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The Other ‘Baseline’

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By Megan Hixson, PT, DPT, CSCS, and Melissa Baudo Marchetti, PT, DPT, SCS, MTC

Do you sometimes leak or have the urgency to go to the bathroom as  soon as you hit the court or during exercise? Maybe it’s just nerves. Or, maybe it’s something more. Have you ever leaked when you sneeze, laugh or cough? Do you have pain in your pelvic region when you exercise or play tennis? Have you previously had a baby? Do you have a history of low back pain, SI joint pain or hip pain? You talk with your friends, and they share your gripes about the discomfort and inconvenience. If so many others have experienced it, it must completely normal, right? Wrong! Urinary leakage and urgency are not normal functions of our bodies, and even though it can be common, it’s not something that should go untreated.

The problem could involve your pelvic floor muscles. Pelvic floor dysfunction is common in active women — especially among female athletes who participate in high impact sports — and can affect women who have or have not given birth. You may be surprised to hear that even men can struggle with pelvic floor dysfunction. Statistics show that one out of every five Americans will experience some type of pelvic floor dysfunction in their lifetime and more than 25 million will have urinary incontinence (involuntary leakage). The National Institutes of Health reported that approximately 25 percent of women have pelvic floor dysfunction.

What exactly is the pelvic floor? The pelvic floor is made up of three layers of muscles that sit within your pelvis. They have four primary functions: 1) urine and bowel continence (the pelvic floor muscles contract involuntarily in healthy people to make sure you don’t accidentally urinate); 2) sexual function; 3) support for the pelvic and abdominal organs (think of these muscles as a hammock that hold up the abdominal organs); and 4) core and pelvic stability. The pelvic floor muscles are important because they are a part of the deep core system. While you may have thought your core was just your abs, core muscles actually run deep along the spine and pelvis. They consist of: the diaphragm (the muscle we use for breathing) at the top, the transverse abdominus from the front, the multifidus muscles that run posteriorly along your spine from the back, and the pelvic floor muscles from below. These muscles create a canister within our core that provides stability. The pelvic floor muscles are connected to the pelvis, the lumbar spine and the hips, so without good pelvic floor function and control, your core stability will be compromised, regardless of how many sit-ups or planks you do.

How does the pelvic floor work during exercise? When we move during sport activity, the pressure in the abdomen increases. As this occurs, the pelvic floor (the hammock/sling system) responds to the load and increased pressure, enhancing stability in our pelvis and spine. Research shows a normal pelvic floor contracts (lifts) automatically prior to any type of movement, whether you are running cross court or just volleying back and forth. The ability of the pelvic floor to not only lift but also lengthen and respond to impact (like jumping and cutting) is critical for spinal support as well as bowel and bladder function. When the pelvic floor is not functioning well, it may stay over-active and chronically lifted, or just give up and not lift at all. This results in pelvic floor dysfunction; when intra-abdominal pressure increases (i.e. during the tennis serve, running cross court or even laughing), leakage of urine or feces may result. Remember how we mentioned earlier that the pelvic floor muscles are connected to the lumbar spine and hips? If an underlying pelvic floor issue is not resolved or goes undetected, it may contribute to persistent low back, SI joint and/or hip pain, which not only affects your performance on the tennis court, but also your performance with daily activities as simple as walking, lifting and caring for your family.

Does pelvic floor dysfunction only apply to women? No, it’s very common in men as well and many pelvic health physical therapists treat both men and women.

How can physical therapy help with my possible pelvic floor dysfunction? A physical therapist who specializes in pelvic floor dysfunction and pelvic pain is able to assess the ability of your pelvic floor muscles to contract properly utilizing real-time ultrasound, or she may manually assess your pelvic floor to determine the system’s ability to work correctly. Urinary or fecal leakage, urgency and pain are the result of different types of pelvic floor dysfunction. The muscles of the pelvic floor may have difficulty contracting, they may be weak or they may be tight and unable to relax. Many times the issue is more of coordination and control, so learning how to use these muscles in the right way is important in restoring normal function. Regardless of cause, your physical therapist will tailor your program to your specific needs. Your PT will utilize techniques, including manual therapy and massage, breathing techniques and stretching to facilitate muscle relaxation if the pelvic floor muscles are overactive or tight (hypertonic). If the pelvic floor muscles are found to be too weak or underactive (hypotonic), techniques and exercises that facilitate good muscle activation would be implemented so the deep core and pelvic floor muscles can work together as a system to restore normal function.

You may have been told that to prevent or to improve urinary leakage you should do Kegel exercises. While Kegels may be helpful, not all people or all exercises were created equal. If your pelvic floor dysfunction is due to tightness, over-activity or poor coordination, doing Kegels could make your situation worse. A thorough evaluation by a skilled physical therapist who understands pelvic floor dysfunction will outline which interventions are best for your specific case. Your PT will implement a plan of care that is tailored to your needs in order to get you back on the court — without leaking!

Should I see a pelvic physical therapist or women’s health specialist? If you have recently had a baby, regardless of C-section or vaginal delivery, it is important for you to be cleared by a pelvic physical therapist in order to prevent pelvic, low back or hip pain. You may not have pain now, but it may develop as your baby gets bigger and heavier for you to lift, or you could have a diastasis recti, which is a separation of the abdominal muscles. Diastasis recti is treatable and pelvic PTs are well trained in how to restore your postnatal body.

If you are already seeing a physical therapist for your tailbone, hip or back pain and they are not trained to evaluate your pelvic floor function, have your current PT co-treat with a pelvic PT so together they can help you achieve your wellness goals.

While many of the above symptoms can be difficult or embarrassing to talk about, the good news is pelvic floor dysfunction is manageable with conservative treatment for most people, so a consultation with a pelvic health physical therapist will be worth it. In many cases, you may directly see a physical therapist without a referral, or you may contact your physician or OBGYN to seek a referral to a pelvic health specialist in your area. For Atlanta residents, visit onetherapy.com for more information or locate a pelvic health physical therapist in your area at womenshealthapta.org/pt-locator.