What is Women’s Health/Pelvic Floor Physical Therapy?

Today’s blog post is from our Women’s Health Specialist and OSSPT physical therapist, Jenna Jarvis. We hope you enjoy and share with your friends.

When I started physical therapy school, I suspected I would likely work in an orthopedic and sports setting; however, I never suspected I would become a Women’s Health Specialist and treat pelvic floor dysfunctions.  In fact, prior to physical therapy school, I did not even know women’s health or pelvic floor therapy existed. People often ask me what led me down this path and why I chose this specialty.  In reality, I didn’t choose to become a Women’s Health Specialist as much as it chose me.

Beginning in my first year of physical therapy school, I started developing a constant, aching pain in the back of my right hip and thigh when sitting for long periods of time while studying or riding in the car while commuting to school.  Not long after, I began experiencing pain with running, my main outlet from the stress of school.  After a few weeks of continued pain, with no help from any of the exercises I “Googled” online and knew from PT school already, I decided to schedule an appointment with a physical therapist for further evaluation.  After a few weeks of treatment, I still noticed only a minimal difference in my symptoms and became quite frustrated with my situation.  I continued consulting with other physical therapists and an orthopedic surgeon, but never found any answers or treatment that relieved my pain.  I started to feel a little crazy, and question whether it was all in my head.  My pain was so intense, I could hardly sit in the car without a cushion and I had to stand in the back of the classroom during lectures.  Most frustratingly, I could no longer run due to the pain being so severe.

Nine months of continued, unrelenting pain later, we had a guest lecturer present about women’s health physical therapy. As I stood in the back of the room (remember the pain was too intense to sit), she presented a case study of a 20 year old female who had pain with running and sitting. As she continued discussing the case, all the symptoms matched mine entirely.  I knew I needed to explore this treatment more.  After class, I talked with the Women’s Health Specialist and she confirmed that, in fact, a lot of my symptoms were common with pelvic floor dysfunctions and that she felt confident she could help me.  To this day, I can still not explain the amount of relief I felt to know that my symptoms, not only made sense, but that a solution was also available as well.  Within the first few weeks of treatment, I already noticed a reduction in pain, returned to some light running, and I could finally sit in class again. Within a few months of treatment, I was at least 95% better and ran my first marathon, qualifying for the Boston Marathon. I finally had my normal life back!

Following my personal experience and success with pelvic floor therapy, I knew I wanted to offer these same services to my future patients.  Knowing that these advanced women’s health treatments were not taught in PT school, I found and attended some of the most advanced and respected pelvic floor and women’s health courses and completed a long term clinical rotation with one of the premiere women’s health specialists in the country treatments women with pelvic floor dysfunctions on a daily basis.  Additionally, I am constantly learning more about this specialty every day.  In my experiences, I am always astonished with how many of patients have lived through years of pelvic and low back pain with no answers before they discovered pelvic floor therapy. Pelvic floor physical therapy is truly my passion and my professional mission is to educate the medical field and the public about pelvic floor therapy and its benefits.

What is Pelvic Therapy/Women’s Health Physical Therapy?

Pelvic floor physical therapy is a common term for a thorough examination, assessment, and treatment of the thoracic, lumbar, and sacral spine, pelvis, and lower extremities and various related physiological systems that could be causing pain or dysfunction. Pelvic floor therapy is also known as women’s health physical therapy, pelvic floor physical therapy, pelvic rehab, or urogynecological physical therapy.  In addition to the pelvic realm, women’s health therapy can also be beneficial for women following breast cancer and radiation treatment to address pain, decreased upper extremity mobility, and other dysfunction related to treatment of cancer.

Who can benefit from Pelvic Therapy/Women’s Health Therapy?

Pelvic and women’s health therapy can be beneficial for patients experiencing the following:

  • Urinary incontinence
  • Pelvic pain
  • Pregnancy and post-partum
  • Bowel incontinence
  • Constipation
  • Fibromyalgia
  • Pelvic organ prolapse
  • Scarring from abdominal surgeries
  • Post-partum- Cesarean section or vaginal delivery
  • Diastasis recti (separation of the abdominal muscles)
What are common signs and symptoms of a Pelvic Floor Dysfunction?
  • Urinary leakage with coughing, sneezing, or laughing (although urinary incontinence is common, it is not normal in any situation)
  • The urge to urinate frequently or a sudden, uncontrollable urge to urinate immediately
  • Waking up multiple times throughout the night to urinate
  • Pelvic, lumbar, thoracic, or lower extremity pain
  • Pain with sitting
  • Pain with sexual intercourse
  • Chronic urinary tract infections
Where does Pelvic Floor Dysfunction Pain Refer to?

Pelvic Floor referral pattern

What can I expect with pelvic floor therapy?

In your first visit, you can expect a thorough examination of your past medical history, eating, drinking, voiding, and sexual habits and how they may relate to your pain or dysfunction. In addition, an examination of the thoracic and lumbar spine, pelvic, and lower extremities will be done to assess any orthopedic dysfunction that could be contributing. Finally, an examination of strength and control of the surrounding musculature will be assessed, which will include an external and possibly an internal examination.  Patient comfort and safety is always my top priority.  I understand that every patient will have differing levels of comfort and we can always modify the examination and treatment to the patient’s preference.

What treatments are used for physical therapy?

Treatment for pelvic floor therapy may include, but is not limited to the following:

  • Pelvic floor, core, and lower extremity exercises and re-training
  • Soft tissue mobilization
  • Joint and spinal mobilization and manipulation
  • Creating a bladder diary to track progress
  • Diet education
  • Behavioral techniques and education
  • Postural and functional retraining

Kegel exercises are specific exercises that focus on strengthening the pelvic floor.  Although these exercises can be beneficial in the right situation, Kegel exercises do not fix all pelvic floor dysfunctions.  In fact, often times Kegel exercises magnify a patient’s symptoms.  Pelvic floor dysfunctions are not caused purely by weakness; they are due to an inability to properly engage the pelvic floor musculature, which can be either over-active or under-active musculature.  This is one of the biggest reasons why a patient cannot simply “Google” their problem and why they need to be individually evaluated by a specialist to determine the true cause of their pelvic floor dysfunction and to create an individualized plan to properly retrain the pelvic floor musculature.

When a patient is experiencing a significant pelvic floor dysfunction it can be debilitating and life altering.  To make matters worse, resources to address these issues are often limited; patients are often initially misdiagnosed and improperly treated.  If you are someone who has been suffering from a possible pelvic floor dysfunction, please do not give up.  I have been in your shoes and I can help.  If you have any additional questions or would like to schedule an evaluation, please call us at (405) 735-8777.

 

Latissimus Tears: The Newest Injury for Throwing Athletes (Part II)

Just when you thought rehabbing pitchers was hard enough, a new injury has emerged in the throwing population

If you haven’t read Part I of our series, please check it out now. In part I we discussed anatomy, how the lats are in involved with pitching, reasons for the increase in lat injury frequency, and a brief surgical review.

For Part II, we are discussing common compensations we see in the “lat dominant” population and demonstrate a few examples of our favorite functional exercises to retrain this dominance with video demonstration by OSSPT patient and San Francisco Giants prospect, Caleb Simpson.

As previously mentioned, the lats have multiple attachment sites, spanning across several joints in the body, including the thoracic and lumbar spine, pelvis, ribs, scapula, and humerus. Because of all these various attachment sites, the lats have a major influence on posture, breathing, pelvic control, scapular mobility, and glenohumeral positioning. When the lats are working properly, they are crucial in power development with throwing; however, when the lats become too dominant, they are at risk of injury.

Although we are big believers of implementing deadlifting, horizontal/vertical pulling, and carrying into an athletes plan of care, we need to make sure the lats do not become the dominant muscle with all lifts for the throwing athlete.  When presented with a task that is too demanding for the throwing athlete, he/she will revert to over-utilizing the dominant muscles.  Our job as physical therapists is to, first identify these compensations, then educate and correct the athlete of proper movement patterning.  We must prescribe the athlete with exercises that are challenging, but also achievable.

To assist with better identifying when the lats may have become too dominant, we have listed some common compensation patterns to look for.

Common “Lat Dominant” Compensations

1. Excessive lumbar extension/anterior pelvic tilt: with attachments anterior pelvic tiltto the thoracolumbar fascia, spine, and pelvis, overly dominant lats will often lead to excessive lumbar extension and an anteriorly pelvic tilted position.  Overly-dominant muscles often lead to shortened muscles so we need to incorporate exercises that force the lats to work in an eccentric, lengthened position while maintaining a neutral spine.

2. Faulty breathing mechanics: most of our patients, particularly our athletes, have poor diaphragmatic breathing and often over recruit the accessory respiratory muscles, including the lats.  Many of the accessory respiratory muscles further pull the body into a lumbar extended, anteriorly pelvic tilted position. At rest, we breathe approx. 15,000-20,000x/day. If we are constantly breathing improperly, the lats are living in faulty, shortened positions.  We spend a lot of time teaching proper diaphragmatic breathing to our throwing athletes and incorporate diaphragmatic breathing into our exercises when possible.

3. Rib flaring: the first two compensations we discussed will often lead to rib flaring, so if we correct the excessive lumbar lordosis/anterior pelvic tilt and faulty breathing mechanics, the rib flare may resolve; however, a rib flarerib flare can also develop due to weakness of the anterior core.  With our throwing athletes, we must incorporate anterior core control exercises while in an overhead position. This will ensure our pitchers can successfully control the rib cage, which is vital to ensure proper scapular position as well.

4. Shoulders falling into IR and/or adducted positions: the most common technique used to identify this compensation pattern is the prone horizontal abduction exercise.  Instead of the shoulder remaining at 90 deg. during the arm raise, the overly dominant lat will pull the arm down toward the hip (as you can see in the picture below). In early stages of rehab, teaching and performing this exercise correctly can be an appropriate intervention to reduce the lat dominance and improve mid trap and rhomboid activation with this movement.

Lat dominant prone T5. Insufficient scapular elevation/upward rotation: due to the lats attachment to the inferior aspect of the scapula, “dominant lats” can lead to depressed scapula, or at the minimum, dominant lats can prevent proper scapular elevation/upward rotation with overhead movements. For the throwing athlete, a lack of proper scapular control and movement will lead to impaired glenohumeral joint congruency and contribute to rotator cuff/labral pathology.

Exercise Examples

1.Plank –> Downward Dogan excellent upper extremity closed chain movement that promotes proper scapular upward rotation and requires anterior core control, while putting the lat in a lengthened position. We cue the athlete to drive thru the palms, maintain a neutral spine, and bring the hips to the sky. We will use this exercise as a primer before introducing higher level overhead movements.

2. MedBall Lat Pullovers: this exercise forces the athlete to maintain a neutral spine, not allow rib flaring while controlling the medball overhead, and teaches proper eccentric lat control. We will often incorporate diaphragmatic breathing techniques while in the overhead position as well. Just like our previous exercise, this can be another primer movement.

3. Wall Angels: this exercise is an excellent choice for the general population to address common postural dysfunctions including excessive lumbar lordosis, anterior pelvic tilt, increased thoracic kyphosis, rounded shoulders, and forward head positioning. To perform correctly, the athlete cannot allow rib flaring either.

4. Half Kneeling S.A. 90-90 Row-ER-Press: as we progress through our exercise examples, we are gradually increasing loads as well. With this exercise, we continue to demand proper core control, emphasized by adding an unstable surface via the Dynadisc for the R knee. This exercise also demands proper posterior rotator cuff activation as we cue the athlete to drive his fist straight to the sky during the press movement. To better replicate the pitching demands and mimic a glove side pulling that many pitching coaches instruct with an isometric glove side row.

5. Unilateral Overhead KB Marches: this exercise is a great stability based exercise in multiple planes of movement, particularly when we add the band resistance as well. The big thing to watch for is excessive lumbar extension, rib flare, pelvic drop, or the athlete not keeping the KB shoulder in full flexion with slight shoulder ER. We cue them to drive the KB to the sky w/o allowing the shoulder to shrug. As we can see in the video below, Caleb is having some difficulty with maintaining extended elbow position and he is allowing the shoulder to rotate internally.

6. Tall Kneeling Halos: our last exercise may  look easy from the surface, but halos will reveal compensations really quickly. This exercise demands excellent core stability and a combination of excellent shoulder stability and mobility.

The lats are important muscles for the throwing athlete and it’s vital that we identify and correct common movement dysfunctions and implement appropriate exercises to re-train these faulty movement patterns.

I hope you enjoyed our 2 part blog post. I wanted to provide a quick shout out to Mike Reinold and Eric Cressey.  I was introduced to these two guys eight years ago while working with the Atlanta Braves and I have attempted to read everything they have produced since that time and they are two of the biggest influences in my professional career. Both guys put out great material on a daily basis and so much of how I treat our baseball players is either directly or indirectly influenced by them, including this blog post. I want to say a big thank you to Mike and Eric for how much they have helped, not only me, but the medical and performance profession as a whole.

 

We Must Build a Foundation Before We Can Build Walls

A few nights ago, I couldn’t sleep and ended up watching a show about the construction of the Burj Khalifa, the tallest building in the world. In the show, they mentioned that the design used approx. 50% the amount of steel used in the construction of the Empire State Building, which is half the height of the Burj Khalifa. That fact initially surprised me, before realizing it was a simply matter of improved design efficiency and building a better foundation which could tolerate higher loads. That concept brought me back to one of our principal philosophies we apply at OSSPT, which is to ensure we build a better foundation of movement quality, before we ever increase movement quantity. The foundation of physical therapy should be about correcting faulty movement patterns.

“Tarzan, to me, is the epitome of fitness.  The guy is strong, agile and quick.  He can run, jump, climb and swing through trees.  If we take a person who moves well and put them on a Crossfit type of training program, we turn them into Tarzan.  If we take that same program and give it to the majority of people in society who move poorly, we turn them into a patient.”

– Gray Cook

Faulty movement patterns are the underlying reason behind ALL chronic conditions and many acute injuries. Without fixing the foundation, we are fighting a losing battle and eventually the walls will come crashing down, whether that be a recurrence of previous injury, worsening of current symptoms, or simply developing a new injury complaint. The number one risk for musculoskeletal injury is a previous injury, clearly indicating that something we are doing in the rehabilitation process is wrong and insufficient.

Ever wonder why your hip or knee become arthritic on one side and not the other? Ever wonder why your neck or low back are not getting better with years of adjustments, massages, etc? Ever wonder how you developed bone spurs in your your foot, heel, hip, shoulder, etc? The most likely answer is that you moved incorrectly, year after year, until finally, you developed structural changes, and then pain. As Gray Cook asks, are you moving poorly because you are in pain? Or are you in pain because you are moving poorly? We know that structural changes begin before we start experiencing pain, and we know that structural changes happen when we move improperly; therefore, we know that faulty movements lead to pain overtime. Here’s the great news… we can change how we move and if we change how we move we have an excellent opportunity to eliminate the pain cycle once and for all. baby squat

Try this quick test… perform a squat just like the kiddo in the picture to the right. If you can’t do it as well as that infant, then you are predisposed to injury. It’s as simple as that. We must squat, lunge, walk, climb stairs, push, pull, reach, etc. with proper mechanics, not because we are attempting to be elite level athletes, but simply because we are human beings and we must successfully build a solid movement foundation before we can build the walls of strength, flexibility, etc. around it.

“Success is doing the ordinary things extraordinarily well.”

– Jim Rohn

 Not sure if you move correctly or not, schedule an evaluation with me and we will perform the Functional Movement Screen, a reliable and valid tool, to determine what weak links you may have that could eventually be the crack in your foundation, and then provide you with the proper tools to fix it before it becomes a bigger problem.

 

The Straw that Broke the Camel’s Back

We have all heard the common proverb “It’s the last straw that breaks the camel’s back“, referring to how something presumably minor can, overtime, cause a catastrophic and sudden reaction, due to the cumulative effects of the individual actions. Whether this refers to car tires wearing down overtime until the tire eventually blows a flat, a tree covered in ice during a snow storm that slowly bends more and more until it finally snaps, or continually “squeezing” into those tight jeans until finally one day you try squeezing into them and they rip at the seam, the overlying idea is that it was not one single event that led to the destruction; instead, it was gradual wear and tear over time. The same holds true for a large majority of injuries to the human body.

“It’s the little details that are vital. Little things make big things happen.”

– John Wooden

Many of the injuries we treat are not due to a single traumatic event, but are more often from chronic wear and tear, or as we describe it, repetitive microtrauma. Whether that be rotator cuff tears, carpal tunnel syndromes, lateral Epicondylagia/Tennis Elbow, Bulging/Herniated Discs, Arthritic related conditions, knee pain, tendonitis, etc., the underlying cause of the dysfunction is due to repetitive microtrauma leading to tissue breakdown and pain. 

What causes repetitive microtrauma?

The simple answer is an underlying movement dysfunction and/or sustained postures, which results in muscle imbalances, soft tissue restrictions, joint dysfunctions, adverse neural symptoms, impaired stability/motor control, and eventually structural adaptations. Our job as physical therapists MUST be to not only treat the site of pain, but to identity and treat the underlying movement dysfunctions which led to pain and limitation in the first place. In other words, we must identify and treat the cause of the cause.

If my pain goes away, why does it matter?

When a patient comes into OSSPT with a rotator cuff tear, whether it be post-surgical or for conservative treatment, our first priority is to provide a proper environment to allow adequate healing to the damage tissue. Then we must identify and treat the underlying movement dysfunctions which led the rotator cuff to tearing in the first place, to prevent future recurrences. Simply giving generic range of motion and strengthening exercises is not enough and will result in short term improvements, at best. If we don’t fix the underlying cause of the cause, the likelihood of future re-injury is high.

Physical therapists wonder why so many of their patients return to the clinic weeks/months/years later complaining of the same symptoms they were previously treated for, often, blaming the patient for being non-compliant, a failed surgery, age, etc., without ever looking internally. We, as a profession, need to spend more time educating and proving to patients that we are more than just a profession of people who give out “stretches and stuff” as some claim, and prove to patients we are an invaluable member of the medical team, because right now, we are heading in the wrong direction as a profession, having become a bunch of overqualified exercise supervisors. If we keep heading this direction, doctors will continue to disregard our abilities, insurance companies will continue to cut reimbursement, and patients will continue to devalue the services we provide, until eventually, it will be the straw that broke the camel’s back for our profession.

Here’s to the Crazy Ones…

“Here’s to the crazy ones, the misfits, the rebels, the troublemakers, the round pegs in the square holes… the ones who see things differently — they’re not fond of rules… You can quote them, disagree with them, glorify or vilify them, but the only thing you can’t do is ignore them because they change things… they push the human race forward, and while some may see them as the crazy ones, we see genius, because the ones who are crazy enough to think that they can change the world, are the ones who do.”

– Steve Jobs

What made Steve Jobs so special was not his genius. We are surrounded by “geniuses” everyday. What truly made Steve Jobs so special was his laser focused vision, his imagination, his optimism, and his determination. It was his unwillingness to accept the status quo. He wanted more from his employees and his company.

When Geoff and I opened OSSPT we committed ourselves to only hiring those same likeminded people who wanted more for themselves and for others. We searched for individuals who might be considered the crazy ones, the misfits, the rebels, the troublemakers, the round pegs in the square holes”. We didn’t want the typical physical therapist; we wanted the outlier. We wanted the physical therapist who voluntarily works full time, while simultaneously completing a very expensive and time consuming 2.5 year orthopedic residency program because he/she wanted to provide a better quality of care to his/her patients. We wanted the physical therapist who works 45 hour work weeks then spend his/her days off completing extensive manual therapy fellowship training. We wanted physical therapist who is not satisfied with being “average” or “typical”… and we luckily found just that.

Our physical therapists have the most advanced training possible and are the most highly qualified to treat your specific needs. You can quote them, disagree with them, glorify or vilify them, but the only thing you can’t do is ignore them because they change things… they push the human race forward.” We are challenging the traditional treatment model of chasing pain, treating symptoms and not causes, searching for short term relief in spite of long term improvements. We are striving to change the norm and in some small way, change the world. While some may see them as the crazy ones, we see genius, because the ones who are crazy enough to think they can change the world, are the ones who do.”

So what makes our staff so special? It’s our laser focused vision, our imagination, our optimism, and our determination to truly make a positive and lasting impact on our patients. We are not satisfied with being average. We are not satisfied with doing the norm and while we have a long way to go, we are tirelessly working every day to improve. The norm has been failing patients for years and they deserve better, and that is what we aim to provide. If all our individual contributions result in a tiny positive change to the world for the better, then we have succeeded. So… Here’s to the crazy ones!

Our Profession Owes You an Apology

When an individual has a heart related condition, they see a cardiologist… When an individual has a skin related condition, they see a dermatologist… When an individual has a cancer related condition, they see an oncologist.

In every area of our lives we search for the experts, why should physical therapy be any different?

The quality of care we have come to expect from the physical therapy profession has become so low that the assumption is that all physical therapy is the same; however, this could not be further from the truth. When a physical therapist graduates from school, in a sense, they become a “jack of all trades”. They have a very broad knowledge base making them novices in all aspects of physical therapy including orthopedics, pediatrics, acute care rehab, neurological, spine,  sports rehabilitation, etc; similar to how graduates of medical school have developed a foundation of cardiology, neurology, immunology, etc. The major difference between medical school and physical therapy school, is that for the majority of physical therapists, the structured training ends after PT school, unlike medical school graduates who then advance to a multiyear residency program focused on a singular specialty, often followed by fellowship training to further specialize.

As any orthopedic surgeon would agree, not until the residency and/or fellowship programs do they become confident in providing the quality of care necessary to make measurable improvements for their patients.

“I fear not the man who has practiced 10,000 kicks once, but I fear the man who has practiced one kick 10,000 times.”

– Bruce Lee

Why don’t more physical therapists undergo additional training?

The unfortunate, but honest answer is that it’s not required and patients aren’t demanding that their physicians refer them to the experts. Most patients do not search for the best physical therapy clinic to attend and often go wherever the doctor recommends. Unfortunately, many of these referral decisions are based on location, personal relationships, or financial ties with that clinic. Furthermore, Less than 10% of physical therapists have completed a post graduate residency program and less than 2% of physical therapists have completed a manual therapy fellowship program, so the public often does not even know these residency and fellowship programs exist.

Does this mean that you can not be a good quality PT without completing a residency or fellowship program? 

Definitely not. I know quite a few good PT’s who have not completed residency and fellowship training, but I know for a fact that  these same PT’s would love to  complete a residency program if the costs were not so high, the time demands were not so much,  if their employers were more supportive, and if insurance reimbursement was paid based on results.

How is OSSPT any different?

First, every one of our therapists has completed fully accredited advanced orthopedic and/or sports residency programs. Also, our physical therapists have completed or are actively completing a manual therapy fellowship program to further improve his/her skills. Additionally, our company is independently owned by the same physical therapists treating you in the clinic with no outside influence by any hospitals, medical groups, or corporations, so patients can take a lot of confidence in knowing that the only reason physicians recommend us is based on the quality of care we provide and our excellent results. Finally, we are such strong advocates of residency and fellowship training that we cover the entire cost to complete the programs for all new physical therapy employees.

Moving forward, I challenge you, the patients, to demand more from us. Do your homework and seek a higher level of physical therapy care. We spend hours debating the best restaurants to eat, searching the internet for the best shopping deals, and researching the best physicians and surgeons, then blindly go to the nearest physical therapy clinic to our home/work without thinking twice. Ask friends for recommendations, ask your physician if they have any financial ties to the clinic they are referring, drive the extra 5 minutes to receive a superior level of care, understand you have a right to choose where you want to attend physical therapy.

If you have the choice of a superior level of care, for the same price, with the same therapist each visit, why not choose OSSPT? If you have more questions or would like to specifically discuss your case please reach out to me personally at Jeff@OSSPT.com or call us at 405.735.8777 to schedule an evaluation.