 looked at groups of women with MS, and split them into groups to undergo pelvic floor muscle training with and without some form of electrical stimulation. The emphasis of this intervention was to train the pelvic floor muscles how to activate without compensation from surrounding muscles, over the course of several months (6,7) By the end of one study, women in both groups demonstrated increased pelvic floor strength and endurance, decreased symptoms of overactive bladder, and decreased anxiety and depression (6). In the other study, all three groups exhibited a decrease in pad weight, which measured the amount of urinary leakage, as well as decreased frequency of urgency and urge incontinence episodes(7). This research is showing that direct treatment to the pelvic floor muscles help to decrease urinary symptoms in people with MS, as muscle strength and endurance are increased.

Sexual Dysfunction:

Sexual dysfunction is also common in individuals with MS (affecting 40%-80%)(8). Sexual arousal begins in the nervous system with the brain sending signals through the spinal cord and nerves to the sexual organs. These pathways can become damaged due to the effects of MS on the nervous system, which in turn impacts a person’s sexual response or sensation. Symptoms of this may manifest as difficulty achieving orgasm or loss of libido, as well as erectile dysfunction in men, and altered clitoral/vaginal sensation or vaginal dryness in women (9). Other symptoms of MS, such as fatigue, muscle weakness, and spasticity also negatively impact sexual response in this population (8).

Pelvic floor muscles are responsible for rhythmical involuntary contractions during orgasm. These contractions occur when sensory information travels through nerves to these muscles. Continued, uninterrupted stimulation may allow for sexual arousal to progress and build up to a maximum point. Once this point is reached, the pelvic floor muscles, which have been gradually becoming tighter and tighter, get even tighter, hold this tension momentarily, and then release all tension; this is an orgasm (10). Through various research, it has been shown that weak pelvic floor muscles can lead to a decrease in orgasm and arousal (8) and specific pelvic floor muscle strengthening can help improve sexual function, especially in females (11,12,13).

One study that looks at MS-related sexual dysfunction is a 2014 article published in the Multiple Sclerosis Journal. This article took 20 women diagnosed with relapsing-remitting MS, and divided them into three treatment groups: pelvic floor muscle training alone, pelvic floor muscle training with intravaginal electrical stimulation, and pelvic floor muscle training with electrical stimulation applied over a nerve in the leg. The pelvic floor muscle training in each group consisted of teaching each participant how to contract her pelvic floor without using surrounding muscles as a compensation, and then performing both fast and slow contractions, over twelve weeks of treatments. After the twelve weeks of treatment, individuals in all three groups demonstrated significant improvements in muscle power, endurance, and fast contractions of the pelvic floor. They also reported an increase in the total score, as well as the arousal, lubrication, and satisfaction subscores, of the Female Sexual Function Index.8 What this study has shown is, in women with MS, physical therapy can help to treat sexual dysfunction by enhancing muscle response and activity in the pelvic floor.

Conclusion:

All bowel, bladder, and sexual function rely in part on strong and flexible muscles in the pelvic floor. With Multiple Sclerosis, these muscles tend to lose either mobility and then strength, and/or muscle tone and coordination. Either way, the loss of efficient tissue tension, coordination, and strength, makes the performance of these important functions much more challenging. While various medications or other interventions, may also be necessary to help individuals with MS manage their symptoms, physical therapy has been proven to be an important part of the healthcare team. Here at Beyond Basics Physical Therapy, all our clinicians have specialized training to evaluate and treat the pelvic floor, so each one of us is in a strong position to help you manage these symptoms and improve function! Feel free to contact our office at 212-354-2622, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information!

Sources:

  1. National Multiple Sclerosis Society. https://www.nationalmssociety.org
  2. de Abreu Pereira CM, Castiglione M, Kasawara KT. “Effects of Physiotherapy Treatment for Urinary Incontinence in Patient with Multiple Sclerosis.” Journal of Physical Therapy Science 2017; 29(7): 1259–1263.
  3. Marola S, Ferrarese A, Gibin E, et al. “Anal Sphincter Dysfunction in Multiple Sclerosis: An Observation Manometric Study.” Open Medicine 2016; 11(1): 509–517.
  4. Chiotakakou-Faliakou E, Kamm MA, Roy AJ, et al. Biofeedback provides long-term benefit for patients with intractable, slow and normal transit constipation. Gut 1998;42:517–21.
  5. Wiesel PH, Norton C, Roy AJ, et al. Gut focused behavioural treatment (biofeedback) for constipation and faecal incontinence in multiple sclerosis. J Neurol Neurosurg Psychiatry 2000;69:240–243.
  6. Ferreira, Ana Paula Silva, et al. “Impact of a Pelvic Floor Training Program Among Women with Multiple Sclerosis.” American Journal of Physical Medicine & Rehabilitation 2016; 95(1): 1–8.
  7. Lúcio A, Dʼancona CA, Perissinotto MC, et al. “Pelvic Floor Muscle Training With and Without Electrical Stimulation in the Treatment of Lower Urinary Tract Symptoms in Women With Multiple Sclerosis.”Journal of Wound, Ostomy and Continence Nursing 2016; 43(4): 414–419.
  8. Lúcio AC, D’Ancona CA, Lopes MH, et al. “The Effect of Pelvic Floor Muscle Training Alone or in Combination with Electrostimulation in the Treatment of Sexual Dysfunction in Women with Multiple Sclerosis.” Multiple Sclerosis Journal 2014; 2 (13): 1761–1768.
  9. “Sexual Problems.” National Multiple Sclerosis Society, http://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms/Sexual-Dysfunction.
  10. Lowentein L, Gruenwald I, Gartman I, et al. Can stronger pelvic muscle floor improve secual function? Int Urogynecol J 2010; 21: 553-556.
  11. Bo K, Talseth T, Vinsnes A (2000) Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol Scand 79(7):598–603
  12. Beji NK, Yalcin O, Erkan HA (2003) The effect of pelvic floor training on sexual function of treated patients. International urogynecology journal and pelvic floor dysfunction 14(4):234–238
  13. Zahariou AG, Karamouti MV, Papaioannou PD (2008) Pelvic floor muscle training improves sexual function of women with stress urinary incontinence. International urogynecology journal and pelvic floor dysfunction 19(3):401–406.

Why seek out a physical therapist with advanced orthopedic training? The case for CFMT and OCS

Pelvic 3By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT

If you have perused our website, you might have noticed that here at Beyond Basics, we have many physical therapists who have a CFMT certification, or are in the process of completing one. Now the question lies, what is a CFMT? How is this approach unique? How can this approach be of benefit to me?

The acronym CFMT stands for Certified Functional Manual Therapist. This certification is through the Institute of Physical Art (IPA), which is an organization founded by two physical therapists, Gregg and Vicky Johnson.

With the CFMT approach, we evaluate and treat every individual’s mechanical capacity (how your tissues and joints move), neuromuscular function (how your system stabilizes itself, and the coordination of muscle activation), and motor control (how an individual moves and performs daily tasks). Furthermore, we assess and retrain how these three individual components interact to ensure each person can return to the tasks/activities they need and love to do.

What this means is, when a new patient walks through our door, we don’t just focus on one small area, such as only the knee in which you report pain. Instead, we will look at the big picture by assessing your strength, amount of limb and segmental motion available to you, posture and alignment, and movement, which can be as simple as getting out of a chair, or a higher level activity such as running, weight lifting or other sport-related activity. This will allow us to get a thorough impression of what impairments you might have, and will help us determine what the cause of your symptoms and functional limitations is (what is the driver?). From here we can figure out the most effective approach to your treatment, and will apply progressive interventions that help to ensure continued benefits from each session. We have found that this approach commonly gets you back to your activity or sport faster!

Now you may be asking yourself, “Well this sounds interesting, but why does it matter?” Looking at the whole person and treating your system overall, allows us to make lasting changes, not only to a specific body part that is causing problems for you, but also with your habits of how you hold yourself and move. By becoming more aware of your body and moving with more efficiency, you will find day-to-day activities, and even sporting activities, are easier for you to perform. Furthermore, and most importantly, if you are able to move and live in a more efficient way, you are decreasing the risk of future injury.

So whether you are experiencing incontinence, pelvic pain, low back pain, or a shoulder injury, having a knowledgeable therapist work with you, can make a significant impact on your function and quality of life.

 

Pediatric Bowel Part II: How to Make Pooping Easier for your Kiddo

poop

Fiona L McMahon, PT, DPT

Hey everyone! We are resuming our conversation about potty issues with kiddos. In our last blog, we discussed how issues with pooping can occur with kiddos and how often times it is easy to overlook long standing constipation in kiddos with fecal and urinary accidents. We learned that although it can seem like someone is doing something wrong, potty issues are no one’s fault. Even though poo problems are no ones fault, they are problems that families can work on together to be solved.

In this blog, we are going to discuss right here and right now what you can do today to help your child poop easier. Some of the changes are astonishingly simple while some may require a bit more work and change from the whole family. Keep in mind in order for anyone’s bowel to change ( not just kids), you must be consistent, and these changes may take a very long time to occur. Be patient, you and your child will get there. Let’s go over ways to get back on the right track now.

STEPS to help with bowel issues:

Step 1: Allow your kiddo enough time to poop

Ever have to catch an early morning flight and noticed that you skip pooping that day, or even worse, you get a little bound up in the following week? Getting up early and rushing in the morning can constipate anyone and the thing is that’s what most kids are having to do. Many children have between half an hour to an hour to scarf down their food, dress, and brush their teeth before rolling out to school, leaving very little time to sit on the toilet and have an effective bowel movement. Kids then often find themselves at school with public bathrooms or single bathrooms within the classroom that don’t lock, making it hard to be comfortable enough to have a bowel movement. Then they usually must rush to extracurriculars and complete homework before bed. There simply is not enough time to poop.

Allowing your child 10-15 minutes to sit on the toilet 10-20 minutes after they eat can allow them to use what’s called the gastrocolic reflex. Basically what that means is when you eat, the body makes room for the new food by moving everything down further in the digestive canal. Therefore, after meals is the time when we are most likely to have a poop.

Allowing more time in the morning is the most easily modifiable part of your routine to start with when trying to improve your kiddos pooping habits. Get up about 30 minutes earlier to allow your child time to eat and to sit on the toilet. Follow with sitting on the toilet after lunch and after dinner.

Step 2: Fit the toilet to you child; don’t fit your child to the toilet

Studies show that toilet posture is imperative to good poops. My colleague, Sarah Paplanus, DPT, explains in detail the importance of having your knees above your hips while pooping in her blog on the squatty potty. Step stools will help your child get their knees above their hips, just remember to make sure that they keep their legs somewhat separated. Also, for the little littles, a child size toilet seat will help make sitting on the toilet more comfortable for kiddos with little tushes.

Also, check out this video on potty posture, with fellow peds therapist, Victoria LaManna PT, DPT, CLT

Step 3: Improve Diet

Most adults are aware that diet is important, but diet is equally as important with children. Making sure your child is getting enough fruits and veggies (approximately 5 servings daily), skipping sugary and refined foods like white bread, pastries, candy, and chips, and getting enough water (about half their weight in ounces) is so important to keep their stool soft and moving.

Step 3: Recognize Progress and Hard Work

Bowel issues are hard work for all involved. Make a sticker chart to track how often your child is compliant at sitting on the toilet, eating well, and having bowel movements. Make a goal for how many stickers your child will earn and celebrate when they achieve their goal. It is a long process so make sure to recognize even the smallest of victories.

Step 4: Get Help from Professionals

There is help out there. Make sure you go to a knowledgeable doctor and physical therapist to ensure your child gets the best chance at improving their bowel issues as quickly as possible. Do not accept any medical professional telling you it is normal for children to have accidents past potty training age, (age 5), or that it is your fault as a parent, or it is the child’s fault. It’s not. A knowledgeable doctor will run appropriate tests to rule out dietary allergies that could be contributing as well as starting your child on medicine or supplements to help improve bowel movements.

Pelvic floor physical therapy is a mainstay of care for kids with bowel issues, Skilled pediatric physical therapists will help your child re-learn how to use their pelvic muscles to better hold in waste as well as eliminate it when appropriate. We will teach you how to use techniques to help stool move more effectively, and we can perform hands on work to reduce pain and discomfort associated with bowel dysfunction. In addition to our clinical skills, we will help you to find doctors to help compliment the treatment your child is receiving in PT. If your child is suffering from bowel problems, don’t waste another day, call our front desk to make an appointment today!

New Year’s Resolutions: Weight Loss

Fitness and health

Fiona McMahon PT, DPT

It’s that time of year again. We are all nobly setting out on our self improvement journeys. Resolutions are often deeply personal goals we set for ourselves and can involve spiritual, physical, and emotional aspects. Overwhelmingly, one of the most common goals people have is weight loss. The desire to lose weight often goes beyond aesthetic. People can be motivated to reduce pain in their joints, improve heart health, and to have more energy. As physical therapists we see the harms of the burden of carrying around extra weight on aching joints as well as the fallout from initiating a program with a little too much vim and vigor.

Goal Setting

Goal setting is something almost every article on New Year’s resolutions addresses, for good reason. Goal setting properly is imperative to success. We can think of goal setting in two ways. Sometimes we think of goal setting like a wishlist, “it would be great if I achieved x”. These kind of goals are great for getting you to look at the final picture, but provide no direction on how to get to your end result. Writing down a goal to lose 10 pounds is all well and good, but without a solid plan, you are left without any real steps to put in motion.

In goal setting I suggest you borrow some tools from us physical therapists. When we assess patients we develop short and long term goals to get them to their ultimate fitness and health goals. The short term goals we make, allow us to zero in on small and discrete changes we can make towards the ultimate goal.

Think about what habits you currently are doing that are holding you back from weight loss. Are you having an extra glass of wine at night you could cut out, are you not getting enough sleep, so working out seems impossible? Break things up into small behavioral changes to concentrate on. Keep in mind goals can also be positive, what things are you currently doing that are helping you on your path that you would like to continue doing. It’s important to recognize where you are being an absolute rockstar already and use that positive energy towards things that might be harder to change.

Track your goals and think about how often you want to make sure you are doing them. Personally, I find it helpful to track my goals to see if I am generally sticking to them. There are apps out there, that you can install on your phone that will help track your success in sticking to your goals. I use a free app called “Productive”.  It allows me to make a recurring checklist for my goals. You can use the app to schedule out what time of day you would like to do your goals, how many days a week you’ll do them, and provides stats on how regularly you are achieving them.

Finally, it is important to be realistic with your goals. Goals that are too easy or too hard are less likely to get you where you want to be. Allow yourself some flexibility, to keep your journey less of a burden. Over time, check in with your goals you may find you have outgrown them or they are unrealistic. It is perfectly okay to tailor as you go.

 

Eating

We all know diet plays a major key in weight loss. A friend to the clinic, Nutritionist, Jessica Drummond will often say, “ You cannot exercise your way out of a bad diet”. Poor diets can stymie any exercise plan.

Dietary needs vary widely from individual to individual, but overall it’s best to avoid highly processed foods. These foods tend to be chalk a block with salt and easily digestible sugars that can spike appetite. No good.

Be wary of fad diets and health crazes. Gluten free foods are all the rage right now. I, myself am gluten free for health reasons, but if you do not have celiac disease or non celiac gluten sensitivity, reaching for the gluten free pizza or cookie is not the wisest choice as a weight loss strategy. In addition to usually being more expensive, gluten free options, like cookies, bread, and pizza often are higher in calories than their “glutenful” counterparts. It only took a quick stroll over to my refrigerator to prove this point. I compared a slice of traditional bread next to a gluten free slice. As you can see in the photo below, the traditional bread is larger than the gluten free bread. Not only do you get more food for serving with the traditional bread, the traditional bread has 20 fewer calories per serving than the gluten free bread. This goes to show that regardless of your dietary needs, consuming foods that are not processed like sweet potatoes, quinoa, and rice, over processed food like bread, is a good way to avoid hidden calories.

It is important that you eat enough to sustain your metabolism, your energy, and your mood, and furthermore, to allow your diet to be a sustainable change you can carry out long term to ensure success. There are apps on your phone that can help you track your calorie input, how many calories you have burned off, and what the composition of your macronutrients are. Macronutrients are protein, carbs, and fats. A diet higher in protein is generally used to help build muscles, which can in turn, burn more fat. These apps, like Myfitnesspal and Lose It! can give you target calorie intake for your desired weekly weight loss. It is important to set your target with some element of moderation so it is easier to stick to. Caloric restrictions that are too extreme can backfire by tanking your metabolism, energy, and triggering food binges.

Exercise

Exercise is so important. In addition to helping you progress towards your weight loss goal, exercise has so many health benefits that will pay dividends well into the future. From stress reduction, cardiovascular health, bone health and more, exercise is an essential element of self care even for those who do not wish to lose weight.The

American Heart Association recommends adults exercise at a moderate intensity for at least 30 minutes five times a week or vigorous activity for 25 minutes 3 days a week. In addition to moderate to high intensity  strengthening activity at least 2 days a week.

Finding the right exercise can be daunting. This is where having a physical therapist can be a tremendous advantage. Personally, I don’t believe in “the one best exercise”. Everybody is different and every body is different. Physical therapists are the movement specialists of the healthcare world. We can help you find good workouts for where your body is now, as well as strengthen your body so you can do the workout or event of your dreams while avoiding injury. Take a look at the series we wrote chronicling how physical therapy prepared my body for the rigors of the New York City Marathon and allowed me to complete it in record time, to see a great example of what physical therapy can do for you. I have included our blogs on physical therapy and exercise at the bottom of this article.

Once you have an idea of where to start and where you want to go, then slowly get started on trying out different routines. I once heard a quote from an exercise physiologist who said, “the best exercise is one you actually do”. So remember when starting your exercise program, it is okay to not like a certain exercise routine and move on. You might abhor the treadmill, but find tremendous joy in a Zumba class. Finding  a workout that brings you joy, and at the very least, does not bring you dread is imperative. It’s kind of like dating, keep trying different routines until you find what works for you.

Once you find your dream routine, remember moderation. Allow yourself at least a day of recovery if you are a seasoned exercise veteran, and more if you are an exercise newbie. Rest not only prevents injury, but it gives the body time to get to the job of laying down more muscle fibers and making you stronger.

Injury can happen with new exercise routines and really, nothing is more frustrating than being super gung ho about a new program only to be sidelined with an injury. Again this is where having a good PT on your side really helps. Seeing us before starting exercise can help us spot both literal and figurative achilles heels in your posture, strength, and flexibility and will allow us to address these issues before they become mega impairments later on. We can help you decide when it is time to progress and how to do so safely. Additionally we can help you recover from an injury faster and prevent injury recurrence if you see us when you do have an injury.

 

Failure and Success

Repeat after me, “ I am a person, not a machine”. You will fail at certain elements of your plan. Notice I used “will” and not “may”. When you do overindulge, miss a workout, or whatever else. Remember it is a process and small failures do not indicate that you will fail in your ultimate goal of greater health. Nor is failure in any way an indicator of your worth as a human being, neither is the number on the scale, by the way. Progress will be slow, but you will likely get there if you are consistent. Failure is a good time to re-evaluate your goals. Maybe five workouts a week is completely unrealistic and maybe sticking with three is a much better balance. Regardless of what obstacles you face in your journey, remember to be kind to yourself, you are doing the best you can. Find what changes you can stick with and go from there. It can take a lot to change up your whole routine, but keep working at it and you will find success.

Check us out at BBPT!

Although we do specialize in orthopedic and pelvic floor physical therapy at Beyond Basics, we do so much more than that. All of our physical therapists are trained in orthopedic and sports rehab, and many of our therapists have earned prestigious orthopedic certifications like the OCS and CFMT. We can help you to figure out where to start, how to progress your exercises appropriately, and how to keep your body healthy so you can continue to achieve all of your goals.

 

Additional Blogs Exercise and Fitness:

Time to PUMP SOME IRON! September is Healthy Aging Month

Exercising While Pregnant

Preparing for the Marathon with Physical Therapy at Beyond Basics!

Beyond Basics’ Marathon Prep Program: The Evaluation

Marathon Prep with Beyond Basics: Weeks 1-3

Marathon Update: Sickness When to Run and When to Take a Break

Marathon Training Update

Marathon Update: Shaving Time off my Race with Physical Therapy and Doing Good in the Name of Multiple Sclerosis Research

 

Sources

American Heart Association. American Heart Association Recommendations for Physical Activity in Adults. Updated Dec 14, 2017