How can physical therapy help


Not an instant fix, but most people make significant improvements over time

When I started working in this field I spent a year observing another very experienced pelvic physical therapist interview, examine and treat her male and female patients. What always struck me on the first meeting was the thought "how on earth can we help this person?" Many of you have really long and pretty miserable tales of pain, multiple doctor visits, surgeries, and other health problems that can make our job seem pretty daunting! However, I would see people who had years of pain or suffering come back the next week and say "Well, I think I am doing a bit better" or "it hurt for a while and then it felt a little less painful" or "the stretches you gave me helped me " or "I already feel like I am in more control of my leaking".  Sometimes, even at the end of the first session they would say "I already feel better now you have explained why I hurt or leak". Over the next few weeks and months they would make more progress and if we looked back to where they started, there were often huge improvements. This isn't to say everyone got better, but the good news is that most people do improve significantly with physical therapy. 

The kind of help that physical therapy provides isn't a quick or instant fix and it does requires some homework such as stretching or strengthening exercises, relaxation practice or modification to your diet or lifestyle. We aren't always able to totally get rid of the problem, but the improvements are enough that people would say things like" I am so grateful you are on the planet" or "thank goodness I finally found you" and also " I wish that someone had told me about this years ago".
 



So how does physical therapy help?

So what do we do that helps? The first thing, as I mentioned, is that we sit down and explain what is causing the problems you are having and how they can be helped; for many people this is the first time someone has had the time or in-depth understanding to do this. Knowing that some or all of your problems are caused by muscles and not some other scary or unknown disease is hugely reassuring and you start to have some hope that there is an end in sight.

In order to understand how physical therapy helps pelvic pain or incontinence one needs a quick tour of the pelvis and an introduction to the pelvic floor. The pelvic floor is literally the floor of the pelvis and like any floor it needs to be strong enough to support anything that is resting on it, which in women is the bladder, uterus and bowel and in men is the bladder, prostate and bowel. The added complication of this floor is that it has to be both strong and at the same time, flexible.  In addition, it has to be able to relax to let urine and bowel movements through and perform it's important functions during sexual activities. Finally, for women it has to be  able to stretch a ridiculous amount during childbirth. No wonder this floor has some problems! 


Female pelvic floor- what is has to bear!


The female pelvic floor not only has the daily jobs of supporting all the organs and being the gatekeeper for urination, defecation and sexual activity but the pelvic floor also has to be able to stretch an inordinate amount if and when a woman has a child. With monthly fluctuations in hormones and various other complications women can have, the pelvic floor is at a high risk for some trouble at some point in a woman's life. For men and women anxiety and stress can also result in pelvic floor problems; some of us "hold tension" in our necks and some of us hold it in our pelvic floors.










Men have pelvic floors too!

Yes, men have pelvic floors too and they can have the same kinds of problems that women have, such as pelvic pain, difficulty or pain with sex, frequent urination or urinary or fecal leakage or incontinence. Sometimes men have to wait even longer than women to get pelvic physical therapy, which is saying something.

Many men are diagnosed with prostatitis for many years, without the main factor of pelvic floor spasm being recognized and or treated.

There are more and more physical therapists treating men now, sadly as few therapists as there were for women, there were even fewer who treated men, but this is changing and there are also now some more male physical therapists emerging to treat men 











Stress and the pelvic floor
Men, like women suffer from pelvic pain as a result of stress, physical and emotional, although their pelvic floors do not have the onslaughts that women's pelvic floors have, they can have injuries and/or surgeries in the  area that result in pelvic floor pain. Additionally, men who have been in abusive family or domestic relationships, stressful jobs or positions that involved prolonged sitting can develop pelvic pain as a result.

Tightening your pelvic floor is a basic response to a threat, just as the dog drops his tail and tightens his pelvic floor when afraid, so do we. Of course, there were times when protecting yourself like this was the most important self preservation technique you could have, in every day life it quickly backfires as a protective strategy and becomes a huge problem for you that your pelvic floor is always tightening.
















The pelvic muscles in detail- what goes wrong?



Here's a view from above looking down into the pelvis after everything but the muscles have been removed. The true pelvic floor muscles are several different muscles that combine to from the circular "hammock" that you see in the center of the pelvis. The hole in the middle of them is the opening to the rectum or anal canal and below that, towards the front of the pelvis is the opening for the vagina or the penis. It doesn't matter so much what the muscles are all called or where they start and finish, what's important is to realize that there are a quite a few of them and they are involved in some pretty vital functions like urination, defecation, sex and giving birth. They also have some postural functions, which means that they are involved in keeping us up straight and balanced when we move around. With this many important and varied functions you can start to see how spasm or weakness in these muscles would upset a lot of important things.




Same kind of problems as other muscles- just more dire consequences!

The pelvic floor muscles have all the same kinds of problems as other muscles do-just with more dire consequences. If your neck muscles are tight-it might be hard to turn your head or reverse the cars, but if your pelvic floor muscles are tight you may not be able to empty your bladder or have a bowel movement and most likely sexual intercourse will be painful. If your neck muscles are weak-you may get tired holding it up and not be able to sit at the computer for very long, but if your pelvic floor muscles are weak you can might go through 6 or 8 pads a day and might no longer be able to exercise at all because of fear of leakage and embarrassment. 
 
 If you keep in mind how we as physical therapists might treat someone's tight or weak muscles in the neck, it makes sense that we would do similar treatments for tightness and weakness in the pelvic floor muscles. Tight muscles need to be stretched and worked on and weak muscles need to be strengthened. The pelvic floor is of course a more awkward place to work on than a shoulder, but you can access these muscles internally though the vagina and anus and can strengthen them through special exercises called Kegel exercises. As with other muscles in the body physical therapists are always great detectives and like to understand as much as possible about why you may have developed your problem. They will look at everything in your history and look at the way you walk, stand and move and they will consider whether anything you are doing is contributing to the pain or weakness.
 
Tight pelvic floor and muscle spasm- how does PT help this?

 Pain in your pelvis can often be caused by knots or trigger points in the pelvic floor muscles, just as these same knots cause pain in your neck muscles. Pelvic floor muscles get these knots for many different reasons, just as there are many different reasons why our necks get sore. It may be from stress, from pain in your bladder, from a hormone change, from a series of bladder or yeast infections, from surgery, from a stomach problem, from pregnancy , from a fall or an injury to your back, hip or tail bone. There is a long list of possible causes but the treatment is really very similar. Physical therapists will teach you hip and pelvic stretches that will stretch the pelvic floor muscles and help to relieve the tightness and pain, they can also do the internal stretching and knot releasing or trigger point releases with one or two fingers working through your vagina or in men, through the rectum. They can also teach you how to do these internal stretches at home. Sometimes the surrounding muscles such as the abdominals, buttock muscles or inner thigh muscles are also tight and need some attention too. Another essential aspect of getting better is to teach you to be more aware of your pelvic floor so that you start to know whether you are squeezing or holding those muscles unnecessarily throughout the day. This can also help to reduce the spasm and therefore pain. Muscles go into spasm and develop knots when they have been working overtime, just as the muscles in your neck will start to develop knots and hurt after you have spent hours on the computer writing up a paper or project for work. Relaxation techniques and a knowledge of what your pelvic floor feels like when it is relaxed is very important to your recovery.



Incontinence or leaking- weak pelvic floor muscles

If your problem is that you leak urine when you cough or run or even just standing up from sitting, then the problem is most likely to be a weak pelvic floor or one that is not working as it should be.  Our pelvic floors become weak or stop working properly for the same reasons other muscles in our body become weak: through lack of use, gravity and also pain inhibits or stops muscles from working properly. Particular to the pelvic floor muscles, weakness is also caused by the stretching or tearing that occurs during pregnancy and delivery and also abdominal and pelvic surgeries can result in a weaker pelvic floor. An important point to make is here that pelvic floor muscles can actually be both tight and weak at the same time,so some people will have both pelvic pain and leaking, which is doubly miserable. 

 The great news is that just like other muscles in the body can be built up through strengthening, so can the pelvic floor muscles. There are two stages to the improvements you can make, the first stage is due to changes in how you use the muscles, actually how your nervous system recruit the muscle fibres. These changes can happen quite quickly within the first few days or weeks and are can give you some noticeable improvements. The second stage the true strength changes can take 2-3 months of daily exercises and focus to achieve. As with other muscles in your body the sky is the limit with strengthening, but as we can't exactly show off the pelvic floor muscles ,most people are happy when they have regained control of their basic functions! 

 The good news with pelvic floor muscle strengthening is that you don't have to actually go to a gym to strengthen them or change into work-out clothes and you can do the exercises without anyone even realizing you are doing them. The challenge however, is to remember to do them. There are some very good strategies to use to overcome this, the main one being finding an activity that you do several times a day with which you come to associate doing your exercises with. Pelvic floor exercises are also called Kegel exercises, your physical therapist can tell you how to do them, make sure you are doing them correctly, tell you what position to do them in and how many to do each day. They can also encourage you to stick with it so that you make the progress you want.  


What if it isn't a pelvic floor muscle problem?



Of course physical therapists are biased to see everything as a muscle problem and this is not of course the case. The pelvis contains not only muscles but major organs such as the bladder, uterus, ovaries and bowels, as well as glands such as the prostate, blood vessels, nerves, ligament and fascia, which is the packing or connective tissue. There are also skin and tissue problems in the vulva and rectum that can cause problems. All of these things are obviously outside the scope of physical therapy diagnosis and management.  This is why it is essential that you see your regular doctor or OB/GYN to rule out these major issues before seeing a physical therapist. However, any pelvic floor muscle problem, just like any other muscle problem is easier and quicker to fix if we see you sooner than later. I encourage you therefore to come in and see a pelvic physical therapist as soon as you have had an initial screening by your doctor, even if you are still having tests or seeing specialists. 

There are many conditions which may be caused by an organ or another part of your pelvis than the pelvic floor, but at the same time or as a result of this problem, you can develop problems in your pelvic floor. This is the part we as physical therapists can help with and is the part that is currently often being missed.