Author Archives: LilaAbbate

Toilet Heights and Chronic Constipation

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Chronic constipation affects many Americans at some point in their lives.  “Chronic constipation can be caused by several conditions: colonic disorders, pelvic floor dysfunction or secondary constipation. Causes of secondary constipation include colon cancer, endocrine conditions (e.g., diabetes mellitus, an underactive thyroid gland), medications (e.g., narcotics) or neurological diseases (e.g., Parkinson’s disease, multiple sclerosis). Colonic disorders cause constipation when the movement of contents through the colon and/or colonic sensation is disturbed. The colonic disorders include irritable bowel syndrome (IBS), which is often associated with constipation, and slow-transit constipation.” 1

It has been thought that poor dietary intake can also be a leading factor in chronic constipation.  It may import to monitor your fiber and liquid intake in order to eliminate the toxins and residuals of what we ingest.2However, who would think that your toilet height would be contributing to your chronic constipation?

Westernized seating has produced ill effects on evacuation.  The introduction of the toilet bowel is a necessary seat.  They are now indoors, come in several heights, colors and are surrounded by, at times, beautiful décor and tile.  However, it can prove a difficult place for elimination for shorter-stature people and children.  Proper bowel elimination seating can create appropriate relaxation of the pelvic floor muscles which can lead to successful defecation.  When you sit on the toilet, your knees may need to be higher than your hip bones.  There should be a greater than 90 degrees angle created at your hip that can help you relax your muscles enough so that you can have full pelvic floor muscle relaxation.

toiletposture

A pelvic floor physical therapist is able to help you to determine if your muscles are part of the problem of your chronic constipation problems.  While there are many facets to pelvic floor muscle problems relating to chronic constipation, a relatively quick muscle activity assessment in sitting, using computerized-biofeedback, with your hip and knees at different heights can help you determine the best position for muscle relaxation during defecation.

What is a quick solution to this problem if you can’t change the height of your toilet bowl?  Think about using a stool, or a large book you can place your feet upon to change your hip/knee angle.  Children should definitely be given a stool if their feet are dangling.  If this quick fix is not solving your problem and you have seen several doctors for chronic constipation, there may be a muscle dysfunction that can be the cause.   A physical therapy assessment could be just what the doctor ordered.

Lila Abbate PT, DPT, OCS, WCS

References:

  1. http://www.mayoclinic.org/constipation/.  January 6, 2011.
  2. Annells M, Koch T. Constipation and the preached trio:  diet, fluid intake, exercise.  Int J Nurs Stud. 2003: Nov, 40 (8):  843 – 852.

Endometriosis and Physical Therapy

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Endometriosis is the growing of endometrial cells (cells of inner lining of uterus) outside the uterus. It affects 2% – 10% of women in general population in the North America 1, and 71% – 87% of women with chronic menstrual pain2. Women with endometriosis typically experience pain in the abdominal and pelvic region, and the pain can also affect lower back and refer to lower extremities2. While the medical and surgical treatments help with the pain associated with the endometrial implants, women with endometriosis can still suffer from pain associated with adhesions and scarring of the tissues.

Women with endometriosis who suffer from pain over time can also develop pelvic floor dysfunction. The pelvic floor consists of muscles, connective tissues and supporting ligaments. They form a sling from the pubic bone to the coccyx (the tailbone), and function to support the internal organs as well as assist with sphincter and sexual functions. People with pelvic floor dysfunction may have muscles that are too weak, in spasm or too tight. Additionally, women with endometriosis may have adhesions and scar tissues that further impair the pelvic floor muscle and connective tissue functions.3

A co-contraction of pelvic floor muscles and abdominal muscles during functional activities is normally desired, unless there are dysfunctions present in the musculature.  Women with endometriosis generally undergo laparoscopic surgeries, which leave behind painful scars and inflamed muscles on their abdomen. The presence of muscle trigger points and adhesions may be the limiting factors to the normal co-contraction.3

In general, pelvic floor muscle dysfunction is more difficult to diagnose secondary to the internal anatomical position of the muscles. A comprehensive evaluation done by a properly trained physical therapist is essential for women with endometriosis to determine whether they would benefit from the treatments. Therapists in New Dimensions Physical Therapy are trained in evaluating and treating problems relating to pelvic floor muscle dysfunction, as well as other general dysfunctions. Make an appointment today to schedule a physical therapy evaluation with us, and start the process of returning to pain-free lifestyle!

Lila Abbate PT, DPT, OCS, WCS

References:

  1. Endometriosis. Rockville, Md: National Institutesof Health, National Institute of Child Health and Human Development, US Department of Health and Human Services; 2002. NIH Publication 02-2413.
  2. Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009
  3.  Herzig N, Stein A. Physical Therapy and the Treatment of Endometriosis. IPPS. 14(2): 1-2.

Post-Stroke Urinary Incontinence

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So, you’ve had a stroke. In the aftermath, you may have found that one side of your body has become rebellious against your desires, making everyday tasks seem infinitely harder than they ever were in the past.  But, if that weren’t frustrating enough, you could also be experiencing some bladder-related issues. Maybe you have trouble holding in your urine when you laugh, cough, or sneeze (stress incontinence) or you are simply unable to control the urge to urinate when it comes on (urge incontinence).  If you have these issues, you are not alone.  The prevalence of urinary incontinence one week after a stroke has been estimated at 54%, with 32% of people still experiencing problems over a year out2.

The good news is that urinary incontinence after a stroke is treatable, and taking action even a few years afterward to address it has been proven to improve outcomes4.  If you are experiencing the symptoms of stress incontinence as described above (i.e. urinating while coughing) or a mixture of stress and urge incontinence, there are exercises that your physical therapist can teach you to help you fix these problems.  Two different studies have been published specifically showing that strengthening the muscles of your pelvic floor (think: Kegels) after a stroke significantly improves urinary symptoms, including frequency of urination, urine leakage, pelvic floor muscle strength, and overall quality of life5,6.

In addition, if you are experiencing the symptoms associated with urge incontinence (i.e. as soon as the urge to urinate hits you, it cannot be suppressed), there are ways your pelvic floor physical therapist can help with this as well.  Two separate studies published in 2014 showed that using transcutaneous electrical nerve stimulation (TENS) with people who experienced urge incontinence after a stroke significantly improved in urinary urgency, nocturia (waking up at night to urinate), frequency of urination, and overall quality of life1,3.  This process simply involves very low voltage electrical impulses to be transmitted via electrodes placed on the skin.  This is a non-invasive, convenient, outpatient treatment that is only performed for 30 minutes per day as few as 2 times per week, and has been proven to be effective even up to 3 years after a stroke.

Urinary incontinence is a prevalent side effect of a stroke, but all too often it goes untreated.  However, with the help of a skilled physical therapist, you can significantly improve your symptoms.  Contact us today to set up an evaluation with one of our specialized physical therapists.

Lila Abbate PT, DPT, OCS, WCS

Justine Payne, PT, DPT

References:

1.Guo Z, LiuY, Hu G, Liue H, Xu Y. Transcutaneous electrical nerve stimulation in the treatment of patients with poststroke urinary incontinence. Clinical Interventions in Aging, 2014;9:851-856.

2. Kolominsky-Rabas PL, Hilz MJ, Neundoerfer B, et al. Impact of urinary incontinence after stroke: Results from a prospective population-based stroke register. Neurourol Urodyn 2003; 22: 322–7.

3. Monteiro ES, Coin de Carvalho LB, Fukujima MM, Lora MI, Fernandes do Prado G. Electrical Stimulation of the Posterior Tibialis Nerve Improves Symptoms of Poststroke Neurogenic Overactive Bladder in Men: A Randomized Controlled Trial. Urology, 2014;84(3): 509-14.

4. Rotar M, Blagus R, Jeromel M, Skrbec M, Trsinar B, Vodusek DB. Stroke Patients Who Regain Urinary Continence in the First Week after Acute First-Ever Stroke have Better Prognosis than Patients with Persistent Lower Urinary Tract Dysfunction. Neurourology and Urodynamics,2011; 30:1315-8.

5. Shin DC, Shin SH, Lee MM, Lee KJ, Song CH.  Pelvic floor muscle training for urinary incontinence in female stroke patients: A randomized, controlled and blinded trial.  Clin Rehabil, 2015 [Epub ahead of print].

Thoracic and Rib Pain

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Do you suffer from thoracic or rib pain that seems to be relentless?  Has breathing or turning your head and trunk become a chore?   Ribs can become displaced with some minor force.  While they never really go out of place that it would be detected on an x-ray, the ribs can come too close each other and the muscle in between two ribs can go into spasm.  This can cause a chronic, achy pain that seems relentless and breathing can become uncomfortable.  While rubbing the area of pain can make it feel momentarily better, physical therapists can complete rib mobilizations, massage of the intercostal muscles, myofascial release and use modalities to eliminate the pain and return the rib to normal placement.

There are 10 stable ribs, and 2 floating ribs in which the skull attaches above and the appendages of the upper extremities attach to the sides and the pelvis attaches with the spine below.  Neck and shoulder pain can be alone or combined with the rib pain.  Lifting your arm over your head to reach in the cabinet, comb your hair or throw a ball will have a direct impact on your ribs.  A rib dysfunction can be a contributing factor of chronic low back pain.  Despite a massage, a strengthening or a stretching program, low back pain that continues to return may be caused by a long-standing rib problem.2

Physical therapists specialize in muscle and nerve dysfunction throughout the body.  The body is a complex and intricate puzzle that requires biomechanical observation skills, along with the hands-on interventions to treat that dysfunction.  Physical therapists at New Dimensions Physical Therapy are skilled to do just that!  Make an appointment today to return to a pain-free lifestyle.

Lila Abbate PT, DPT, OCS, WCS

References:

  1. http://en.wikipedia.org/wiki/Human_rib_cage, January 6, 2011.
  2. http://www.sidysfunction.com/articles/structuralribdysfunctions.html, January 9, 2011.

Stress Urinary Incontinence: A Surprising Problem in Female Athletes

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Long before I knew anything about pelvic health as a physical therapist, I was 19 years old and at the peak of my athleticism running cross- country for a division one school. In my last half mile of my races, I always gave it my all to the point I felt like I lost entire control of my body. Like clock work, some urine would start running down my leg. I always had my token extra pair of shorts to change into shortly after I crossed the finish line. It was not an uncommon occurrence among my teammates. It was something no one really talked about, but if brought up, we just laughed and said it happens to all of us sometimes.

These conversations may not be as uncommon in groups of female athletes as we might think. In fact, leaking urine may become a “badge of honor” or laughable matter to some athletes. Reebok CrossFit recently was criticized for uploading a viral YouTube video that was perceived by some that peeing during workouts is not a large concern.

Every athlete in the above video is describing symptoms of stress urinary incontinence (SUI). SUI is defined as the involuntary leakage of urine with exertion such as coughing, sneezing, laughing, lifting, jumping, or any form of exercise.1 Weak pelvic floor muscles are a common cause of SUI but other causes of SUI include pelvic floor muscle damage, hypermobility of the urethra, too much repetitive straining such as pushing over a toilet, chronic cough, neurological damage, and a decrease in estrogen during menopause.2

Examples that you may be experiencing SUI as an athlete are:

-If you leak urine during a squat

-If you jump during sport and notice urine leakage

-If you find urine on your underwear after a run.

You do not have to be a post- partum woman or considered in your later years to have SUI. SUI can affect any age bracket ranging from teenage girls to women over the age of 65. Female athletics has drastically increased in the past 20 years. Now more then ever, females are heavily participating in sports. In a study of 86 high school and college athletes, 28% reported SUI during sport and 92% of those with urinary incontinence never reported their symptoms.13 Another study that included 144 college varsity athletes, showed 28% of them also reported SUI during sport, with the most prevalent sport being gymnastics.1 The most common activities to produce leaking were jumping, high impact landings, and running. SUI can become a large embarrassing problem, especially for sports involving minimal tight clothing like gymnastics and figure skating.1

Two common risk factors for SUI if you are a female athlete, are intensive exercise and eating disorders or a combination of both. SUI in eating disordered athletes has been shown to be significantly higher than in healthy athletes.14 The “female athlete triad” can occur with overtraining and poor nutrition related or non related to disordered eating. If you are experiencing increased fatigue with workouts, irregular menstrual periods, or increased stress fractures you should seek appropriate medical care due to possible problems with the female athlete triad.5 All of the above factors can increase your risk of developing SUI.

Female Athlete Triad: 5

triad

One of the most common coping strategies used by female athletes for SUI is use of protective pads. Frequent toilet visits and limiting fluid intake are also common coping mechanisms. Frequent toilet visits may lead to increased urinary frequency that can cause the addition of urge incontinence and be disruptive during practice sessions. Limiting fluid intake may be dangerous for athletes training hard in hotter environments by putting them at risk for dehydration or other heat related events.1

The pelvic floor muscles have to be able to accept loads appropriately as part of a larger support system in order to prevent leakage of urine. The demands of high- level sports can cause pelvic floor muscle fatigue and a repetitive increase in intra-abdominal pressure. If your pelvic floor muscles are already weak, the additional demands of high- level sports can cause urinary leakage.16 Perineal pressure has been found to be decreased in female athletes versus non- athletes in a sample of 40 women ranging 18-30 years of age. Lower perineal pressure may be related to increased urinary incontinence symptoms and pelvic floor dysfunction.7

If you are experiencing involuntary leaking of urine during daily activities, with sports, or with straining, pelvic floor rehabilitation by a women’s health physical therapist should be considered a first line approach with treating your SUI symptoms.1 There is strong evidence to support pelvic floor muscle training is an effective treatment for SUI.89 Appropriate pelvic floor muscle retraining exercises can be provided to increase the strength and endurance of the pelvic floor muscles during high- level demands of sports and work outs. Combining pelvic floor muscle retraining in combination with techniques to decrease intra-abdominal pressure and external pelvic and core strengthening can also decrease SUI in athletes. Training behavioral habits by instructing on fluid and dietary modifications and voiding intervals if needed may be part of treatment.1 The team of physical therapists at New Dimensions Physical Therapy are trained in the above techniques for treating SUI in female athletes. SUI does not have to be the hidden problem among female athletes but rather a very treatable problem by conservative care.

Lila Abbate PT, DPT, MS, OCS, WCS

Andrea Wood, PT, DPT

References:

  1. Heath, A, Folan S, Ripa B, et al. Stress urinary incontinence in female athletes. . J WomensHealthPhys Therap. 2014; 38(3):104-109
  1. Figuers, C. C. (2010). Physical therapy management of pelvic floor dysfunction. In Women’s health physical therapy. (Kindle Edition ed.). Baltimore, Philadelphia: Lippincott Williams and Wilkins
  1. Carls C. The prevalence of stress urinary incontinence in high school and college-age female athletes in the Midwest: implications for education and prevention. Urol Nurs. 2007; 27(1): 21-24, 39
  1. Bo K, Borgen JS. Prevalence of stress and urge incontinence in elite athletes and controls. Med Sci Sports Exerc. 2001;33(11): 1797-1802
  1. Rauh M, Barrack M, Nichols J. Associations between the female athlete triad and injury among high school runners. Int J Sports Phys Ther. 2014; 9(7): 948-958
  1. Brody, L., & Irion, J. (2010). The female athlete. In Women’s health physical therapy. (Kindle Edition ed.). Baltimore, Philadelphia: Lippincott Williams and Wilkins.
  1. Borin LC, Nunes FR, Guirro EC. Assessment of pelvic floor muscle pressure in female athletes. PMR. 2013; 5(3): 189-193
  1. Bo K. Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. World J Urol. 2012; 30 (4): 437-443
  1. Dumoulin C, Hay-Smith J, Habee-Sequin GM, et al. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a short version Cochrane systematic review with meta-analysis. Neurourol Urodyn. 2015; 34(4): 300-308

Low Back Pain During Pregnancy: Women’s Health Physical Therapists to the Rescue

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Physical Therapists, particularly those specialized in women’s health conditions can play a vital role in helping women progress through pregnancy with less pain and improved function, while also preventing post-partum musculoskeletal issues. Weight gain and the position of the growing baby, while considered normal, can lead to a variety of symptoms that can be implicated in low back pain:

Suffering from Low Back Pain During Pregnancy (dragged)

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     In addition to excessive anterior weight gain, the hormone relaxin increases ligamentous laxity during pregnancy leading to excessive joint motion and possible micro-injury to ligaments:

Untitled 2

Pregnancy-related low back pain often begins in the first trimester of pregnancy and tends to increase with advancing pregnancy and subsequent pregnancies.1 Women’s Health physical therapists are musculoskeletal experts in providing core-focused training while preventing overstretching of muscles, tendons, and ligaments, which may be contraindicated in pregnancy. The types of exercise programs that have been shown to be the most effective are stability ball exercises and progressive functional core stabilization programs. Yoga by a trained physical therapist or prenatal yoga expert has also been shown to improve low back pain in pregnant patients.1 Dysfunction of the diaphragm, an essential muscle of breathing, has also been shown to be implicated in low back pain. Pregnancy may inhibit excursion and function of the diaphragm that a physical therapist can retrain through breathing exercises and coordinating appropriate breath with exercise.23 Women’s health physical therapists are also trained in providing appropriate external bracing for pregnant women if needed, especially in the third trimester. Research has shown the use of pelvic belts have a strong positive effect for the treatment of pregnancy related low back pain.4

Diastasis recti, a separation of rectus abominus muscle down the middle can also occur during pregnancy. The presence of a diastasis recti has been found to be significantly related to a support related pelvic floor dysfunction diagnosis and may be implicated in low back pain.5 The occurrence and size of a diastasis recti has been shown to be greater in non exercising pregnant women than in exercising pregnant women.6 Exercises putting too high of an increase in intra-abdominal pressure such as crunches or involving excessive twisting may worsen separation. The transverse abdominus plays an important role in lumbopelvic stability, by activating prior to sudden movements and providing compression to the sacroiliac joints. Women’s health physical therapists are trained in providing appropriate abdominal strengthening and retraining of the transverse abdominus.7 They also can provide temporary taping methods of the diastasis recti to decrease pain during exercise.

The common daily activity of prolonged sitting can lead to a variety of issues. Ergonomic advice on proper workstation set up involving a desk attachment board to support the forearms has been shown to reduce low back pain in a sample of pregnant women.8 Easy to do postural exercises throughout the day with or without a band can also help with shoulder, neck and upper back pain from prolonged time spent at the computer. Coccyx or tailbone pain may develop during pregnancy due to hormonal changes, stretch to the pelvic floor muscles, and postpartum due to difficult delivery. Altered sitting postures due to tailbone pain can lead to increased low back pain. Women’s health physical therapists can provide instruction on proper sitting supports and treatment to the appropriate muscles when indicated to improve coccyx pain. 910

Women should not have to suffer with chronic neck and back pain during pregnancy, and should be advised to see a specialized women’s health physical therapist as soon as possible. The sooner a patient can begin appropriate exercises for pregnancy, the easier it is to retrain muscles and prevent faulty biomechanics during daily activities. New Dimensions Physical Therapy has a team of specially trained women’s health physical therapists to help patients progress through pregnancy comfortably. An evaluation will consist of a musculoskeletal and postural evaluation from head to toe, along with questions about what activities bring on symptoms. Sessions may include pelvic supports, taping, manual therapy as needed, and advice on proper seating and sleeping positions. Methods to activate core muscles appropriately, particularly the transverse abdominus during functional activities and modifications of activities may be taught. Additionally, an exercise program and possible referral to either Pilates or yoga programs should be provided for the patient to independently work towards reducing and keeping symptoms tolerable as pregnancy progresses and to restore your body from the childbirthing process. 9

 Lila Abbate PT, DPT, OCS, WCS

Andrea Wood, PT, DPT

References:

  1. Belogolovsky I, Katzman W, Christopherson N, et al. The effectiveness of exercise in treatment of pregnancy- related lumbar and pelvic girdle pain: a meta-analysis and evidence based review. J WomensHealth Phys Therap. 2015; 39(2):53-64.
  1. Kolar P, Sulc J, Kyncl M, et al. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012; 42(4):352-362.
  1. Jassens L, McConnell A, Pijnenburg M et al. Inspiratory muscle training affects proprioceptive use and low back pain. Med Sci Sports Exerc. 2015;47(1):12-19.
  1. Stephenson R, Steiner S, Puniello M. The effect of lumbopelvic support in the third trimester of pregnancy. J Womens Health Phys Therap. 2007; 31(1):25.
  2. Spitznagle T, Leong F. The relationship between diastasis recti abdominus and pelvic floor dysfunction diagnosis. J Womens Health Phys Therap. 2007; 31(1):26
  1. Chiarello C, Falzone L, McCaslin K, et al. The effects of an exercise program on diastasis recti abdominus in pregnant women. J Womens Health Phys Therap. 2005; 29 (1):11-16.
  2. Lee S, Kim T, Lee B, et al. The effect of abdominal bracing in combination with low extremity movement on changes in thickness of abdominal muscles and lumbar strength for low back pain. J Phys Ther Sci. 2014; 26(1):157-160.
  1. Dumas G, Upjohn T, Dellisle A. Posture and muscle activity of pregnant women during computer work and effect of an ergonomic desk board attachment. Int J Ind Ergonom. 2009; 39(2):313-325.
  1. Tanner H. (2015). Introduction to caring for the pregnant patient [Powerpoint slides]. Retrieved from https://www.medbridgeeducation.com/courses/details/ introduction-to-caring-for-the-pregnant-patient
  1. Maigne JY, Rusakiewic F, Diouf M. Postpartum coccydynia: a case series of 57 women. Eur J Phys Rehabil Med. 2012;48(3):387-392.