This fall is turning into a busy one for us here at EMH! Not only do we have Dr. Echenberg joining us this October, but we will be hosting an event at the end of November for new and expectant moms. In addition to getting to meet other moms, this event will be a talk by our very own therapists, Kirsten Hober and Charissa Morrisroe on the effect pregnancy has on the pelvic floor, how your body changes both during and after pregnancy, and some exercises and posture techniques that are easy to implement while caring for your baby.
In October of 2015, EMH Physical Therapy and The Echenberg Institute for Pelvic and Sexual Pain will begin a collaborative initiative in New York City for comprehensive assessment and treatment of men and women with chronic pelvic pain.
We are pleased to announce that in October 2015, Robert J. Echenberg, MD, FACOG, world renowned for his expertise in the treatment of chronic pelvic, genital and sexual pain, will be working with Evelyn Hecht PT ATC of EMH Physical Therapy, the premier pelvic specialty practice located on the Upper East Side of New York City.
Together, we will offer our expert services in one place where men and women suffering with chronic pelvic pain/pelvic floor dysfunction can be diagnosed, educated, receive a broad range of treatments and find support.
Thirty three percent (33%) of elite female athletes leak urine during training/competition. These girls/women typically do not tell anyone (coaches, parents, teammates) because they feel embarrassment and shame. They try to manage their leaking issues on their own by wearing pads, make frequent bathroom trips and even restrict fluid intake which does not address the cause of leaking. Pelvic physical therapy helps female athletes overcome leaking within 1-2 months of treatment so the athlete can focus on achieving their best performance.
Elite female athletes are typically between the ages of 15 and 39 years, train a minimum of 8 hours per week for their sport and qualify for a high-level or national team.
Sports that involve jumping, high impact landings and running were the activities most likely to provoke urine loss. Many of these athletes reported that leaking issues interfered with their mental focus to achieve top performance in their sport. The following are results from a number of studies regarding elite athletes and leaking:
95% of Female athletes who had an involuntary loss of urine experienced this during training and 50% experienced this during competition.
28 to 35% of high school and collegiate female athletes report incidents of leaking
88% of young trampolinists in one study had an incident or more of urine loss during their jumping activities.
Uncontrolled loss of urine, from a few drops to more, is called Stress Urinary Incontinence(SUI).
SUI is defined as the involuntary loss of urine during activities such as exercise, coughing, laughing or sneezing. Leaking occurs because the force from the abdominal region during laughing or lifting overcomes the strength of the pelvic floor muscles which surrounds the urethra to prevent leaking. The urethra is the hose-like structure that runs from the bladder. The pelvic floor muscles lie at the bottom of the pelvis surrounding the urethra keeping the urethra closed during activities. The pelvic floor muscles relax allowing the flow of urine when voiding. If they are weak or uncoordinated, the pelvic floor muscles need to be retrained to be more functional and keep the athlete dry during sport.
Female athletes should be educated about leaking issues so they don’t feel shame and can seek help. Some questions to ask female athlete are:
Do you accidentally leak during training or competition?
Do you wear protective pads during training or sports matches?
Do you make frequent trips to the bathroom or go “just in case”?
Do you restrict your water/fluid intake for fear of leaking?
With the expert assessment and guidance by a pelvic physical therapist, female athletes learn that accidental leakage is mainly due to pelvic floor muscle dysfunction. They will learn self help techniques and exercises to retrain their pelvic floor muscles to attain full continence during their sport.
The staff Doctors of Physical Therapy at EMH specialize in pre and postpartum physical therapy for a healthy pregnancy and a fast recovery after delivery. Preventing Diastasis Recti is one aspect of our expertise.
Please forward to all your pregnant/new mom friends and family!
Diastasis Recti Abdominis (DRA) can occur in up to 66% of pregnant women due to hormones that allow ligaments and joints to relax, the increasing baby size in utero, improper weight lifting (ie heavy food bags, other children, furniture etc), a history of prior C-section or abdominal surgery and repetitive poor mechanics during daily activities and lack of regular exercise.
Men can also develop DRA due to faulty weight lifting mechanics, obesity and chronic medical conditions that result in frequent coughing such as bronchitis.
What is a DRA?
DRA is defined as the separation and thinning of the rectus abdominus muscles (see diagram in green) and stretching of the linea alba (see diagram in blue). The linea alba runs from the xiphoid process (base of sternum) to the symphysis pubis (center of pelvic bone). Both the rectus abdominus muscle and linea alba are the main support for the front of the abdomen, keeping the visceral organs in place and functioning well. They also maintain pelvis stability during walking, lifting, bending and squatting.
What are the symptoms of DRA?
Symptoms may include:
- Noticeable small or large bulge in the center abdomen
- Sharp or burning abdominal pain during bending, lifting, standing and walking
- Lower back pain
- Feeling like the intestines or stomach may fall out
- Poor posture
- Longer term problems of prolonged DRA may include Stress Urinary Incontinence, Fecal Incontinence and Pelvic Organ Prolapse.
How To Measure for a DRA?
The best way to measure is a finger width measurement. Lie on your back, knees bent, head resting on floor/pillow. Place tips of 4 fingers across the body at naval or just above/below the naval per your comfort. Now raise your head and shoulders slightly upward. If your fingers descend inbetween the parallel rectus abdominus muscles on either side of your naval, measure how many fingers move downward. If there is a true split of the linea alba, your finger will fall into a space that feels squishy (your intestines live here!). A positive DRA is one where there more than 2 fingertips (1 inch or 2.5cm width) that lower. We have measured women with 3 to 4 inches ( 8cm) wide and have helped them narrow back to 1 inch (2.5cm) wide.
What to Do if you have a DRA?
Best to first consult a pelvic physical therapist for a tailored postural, stabilization and home exercise program targeting the Tranversus Abdominus (deepest and lowest muscle of our abdomen), the pelvic floor muscles and the multifidi muscles (lower back stabilizers). Here are some tips to help you immediately:
- Avoid positions that may further separate the recti muscles, like doing sit ups, crunches, strong stretches of the abdomen, quick trunk rotation movements
- Stand and sit symmetrically (not to weight bear more on one side vs the other)
- During standing, gently unlock your knees and gently pull your stomach inward while breathing normally
- Self bracing of your stomach with your hands pushing the rectus together when sneezing, coughing or laughing
- Wear a pelvic and abdominal support product to help maintain erect trunk posture and decrease pain until your muscles are aligned and strong
Sumer Samhoury, MSPT
Manual Physical Therapy can help some women with Mechanical Infertility achieve pregnancy. To understand what Mechanical Infertility is and how manual pelvic physical therapy helps, let’s first review the steps to becoming pregnant.
Mechanics of pregnancy
To achieve pregnancy, the process of ovulation and fertilization within healthy, mobile, and supported reproductive organs (ovaries, fallopian tube and uterus) without presence of adhesions & scar tissue has to occur. The steps to pregnancy are
- The woman’s body releases an egg from one of her ovaries (ovulation)
- The egg is grasped by the “fingers” of the fimbria, located at the ends of the fallopian tubes.
- The egg travels through the open, non blocked fallopian tube toward the uterus (womb)
- The man’s sperm joins with the egg (fertilization)
- The fertilized egg attaches to the inside of the uterus (implantation)
Mechanical Infertility (MI) is defined as the inability to become pregnant due to intra pelvic and abdominal adhesions on/around or within the reproductive organs. MI affects approximately 2.5 million ( 40%) of the 6 million infertile women in the United States who have not conceived after 1 year of unprotected sexual intercourse.
Adhesions around the ovary can prevent the release of the egg (ovum) from the ovary. Adhesions can squeeze the fallopian tube (s)like a used tube of toothpaste, so the egg cannot travel to the uterus to hook up with the sperm. Adhesions can pull the uterus out of a centered, midline position which makes implantation of the fertilized egg difficult. Adhesions within the uterus could increase uterine spasms which can result in miscarriage.
What are Adhesions?
An adhesion is a sheet or band of scar tissue that binds two parts of tissue or organs together. Normally, with no scar tissue present, organs are slippery and they glide against each other. Adhesions can look like thin sheets similar to plastic food wrap or they can be thick fibrous bands, like ropes. These bands of scar tissue can wrap around your internal reproductive organs squeezing them too tight or pull the organs out of their normal centered alignment which prevents their optimal function during pregnancy.
Cause of Adhesions
Adhesions naturally develop when the body’s healing/repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation. Our body naturally cleans a damaged area, which is followed up by the laying down of collagen fibers to replace the damaged tissue. The replaced new collagen is haphazard, fibers get bunched up and cross-links form. As healing time continues, cross links may grow into microadhesions, then adhesions and may eventually thicken into scars When a woman has pelvic or abdominal surgery, such as a C-section or other gynecological surgeries, the only visible scar is on the outside where the incisions may have been made, but tissue also heals on the inside, resulting in internal scarring.
The formation of internal pelvic adhesions is known to accompany any inflammatory process, whether it be internal trauma and bleeding (ruptured ovarian cysts or ruptured appendix), Endometriosis, or sexually transmitted infections such as Chlamydia, Gonorrhea, pelvic inflammatory disease (PID). Pelvic spasms, bowel obstructions and chronic abdominal/pelvic pain can also lead to adhesions.
The most common cause of adhesions within the uterus is due to previous uterine surgeries such as D&Cs either for abortions, miscarriages, or excessive bleeding. In addition, adhesions may be related to child birth when there are uterine infections or bleeding associated from childbirth, or if a Cesarean Section is performed.
What is Manual Pelvic Physical Therapy?
Manual pelvic physical therapy is a gentle hands on approach, no surgery, no drugs, to improve motion, decrease restriction and improve organ function. Manual therapy techniques for Mechanical Infertility can include:
- Myofascial Release to decrease restricted muscles and fascia (the web-like covering that surrounds all organs, muscles and nerves of the body)
- Visceral Mobilization to improve organ mobility and function
- Pelvic lymphatic drainage to reduce pelvic congestion
Myofascial Release is a safe and effective hands-on technique that applies gentle sustaining pressure to the restricted connective tissue to eliminate pain and restore motion. The slow sustained, gentle pressure allows fascia to elongate.
Visceral mobilization technique is a gentle hands on technique to release tight ligaments and connective tissue which surrounds and supports the internal organs. Just as a therapist would mobilize the shoulder for someone who has lost motion tight ligaments that support the organs also need to be treated.
The lymphatic system helps our body detoxify, drain stagnant fluids, regenerate tissues, filter out toxins and maintains a healthy immune system. Pelvic lymph drainage helps to re-circulate body fluids, stimulates the immune system and promotes relaxation and balance in the autonomic nervous system.
In 2012, Doctor Mary Ellen Kramp, DPT published her infertility case study in the Journal of American Osteopathic Association demonstrating that 6 out of 10 women diagnosed with mechanical infertility conceived and delivered their healthy babies at full term following manual pelvic physical therapy. These women were found to have mechanical infertility due to lymphatic congestion, sacral dysfunction and restrictions in uterine mobility and were treated with a group of manual therapies Dr Kramp described as above and termed “The Infertility Protocol”.
At EMH Physical Therapy, we received training to treat Mechanical Infertility and can offer this service to women to help them achieve pregnancy.
Pelvic physical therapy is an effective non invasive treatment for Pelvic Organ Prolapse vs “high risk” transvaginal mesh surgery
The FDA recently deemed use of transvaginal mesh surgery to be “high risk” to repair pelvic organ prolapse. See news link below:
Pelvic physical therapy is a more effective and non invasive option.
In a 2014 study of 800 women with pelvic floor dysfunction (which includes pelvic organ prolapse) by University of Missouri, researchers found that ” incontinence, constipation, and/or pain improve by 80% with pelvic physical therapy”. Research shows that pelvic physical therapy plus a prescribed home exercise program works better than just engaging in one option.
Pelvic physical therapy teaches patients with pelvic organ prolapse how to build up the “floor” or muscular base of the pelvis. The pelvic floor muscles provide the main support for all pelvic organs. Kegels alone are not the only treatment option. If there is tension in the pelvic floor muscles, they need to to be released via manual therapies or risk further dysfunction. Sitting posture and good voiding habits are addressed, exercises are prescribed and body awareness improved.
EMH Physical Therapy has been providing successful pelvic physical therapy for 18 years in NYC. We have helped thousands of women return to better function. Call us today to get your prescription for pelvic health.
As a licensed physical therapist specializing in pelvic floor and core dysfunction, I treat women who experience pelvic pain, sexual pain, leaking, constipation, urinary urgency, have restricted C-section/episiotomy scars and weak pelvic and core muscles, months or years after delivering their children (Vaginal or C-Section).
If all moms consulted a physical therapist soon after giving birth, this is what I would teach:
1) To prevent leaking urine or feces, or future prolapses of the bladder or rectum, do pelvic floor strengthening exercises (if there is no pelvic pain). Many women do not know how to recruit these small muscles surrounding the vaginal and anal region. Some either hold their breath, or tighten their inner thighs, gluteal and abdominal muscles when doing the pelvic floor muscle contraction. A licensed PT can guide on how to recruit these muscles without substitution via our manual and biofeedback therapies.
Pelvic Floor Strength Exercise: Contract the pelvic floor muscles (squeeze the anal and vaginal regions) for up to 10 full seconds (one – one thousand, two -one-thousand, etc). Then, more importantly, relax, completely let go of the contraction, softening for up to 20 seconds. If 10 second contraction and 20 second relaxation is too much, start with 5 seconds contraction and 10 second relaxation. Do this exercise 10 times, once in the morning and once at the end of the day. They can be performed in lying, sitting even standing (once you are good at the exercise).
2) To reduce pelvic pain, breathe and relax your pelvic floor muscles. Slow deep breathing, produces a calming effect on your muscles, heart, and brain activity. It also gently massages the abdominal contents. If you have pelvic/lower back/hip/groin or abdominal pain, consult with your doctor first and then see a pelvic physical therapist for our targeted therapies and exercises to reduce pain and regain function.
Diaphragmatic Breath Exercise: Inhale for 5 seconds, hold the inhale for 5 seconds, exhale for 5 seconds. Repeat 2 times, twice a day or as needed. During your inhalation, allow your stomach to expand or balloon to allow the diaphragm to descend which fills the lungs with oxygen. As the stomach expands, think letting the pelvic floor muscles widen, soften (no pushing outward!). As you exhale, allow the stomach to contract and see if you can keep your pelvic floor muscles relaxed.
3) To reduce your belly post baby, reduce the DR or “diastasis rectus”, which is the separation of the two long rectus abdominal muscles as the baby grew in utero, you can wear a compression garment and strengthen your lower abdominal muscles. The abdominal binders and/or compression shorts that support the pelvic floor can be worn daily during and after delivery to prevent further widening of the DR.
Core Exercise: Breathe in. Breathe out and think of zipping up a tight pair of jeans. There should be no major movement of your spine, just the lower abdominal region moving “up and in” as it tightens. Hold this for 5 seconds. Breath in as you release. Breathe out as you tighten and hold. Repeat 10 times. Do this 5 times throughout the day. A physical therapist can help with your DR by modifying the exercise. This can be done during pregnancy to minimize the DR and keep a strong core.
4) To prevent binding of fascia, abdominal restrictions and pain, mobilize your C-section scar.
Scar Tissue Massage: Gently press your fingers against the scar and pull the scar in a upward direction and hold the end range for a minute. Then move downwards, to the R, and L sides, holding the end range of each direction for a minute, until you feel less burning, less tension. Eventually you can try to pick up the scar up in-between your thumb and fingers to lift the scar away from your body, affording more stretch. For perineal scars, your physical therapist can perform manual therapies and guide you in self perineal stretches and use of a dilator to help increase the flexibility of the scar.
5) To return to pain free intercourse, if painful due to episiotomy scar, your physical therapist can perform intravaginal manual therapy, scar mobilization and teach you how to gradually and painlessly stretch your vaginal area with dilators.
Along with postural exercises, instruction on how to lift, carry and feed baby, your physical therapist can help you regain your body, prepare for another child and most importantly, prevent the pain and other issues that so many of our mothers took for granted as a “normal part of having babies”.
Physical therapists have helped women in menopause return to painfree, satisfying sexual intercourse. These women could experience pain with intercourse, even after rehydrating their vaginal tissues under the guidance of their GYN, due to pelvic floor muscle tension. The pelvic floor is a group of muscles located at the bottom of the pelvis surrounding the vaginal canal. Intercourse requires that the muscles be flexible to be able to receive the penis and strong enough to contract to provide more intense orgasms. All healthy muscles have a normal length during rest. Unhealthy muscles have knots/fascial restrictions so they are stuck in tight position during rest. So with a tight pelvic floor, the penis cannot enter and women can experience pain.
How to gain a healthy pelvic floor? Treatment by a physical therapist trained in pelvic floor dysfunctions is optimum as we provide you with tailored manual expertise and guidance to heal. Here are some helpful tips:
1) STRETCH HIP/GLUTEAL MUSCLES Stretch the large muscles of your hip, and buttock region as they can actively refer pain into the pelvis and cause the pelvic floor muscles to overwork or be strained. By actively stretching the hip flexors, hip external rotators, inner thigh (adductors), groin and hamstrings, the pelvic floor is released and can function optimally. Hold each static stretch for 30 seconds, done twice, 2x’s times a day.
2) VISUALIZE A RELAXED PELVIC FLOOR Chronically tight pelvic floor muscles need many reminders to relax throughout the day. Every time you look at the watch or your mobile phone, ask yourself, “Where is my pelvic floor?” Think about the area softening, melting, widening. Use any visualization that is calming to you, send a healing color to your pelvis to bring awareness and “let go”.
3) BREATHE Diaphagramatic breathing helps to relax the abdominal and pelvic regions. Lie on your back, pillow under your knees. Place your hands on your stomach, bent elbows resting by your sides. Inhale slowly through your nose for a count of 5 seconds. During your inhalation, allow your stomach expand into your hands. Visualize your pelvic floor muscles widening as well. With each inhalation, imagine or visualize the pelvic floor muscles expanding in all directions, front, back , left , right. Slowly exhale for 5 seconds. Repeat 5 times. Do once in morning and at night.
4) NEUTRAL PELVIS Set up your computer/reading/art work space to fit your body versus your body having to adjust to the environment. The chair should be at a comfortable height so your feet are supported either on the floor or a raised footrest. “Good posture” is when a neutral spine in maintained. When sitting, your weight should be on center of your pelvic bowl, your lower back resting against a lumbar cushion. The lumbar cushion gently pushes your lower back forward to maintain it’s natural curve. You should not slump back to sit on your coccyx bone, nor too far forward on your pubic bone and no sitting on one side/hip for hours at a time. Here is where a PT can really help you gain knowledge and best position of your body.
5) SELF STRETCHING INTRAVAGINALLY This is a technique where you can stretch the intravaginal tissues by inserting a clean left thumb intravaginally up to the level of the first thumb joint. Gently press or sweep your thumb along the right vaginal walls providing a deep stretch. Do a few sweeps from the midline towards bottom of the right vaginal wall. You can hold a few areas that feel tight or uncomfortable. Then insert the right thumb intravaginally and sweep or apply pressure points along the left side of the vaginal wall. Repeat a few times each side. Do once a day.
6) DILATORS Dilators are also used to help women prepare for intercourse and to apply pressure to tight spots within the vaginal walls to stretch. Your PT can guide you on how to use them.
7) PELVIC FLOOR STRENGTH Once your pelvic floor muscles are lengthened, a basic pelvic floor strengthening program can begin. Your physical therapist can teach you how to best recruit these muscles without co contraction of the hip adductors, hip extensors, and breath holding. A basic pelvic floor strength exercise can be done by holding a contraction for 10 full seconds, resting/relaxing for 20 seconds. Repeat this 10x’s. Then do 10 quick contractions and quick relaxations, repeated 10x’s to stimulate the fast twitch fibers of the pelvic floor which are innervated during orgasm
8) SQUAT Squatting exercise helps to lengthen the pelvic floor and increases the strength of your hip and buttocks muscles. When performing either a quarter, half or full squat in good alignment, this provides great balance of the pelvis and pelvic floor muscle function.
9) AN ORGASM A DAY… Yes, an orgasm a day keeps all the pelvic muscles happy and healthy