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Pelvic Physical Therapy helps Children Overcome Bedwetting and “Accidents”

April Any parent will tell you, the potty training years are stressful! There are millions of resources that tell you different information, and on top of that, work and school schedules make it almost impossible to stick to a solid routine. Every day on the streets of New York City I see frantic parents running to the nearest restroom dragging their child who is doing “the pee dance” because 10 minutes ago at home they “didn’t have to go.” At some point, the chaos ends, and children have a better awareness of their needs, but what about those children who don’t?

Almost all children experience wetting or soiling accidents for various reasons during these training years. By age 5, a child’s neuromuscular system is developed to have bowel and bladder control; however 10% of children from age 5 to 7 continue to have regular day and night time accidents. This trend continues with 3% of children age 12, and 1% of children age 18 .

Persistent wetting has emotional and psychological effects on both children and their parents. Parents report feeling frustrated, stressed, bothered, sad, and helpless when their children are not as physically capable as their peers to remain continent. Children can reports feelings of anxiety, embarrassment, and generally become less sociable . So, why does persistent wetting occur?

Children experiencing persistent wetting should be evaluated by a doctor for the following causes:
• A “Twitchy” or “overactive” bladder that signals frequent urgency sensations and premature voiding
• A weak outlet system that is unable to hold back urine during laughing, coughing, or straining
• Urinary tract infection
• Chronic constipation
• Structural abnormalities within the urinary system
• Neurological issues effecting the lower half of the body
• Psychological or emotional trauma

April2      Regardless of the cause, a root issue seen with most of the conditions above is “dysfunctional voiding” from weak, over active, or non-coordinated pelvic floor muscles. In addition to the immediate psychological effects, dysfunctional pelvic floor muscles can lead to improper development of the urogenital system with connections to chronic pelvic pain in their adolescent and adult life. So what can be done to improve the functioning of these muscles?

Pelvic floor physical therapy is a specialty within physical therapy that focuses on the strength and coordination of this vastly important muscle group. When working with pediatrics, the whole family is considered, and involved as a unit. It is NOT just about kegel exercises! Therapy is focused on creating a better awareness of this area of the body, improving the child’s interpretation of the various sensations experienced at different points in the voiding cycle, and developing the strength and coordination to allow more effective voiding habits. To accomplish this, first, keep a bladder diary to keep track of every time your child uses the bathroom, or has an accident, to find any patterns in their bladder symptoms, such as time of day and frequency. After that, “timed voiding” helps retrain the bladder to void only when in the bathroom by having your child use the bathroom every hour, then slowly increasing the time until it is more optimal.

Rewards and praise are excellent motivation for children to want to use the bathroom and let you know when they have to use it. Avoid negative feedback such as reprimands or “time outs” when an accident does occur, this is very discouraging and does not help improve confidence or self-esteem. Exercise consisting of leg and abdominal stretches help keep your child’s muscles more calm rather than tense, which applies added stress and compression to the bladder. And finally, educating your child about their pelvic muscles is key! Many parents find this topic taboo, or uncomfortable to talk about. This sends a message to children that they should dissociate themselves from feelings or sensations in this area rather than really paying attention and developing that complete mind body awareness. If you find this topic uncomfortable, remember, your pelvic muscles are not solely for sexual function, and that part of the conversation does not need be discussed until your child comes closer to puberty. Educate your child on the fact that they have control over this area of their body, they can squeeze those muscles, release those muscles, and push those muscles downward (this maneuver is referred to as “bearing down” and is done during bowel movements). Most of the time, children feel excited to learn they are in control of something since this is usually a rare occurrence in childhood. The more they are taking notice of these muscles and practicing using them, the stronger they will become. In physical therapy, their strength gains are monitored using biofeedback which uses external surface electrodes to quantify the strength of the muscle contractions.

For strengthening when the muscles have significant weakness, pelvic physical therapists engage the child in play activities that facilitate the use of these muscles. Activities include bouncing on therapy balls, negotiating obstacle courses, creating dances, and other full body physical activity that is fun for the child, all the while incorporating pelvic floor contractions in a safe and supportive environment. Training and educating children is more successful when it is fun and engaging. Parents are also instructed in activities they can perform at home as a family to further increase the child’s engagement, and provide effective parent involvement.

If your child is experiencing any of the symptoms discussed, there is hope. In a matter of 2 to 3 months, muscles can be trained to work at their full potential, and you, and your child can develop the confidence and peace of mind to overcome the struggle of persistent incontinence.

Leaking affects One-third of Female Athletes

images[4]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 aimages[9] 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.

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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.

 

 

Strong Abs during Pregnancy and for New Mom’s

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

 

 

Diastasis Recti Abdominis (DRA) or “Split Seams” can be treated by Pelvic Physical Therapy

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 are 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 2.5cm width

 

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 that you can do immediately:

Avoid positions that may further separate the recti muscles, like doing sit ups, crunches and quick trunk rotation movements.  Avoid being on “all fours”  or on hands and knees for too long during exercise classes.  Assuming the yoga, “cow position” where your belly drops down as your head and hips arch upwards,  puts too much pressure on the already stretched linea alba.  Plus, the yoga position of  “Up dog” and extensive backward bends are not recommended.

Stand and sit symmetrically in good posture  (don’t stand on one leg or sit with crossed legs leaning on one hip for too long)

When you are standing, gently unlock your knees and pull  your stomach inward while breathing normally to give abdominal  support and prevent “hanging out” on your ligaments

When you sneeze, cough or laugh you you can self bracing of your stomach with your hands pushing each side of the rectus abdominal muscles towards the midline, or hold a pillow against your stomach for bracing

Wear a pelvic and/or  abdominal support product to help support the growing baby in uteruo , maintain erect trunk posture and decrease pain until your muscles are stronger by doing core exercises.

By keeping your core toned during pregnancy and taking the steps to prevent further widening of your recti muscles, you can prevent extensive DRA.