Pelvic Floor Therapy for Pregnancy
Pregnancy constantly brings many changes to your body, mind, and wellbeing. For many people, it can seem like as soon as you get used to one new transition, another one emerges.
Diastasis Recti
Diastasis Recti is an extremely common condition during late pregnancy and postpartum. Diastasis recti occurs when the linea alba, a sheath of connective tissue that connects both sides of your rectus abdominis muscle, stretches and widens. This thinning of the tissue can make it harder for your rectus muscle to activate properly, sometimes leading to poor core mechanics, low back pain, and difficulty with lifting or strenuous activity.
Most pregnant people have some degree of diastasis, since there is a significant stretch being placed on that linea alba as the baby grows. We can mitigate some of the effects of diastasis during pregnancy by working on breathing mechanics, deep core activation, and functional core exercises that you can incorporate throughout your day to day life.
Your diastasis might resolve on its own after birth, or you may need some additional support from a pelvic floor therapist. This is due to a variety of factors including genetics and connective tissue laxity, habitual breathing patterns, functional movements, and constipation. If you have a diastasis postpartum, it does not mean you did anything “wrong!” It is incredibly common, and there are many interventions we can use to support you.
Urinary Incontinence
Urinary incontinence during pregnancy is very common. When we think of the position of the pelvic organs, it’s very easy to understand one of the reasons why incontinence could happen. As the uterus expands, it’s placing pressure directly on to the bladder. Some people find that they experience more incontinence depending on the growing baby’s positioning as well. Other contributing factors to urinary incontinence include decreased pelvic floor strength, habitual patterns around breathing and pressure management within the abdominal canister, and decreased core activity. Basically, if you hold your breath or strain often, you might find yourself more likely to experience leaking.
Because of the physiological changes that occur during pregnancy, some cases of incontinence are easier to treat than others. Working with a pelvic floor therapist can help mitigate some of the incontinence you might be experiencing.
Prolapse
Pelvic organ prolapse can occur as a result of pregnancy and labor, as well as other contributing factors like genetics and chronic constipation. It’s often associated with sensations of heaviness and discomfort within the pelvic region. If we think of the pelvic floor like a hammock helping to hold up the uterus, bladder, and rectum, it’s easy to see how prolapse can occur. With pregnancy often comes weakened pelvic floor tissue, and labor is often associated with increased pressure down on the pelvic floor. The hammock of tissues thus has a harder time supporting the organs, sometimes leading to a bulge within the vaginal canal.
Many people wonder, “Are my organs coming out of my body?”. If you think of the vaginal canal like a sock, imagine placing your hand inside. Now. pinch one part of the inside with your fingers. That represents a bladder prolapse (cystocele) or rectocele (the rectum pushing in on the back wall of the vagina). This means the bulge itself is often vaginal tissue that’s being pressed on by the organs. A uterine prolapse can descend into the vaginal canal itself, but it’s very rare to have a full descent of the uterus.
It’s very common for bodies to change immensely during pregnancy. And luckily, a qualified pelvic floor physical therapist or occupational can assist you with many of the challenges associated with pregnancy and labor, so that you can return to the activities you cherish the most.
Having a pain-free pelvic floor is about more than just sex
If you’re a queer and/or trans person and experience pelvic pain with any internal input or penetrative sex, you might be ambivalent about seeking support. After all, queer people know best that what we perceive as “sex” is socially constructed, and there are a million, creative ways of having sex together beyond anything centering penetration.
Despite this, you might be someone who still dreads getting a pap smear, or maybe is putting off getting pregnant because imagining the internal aspects of having an IUI (Intrauterine insemination) feel overwhelming and painfu
Moving towards a pain-free pelvic floor doesn’t have to ever be about penetrative sex. It’s just as, if not more important, to feel empowered as you approach whatever kind of reproductive or gynecological care that you might need.
Benefits of pelvic floor therapy beyond pain-free sex
We all have a sensory map in our brain of different body parts, and the size of a body part’s region is dependent on how much attention and use it gets. For example, the sensory map of our hands is quite large, because we are getting so much sensory input into our hands throughout the day. The pelvic floor, however, has a much smaller sensory map, and for the internal parts, even less so. For many of us, if we aren’t actively developing a relationship with the internal parts of our pelvic floor, we might not know how it feels. Especially if we’ve experienced pain in the past, there can be many reasons our nervous systems might automatically assume there would be pain there in the future. Working with a pelvic floor physical therapist or occupational therapist and developing tools to know how to self-evaluate and release your pelvic floor can be a vital part to seeking any kind of reproductive care that involves pelvic exams.
Empowering your reproductive care
Imagine what it might feel like if you were able to go into any gynecological or IUI appointment with a clear sense of what your pelvic floor feels like, and how to relax it with intention and conscious effort. How might that change your sense of what’s possible in terms of your gynecological care? How might that improve your psychological well-being, both leading up to your appointments, as well as during and after, knowing that you have the skills to reduce the risk of having a painful experience? Knowledge truly is power, and the more you understand about your own body, the more agency you’ll have to advocate and take of yourself.
There is so much more to having a pain-free pelvic floor than just being able to have pain free sex. If you’ve been avoiding reproductive or gynecological care because you’re nervous about your pelvic pain, pelvic floor physical therapy or occupational therapy might be right for you.
Hip pain and pelvic floor therapy
“I have pain in my hip–why would I go to pelvic floor therapy?”
There are many reasons why pelvic floor therapy might be beneficial for pain in your hip. First off, what is your “hip bone”? Your hip bone (or os coxae) actually consists of 3 bones-The ischium, the ilium, and the pubis aka “the pelvis.”
Your pelvic floor is a series of muscles that lay across the bottom of your pelvis like a hammock. When we think of pelvic floor muscle action, most people think of “the kegel,” which looks like a drawing up and in of the pelvic floor musculature. But did you know there is one pelvic floor muscle, the obturator internus, that helps rotate your femur out (think butterfly pose in yoga)? It attaches at the bottom of our pelvis, and slings around the lateral part of the pelvic floor to attach to the femur. It also helps suspend all your other pelvic floor muscles.
When we don’t have adequate strength or flexibility in some muscles, it’s common that other muscles will become tightened or strained to help compensate. The obturator internus can often become strained and tight, leading to discomfort or muscle pain.
If your “pain in the hip” is obturator internus pain, it might also look like:
-A feeling of tightness near the acetabulum or hip socket
-Pain with sex
-Urinary frequency or urgency
-Pain deep in your abdomen
How do we treat it?
-We can help your muscles promote relaxation and mobilization through internal or external manual treatment.
-We provide detailed postural analysis to help facilitate both ease and stability.
-We work on finding both hip strength and mobility in order to access a more integrated muscular system
-We coach breathing techniques that help you release tension in your pelvic floor
-We’ll collaborate with you to create an individualized plan that allows you to continue your treatment in the comfort of your home
If you’re in Jamaica Plain, Roslindale, or just greater Boston area, and you’re curious about treating your hip pain through pelvic floor therapy, contact us today.
Return to Running Postpartum
I'm recently postpartum. How do I know when I'm ready to return to running again?
If you're someone who enjoys running, it can be confusing and frustrating to know when your body is ready to return. Before you return to running, it's helpful to consider how to most effectively prevent injury, discourage diastasis recti, and protect your pelvic floor.
Things to consider when thinking about returning to running:
Am I having prolapse symptoms?
If you're experiencing pelvic pain or heaviness after prolonged activity or walks, you may be experiencing symptoms of pelvic organ prolapse. Because running is such a high impact activity, it's especially important if you have a prolapse to work on hip and abdominal strengthening, as well as deep core coordination and strength. If you have prolapse symptoms and you want to return to running, your pelvic floor therapist or OBGYN might suggest you wear a pessary, which is an addaptive device that inserts into your vaginal canal to help support the surrounding musculature. Many people wear pessaries during running to prevent leaking and feelings of heaviness.
How do I feel after a long walk or prolonged activity?
If you're experiencing fatigue, achiness in your hip, discomfort in your feet after prolonged activity, you may need to strengthen your core and hip musculature in order to prepare for your return to running. If you're already fatigued after a short walk, it may not be a great idea to start running quite yet.
How far am I postpartum?
Many people might feel like it's time to start running once their midwife or OBGYN clears them for exercise at 6 weeks. Although you may return to mild or moderate intensity exercise at this time, we also know that for many people, postpartum healing can take 6 to 18 months. Although that may sound frustrating, this is the perfect opportunity to get to know your body better, and work on strengthening and lengthening the right structures in order to optimize your running performance, helping you feel confident and stable. I usually recommend waiting 12 weeks before starting to run again.
What can I do?
1) Strengthen your hips and lower extremities.
By practicing mindfulness during functional tasks, you can use tasks such as sitting back into your chair, or bending down to greet your baby on the floor, as built in strengthening opportunities. Tune into your movement patterns throughout the day, and see how many mini squats or deadlifts you can naturally sneak in. If you are an exercise-motivated person, it may also help to integrate the following movements into your routine: glute bridges, lunges, squats, deadlifts, calf raises
2) Develop your balance and coordination
Your pregnant and postpartum body has had to adjust to many changes in center of mass, which may have impacted your sense of balance. It’s important to work on bringing balance & coordination work into your strengthening routine.
3) Learn to let your belly hang
Many postpartum people make that mistake of thinking that they need to brace their core the whole time that they're running. This creates unnecessary pelvic tension and guarding. One supportive strategy is becoming more mindful of how you hold your belly throughout the day. Tune into your body after a frustrating phone call, a hard moment in traffic, or a stressful email. Do you tend to respond by sucking in your core? Allowing the core to relax facilitates more strength and coordination when we need it.
4) Learning to stack your ribs
Finding a more optimal posture is a great way to ensure that your core can be as responsive as possible. When they first return to running, many people compensate for a lack of core strength by flaring their ribcage out. Finding the sensation of your ribcage stacked over your pelvis, with ribs slightly turned downwards, can be the key to finding the difference between supportive running or not.
5) Starting slow
You don't have to go straight. from walking to running. There can be many transitional exercises in between. To help to start your transition, first try walking slowly up a big hill. Be mindful of what your posture is doing, how your core is responding, and how your pelvic floor feels during and after. Once you feel confident with that, you can play with speed. You can practice walking quickly on flat pavement, and then eventually progress to walking quickly up inclines (aka hiking). If that feels comfortable, start off by doing shorter sprints followed by fast walking. You can try 1 minute of running, and then 5 minutes of walking, and then decrease walking intervals overtime.
Returning to running postpartum can be a journey, and I highly recommend seeking out professional support postpartum if running is your preferred form of movement!
What is trauma-informed care?
Trauma-informed care has become a buzz phrase in recent years, but what does it really mean? All pelvic health care should be trauma-informed, due to the prevalence of trauma and violence in our society. Trauma-informed care must go beyond just being thoughtful and kind. How do we incorporate trauma-informed care into our practice?
Thinking about the context
We often take for granted how impacted we are by our surroundings. Many find that typical healthcare settings, with all-white walls and flooring, fluorescent lights, and strong cleaning agent scents, can feel dysregulating for the nervous system at baseline.
One of the first things you’ll notice in my office is the thought and care put into the layout and environment. I don’t use overhead lighting (unless requested), I incorporate soft, pleasurable colors, and we have space where we can sit and talk before any physical exam even begins.
An additional aspect of creating a safer context within pelvic care is the strategic use of time. Trauma-informed care means being able to go slow. This is one of the reasons why I am out of network–I never have to justify how we spent a session based on arbitrary standards that the insurance company sets for us. I provide full hour sessions, with breaks in between, so that not only can clients have a well-paced session, but myself as a clinician will have a moment to decompress and feel fully present for the next client.
Knowledge of the nervous system
I incorporate into our sessions an understanding of how the nervous system plays a role in trauma, and the relationship between that and pelvic health. Understanding signs of nervous system dysregulation helps the provider assess what kind of intervention may be beneficial or potentially triggering at any given moment. We use many techniques to help clients enter into a state of more ease, including breathwork, mindfulness, somatic awareness, and manual therapy.
Therapeutic use of self
It’s the therapists role to create a container for therapy where the client feels heard, valued, and important. The skills often referred to as “soft skills” such as active listening, compassionate inquiry, validation, and self-awareness are actually vital to the success of any therapeutic relationship. As your therapist, I work hard in and outside of the office to develop a strong sense of empathetic presence and healthy communication skills.
Anti-oppression
For many folks, trauma is related to societal oppression and marginalization. Therapists at Embrace Pelvic Health aim to create an environment that is welcoming to all people who walk through our doors.
Compassion, consent, collaboration, and creativity
My 4 C’s of trauma-informed care: Compassion, consent, collaboration, and creativity, are essential to creating an environment where people feel comfortable and empowered. I use consent throughout our sessions to check in about what a person feels comfortable with, how they want to be approached or touched, and what information they might want to share or not. I use consent as an active form of collaboration, building a session with the person in front of me, rather than assuming that I know what’s best for them. And being in true collaboration requires creativity, allowing us to think outside the traditional therapeutic box in order to meet each client where they’re at. I center compassion throughout my work, in order for clients to feel like they can show up as their full selves.
Pelvic floor physical therapy or occupational therapy can be scary if you have a trauma history. In my office, I do my best to create an environment of safety, relaxation, and ease, so you can feel great about the care you’re receiving.
Birth Prep: Pelvic floor therapy as preventative care
It’s common for clients to view pelvic floor physical therapy or occupational therapy as something that’s only necessary when there’s a “problem” that needs to be “fixed.” This focus on management after an injury isn’t surprising, considering how much of our medical system in the US is focused on symptom management, rather than preventative care.
What if we started shifting our perspective, so that pelvic floor therapy acted more as preventative care for a more empowered birthing process? The more educated you can be about evidence related to interventions and birth outcomes, the easier it will be for you to approach labor and delivery with a sense of confidence and peace. Additionally, starting pelvic floor therapy as a pregnant person is helpful for beginning to consider some aspects of your early postpartum healing and recovery.
So how can pelvic floor therapy support you in preparing for birth? Here are 7 ways a pelvic floor physical therapist or occupational can help improve your birthing experience.
Core control and body mechanics during pregnancy
Hip and spinal mobility
Connecting to your pelvic floor
Breathing and pushing mechanics
Birthing positions
Pain science and childbirth
Perineal massage
Preparing for early postpartum
Core control and body mechanics during pregnancy
As you’re nearing your due date, you may notice that your center of gravity has drastically changed, making it difficult to do many daily movements such as walking, cleaning, bending over, squatting, etc. Your pelvic floor therapist will teach you how to connect to your core in a functional way in order to minimize back pain, diastasis recti, and pubic symphysis dysfunction. Learning how to stabilize your core during pregnancy will benefit your postpartum recovery, as you will have already practiced engaging these muscles and made them a part of your sense memory.
Hip and spinal mobility
You don’t need to be overly flexible in order to have a successful birth. But starting to work on hip and spinal mobility may be helpful for the stages of labor when the baby is moving through the pelvis. Being able to move in and out of hip internal and external rotation, as well as finding mobility throughout your whole spine, may be beneficial for reducing birth injury and increasing options for different birthing positions.
Connecting to your pelvic floor
Although there’s now access to so much more information about the pelvic floor, you may find yourself lost in a sea of suggestions and advice. Working with a pelvic floor therapist before birth can help with not only getting educated about what the pelvic floor is and what it does, but how to actually feel this group of muscles. And no, we’re not going to tell you to do 100 kegels!
Breathing and pushing mechanics
Being able to sense into the pelvic floor will benefit you as you learn about the mechanics of pushing during labor. Practicing what it feels like to actually use your breath to effectively lengthen the pelvic floor will allow you to feel more prepared for when you’re actually laboring.
Birthing positions
There are other ways to labor besides being on your back! Your pelvic floor therapist will go over the research backed positions that will hopefully help you prevent tearing and increase ease of pushing. We’ll talk about positions appropriate for a medicated and non-medicated birth, and help you practice these positions in your body in order for you to feel confident about how to move in and out of them.
Pain science and childbirth
Many pregnant people are concerned about how painful labor may be. Your pelvic floor therapist can help educate you on some of the science around pain, and the role of the brain and nervous system in pain processing. This can help with creating a plan regarding pain management during childbirth.
Perineal massage
Starting perineal massage at about 34-36 weeks postpartum can be helpful for reducing the degree of tearing that can occur during childbirth. Your pelvic floor therapist can help you feel confident that you’re performing the massage correctly, as well as teach partners how to perform the technique as well.
Thinking about early postpartum
Although it can feel empowering and relieving to consider how to best prepare for labor and delivery, it’s just as important to consider how you’re going to feel in the early postpartum period. Your pelvic floor therapist can help you think about stretches, breastfeeding or chestfeeding body mechanics, breathing techniques, and pain relieving measures to ensure that the early postpartum period is as comfortable as possible.
Pelvic floor physical therapy or occupational can be an essential part of your pre and postnatal prep and recovery. I can help guide you towards a birth where you feel knowledgeable, confident, and secure every step of the way.
It’s not a UTI???!!!
Picture this-it’s been weeks of urinary urgency and frequent urination and pain while peeing. You’ve tried every over the counter supplement and old wive’s tale remedy, and nothing is helping. You finally make it to your doctor, and he tells you that your test came back negative for a urinary tract infection. What is happening?!
Symptoms that can look very similar to a UTI, including urinary frequency and urgency and pain with urination, can sometimes be caused by pelvic floor dysfunction and impaired bladder/brain connection. With a little bit of help from your pelvic floor physical or occupational therapist, you may find relief from your symptoms. You’ll feel empowered if these symptoms ever return, knowing that you have tools in your toolbox to address the discomfort.
Bladder irritants: You are what you drink
If the inner lining of your bladder detects urine concentrated with certain irritants, it will try to release the urine as quickly as possible, leading to the sensation of increased urgency. Common bladder irritants include coffee/caffeine, carbonated beverages, and alcohol. Note! “Carbonated beverages” include seltzer! If you need your spicy water to stay hydrated, try creating a “water sandwich”: have a little bit of water, then some seltzer, and then some more water. This will help dilute the seltzer, as well as any other bladder irritant you might be consuming.
Additionally, dehydration can be a bladder irritant. It’s common for people experiencing urinary urgency to cut back on water intake in an attempt to control frequency of bathroom visits. It’s important to keep hydrated, however. Working with a pelvic floor physical or occupational therapist will help you to create strategies on how to better manage the uncomfortable sensation of urinary urgency.
Pelvic floor hypertonicity
If the fascia around the bladder and urethra is overactive, or hypertonic, this can confuse the signals between the bladder and the brain, leading to sensations of urgency that aren’t caused by a full bladder. Additionally, inability to lengthen the pelvic floor can result in more difficulties in emptying the bladder. Urine will then be retained, which could then increase the likelihood of feeling urgency again soon. A pelvic floor physical therapist can help assess if the discomfort you’re feeling might be connected to over recruitment of the pelvic floor musculature.
Bowel Habits
Your GI system health can be intimately connected with feelings of urinary urgency, frequency, and pain with urination. If you’re someone who experiences chronic constipation, this can lead to hardened stool building up over time in the rectum. Because of the proximity of the rectum to the bladder, this can place pressure onto the bladder, contributing to the sense of urgency.
Additionally, experiencing chronic diarrhea can also lead to general inflammation and irritation of the pelvic floor tissue. Because one of the main functions of the pelvic floor is to ensure you don’t leak urine or feces, the pelvic floor muscles can overrecruit when they sense liquid stool in the rectum. This over-recruitment of the pelvic floor musculature can contribute to higher tone of the musculature surrounding the urethra, which could lead to feelings of urgency and pain with urination, as described above.
Interstitial Cystitis/Painful Bladder Syndrome
Interstitial Cystitis, or Painful Bladder Syndrome, is a diagnosis that may include inflammation of the bladder, urinary frequency and urgency, pain with sex, and bladder pressure. Often, these symptoms can be caused by or contributed by pelvic floor dysfunction and over-recruitment. If you have IC or PBS, and you present with hypertonicity in the pelvic floor, it would be helpful to seek out support from a qualified pelvic floor occupational or physical therapist. A trained specialist will help teach you how to lengthen these muscles overtime, hopefully decreasing urinary urgency and frequency.
If you have UTI symptoms with no discernible UTI or other medical cause, it may be time to consider pelvic floor physical therapy or occupational therapy! Using manual techniques, bladder retraining exercises, breathwork, and stretches, your pelvic floor therapist can help guide you towards reducing symptoms and gaining your life back.
Endometriosis
What is endometriosis? Why does it happen?
Endometriosis is a condition in which tissue similar to the lining of the uterus starts growing outside of the uterus. It is most commonly diagnosed in people assigned female at birth (AFAB) ages 25-40. This tissue mostly attaches to pelvic organs, but occasionally can grow to other visceral structures as well–it has been found as far away as the nasal passages. It affects about 1 in 10 people assigned female at birth. Common symptoms include pelvic pain, heavy and extremely painful periods, spotting between periods; and GI issues. Pelvic pain due to endometriosis is typically cyclical and is worse right before menstruation starts.
There are several theories about the cause of endometriosis, though more research is needed.
Endometriosis needs to be formally diagnosed through laparoscopic surgery, although ultrasound or MRI may give your doctor some initial insight.
What are my treatment options?
There is no cure for endometriosis, just management. Medical treatment options may include: hormonal management via oral contraceptives, GnRH-analogues, or progestins; laparoscopic surgery, a minimally invasive surgery used to remove adhesions and scar tissue; and NSAIDS/pain relievers.
If this is a medical condition, why can pelvic floor physical therapy or occupational therapy help?
Pain neuroscience education and central sensitization-In chronic pain conditions, the autonomic nervous system can produce a hypervigilance that perpetuates pain cycles. This is called central sensitization, and it can make pain relief feel elusive. Pelvic floor therapy aims to educate clients about current research in pain science; this education can feel validating and empowering, and studies are suggesting that understanding pain science can help clients with pain reduction.
Self-care around menstruation-If you have endometriosis, you know that your menstrual cycle can be extra challenging. Your pelvic floor therapist will work with you to create a plan around your period pain, which might include brainstorming about lifestyle changes to support pain relief and relaxation; gentle stretches; or breathing exercises.
Pelvic floor relaxation-Many people with endometriosis experience pelvic floor hypertonicity, or overactivity in the fibers on the muscle. This may perpetuate some of the pain or discomfort they are feeling, and contribute to pain with sex. Your pelvic floor therapist will teach you tools for ongoing pelvic floor muscle relaxation.
Pain with sex-If you have endometriosis and you’re experiencing pain with penetrative intercourse, you’re not alone. Through the use of stretches, exercise, breathwork, and therapeutic tools such as a pelvic wand or dilators, your pelvic floor therapist can help address your pain with intimacy.
Endometriosis can be really challenging to manage. Pelvic floor physical therapy or occupational therapy can help educate and empower you, mitigate some of the effects of the condition, and assist in the return to the activities you’ve always loved.
What are hemorrhoids? How do I know if I have them?
Hemorrhoids are swollen blood vessels found internally in the rectum or outside of the anus. These blood vessels cushion the area and protect your anal sphincter and help with closure. Nearly 75% of adults will have hemorrhoids at some point in their lives, often caused by increased pressure in the pelvic region. Causes of this increased pressure may include the weight of your baby during pregnancy, pushing during childbirth, and straining to pass stool. You may also experience hemorrhoids postpartum, as you’re now increasing pelvic pressure by constantly lifting and holding your child. Common symptoms of hemorrhoids may include: blood in your stool, and/or a hard lump and discomfort around your anus. It’s important to check in with your doctor if you’re experiencing any of these symptoms.
Pelvic floor hypertonicity
Maybe you’re already seeking out pelvic floor therapy for vaginismus, dyspareunia, or any other kind of pain with sex. If so, it’s possible that you have a hypertonic pelvic floor. This means that your pelvic floor muscles might hold some overactivity throughout the day. These chronic holding patterns can lead to constipation, which can increase your risk for hemorrhoids. Working with a pelvic floor rehab provider on learning to intentionally relax your pelvic floor can help to decrease some of your habitual patterns, hopefully leading to better stools and decreased hemorrhoid prevalence.
Coordination is key…
Pelvic floor dyssynergia happens when our body unconsciously contracts our pelvic floor when it’s supposed to relax. Ideally during bowel movements, our pelvic floor muscles should lengthen and open, rather than contract. Constantly contracting your pelvic floor muscles while you’re trying to defecate will cause straining and increased pressure on the rectum, possibly leading to hemorrhoids.
Chronic constipation
Chronic constipation impacts 15-20% of the population. Although many people experiencing chronic constipation have pelvic floor involvement, the condition can be caused by a myriad of other factors including not getting enough fiber, movement, and water throughout the day; slow GI motility; chronic stress or trauma; and more. Managing stool consistency through proper evacuation techniques (including using a squatty potty or stool!), diet, exercise, and self-care are some of your best tools in the prevention of hemorrhoids. A pelvic floor therapist can help you parse out and manage some of these factors.
Managing intra-abdominal pressure during defecation
Our entire abdomen is basically a pressure canister that we can use to our benefit or to our detriment. Most of us don’t habitually think about the way we’re passing stool. You may be unconsciously gripping your abdominal muscles and increasing pressure on your pelvic floor. A pelvic floor therapist can teach you methods for reducing this pressure, and for passing stool in a more easeful way.
Hemorrhoids are a nuisance at best, and quite painful at worst. If you live in Jamaica Plain, seeking out pelvic floor physical therapy or occupational therapy can help address the underlying causes of your hemorrhoids, focus on management strategies for the present, and develop preventative treatment for the future.
Pelvic Health Tips for Going to the OB
Going to the OBGYN can feel vulnerable. Here are some tips to make it a little easier:
-Deep 360 degree diaphragmatic breathing. Feel your belly, ribs, back, and pelvic floor expand on the inhale, and let everything relax towards midline on the exhale. Try lightly extending exhales for more parasympathetic nervous system response. Exhaling on a low vowel sound can also feel pleasurable. (You can even just imagine the vowel sound in your head).
-Dancing/intuitive movement. Put on some music that makes you want to move and follow your intuition. See if you can incorporate inner thigh stretching movements, like a deep sumo squat, as well as movement through your rib cage. Elongating the inner thigh muscles (adductors) may help with pelvic floor lengthening, and moving dynamically through your rib cage can help with releasing tension around the diaphragm. Studies show dancing may release more endorphins than regular aerobic exercise, and is great for reducing cortisol levels related to stress.
-Tell a friend. Having someone to pick you up from the doctor, or text when you’re feeling scared, can help alleviate the stress of an appointment.
-Restorative yoga poses. Laying in child’s pose on a bolster or pillows helps bring more proprioceptive input into your stomach. This can help facilitate more relaxation and ease in your abdomen. Sensing into your sit bones moving out towards the sides of your body on the inhale, and back towards midline on the exhale, can help facilitate pelvic floor relaxation.
-Push-open breathing for when you’re at your appointment. In addition to diaphragmatic breathing, it may help to do push-open breathing at your appointment. As the OB or midwife is inserting the speculum, try a diaphragmatic inhale, and on the exhale, keep your belly round and allow your pelvic floor muscles to relax down and out.
-Building a neutral or positive relationship with a speculum. If you’re someone who is concerned with pain or discomfort regarding a speculum, ask for a pediatric one, which is smaller in size. Ask if you can bring one home, and begin to build a relationship with it. This could mean touching it, noticing and naming its objective qualities, practicing having the speculum make contact with your vulva/front hole, or inserting it yourself. Over time, with small simple acts, you can rewire your brain to make neutral or positive associations with the speculum. (I just want to add that it’s okay if you never get there. The speculum has a messed up, racist history, and is baseline uncomfortable for most people. I personally wish we had other tools readily available. I like the look of this redesign.)
-Use a hot water bottle or heating pad for afterwards if you’re feeling any residual discomfort.
What do you do to take care of yourself before or after an OB appointment? Pelvic floor physical therapy or occupational therapy can be a great way to support making OBGYN visits a little easier.
Pelvic Health in the Menopause Transition
Pelvic health physical therapy and occupational therapy can help prepare and support you as your body changes
First: We can help you gain control of your bladder.
As we age, our pelvic floor muscles can weaken, especially during and after the menopausal transition. Some common pelvic floor challenges during this life stage are: urinary and fecal incontinence, urinary urgency and frequency, as well as prolapse symptoms. Your pelvic floor therapist can help you coordinate, strengthen, and relax your pelvic floor and deep inner core so you can participate in the meaningful activities in your life without fear of leaking. And if your bladder is the culprit for nightly wakings, pelvic health physical therapy or occupational therapy can support you to develop useful bladder habits so you can get the rest you need.
Second: We can help with pelvic pain during intimacy
Hormonal changes during menopause can cause vaginal tissue to become dryer and thinner, which can lead to pain with sex. Pelvic floor therapy can help by teaching you how to coordinate and relax your pelvic floor musculature so you can feel more at ease during intimacy.
Third: We can help keep your bowels moving smoothly.
Constipation becomes more common as we age. For optimal bowel functioning, we need the pelvic floor muscles to open and coordinate correctly with the breath. Pelvic PT/OT can help you correctly relax these muscles, and learn better bowel habits to keep you regular.
Fourth: We can help keep you moving and exercising.
After the age of 50, bone density begins to decline. Physical therapists & occupational therapists can also help you maintain and gain overall strength so you can keep doing the things you love. We can collaborate with you on a realistic program to keep your muscles and bones healthy and strong.
Diastasis Recti Rehab
What is diastasis recti?
Your rectus abdominis muscle is the traditional “6 pack” abdominal muscle, and it connects on either side of your body through a piece of connective tissue called the linea alba. During pregnancy as the belly expands, the linea alba stretches and thins, resulting in an increase in the separation between each side of the muscles. Studies indicate that the prevalence of diastasis in pregnancy can vary between 30-70% of pregnant people. Many people recover without any rehabilitation during the postpartum period, although some people may benefit from pelvic floor physical therapy or occupational therapy. Diastasis can occur in people who have not been pregnant as well, due to habits that place increased pressure on the linea alba, including poor core mechanics or straining to pass stool. A functional diastasis is two finger widths apart. If your diastasis is wider than two finger widths, or you’re still feeling disconnected from your core postpartum, it can help to see a pelvic floor physical therapist or occupational therapist.
Why seek help?
Connecting a strong and dynamic core allows you to move through postpartum life with a decreased risk of pain and dysfunction. In early postpartum life, you’re suddenly “strength training” many times a day by picking up, holding, and putting down a ~6-10lb weight (your baby :) ) many times a day. Postpartum rehab will help teach your body to activate more of your deepest abdominal muscle, your transversus abdominis, which will put less strain on your diastasis, and will allow you to feel not only confident in performing your new day to day tasks with your baby, but will give you the support and coordination you need to return to exercise.
What to do?
Many people associate “core exercises” with things like crunches, v-sits, or planks. Ideally, people in early diastasis recovery are not performing those exercises, as they put more pressure on the linea alba. Your pelvic floor therapist will teach you simple ways to use your breath to activate the transversus abdominis muscle, facilitating increased strength. Besides working on deep core strengthening, there are many other important aspects of a person’s lifestyle that are important to address for diastasis healing.
Posture
Posture can play a big role in diastasis rehab. Many pregnant people compensate for the new center of mass by leaning backwards, which can place an increased stretch on the linea alba. Other postural habits that can create more tension on the linea alba are flaring the ribs, excessively anteriorly or posteriorly tilting the ribs, rounded shoulders, and forward head posture. Body mechanics throughout the day, including always holding your baby in one particular way, can also place stress on your rectus muscle. Finding dynamic postures and body mechanics throughout the day can help the abdominals activate more effectively,
Breath holding/Pressure management
Many of us tend to hold our breath when we’re doing something that requires a lot of strength, including picking up something heavy, pushing a heavy stroller, or even putting away groceries. Breath holding can put excessive strain on the linea alba due to increased pressure in the abdominal cavity. It’s important to try to “blow as you go” or “exhale on exertion” and make sure you’re not breath holding when you don’t need to be.
Exercise
Returning to exercise too quickly postpartum, especially heavy weightlifting, can put a strain on your diastasis. Diastasis healing is also about taking the time you need to recover proper core functioning. For some people this is 2 months, for others it looks more like 18 months. Returning to exercise slowly and with the guidance of your pelvic floor physical therapist or occupational therapist will help you know which exercises you can do with confidence and control, and which exercises you need to build back strength for.
Constipation
Managing chronic constipation can become a very important part of diastasis management. People with long term constipation may be used to straining or using breath holding to pass stool, which puts excess pressure on the linea alba. Your pelvic floor therapist can work with you to build better bowel habits to ensure that you’re not straining to pass stool.
So what next?
Diastasis healing is multifactorial, involving proper muscle recruitment and coordination, spinal and thoracic mobility, breathing mechanics, posture and functional movement training, and managing bowel habits.
Is it “too late” to see a pelvic floor physical therapist or occupational therapist?
It’s amazing to see the larger cultural trend of increased numbers of pelvic health providers. There’s more widespread education about pelvic health, pregnant people have more access to preventative care, folks with pelvic pain have more resources to experience pleasure. The list goes on! This is how it should be. But what if your pelvic floor challenges began when you had a baby 10, 15, 30 years ago? Your doctor might have sent you home with some highly prescriptive information about kegels, and maybe that was it. Maybe you were forced to accept that leaking or weakness was just going to be a part of your life forever. Maybe you’re resentful that no one was talking to you about the pelvic floor when your specific challenges began. You might be thinking, “Is there even a point to see a pelvic floor therapist now?”
The answer is: YES! It is NEVER too late.
Will your rehab look different than someone coming in with newer challenges? Yes. Your body may have developed compensatory strategies for dealing with core weakness or incontinence. You may have more ingrained motor patterns that are causing you to walk, sit, or stand in a certain way that exacerbates dysfunction. Although the neural pathways that support motor learning may decrease with age, there’s great research to suggest that continued motor learning is beneficial for cognitive and physical functioning. So attending pelvic floor physical therapy or occupational therapy might be beneficial for your body AND your mind.
In a typical session, your pelvic floor therapist may look at posture, gait, and functional movements like sitting down, standing up, or squatting. We may look at your breathing mechanics, and evaluate the muscle strength of your hip and pelvic floor muscles. We assess more restricted or tense muscle groups and may use manual therapy to support lengthening of the muscle or relaxation.
It’s never “too late” to go to pelvic floor physical therapy or occupational. You don’t have to accept pelvic floor dysfunction as part of your life. You deserve easeful and meaningful participation in the activities that matter most to you, at any age. If you need pelvic floor therapy in Jamaica Plain or Roslindale, give us a call.
Casual Sex with Pelvic Pain
If you’re someone who experiences pelvic pain, vaginismus, or vulvodynia, it probably influences how you approach sex. Often times clients come in experiencing pelvic pain, and they’re in long term, monogamous partnerships. If this is the case, I often spend time asking questions about the dynamic between my client and their partner, and how their partner can help co-create a context where pain free or less painful sex can occur. Within this kind of conversation or intervention, there’s an assumption of the possibility for ongoing communication and difficult conversations. There’s an assumption around an inherent foundation within the relationship built on trust and understanding.
Other times, folks come in, wanting be able to date and sleep around in a more casual way. When this happens, it can be helpful to think about what the expectations around treatment can look like, and how to best proceed. When someone wants to be slutty with pelvic pain, I tend to think of it in three options, that can always feed into each other:
Be open and vulnerable about what you’re experiencing; see if the person can hold the complexity of that
Don’t engage in casual sex until you are having pain-free experiences, either in the clinic or on your own
Engage in sex that does not trigger your pelvic pain
Option 1: Being vulnerable
This is a great option if you a) want to practice being open and honest without shame, for the sake of practicing those skills #badass b) if you’re with someone that you feel you can trust, even if it’s just casual or c) if you’re having sex with someone who might become a longer term connection, even if it’s still casual.
It’s hard to state our needs and to practice setting boundaries. It places you in a position where you might feel more at risk for getting hurt. BUT it can feel empowering to own your experience and try to communicate that to another person. ESPECIALLY if you’re having sex with someone who’s a decent person and who makes it clear that they care about your experience.
Once you decide whether or not this person can hold your experience, you can also discern if you want to try engaging in the kind of sex that might trigger a pain response. Having discussions around safe words and after care can also be part of this disclosure. Additionally, if you end up not being able to have the kind of sex that you want to have, how do you and this other person want to manage potential disappointment together? Can you hold disappointment while pivoting to some other kind of sexy connection? Or do you need space to process and feel your feels on your own? This can be helpful to think and talk through, especially if you’re not trying to develop too much emotional intimacy with someone!
Option 2: Don’t have casual sex until you’re pretty sure it won’t be painful
This is a great option if you’re someone who likes have feel more in control over their experience. If the thought of being vulnerable with a stranger makes your stomach turn, you’re definitely not alone. In pelvic floor physical therapy or occupational therapy, you can work on reducing your pelvic pain, as well as on your own. Tools that can be helpful are movement, dilators, breathwork, nervous system settling, sex therapy, and manual work. As you progress in your journey, you will hopefully feel more confident that you can have the kind of sex you want. Once this feels true, having casual sex might feel more accessible.
Option 3, which can definitely feed into option 1: There’s a million ways to “have sex”
It can feel hard to undo the cultural hierarchy around sex that most of us have inherited to some degree, where sex=some form of penetration. When penetrative sex is placed as the pinnacle sexual experience, and everything else is just foreplay or second tier, it may feel hard to take PIV sex off the table. I think it’s really helpful to question the assumptions we have about what sex should look or feel like. It may be helpful to go through a Yes/No/Maybe list by yourself first to start to envision what a sex life that decenters penetration could look like. This might allow you to approach your sexual encounters with a new found empowerment and understanding around what you want and how to communicate it.
I always say: having pain with sex requires creativity, which can make it more fun! But reflecting on what you want out of casual sexual encounters as someone with chronic pain can definitely help to create a sense of empowerment and safety. Try pelvic floor physical therapy or occupational therapy can definitely help you figure out what tools are right for you!
A pain in the butt
Did you know as embryos, we briefly have tails? Around the 8th week of intrauterine life, the tail disappears. We’re left with a tailbone or coccyx, consisting of 3-5 vertebral segments, sitting below the sacrum at the very end of our spine. The coccyx is integral to the pelvic floor, and vice versa, because some of our pelvic floor musculature attach to the coccyx. Because of these attachment sites, trauma to the tailbone can cause referred pain to other parts of the pelvic floor. And a tight or hypertonic pelvic floor can make it difficult for a coccyx injury to heal.
Coccydynia, or tailbone pain, can occur for a variety of reasons. Difficult childbirth, especially forceps delivery, seems to have higher associations with coccydynia¹. Direct trauma to the coccyx (someone needs to do a study on coccydynia and roller derby players) can also be a common cause. Sitting slumped while feeding your child can also put pressure on your coccyx, exacerbating any pain you might have from the birthing process.
The prevalence of coccydynia, or tailbone pain, is unknown, although it seems to be more common in AFAB (Assigned Female at Birth) than AMAB (Assigned Male at Birth) people, most likely due to birth injuries. The good news is that conservative treatment, including pelvic floor therapy, can be successful in treating up to 90% of cases².
How do you know if you have tailbone pain? You may experience discomfort or pain with prolonged sitting or standing–especially if you are feeding a little one or sitting at work. People with coccydynia commonly experience pain when moving from sitting to standing. Finding the right chair might feel like a nuisance for you: hard chairs are too hard, soft chairs are too soft. It’s challenging to find that “just right” fit.
Pelvic floor physical therapy or occupational therapy can help. Through a combination of postural retraining, manual therapy techniques, breath and pelvic floor coordination, and learning to optimize your core functioning and stability, a pelvic floor OT or PT can support you with alleviating tailbone pain. We can help you strategize about proper adaptive cushioning (don’t use a donut!) and managing constipation. In the meantime, limit your time sitting, stay hydrated, and call us to set up an appointment today.
Lower Back Pain Postpartum
Many people come see a pelvic floor physical therapist or occupational therapist due to lower back pain postpartum, having never experienced lower back pain before. Why are they only now experiencing this? There can be many drivers to lower back dysfunction, especially as a new parent. Here’s some of the things we would look at:
How is your core functioning: Most postpartum people could benefit from some core rehabilitation after pregnancy. A strong core helps support good body mechanics to prevent lower back pain. If you are experiencing diastasis rectii and/or had a c-section, you may need even more support activating your core in order to protect your other muscles from overcompensating during harder movements.
How are your glutes functioning: Many people experience some glute weakness due to postural changes during pregnancy. In order to protect the low back when lifting your baby, your glutes need to fire effectively.
How are you breathing: Did you know the diaphragm, our main respiratory muscle, connects to the front and the back of your body? This means that when the diaphragm is working optimally, we should have 360 degree expansion of our torso. True diaphragmatic breathing can help restore range of motion and lengthen tissues in your back body. Most of us are shallow, chest breathers, which can restrict range of motion in the low back.
How are you lifting? Think about the literal movements your body made throughout the day before your baby was born. Maybe you went for walks, occasionally lifted groceries to the counter, occasionally bent down to pick up some trash on the floor, worked out a few days a week? When you’re newly postpartum, your body is making repetitive movements that it might not be used to, especially when it comes to lifting. How many times a day are you picking your baby up and putting them back down? You’re suddenly a full-time athlete in a sport that you might not have trained for! Most of us don’t naturally coordinate our posture, core, and breath in order to optimize lifting strategies to prevent low back pain.
How is your posture? Most newly postpartum people are understandably tired and newly adapting to the baby’s routines and rhythms. Depending on your labor, different parts of your body may be sore or tender, resulting in new postural patterns. Additionally, your body may still be accommodating postural changes that occurred as compensations during pregnancy. Think of your new daily routines–are you suddenly sitting on the couch way more, without a lot of lumbar support? Are you rounding your back more when you feed your baby? Posture throughout the day can have a big impact on the lower back overall.
How is your pelvic floor? Did you know that parts of the deep pelvic floor attach to the sacrum and coccyx, aka the bottom of the spine? A hypertonic or overactive pelvic floor is very common, and can contribute to lower back pain.
How often are you having a bowel movement? Constipation in the early postpartum stage is very common! A distended, impacted rectum can irritate the muscles of the pelvic floor and low back.
How is your nervous system? The transition from pregnancy to labor to postpartum can be wonderful, but also challenging. If you find the newly postpartum period stressful or tiring, you’re not alone. Our nervous system plays a huge role in how we manage and interpret pain signals from our bodies. Additionally, stress can manifest as tension in the muscles of the low back.
There are so many understandable reasons why you may have low back pain postpartum. Pelvic floor physical therapy or occupational therapy can be a great resource for getting you back to functioning.
Can I just journal my way out of chronic pain?
There are so many ways to work with chronic pain, and there’s research to support many different modalities. Expressive arts therapy, acupuncture, listening to music, meditation, and spending time in nature, all have studied benefits for reducing chronic pain.
If you’ve been in chronic pain long enough, at some point or another, you may have come across a well-known and controversial book, Healing Back Pain by John E Sarno. Sarno theorizes that folks with chronic back pain who, after repeated testing, have no discernible pathologies, are suffering from what he calls Tension Myositis Syndrome, also known as TMS. Sarno suggests that chronic pain is a manifestation of the subconscious mind in response to repressed emotions, especially anger. The pain is meant to distract you from feeling these intensified emotions. This results in an autonomic nervous system response that slightly deprives oxygen to the tissues, contributing to the feeling of pain.
TMS healing protocol involves some degree of education about how pain is processed (aka pain is created by the brain, not the body). It involves a return to “normal activity,” encouraging mindset shifts around the psychological nature of pain. And a large part of the healing is…journaling.
Sarno and his proponents think that your pain will only resolve when you deal with your unprocessed and unresolved emotions. There seem to be a few TMS-based journaling techniques, but many involve writing a list of all the things that cause stress or anger in your life, past or present, and taking the time to write about them. Others just suggest writing about your day, and about the challenges and emotions associated with the day. The point is to find a safe space to express unprocessed emotions.
So if you’re asking, is TMS an evidence based theory? The answer is…no. I found one study that showed a positive effect when 51 patients used a TMS protocol, but that’s too small of a study from which to glean large scale conclusions. Is there evidence to support expressive journaling for chronic pain? Most certainly. Do we know that the mind-body connection contributes to the perception of pain? Definitely! But I don’t buy the physiological underpinnings of Sarno’s theory, and I don’t buy a one-size-fits-all pain resolution approach.
Is it for everyone? Why the vast appeal?
From my research, it seems like a lot of folks who are interested in TMS are now applying the concepts to research around pain neuroscience. So even if the theory in and of itself is ~off~, people are justifying it in certain ways by talking about biopsychosocial approaches to pain, and nocioception (see past newsletters if you’re not sure what I’m talking about!). The Curable App, which many of my clients have found useful, is founded on principles of TMS.
Ableism and self-healing
There’s this certain strand of ableism that can be embedded within TMS theories, where if you just work hard enough, you can cure yourself. This doesn’t take into account many social determinants of health, how bad healthcare is in this country, and how hard it might be to work on healing your trauma if you live in an environment without clean water, air, food, and relative safety and stability. The rugged individualism of ~self-healing~ leaves so many folks out of the equation. Healing is relational, and most of us need more support in order to develop more skills for working with pain, chronic stress, and illness.
No one size fits all approach
Do you love to journal? Maybe you should do it then! It’s associated with decreased stress and pain scores. But do you open a notebook and feel dread, guilt, fear, boredom? Then let’s try something else that maybe fits your needs better. To prescribe a one-size-fits-all approach to healing chronic pain only further isolates folks for whom these these protocols don’t work. I encourage my clients to do the kind of nervous system work that brings them pleasure. I enjoy writing, but I certainly don’t want to wake up every morning and spend 20 minutes writing about the worst and most stressful parts of my life, as some TMS experts suggest. Doesn’t feel very trauma-informed to me.
Expectations matter
So why do so many people swear by TMS? EXPECTATIONS MATTER. Evidence shows an association between expectations around treatment and treatment results.
When you’re in chronic pain, and a very confident person tells you they know EXACTLY what’s going to make you feel better, what do you have to lose by buying in?
I prefer living in a murkier world, where we can hold the complexity of the mind-body connection without reducing it to something as simple as TMS. Everyone could benefit from some nervous system resilience, sure, and also unions, fair wages, more time off, and more connection to supportive people and the earth, etc. I’m never going to tell a client that I know precisely why they have chronic pain, and I know exactly how to fix it. Let’s honor the fact the healing is often a windy journey of trial and error, and that you get to discover what works best for you.
Learning to Breathe Again Postpartum
After your child is born, you may find that you suddenly have to readjust to many new body mechanics, including learning to breathe again. Many pregnant people can struggle to regain control over their breathing mechanisms, and can find it difficult to reconnect to their diaphragm–muscle that helps us draw in air even when we aren’t conscious of its hard work.
The “Why”
Many people develop a rib flare during pregnancy to compensate for core instability and to feel like they have more “room” to breathe. With ribs in this hyperextended, position, it becomes harder to engage the full range of motion of the diaphragm. Many pregnant people develop a ribcage positioning pattern in which their ribs can feel a little “stuck,” making it harder to feel like you’re taking the deepest breath possible. This hyperextended “stuck” rib cage also makes it more difficult to engage your core, as you are putting the core muscles on a stretch. Additionally, your rib cage often widens during pregnancy by 2-5 cm. The combination of this new, widened rib cage, alongside a more flared rib position, may make it difficult to feel like you’re taking the deepest breath possible.
Postpartum Breathing
You’ve just had your baby, you’re exhausted and adjusting to one of the biggest transitions in your life. Maybe you’ve noticed that your body feels a little awkward, and returning to the breathing pattern you had pre-pregnancy feels challenging or impossible. What can you do?
Find the bucket handle and the pump handle
The motion of the ribcage is often discussed in terms of a bucket handle and a pump handle. Your bottom, floating ribs tend to move out towards the side of your body on the inhale, similar to a bucket handle. You can feel this more by cupping your rib cage in a C-shaped grip, with your thumb towards your back body and the rest of your hand cupping your ribs in the front. You can also use a band to wrap around your ribcage as well. Can you feel the ribs expanding out towards the side on the inhale? Accessing more of that lateral breathing will help support diastasis healing and postpartum core rehab.
The other movement of the ribs is more of an up and down movement, like a pump handle. It’s important to note that this motion comes from both the front and back body. It sometimes helps to pay attention to your sternum, connecting both sides of your ribs. Can you feel it rise like a pump handle on the inhale, and then fall back down on the exhale?
Ideally, diaphragmatic breathing looks like this 360 degree expansion, with the ribs moving laterally as well as up and down.
What could be impacting your ability to find full rib cage expansion?
If you’re early postpartum and feeling like you cannot access this sensation of 360 diaphragmatic expansion, you’re not alone. There are many things that are occurring in early postpartum life that could make it hard to access full range of motion of the diaphragm, including:
-Fatigue/exhaustion
-Postural dynamics, including forward head and rounded shoulders
-Pelvic positioning (either anterior pelvic tilt or posterior)
-Lack of core stability
What can you do
Finding an expansive diaphragmatic breath is an important part of postpartum rehab. It impacts the ability to find your core strength, as well as support proper pressure management techniques in order to support your pelvic floor. So what can you do?
Sometimes it’s helpful to go into exaggerated postures in order to develop a felt sense of their impact on their body. Here’s one common pregnant and postpartum posture: bring your pelvis all the way forward so that your lower back arches. Extend your rib cage up and open. Try to take a deep breath here. You may find that your abdominal muscles feel too stressed, and that there’s no room for the diaphragm to expand.
Now play with a more optimal posture. In sitting, find pelvic neutral, with the sensation of your sit bones connecting to the chair or the ground. Your front hip bones and your pubic bone should be sitting on the same frontal plane, with neither too far forward or back.
Come sense into your ribs. Align your rib cage over your pelvic. Tuck your ribs down, and sense into a heavy sternum. You may find from just this adjustment that you can feel your core a little bit better.
Now, try to take a deep diaphragmatic inhale. Go slowly, through your nose, and count to five. It sometimes helps to look in the mirror to see what’s happening. Do you see a lot of movement in the shoulders and neck? Try to soften it. Find that lengthening quality in your front, sides, and back body, right underneath your rib cage. Hopefully you’ll now find that it feels like there’s more “room” for your breath.
Neuromuscular patterns that got codified in pregnancy are sometimes challenging to unlearn. Playing with posture and 360 degree diaphragmatic breathing can make it easier for you. If you’re finding that certain areas of your body feel “too tight” to find that 360 breath, you benefit from pelvic floor physical therapy or occupational therapy, which will help you strengthen, lengthen, and coordinate the right muscles in order to access the deep breath you’re looking for.
What if time plus effort doesn’t always equal progress?
What if time plus effort doesn’t always equal progress?
There’s a longstanding assumption within rehab fields that with concerted practices, exercises, or ~work~, over a distinct period of time, change and success will flourish. A lot of this (I think) is derived from some of the pitfalls of how scientific studies work in a profit-driven society. Universities and research groups only have a certain amount of money to perform a certain set of interventions over a certain period of time. So we’re left with an assumption that these interventions and time periods are translatable to the person standing in front of us, which often robs the person of their unique complexity.
A theme that’s come up in my work with several folks lately is something we all know innately: healing is non-linear. But I want to break that down a little more to identify some of the assumptions we can make when trying to move towards goals in rehab, especially regarding pelvic pain, trauma, or any other kind of pelvic floor dysfunction.
When effort has a sympathetic charge
There’s a high correlation in pelvic pain research between anxiety and/or trauma, and pelvic floor dysfunction. What happens if/when the subject of a person’s sense of hypervigilance is their own healing? Especially in such a time-scarce culture, healing can feel like another part-time job required to feel better. There are times when I think this is can be necessary. But when our movement towards some kind of change in our bodies is driven by the same stress that contributes to the pain in our bodies, how can we reorient towards another approach?
As we have moved towards more commodified wellness industries, what are the ways our expectations of perfect health and wellness, often fueled by hyper-individudalism and ableism, reinforce a sense of fight and flight in the body? That’s why I’m so focused on accessibility in my work: how can we make this as easeful as possible? Our lives are hard and complicated enough. What is that one small, bite sized thing that you know you can commit to? How can we work towards some level of consistency, rather than only trying to do our home program when we feel like we have a full 30 minutes available?
What’s your relationship to effort? When you think of working towards a goal, does it feel all or nothing? How do you ask for support, whether through friends, therapists, or other resource, to guide you in your goals?
The body often clings to what it knows, even if it’s not serving the person, because it feels safer. How do we continue establishing safety in order to move towards something different?
Healing and Time
I’ve written about this before, but as Americans, we are obsessed with linear time. The calendar and the clock drives our actions, the way perceive change, and what we expect out of seeking help.
We have this idea that if we can apply enough effort towards our goals over time, that we will inevitably seek success or progress. But what if there are so many unpredictable factors that impact how our body integrates any change work? When I worked in early intervention, it was quite common that a family would go on vacation and suddenly see a strong growth spurt in terms of motor and language skills in their little ones. There could be so many factors influencing this, but it was a great example of how we can’t always control how and why work integrates. What does it look like to trust the non-linearity of healing? Here are some examples of “random” life changes that could positively influence a person’s pelvic healing timeline:
-An important conversation with a friend
-A small dietary change that leads to pooping more
-Moving to a different department at work
-Walking a lot on vacation
-Wearing a sleep mask
-Joining a choir
-Getting more childcare
-Taking an art class
-Weather changes
-Getting a dog
-Reading a validating book
-etc.
We don’t know and can’t say how many factors, contexts, or other influential practices could impact us. When you go to pelvic floor physical therapy or occupational therapy, the home program is just one container of healing, and your life is the rest. I’ve seen expedited changes in healing journeys come from a person moving homes, starting a new trauma therapy, changes in work/life balance, relatives coming to live with a person, a new romantic relationship, etc. We have to make room for life to unfold unpredictably so we can develop the kind of relationship with progress that doesn’t see it as something we’re entitled to, but rather something that unfurls with grace and messiness if we give it enough gentle attention.
A relational approach to chronic pain
What could a relational approach to chronic pain look like?
There are so many methods and approaches to working with chronic pain/pelvic pain. One that I’ve found particularly useful for clients is actually learning about the biological mechanisms of pain, and then learning how to relate to the pain differently overtime. If you’re someone who suffers from chronic pain, I think it’s always helpful to ask-What are my assumptions about what pain “means” or how it acts in my body? What thoughts, feelings, and behaviors come up when I think about my pain? As we start to elucidate some of these associations with pain, we can get clearer about what’s actually happening in the body, and have more agency in terms of how to work with it.
When I start asking clients questions about their assumptions about pain, it’s often assumed that pain is a result of something bad in the body that needs to be “fixed.” For many years, rehab clinicians and manual therapists have said “the issue’s in the tissues,” but we know that’s only part of the truth.
Pain is not just “in your head” but it’s not just “in your body” either/Pain Science 101
Take a moment to pause and consider what you understand about pain. It’s really easy to think that pain is something that comes from the skin or tissues when we consider a paper cut. There’s a painful stimuli that shows distinct damage to some part of the body, followed by unpleasant sensations.
The body itself does not have pain neurons. The body itself does not “detect pain”. We have what are called nocioceptors, which help detect danger. These neurons then send this signal through the spinal cord, and into the brain. The brain then interprets, based on many factors and associations, whether or not to make this stimuli “pain.” We’re talking about memories, contexts, social factors, past experiences of pain, etc. In a split second, the brain can then “decide” to send neurochemicals back down to the body, which we then experience as pain.
With chronic pain, the central nervous system becomes more intensely attuned to these danger signals. Chronic pain is thus an evolutionarily protective response, designed to help protect us from experiences that could threaten our lives.
So once we understand that pain does not necessarily mean distinct tissue pathology, that something is “wrong” or “broken”, we can get really curious. It may help to redefine chronic pain. What if we defined chronic pain as a mind-body system habitually and automatically attuned towards protecting us from uncomfortable and negative stimuli?
We know through neurobiology research that we are hardwired to notice and remember negative stimuli/memories more than positive stimuli/memories. This is why, although research is still burgeoning, I’m interested in somatic approaches to chronic pain. If we can orient the nervous system towards pleasure or neutrality, can we build more positive associations with sensation and embodiment, thus shifting some of the brain’s interpretive networks around pain?
This is where I’m working on developing a relational approach to working with chronic pain/chronic pelvic pain. When folks hear about embodiment or somatic approaches, I think there’s often shame or confusion about “how much” or “how often” a person is “supposed to be” embodied. I think this can create its own kind of hypervigilance about this way of being in the world. But when we think of embodiment as an output of curiosity, creativity, and relating, more space opens up.
I sometimes give the analogy of building a budding friendship. Consider questions like, what makes me feel drawn to this person? How does that interest show up in my nervous system?
And making a new friend can feel vulnerable. So when you’re thinking about reaching out, maybe you delay it when you’re in a weird spot, have increased stress, or have family in town.
And think about pacing when building a new relationship. Most people don’t decide to be friends with someone and then start texting them all day. It takes time, and it’s a dance of connection and disconnection, space and togetherness.
And when we’re developing a new friendship, it’s often easier when we have older, easier relationships to return to. This helps us remember who we are and how we like to be with others.
So how can we similarly think about building a somatic relationship with chronic pain? You can get really curious about the pain. Build a slow rapport with your dynamic felt sense over time. Give it space and allow yourself to disconnect. Gradually develop more easy access to pleasurable resource within the nervous system.
We can then start to think of relating to sensation in the body as part of a larger ecosystem or community. When pain flairs, what else is there to support you? Finding new, felt-sense ways to build relationship with this web of support can bolster you when pain inevitably arises, and possibly change the brain’s perception of pain overtime. We can then also consider our wider webs of support outside the body, which could include: the relationship you have with a therapist or rehab professional, social supports, spiritual resource, and more.
Understanding pain management as relationship building can give us the opportunity to learn new, gentler ways of approaching chronic pain. This can allow us find organic ways of “being with” our pain that doesn’t overextend or deplete us. We can learn to follow our subtle impulse in connecting to our body, expanding our capacity to stay embodied when pain inevitably arises. When we can access the creativity and curiosity that relating requires, it can bring us out of our stress responses associated with a pain flair, and into a space where there might be more agency over our direct experience.