One of my greatest nemeses when I was racing at 30 years of age was a woman in her 50’s. Although I hated losing to her, I was always inspired by her speed at her age. She motivated me to continue training hard, realizing my fastest days could be yet to come. As I now race in the “master’s” category in my 40’s, I still find myself crossing the line behind an older competitor occasionally. Research shows I should take heart and keep in step with females who continue to move their bodies beyond menopause.

Mazurek et al., (2017) studied how organized physical activity among post-menopausal women could reduce cardiovascular risk. The study included 35 sedentary women aged 64.7 ± 7.7 years who had no serious health issues. They all participated in the Active Leisure Time Programme (ALTP) 3 times per day for 40–75 minute sessions for 2 weeks, including 39 physical activities. Exercise intensity stayed within 40–60% of maximal HR, and ratings of perceived exertion (RPE) on the Borg scale stayed between 8 and 15 points. This exercise training was followed by 3 months of the Prevent Falls in the Elderly Programme (PFEP), which is a general fitness exercise program to prevent falls in the elderly. Health status was measured at baseline, 2 weeks into the program, and after 3 months. The results showed significant reductions in central obesity, which increased the exercise and aerobic capacity of the subjects and improved lipid profiles. A significant reduction also occurred in the absolute 10-year risk of death from cardiac complications. The authors concluded these exercise programs could be effective in preventing primary and secondary cardiovascular disease in the >55 years old female population.

Nyberg et al., (2016) took a physiological look at exercise training on the vascular function of pre- and postmenopausal women, studying the prostanoid system. Prostanoids are vasoconstrictors, and prostacyclins are vasodilators. The loss of estrogen in menopause affects the ability of the vasodilators to function properly or even be produced, thus contributing to vascular decline. The authors checked the vasodilator response to an intra-arterial fusion of a prostacyclin analog epoprostenol as well as acetylocholine in 20 premenopausal and 16 early postmenopausal women before and after a 12-week exercise program. Pre-exercise, the postmenopausal women had a reduced vasodilator response. The women also received infusion of ketorolac (an inhibitor of cyclooxygenase) along with acetylcholine, creating a vasoconstriction effect, and the vascular response was reduced in both groups. The infusions and analyses were performed again after 12 weeks of exercise training, and the exercise training increased the vasodilator response to epoprostenol and acetylcholine in the postmenopausal group. The reduced vasodilator response to epoprostenol prior to exercise in early postmenopausal women suggests hormonal changes affect the capacity of prostacyclin signaling; however, the prostanoid balance for pre and postmenopausal women was unchanged. Ultimately, the study showed exercise training can still have a positive effect on the vascularity of newly postmenopausal women.

There are randomized controlled clinical trials and scientific evidence supporting the importance to keep moving as women (and men) age. Menopause should not be a self-proclaimed pause from activity in life. Not everyone has to become a competitive athlete to preserve cardiac and vascular integrity as we age, but we need to engage in some physical activity to keep our systems running for years to come.

Those interested in learning more about menopause rehabilitation considerations should consider attending Menopause Rehabilitation and Symptom Management.

Mazurek, K., Żmijewski, P., Kozdroń, E., Fojt, A., Czajkowska, A., Szczypiorski, P., Tomasz Mazurek, T. (2017). Cardiovascular Risk Reduction in Sedentary Postmenopausal Women During Organised Physical Activity. Kardiologia Polska. 75, 5: 476–485. http://doi:10.5603/KP.a2017.0035
Nyberg, M., Egelund, J., Mandrup, C., Nielsen, M., Mogensen, A., Stallknecht, B., Bangsbo, J., Hellsten, Y. (2016). Early Postmenopausal Phase Is Associated With Reduced Prostacyclin-Induced Vasodilation That Is Reversed by Exercise Training: The Copenhagen Women Study. Hypertension. 68:1011-1020. https://doi.org/10.1161/HYPERTENSIONAHA.116.07866

As I read about male phimosis, I thought about a shirt that just won’t go over my son’s big noggin. I tug and pull, and he screams as his blond locks stick up from static electricity. Ultimately, if I want this shirt to be worn, I either have to cut it or provide a prolonged stretch to the material, or my child will suffocate in a polyester sheath. This is remotely similar to the male with physiological phimosis.

In a review article, Chan and Wong (2016) described urological problems among children, including phimosis. They reported “physiological phimosis” is when the prepuce cannot be retracted because of a natural adhesion to the glans. Almost all normal male babies are born with a foreskin that does not retract, and it becomes retractable in 90% of boys once they are 3 years old. A biological process occurs, and the prepuce becomes retractable. In “pathological phimosis” or balanitis xerotica obliterans, the prepuce, glans, and sometimes even the urethra experience a progressive inflammatory condition involving inflammation of the glans penis, an unusually dry lesion, and occasional endarteritis. Etiology is unknown, but males by their 15th birthday report a 0.6% incidence, and the clinical characteristics include a white tip of the foreskin with a ring of hard tissue, white patches covering the glans, sclerotic changes around the meatus, meatal stenosis, and sometimes urethral narrowing and urine retention.

This review article continues to discuss the appropriate treatment for phimosis (Chan & Wong 2016). Once phimosis is diagnosed, the parents of the young male need to be educated on keeping the prepuce clean. This involves retracting the prepuce gently and rinsing it with warm water daily to prevent infection. Parents are warned against forcibly retracting the prepuce. A study has shown complete resolution of the phimosis occurred in 76% of boys by simply stretching the prepuce daily for 3 months. Topical steroids have also been used effectively, resolving phimosis 68.2% to 95%. Circumcision is a surgical procedure removing foreskin to allow a non-covered glans. Jewish and Muslim boys undergo this procedure routinely, and >50% of US boys get circumcised at birth. Medical indications are penile malignancy, traumatic foreskin injury, recurrent attacks of severe balanoposthitis (inflammation of the glans and foreskin), and recurrent urinary tract infections.

Pedersini et al., (2017) evaluated the functional and cosmetic outcomes of “trident” preputial plasty using a modified-triple incision for surgically managing phimosis in children ages 3-15. All patients seen in a 1 year period who were unable to retract the foreskin and had posthitis or balanoposthitis or ballooning of the foreskin during urination were included and treated initially with a two-month trial of topic corticosteroids. Only the patients unresponsive to corticosteroids were treated with the "trident" preputial plasty. At 12 months post-surgery, 97.6% (all but one of the 41 subjects) of patients were able to retract the prepuce, and cosmetics and function were satisfactorily restored.

Phimosis is apparently not a highlight in medical school curriculum, and parents often seek attention for other issues that lead to the diagnosis of phimosis. Like the tight material lining the neck of a shirt, the prepuce can be given a prolonged static stretch, and, over time, may retract appropriately. Or, cutting the shirt material may be necessary for long term success. Similarly, surgical intervention such as circumcision or the newer “trident” preputial plasty may be required.

Chan, Ivy HY and Wong, Kenneth KY. (2016). Common urological problems in children: prepuce, phimosis, and buried penis. Hong Kong Medical Journal. 22(3):263–9. DOI: 10.12809/hkmj154645
Pedersini, P, Parolini, F, Bulotta, AL, Alberti, D. (2017). "Trident" preputial plasty for phimosis in childhood. Journal of Pediatric Urology. 13(3):278.e1-278.e4. doi:10.1016/j.jpurol.2017.01.024

Recently I had a patient referred to me for fecal incontinence. She looked so familiar to me and we realized she had seen me before, years ago, for bladder issues. She was a sweet 60 something single woman who had raised 6 kids on her own after her husband left her. We laughed as she remembered something funny I had said back then. Then we got down to business. In recent years my patient “Inez” had been diagnosed with both diabetes and Crohn’s disease. She was managing the Crohn’s very well but her sugars were much harder for her to get under control. When I asked her about her current complaints and symptoms she reported that most days her bowels were perfect. She reported one or two soft easy to pass stools per day. But when she had to leave the house for a doctor appointment, she would have explosive diarrhea. This didn’t happen if she went to the grocery store or to visit a friend. Upon further questioning she realized she was really anxious about her diabetes and her interactions with her medical provider regarding her diabetes had not been positive. She felt frustrated, scared, and powerless.

As a pelvic health PT I could have treated Inez in a variety of ways. With my initial exam I did not see any glaring musculoskeletal issues. I suggested to Inez the possibility that her nervous system was sending the wrong kind of signals to her bowels when she got anxious and that we could address this in PT. Inez agreed that she would like to try this approach. We decided that we would reevaluate after four visits to see if we needed to change the plan. Over four visits I used craniosacral therapy protocols to address nervous system upregulation and tension. I taught Inez relaxation techniques and encouraged 10 or 15 minutes of daily relaxation practice. Inez opened up about her relationship with her kids and how they tended to be takers but not givers. She would get frustrated and feel a bit used at times. We had conversations about boundaries and saying “no” and I shared some of my own experiences and struggles as well. Lastly we talked about how what we think can affect how we feel and what we do. Inez’s faith was important to her. She found a few bible verses that were meaningful to her about fear and anxiety and would repeat those during her daily relaxation time. On her fourth visit, Inez was all smiles. She brought me a jar of her homemade salsa as a graduation present. As we sat down to talk she reported to me that she saw her doctor yesterday. She had no bowel issues. And more than that, as her doctor began to talk over her she said to him, “No. Stop. You are always talking and never listening. I need you to listen to me today.” She went on to explain to him how it worried her that she was not able to control her diabetes well and she didn’t think he was doing enough to help her. Her physician did stop and listen and asked Inez, “what would you like me to do for you?” She asked for a referral to a specialist and he obliged. Inez was thrilled that she was able to manage her anxiety in a way that helped her bowels and to find the courage to confront her doctor to get the care she felt she needed.

As we grow in the knowledge of how the human body works it seems like all roads lead back to the nervous system. All of our treatments and interactions with patients affect the nervous system in one way or another. In our fast paced, stressed out world, finding ways to be intentional in addressing the nervous system can be a game changer for patients (as well as for ourselves). If this is an area you would like to grow in, please consider a new course being offered this January in Tampa, Florida. Participants taking Holistic Interventions and Meditation will experience and explore evidence-based information on strategies to address the nervous system. Topics covered include practical meditation, use of essential oils, supplements, yoga, calming and centering manual techniques and instruction in how to best dialogue with patients struggling with pain, anxiety and the effects of trauma. Nari Clemons and I hope to see you there.

Faurot, K. K. R., Gaylord, S., Palsson, O. S., Garland, E. L., Mann, J. D., & Whitehead, W. E. (2014). 715 Mindfulness Meditation Has Long-Term Therapeutic Benefits in Women With Irritable Bowel Syndrome (IBS): Follow-Up Results From a Randomized Controlled Trial. Gastroenterology, 146(5), S-124.
Kearney, D. J. (2012). Mindfulness meditation for women with irritable bowel syndrome–evidence of benefit from a randomised controlled trial. Evidence-based nursing, 15(3), 80-81.
Keefer, L., & Blanchard, E. B. (2001). The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study. Behaviour research and therapy, 39(7), 801-811.

On my son’s due date, I ran 5 miles (as I often did during my pregnancy), hoping he would be a New Year’s baby. The thought of low bone density never crossed my mind, even living in Seattle where the sun only intermittently showers people with Vitamin D. However, bone mineral density changes do occur over the course of carrying a fetus through the finish line of birth. And sometimes women experience a relatively rare condition referred to as pregnancy-related osteoporosis.

Krishnakumar, Kumar, and Kuzhimattam²⁰¹⁶ explored vertebral compression fracture due to pregnancy-related osteoporosis (PAO). The condition was first described over 60 years ago, and risk factors include low body mass index, physical inactivity, low calcium intake, family history, and poor nutrition. Of 535 osteoporotic fractures considered, 2 were secondary to PAO. A 27-year-old woman complained of back pain during her 8th month of pregnancy, and 3 months postpartum, she was found to have a T10 compression fracture. A 31-year-old with scoliosis had back pain at 1 month postpartum but did not seek treatment until 5 months after giving birth, and she had T12, L1, and L2 compression fractures. The women were treated with the following interventions: cessation of breastfeeding, oral calcium 100 mg/day, Vitamin D 800 IU/day, alendronate 70 mg/week, and thoracolumbar orthosis. Bone density improved significantly, and no new fractures developed during the 2-year follow up period.

Nakamura et al.²⁰¹⁵ reviewed literature on pregnancy-and-lactation-associated osteoporosis, focusing on 2 studies. The authors explained symptoms of severe low back, hip, and lower extremity joint pain that occur postpartum or in the 3rd trimester of pregnancy can be secondary to this disorder, but it is often not considered immediately. A 30-year-old woman with such debilitating pain in her spine with movement 2 months postpartum had to stop breastfeeding, and 10 months later, she was found to have 12 vertebral fractures. She had low bone mineral density (BMD) in her lumbar spine, and she was given 0.5mg/day alfacalcidol (ALF), an active vitamin D3 analog, as well as Vitamin K. No more fractures developed over the next 6 years. A 37-year-old female had severe back pain 2 months postpartum, and at 7 months was found to have 8 vertebral fractures due to PAO. Her pain subsided after stopping breastfeeding, using a lumbar brace, and supplementing with 0.5mg/day ALF and Vitamin K. The authors concluded goals for treating PAO include preventing vertebral fractures and increasing BMD and overall fracture resistance with Vitamins D and K.

Other treatment approaches for similar case presentations have been published. One gave credit to denosumab injections giving pain relief and improved BMD to 2 women, ages 35 and 33, after postpartum vertebral fractures (Sanchez, Zanchetta, & Danilowicz²⁰¹⁶). Guardio and Fiore²⁰¹⁶ reported success using the amino-bisphosphonates, neridronate, in a 38-year-old with PAO T4 fracture.

Thankfully for these women experiencing PAO vertebral fractures, supplements boosted their BMD and prevented further fractures. However, they all had to prematurely stop breastfeeding to reduce their pain as well. This rare condition can be used as a warning for women to proactively increase their BMD. The course, Meeks Method for Osteoporosis, can help therapists implement safe, effective, and active ways to promote bone health for all - especially the pregnant population in serious need of support.

Krishnakumar, R., Kumar, A. T., & Kuzhimattam, M. J. (2016). Spinal compression fractures due to pregnancy-associated osteoporosis. Journal of Craniovertebral Junction & Spine, 7(4), 224–227. http://doi.org/10.4103/0974-8237.193263
Nakamura, Y., Kamimura, M., Ikegami, S., Mukaiyama, K., Komatsu, M., Uchiyama, S., & Kato, H. (2015). A case series of pregnancy- and lactation-associated osteoporosis and a review of the literature. Therapeutics and Clinical Risk Management, 11, 1361–1365. http://doi.org/10.2147/TCRM.S87274
Sánchez, A., Zanchetta, M. B., & Danilowicz, K. (2016). Two cases of pregnancy- and lactation- associated osteoporosis successfully treated with denosumab. Clinical Cases in Mineral and Bone Metabolism, 13(3), 244–246. http://doi.org/10.11138/ccmbm/2016.13.3.244
Gaudio, A., & Fiore, C. E. (2016). Successful neridronate therapy in pregnancy-associated osteoporosis. Clinical Cases in Mineral and Bone Metabolism, 13(3), 241–243. http://doi.org/10.11138/ccmbm/2016.13.3.241

So many physiological changes occur to a woman’s body during pregnancy, it is no wonder that pregnant women have back and lower extremity aches and pains. These women experience hormonal changes, weight gain, reduced abdominal strength, and their center of mass shifts anteriorly. These physiological changes result in altered spinal and pelvic alignment, and increased joint laxity. Also, many women report increases in size of their feet and a tendency to have flatter arches during and after pregnancy. Alignment changes may influence pain. Altered alignment could change the physical stresses placed upon different tissues of the body, which that specific tissue was not adapted to, therefore, causing pain or injury to that tissue.

A recent study published in 2016, in the Journal of Women’s Health Physical Therapy¹, investigated if there may be a relationship between anthropometric changes of the foot that occur with pregnancy, and pregnancy related musculoskeletal pain of the lower extremity. The study included 15 primigravid women and 14 weight matched controls. This study was a repeated-measurements design study, where the investigators measured foot length, foot width, arch height index, arch rigidity index (ARI), arch drop (AD), rear foot angle, and pelvic obliquity during the second and third trimesters and post-partum. The subjects were surveyed on pain in the low back, hips/buttocks, and foot/ankle.

The author’s findings were that measures of arch flexibility (ARI and AD) correlated with pain at the low back and the foot and ankle. They concluded that medial longitudinal arch flexibility may be related to pain in the low back and foot. The more flexible arches were associated with more pain in the study participants. They reported the participants in their study did not have very high pain levels in general, and recommend further studies to compare pregnant women who experience severe pain with women who do not while comparing their alignment factors. This article is a good reminder for physical therapists to consider the changes that occur to the foot including changes in arch height, arch flexibility, and foot size and how that influences the pelvis and lower extremity for prevention and treatment of musculoskeletal pain during pregnancy.

Educating our pregnant patients on shoe wear seems even more important now. Making recommendations, unique to each individual patient based on their objective data, foot type, and arch flexibility status seems like an appropriate addition to a well-rounded treatment plan. Doesn’t it seem prudent to wear shoes that provide some arch support to hopefully reduce musculoskeletal pain associated with pregnancy changes? I have observed some patients who are pregnant arrive to physical therapy wearing unsupportive flip flops and other poor shoe wear choices. I understand there are barriers for pregnant patients, I remember from when I was pregnant that reaching your feet to put shoes on can be very difficult, and sometimes your feet are swelling so it may be near impossible to physically get shoes on your feet. You might even need a new pair of shoes, as your shoes may no longer fit. However, an article such as this one, seems like something I could easily share with a patient to help persuade them of the importance of good shoe wear or at least proper arch support. Being able to discuss a recent scientific study with a patient can be powerful and motivating to a patient. Additionally, an article such as this reminds a practitioner of specific objective data to monitor such as arch height and flexibility as it changes throughout the patient’s pregnancy. How does the patient’s changing arch height and flexibility influence their specific pelvic, hip, knee, and ankle alignment? How does swelling play a part in the patients’ foot anthropometrics day to day, trimester to trimester? Ask more questions about their daily activities, are they ‘barefoot and pregnant’? Could something as simple as having them wear appropriate, arch supportive shoes while in the home reduce their lower extremity or back pain?"

Harrison, K. D., Mancinelli, C., Thomas, K., Meszaros, P., & McCrory, J. L. (2016). The Relationship Between Lower Extremity Alignment and Low Back, Hip, and Foot Pain During Pregnancy: A Longitudinal Study of Primigravid Women Versus Nulliparous Controls. Journal of Women’s Health Physical Therapy, 40(3), 139-146.

Appropriate sun exposure and/or daily supplements provide our bodies with sufficient amounts of Vitamin D. I would venture to guess almost every one of the patients I treated in Seattle had a deficiency of Vitamin D if they were not taking a supplement. Running outside year round has always kept my skin slightly tan and my levels of Vitamin D healthy; however, when I was pregnant in the Pacific Northwest, I had to supplement my diet with Vitamin D, which was a first for this East Coast beach girl. The benefit of Vitamin D has spread beyond just bone health, with studies showing its impact on pelvic floor function.

Parker-Autry et al., (2012) published a study discerning the Vitamin D levels in women who already presented with pelvic floor dysfunction versus “normal” gynecological patients. The retrospective study involved a chart review of 394 women who completed the Colorectal Anal Distress Inventory (CRADI)-8 and the Incontinence Impact Questionnaire (IIQ-7). These women all had a total serum 25-hydroxy Vitamin D [25(OH)D] drawn within one year of their gynecological visit. The authors defined a serum 25(OH)D of <15ng/ml as Vitamin D deficient, between 15-29ng/ml as Vitamin D insufficient, and >30ng/ml as Vitamin D sufficient. In the pelvic floor disorder group comprised of 268 women, 51% were found Vitamin D insufficient, 13% of whom were deficient. The CRADI-8 and IIQ-7 scores were noted as higher among the Vitamin D insufficient women. Overall, the mean 25(OH)D levels in the women without pelvic floor issues were higher than those who presented with pelvic floor disorder symptoms.

Another case-control study in 2014 by Parker-Autry et al., focused on the association between Vitamin D deficiency and fecal incontinence. They considered 31 women with fecal incontinence versus a control group of 81 women without any pelvic floor symptoms, looking at serum Vitamin D levels. The women with fecal incontinence had a mean serum Vitamin D level of 29.2±12.3 ng/ml (insufficient/deficient), while the control group had a higher mean level of 35±14.1 ng/ml (sufficient). The women completed the Modified Manchester Health Questionnaire and the Fecal Incontinence Severity Index, and women with deficient Vitamin D scored higher on the questionnaire, indicating fecal incontinence as a burden on quality of life. The severity scores were higher for Vitamin D deficient women, but there was not a statistically significant difference between the groups.  Once again, the pelvic floor disorder and Vitamin D deficiency correlation prevailed in this study.

An even more recent study looked at postmenopausal women and Vitamin D deficiency (Navaneethan et al., 2015). This prospective case control study involved 120 postmenopausal women, 51 of whom had pelvic floor disorders. The serum 25-hydroxy Vitamin D levels were obtained, and the results revealed a deficiency in those women with pelvic floor dysfunction. Vitamin D levels were found to be significantly lower in women who were 5 years or more into menopause. Overall, Vitamin D was deemed a worthy factor to consider in the pelvic floor disorder population as well as in postmenopausal women.

Taking time to talk to patients about their lifestyle, daily supplements, and diet can often shed light on their ability to benefit from our treatments. If a Vitamin D deficiency sounds possible, discuss current research with them and suggest they get their serum Vitamin D levels checked. Don’t underestimate the power of a little sunshine – it just might have a positive impact on pelvic floor health.

Parker-Autry, C. Y., Markland, A. D., Ballard, A. C., Downs-Gunn, D., & Richter, H. E. (2012). Vitamin D Status in Women with Pelvic Floor Disorder Symptoms. International Urogynecology Journal, 23(12), 1699–1705. http://doi.org/10.1007/s00192-012-1700-8
Parker-Autry, C. Y., Gleason, J. L., Griffin, R. L., Markland, A., & Richter, H. E. (2014). VITAMIN D DEFICIENCY IS ASSOCIATED WITH INCREASED FECAL INCONTINENCE SYMPTOMS. International Urogynecology Journal, 25(11), 1483–1489. http://doi.org/10.1007/s00192-014-2389-7
Navaneethan, P. R., Kekre, A., Jacob, K. S., & Varghese, L. (2015). Vitamin D deficiency in postmenopausal women with pelvic floor disorders. Journal of Mid-Life Health, 6(2), 66–69. http://doi.org/10.4103/0976-7800.158948

Many therapists transition to treating men with the knowledge and training from female patients. When therapists apply this knowledge, for the most part, it works. When we spend some attention on learning what is a bit different, we might be drawn to the superficial muscles of the perineum. This old anatomy image does a wonderful job of "calling it like it is" or using anatomical terms that describe an action versus naming only the structure. In the image we are looking from below (inferior view) at the perineum and genitals. Just anterior to the anus we can see the anterior muscles within the urogenital triangle, with the base of the shaft of the penis located just anterior to (above in this image) the anus and perineal body. Notice that at the midline, we see muscle names the "accelerator urine". Modern textbooks refer to this muscle as the bulbocavernosus, or bulbospongiosus. Taking the name of accelerator urine, we can understand that this muscle will have an effect on aiding the body in emptying urine. It does this through rhythmic contractions, most often noted towards the end of urination, when the typical spurts of urine follow a more steady stream. This assistance with emptying can take place because the urethra is located within the lower part of the penis, the portion known as the corpus spongiosum. Because the bulbocavernosus muscle covers this part of the penis, and the inferior and lateral parts of the urethra are virtually wrapped within the bulbocavernosus, the muscle can have an effect on emptying the urine in the urethra.

Notice that if you follow the fibers of the accelerator urine muscle towards the top of the image, where the penis continues, you will notice fibers of the muscle wrapping around the sides of the penis. These fibers will continue as a fascial band that travels over the dorsal vessels of the penis. This allows the muscle to also have a significant action during sexual activity, in which blood flow (getting blood into, keeping blood in, and letting blood out of the penis) is paramount.

On either side of the penis we can see what is labeled the erector penis. As these muscles cover the legs, or crura which form the two upper parts of the penis, when the muscles contract, blood is shunted towards the main body of the penis. This of course helps with penile rigidity, as the smooth muscles in the artery walls of the penis allow blood to fill the spongy chambers.

Once we discuss the usual functions of these muscles, we can then imagine the dysfunctions potentially created by less than optimal activity. Consider the difficulty that these muscles will create in contracting or relaxing if they are either too weak, or too tense. These issues can create difficulty emptying well the urethra, often leading to post-void dribble. Blood flow and therefore penile rigidity with erections may be negatively impacted by inability of these muscles to contract or stay contracted, and blood flow leaving the penis may be impaired if the muscles cannot relax. When we work with patients who have genital pain, pelvic floor muscle weakness, dyscoordination, or tension, we can often improve sexual function, bladder emptying, and tasks that might otherwise be affected by pain.

If you are interested in learning more about how to assess and treat these muscles, you have one more opportunity this year to attend the 3-day Male Course instructed by Holly Tanner. Holly has been teaching this course for over 10 years when she co-wrote the first course with colleague and faculty member Stacey Futterman. The course has been updated and turned into a 3-day course to include more manual therapy techniques. Hurry to grab one of the remaining spots in the October 27-29 course in Grand Rapids!

At the peak of my racing career I won awards in all my races from 5k to marathon. While warming up I would scope out my competition, intimidated by muscular females wearing outfits to accentuate their physiques. Many times, appearance out-weighed running capacity. In a similar manner, one strong pelvic floor contraction produced by a female athlete does not always mean she has the endurance to stay dry in the long run.

Brennand et al. (2017) researched urinary leakage during exercise in Canadian women. A summary of their findings concluded that skipping, trampoline, jumping jacks, and running/jogging were most likely to cause leakage. To combat the problem, 93.2% emptied their bladder just before exercise, 62.7% required voiding breaks during exercise, and 37.3% actually restricted their fluid intake to minimize leakage. While 90.3% of women who reported leakage impacted their activity just decreased their intensity, 80.7% avoided the activity entirely. Many women used pads (49.2%). Interest in pelvic floor physiotherapy to improve their UI was high (84.6%), but 63.5% of women still sought pessary or surgical management. Unfortunately, 35.6% of the women had no idea treatment was even an option.

Nygaard & Shaw (2016) reviewed and summarized the cross-sectional studies regarding the association between physical activity and pelvic floor disorders. Trampolinists, especially those in the 3rd tertile of competition, even those who were nulliparous, experienced greater leakage. Competitive athletes in the highest quartile of time exercising were found to have 2.5 times the amount of urinary incontinence (UI) as the lowest inactive quartile; however, 2nd and 3rd quartile recreational athletes had no difference in UI compared to inactive women. Type and dosage of exercise were both factors in UI risk. Various studies showed habitual walking decreased UI in older women, moderate exercise decreased the risk of UI, and no exercise increased the risk of UI. The incidence of UI being related to having performed strenuous exercise early in life has been limited and variable, with one study of Norwegian athletes and US Olympians not having any greater UI later in life, while another showed middle-aged women who used to exercise 7.5 hours per week had a higher incidence of UI. This review also reported athletes had a 20% greater cross sectional area of the levator ani muscle and a greater pubovisceral muscle mean diameter; however, the pelvic floor strength recorded was lower than non-athletes.

Interestingly, Leitner et al. (2017) explored pelvic floor muscle activation for continent and incontinent females during running. For 10 seconds, EMG tripolar vaginal probe recorded activity at 7, 11, and 15km/h. No statistically significant differences between continent or incontinent subjects were found for the EMG values. Pre-activity and reflex activity mean EMG increased significantly with speed; mean pelvic floor muscle EMG activity during running was significantly above onset activation value; and, maximum voluntary contraction was exceeded 100% for all time intervals at 15km/h in women with UI. These authors suggested the stimulus of running could actually be beneficial in pelvic floor muscle training considering the reflex activity of the muscles.

At races now, I still silently survey my competition, but now I am more curious as to how many women are actually able to complete the run without leakage. The prevalence of UI among athletes continues and is becoming more of an open topic of conversation. The research as to how much and which kind of exercise correlates with UI or what activity and level of participation may be preventative for UI is growing. The need for pelvic floor therapists to treat athletes who are fit to be dry is ever increasing.

Brennand, E., Ruiz-Mirazo, E., Tang, S., Kim-Fine, S., Calgary Women’s Pelvic Health Research Group. (2017). Urinary leakage during exercise: problematic activities, adaptive behaviors, and interest in treatment for physically active Canadian women. International Urogynecology Journal. http://www.doi:10.1007/s00192-017-3409-1
Nygaard, I. E., & Shaw, J. M. (2016). Physical Activity and the Pelvic Floor. American Journal of Obstetrics and Gynecology, 214(2), 164–171. http://doi.org/10.1016/j.ajog.2015.08.067
Leitner M, Moser H, Eichelberger P, Kuhn A, Radlinger L. (2017). Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurourology and Urodynamics. 36:1570–1576. https://doi.org/10.1002/nau.23151

In some families, puberty is not only a time to have to deal with all the physical, hormonal, and emotional changes that are occurring, but it is a time to have to worry about and check for spinal abnormalities that can run in families. Adolescent idiopathic scoliosis is an abnormal curvature of the spine that appears in late childhood or adolescence. The spine will rotate, and a curvature will develop in an “S” shape or “C” shape. Scoliosis is the most common spinal disorder in children and adolescents. It is present in 2 to 4 percent of children between the ages of 10 and 16 years of age. There is a genetic link to developing scoliosis and scientists are working to identify the gene that leads to adolescent idiopathic scoliosis. Adolescent girls are more likely to develop more severe scoliosis. The ratio of girls to boys with small curves of 10 degrees or less is equal, however the ratio of girls to boys with a curvature of 30 degrees or greater is 10:1. Additionally, the risk of curve progression is 10 times higher in girls compared to boys. Scoliosis can cause quite a bit of pain, morbidity, and if severe enough can warrant spinal surgery.

A recent article in Pediatric Physical Therapy by Zapata et al. assessed if there were asymmetries in paraspinal muscle thickness in adolescents with and without adolescent idiopathic scoliosis. They utilized ultrasound imaging to compare muscle thickness of the deep paraspinals at T8 and the multifidus at L1 and L4. They found significant differences in muscle thickness on the concave side compared to the convex side at T8 and L1 in subjects with scoliosis. They also found significantly greater muscle thickness on the concave side at T8, L1, and L4 in patients with adolescent idiopathic scoliosis compared to controls. This is very interesting to me, and exciting to think about the possibilities of how we therapists might can use this information! My first question is, is the difference in muscle thickness a cause or result of the curvature of the spine? My next question is if we trained the multifidus on the convex side, the side that is thinner, would it make a difference in supporting the spine and therefore help prevent some of the curvature? Would strengthening the multifidus in a very segmental manner comparing right versus left and targeting segments and sides that are weaker than others help prevent rotation and curvature in individuals who have a familial predisposition to developing idiopathic scoliosis? I hope so! I hope this group continues to study scoliosis and provides some evidence-based treatment that can help decrease the severity of curvature.

Assessing the multifidus thickness and strength, and differentiating it from the paraspinal muscles can be tricky. The best way to do this is the same way the authors of this article did, using ultrasound imaging. Ultrasound imaging gives unparalleled information on muscle shape, size, and activation of the muscle. Learning to use ultrasound imaging will change your practice! You will see dramatic differences in how you treat patients as well as the results you get when training the local core musculature. It also may open doors to treating different patient types than you are treating now, like adolescents with scoliosis. Join me in Spokane, WA on October 20-22 to further discuss how ultrasound can change your practice and perhaps help you reach out to a new population that you may not be treating now!

Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:343–52.
Roach JW. Adolescent idiopathic scoliosis. Orthop Clin North Am. 1999;30:353–65.
Zapata KA, Wang-Price SS, Sucato DJ, Dempsey-Robertson M. Ultrasonographic measurements of parspinal muscle thickness in adolescent idiopathic scoliosis: a comparison and reliability study. Pediatr Phys Ther. 2015; 27(2): 119-25.

The first time I experienced the effects of Post-Traumatic Stress Disorder (PTSD) was when my patient dissociated during a treatment session and relived the rape that had occurred when she was ten years old. It was devastating. I didn’t know what to do. She was unresponsive to my intervention. Her eyes didn’t see me, alternating between wide-eyed, horrified panic and clenched-closed, lip biting excruciating pain. It was my late night and I was alone in the clinic. I sat helplessly next to my sweet patient hoping and praying that her torture would end quickly. When she finally stopped writhing, she slept. Deep and hard. Finally she woke up disoriented and scared. She grabbed her things and left. For me, this experience was my initiation into the world of trauma.

Approximately 5-6 % of men and 10-12% of women will suffer from PTSD at some point in their lives. Researchers believe that 10% of people exposed to trauma will go on to develop PTSD. The expression of PTSD symptoms can present differently in men and women. Men may have more externalizing disorders progressing along a scale that includes vigilance, resistance, defiance, aggression and homicidal thoughts. Women tend to present with internalizing disorders such as depression, anxiety, exaggerated startle responses, dissociation, and suicidal thoughts. The research is clear that both men and women with PTSD display changes in brain function. The mid brain (amygdala, basal ganglia and hippocampus) tends to be overactive in sounding alarm signals while the prefrontal cortex fails to turn off the mid brain when a threat is no longer present. Since the prefrontal cortex is not always functioning correctly, traditional talk therapy may not be as effective for treating PTSD. Instead, say many researchers, breath and movement exercises may help regulate brain functioning. Yoga, Tai Chi, and meditation have been shown to have a positive impact on down regulating the mid brain and improving cerebral output. As pelvic floor therapists we deal with trauma on a daily basis, whether we know it or not. Although we are not trained in psychology, understanding PTSD and equipping ourselves with tools to support our patients is imperative for both our patients and ourselves.

You might be wondering what happened after that frightful night in the clinic? My patient was determined to get better. She had a non-relaxing pelvic floor. She was a teacher and was plagued by urinary distress. She either had terrible urgency or would go for hours and not be able to empty her bladder. So we met with her therapist to learn strategies to help us to be able to work together without triggering dissociation. It was a slow road, but the three of us working together helped my patient not only reach her goals but to be able to be skillful enough to maintain her gains using a dilator for self-treatment.

If you would like to learn more about PTSD, meditation, yoga, chronic pain, psychologically informed practice and self-care for patients and providers please join Nari Clemons and I in Tampa in January as we present a new offering for Herman and Wallace, “Holistic Intervention and Meditation.” We would love to see you there.

Bremner, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in clinical neuroscience, 8(4), 445-461.
Kerr, C. E., Jones, S. R., Wan, Q., Pritchett, D. L., Wasserman, R. H., Wexler, A., ... & Littenberg, R. (2011). Effects of mindfulness meditation training on anticipatory alpha modulation in primary somatosensory cortex. Brain research bulletin, 85(3), 96-103.
Morasco, B. J., Lovejoy, T. I., Lu, M., Turk, D. C., Lewis, L., & Dobscha, S. K. (2013). The relationship between PTSD and chronic pain: mediating role of coping strategies and depression. Pain, 154(4), 609-616.
Olff, M., Langeland, W., & Gersons, B. P. (2005). The psychobiology of PTSD: coping with trauma. Psychoneuroendocrinology, 30(10), 974-982.
The Role Of Yoga In Healing Trauma