Prenatal yoga has been shown to reduce stress and anxiety, support your changing body during pregnancy, improve connection to your pelvic floor and increase maternal comfort during labour and delivery.

If you are pregnant and looking for a safe way to move your body and prepare for labour and birth, give this gentle flow a try:

Side Lying Quad to Hamstring Stretch

• Lying on your side, use your arm or pillow to support your head comfortably, bend your bottom knee for support and balance.

• Bend your top knee so that you can grab your ankle with your top hand.

• Pull the knee back so that you feel a stretch in the quad region.

• The top knee should be directly above the bottom knee, forming a parallel line (as shown in the picture).

• Make sure to keep your pelvis leveled and lower back flat (do not arch the lower back).

• Remaining on your side, let your top arm take ahold behind your top knee and encourage the foot up towards the sky

• Relax your glutes, close your eyes and breathe

Symptoms of dysmenorrhea generally include pain that is experienced in the pelvis or lower abdomen. Other symptoms can include lower back pain, pain that radiates to the thighs, diarrhea and/or nausea. In young women painful periods often occur without an underlying problem. In older women however, it is more often due to underlying issues such as uterine fibroids, adenomyosis (thickening of the lining of the uterus), or endometriosis (endometrial tissue from the lining of the uterus is found outside of the uterus in the pelvic cavity and beyond).

A 2014 review of literature, aimed to see if physiotherapy could help with painful periods. The review found that due to the fact that the uterus is a hollow, muscular organ, therapeutic interventions from a pelvic floor physical therapist can help reduce discomfort with periods.

The treatments from a pelvic health therapist that are the most beneficial for easing dysmenorrhea include:

• Therapeutic Exercises
  • These are exercises that increase range of motion, mobility, and lubrication in the low back and pelvic region, reducing stiffness and pain.
• Neuromuscular Re-Education
  • Following a thorough assessment, if dysfunction is present, helping to re-coordinate your brain and body to help the pelvic floor muscles rest in a more relaxed state can reduce pelvic cramps and muscle spasms in the area
•  Abdominal massage
  • These are techniques to help you relax the tissue restrictions in the abdominal and pelvic cavities that could be contributing to cramps and bloating.
•  Myofascial Release

• • Using manual therapy to address abdominal and pelvic girdle muscles that can be tight or in spasm, causing pain.

Another study on Pelvic Pain interventions completed in 2007 also found abdominal, myofascial, and connective tissue massage successful in reducing pelvic pain, including pain with menstruation. The study observed that Therapeutic exercise including Pilates, yoga and belly dance were shown to have clinical benefit for pain with periods.

Dyspareunia is the term for persistent and/or recurring pain or discomfort before, during or after sexual intercourse. This pain is typically localized to the vagina or lower pelvis and occurs in the absence of other medical conditions. Clinical trials by the Meirs Medical Centre found that Postpartum dyspareunia (PD) is a recognized phenomenon and stated that on average “ 50-60% of women have dyspareunia 6 to 7 weeks following delivery, and 33% and 17% will still report pain during intercourse three and six months after delivery, respectively”. These clinical trials also evaluated the prevalence and the causes for PD and interestingly discovered no clinical difference between the prevalence of PD between between vaginal deliveries and cesarean sections. According to their findings it can be assumed that the mechanical trauma to the vagina and pelvic floor during delivery is not the main cause for the development of PD. Multiple studies have shown a number of different causes that may lead to dyspareunia. Some of theses causes include:

• Injury to the pelvic floor: child birth, post surgical conditions, pelvic inflammatory disease, endometriosis, scar adhesions and scar tissue build up

• Musculoskeletal dysfunction: the pelvic floor muscles may be overactive and have difficulty fully relaxing

• Breastfeeding: breastfeeding decreases the amount of estrogen in postnatal womans’ systems. Estrogen is a key hormone for arousal and natural vaginal lubrication. With the low levels of the hormone, arousal and vaginal dryness may result causing the vagina to be too dry for comfortable penetration during intercourse

• Psychosocial factors: stress, depression and anxiety

Fortunately, painful sex can be treated by a Pelvic Floor Physiotherapist. Pelvic floor physiotherapy can help to reduce vaginal pain with intercourse by mobilizing muscle and soft tissue to release tight pelvic floor musculature, improve circulation and desensitize areas through manual therapy and normalize overactive muscles through education and awareness. A pelvic floor physiotherapist will also give you specific exercises that focus on relaxing your pelvic floor and teach appropriate techniques for penetration.

In the meantime, try to avoid repetitive contractions of the pelvic floor muscles such as “kegels” and instead focus on taking deep expansive inhales into your back and side ribs around the level of your bra strap. When we actively contract our pelvic floor muscles by performing a kegel, we are causing increased tension in what may be already tight and overactive muscle. This could potentially increase pain.

Exercises initially should focus on relaxation of the pelvic floor muscles with diaphragmatic breathing and imagery. A good position to start is in a seated position with feet flat on the ground. Begin by bringing awareness to where your sit bones are. Take a deep breath in and imagine the sit bones moving away from each other. As you exhale feel the gentle gliding of the sit bones moving inward without performing a contraction. When we inhale our pelvic floor hammock descends, expands and widens. As we exhale our pelvic floor gently comes together and “hugs up and in”. Focusing on deep belly breathing or diaphragmatic breathing and visualizing the release of the pelvic floor musculature can release both physical and emotional tension decreasing the level of discomfort felt with intercourse.

A tense pelvic floor can occur when the muscles of the pelvic floor have difficulty fully relaxing or letting go. The following signs and symptoms may indicate it is time to work on relaxing your pelvic floor!

• Constipation and pain when passing stools or having a feeling of incomplete emptying of bowels. ·

• Low back, pelvic, hip or buttocks pain

• Painful sex

• Urinary or bowel urge incontinence (leaking on the way to the bathroom)

• Incomplete emptying of the bladder, slow flow of urine or stopping/starting of urine stream

• Hesitancy or delayed start of urine stream

• Urinary or bowel urgency frequency- feeling like you need to go to the bathroom all the time, and only voiding small amounts

• Painful urination

It is very important to be able to fully and consciously relax your pelvic floor muscles as well as be able to contract them. If the muscles of your pelvic floor are already stiff and tense, it is very difficult to contract them effectively and build strength. A tense pelvic floor ix a weak pelvic floor! In order for the muscles of your pelvic floor to be able to function properly and be pain free, you must first learn how to relax them. Relaxing your pelvic floor is often called down-training of the muscles and referred to as a reverse kegel. Physiotherapists from Pelvic Floor Health Solutions likens the feeling of releasing your pelvic floor to the moment of relief you feel when you have reached the bathroom; when you urinate or have a bowel movement.

To do a reverse kegel, start by lying on your back with your knees resting open on pillows. Gently contract the muscles of your pelvic floor on your exhale to feel what tightening the muscles feels like. Then relax, and allow that tension to release completely as you take a big breath in. Feel the difference between tension and relaxation. Next, without moving your pelvis or your spine, visualize that the muscles between the pubic bone and tailbone lengthening away from one another by gently moving your pubic bone towards the ceiling and gently move your tailbone towards the surface you are lying on. Imagine that the pelvic floor muscles are getting longer as this happens creating more space in your pelvic floor. Do this at the same time that you take a deep breath in. Be patient. This takes some time to feel the letting go or lengthening of these muscles. This can be practiced in sitting and standing as well. Eventually, once you have mastered the art of relaxing your pelvic floor muscles, you can begin with gentle pelvic floor strengthening exercises. Don’t forget to check in with your pelvic floor throughout the day, and let go of any tension that you discover.

Physical Therapy and Exercise Rehabilitation is important for both our physical and mental well being, but with the rise in COVID-19 numbers province wide, what is the safest way to continue your care??

Recent research on Telerehabilitation has studied patient outcomes such as pain, endurance, strength, balance, general health status, activity participation and more. It has shown that regardless of the patient population or disease (chronic lower back pain post-operative total hip or knee replacements, stroke, osteoarthritis, nonspecific low back or neck pain, pelvic floor dysfunction etc.) telerehabilitation is comparable to clinic-based therapy. Interestingly, studies on telerehabilitation studies have also shown significantly better outcomes in the telerehab groups compared to the in-clinic care groups for increased compliance with home exercise programs, ease to access appointments and overall satisfaction with care.

Therefore, if you are in need of Physical or Athletic therapy and in person sessions are not an option for you, Telerehabilitation is an effective alternative in most scenarios.

Telerehabilitation is the delivery of rehabilitation services over secure telecommunication networks and the internet. Telerehabilitation allows patients to interact with their physio/athletic therapist via video remotely and can be used both to assess patients and to deliver therapy. According to the College of Physiotherapists of Ontario, “Tele-rehabilitation relates to all aspects of patient care including the patient interview, physical assessment and diagnosis, treatment, maintenance activities, consultation, education, and training. It can include the use of media such as videoconferencing, email, apps, web-based communication, and wearable technology”.

Both physiotherapy and athletic therapy are professions that are very hands-on and “physical”. Therefore, it would make sense to be apprehensive about the effectiveness of Telerehabilitation compared to in person sessions. While it makes sense that most physical rehabilitation is provided in person and hands-on, technology that can connect us in real time, provides an opportunity for physio and athletic therapists to provide alternate or supplemental care when circumstances do not allow in person visits. For example, the College of Physiotherapists outlines that, “virtual care would be appropriate if a patient cannot easily attend in-person sessions because of things like a shortage of physiotherapists in their region, transportation or mobility issues, or a health pandemic that discourages physical contact”.

Physiotherapists and Athletic Therapists are experts in movement and movement conditions that affect one’s quality of life and optimal physical functioning or performance. Therefore, while you may receive hands on or “manual” treatment during your in person sessions, physical and athletic therapists have many other tools and ways to assist people in their return to optimal function and health. Some examples include, patient education, self care strategies and tools, as well as remedial or therapeutic exercises, the core and foundation of our training, to compliment manual therapy treatments.

Undeniably, there will always be times when hands on therapy, assessment and treatment are the appropriate option for care, but with recent events such as the global COVID-19 pandemic, busy schedules, extreme weather events etc. how wonderful is it that there is an option that allows us to receive a high quality of care from the comfort of our own homes!

Rib flare is a term that you may often hear in the postpartum rehab world, but what is it exactly? If you are newly postpartum you have likely experienced rib flaring as a result of your body’s natural instinct to push the ribs up and open to make room for baby. Rib flare is easily identified when you can see your bottom ribs protruding. Rib flare can refer to two different things. One is rib positioning, and one is rib angle.

Rib positioning is when your posture affects the positioning of your rib cage. Sometimes posture is affected by tightness and restrictions forcing it into different positions, and sometime it is simply a habit of how we hold our bodies. Although, there is no such thing as perfect posture, having the rib cage line up with the pelvis improves the ability of the pelvic floor and diaphragm to work as they should, in unison. Pelvic floor Physiotherapist Sarah Duvall uses the analogy of rib cage and pelvis malalignment to that of an engine belt in a car being “off”. “The car will still run, but you get that annoying squeaking noise. If you have less than optimal posture most of the day, your body will start to squeak at you in the form of aches and pain or perhaps diastasis and pelvic floor issues that won’t improve”.

Rib flare caused by the rib angle can be harder to address as it involves changing how your muscles fire. The small muscles that run between your ribs are called your internal intercostals and they work with the abdominals to produce a forced exhale. When your ribs are flared, there is no integration between your diaphragm and the abdominal muscles and you become “stuck in a state of inhalation”. When you have good rib positioning, the overlap of your diaphragm and abdominal muscles is called a ZOA, or zone of apposition. Duvall states that “when your ribs are flared, the ZOA is lost, causing poor diaphragmatic pressure (aka not so great breathing) and poor activation of your abdominals”.

When your ribs are stuck in a flared position, it is impossible to completely exhale. This in turn causes your upper back, or thoracic spine, to be pulled forward into extension-compromising scapular glide as well as your shoulder range of motion and stability. Not being able to fully exhale can also lead to low back pain and pelvic floor dysfunction. In order for your pelvic floor to function properly, you must be able to breathe properly. With flared ribs, your diaphragm is generally being pulled back not allowing you to take a proper full breath. If you are unable to complete your exhale, your lumbar spine is pulled forward into extension and your pelvis into an anterior tilt which may result in tight hip flexors, back extensors and weak abdominals, glutes and hamstrings.

In conclusion, everything is connected. Rib flare doesn’t allow you to expand properly through the front, back and sides of your diaphragm during inhalation, and take a FULL exhalation. Getting your ribs down and in and getting a great exhale can go a long way for your overall health. I hope this helps explain what rib cage flare or rib cage angle means and gives you a helpful point of reference for reflecting on your posture.

Could your persistent low back pain be connected to your pelvic floor?

Do you suffer from low back pain that does not seem to go away despite your efforts to find relief?

According to the National Institutes of Health (NIH), more than 31 million people suffer from chronic lower back pain, and about 80 percent of all adults experience lower back pain at some point in their lifetime. About 25 percent of adult women suffer with pelvic floor dysfunction (PFD) issues such as incontinence, pelvic organ prolapse, and pelvic pain. As women age, this ratio increases. Recent research has also shown that of women with low back pain more than 95% had pelvic floor dysfunction as well. This included pelvic tenderness (71%), weakness (66%) and even pelvic organ prolapse (41%). Other research has tied low back pain to urinary incontinence, with nearly 80% of women with chronic back pain reporting at least occasional incontinence.

Back pain and pelvic floor dysfunction (PFD) are so closely related because all the muscles that support the pelvic floor must also work to support and protect the spine. When the back is in pain, the pelvic floor muscles may tighten to try and protect the sensitive area. This can overwork the pelvic floor, causing tender points, tightness, and muscular fatigue.

The alternative may also be true. Weakness in the pelvic floor may lead due to decreased core function, strength and stability in the back. Studies have shown that people with lower back pain tend to have significantly lower pelvic floor muscle function compared to those without lower back pain. Those most at risk for PFD are athletes, prenatal and postpartum women, people who have had a pelvic or back surgery, and men who have had prostate surgery.

Urinary incontinence — the loss of bladder control — is a common and often embarrassing problem. The severity ranges from occasionally leaking urine when you cough, sneeze, run or jump to having an urge to urinate that is so sudden and strong you don’t get to the toilet in time.

Although it is occurs more often as people age and in women who have given birth, urinary incontinence isn’t an inevitable consequence of aging or of having had kids.

If urinary incontinence affects your daily activities, seeing a Pelvic Floor Physiotherapist can certainly help. Fortunately, for most people simple lifestyle changes and specific pelvic floor activation/relaxation exercises and bladder training can ease discomfort or even stop urinary incontinence.

Read on to learn about the symptoms of urinary incontinence and how you can effectively retrain your bladder to ease these unwelcome and discerning symptoms.

1. Stress incontinence. This occurs when urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
2. Urge incontinence. This occurs when you have a sudden and intense urge to urinate followed by an involuntary loss of urine. It may also cause you to feel the urge to urinate more frequently.
3. Overflow incontinence. This occurs if you experience frequent or constant dribbling of urine due to a bladder that doesn’t empty completely.
4. Mixed incontinence. This occurs if you experience more than one type of urinary incontinence. For example, you can suffer from both stress and urge incontinence at the same time.

Bladder Training

Whether you are currently suffering from mild-severe symptoms of urinary incontinence, or not currently experiencing any symptoms at all, you may be unintentionally teaching your bladder bad habits that can gradually result in incontinence or increased urinary frequency/urgency.

For example, if you have a habit of urinating before your bladder is full we call these ” just in case pees”. Your bladder learns to signal the need to go when less volume of urine is present. Thus starting a vicious cycle, as you respond to the new urges and teach your bladder it’s full when less urine is present.

Fortunately, according to Harvard Health, “…old bladders can learn new tricks. Bladder training, a program of urinating on schedule, enables you to gradually increase the amount of urine you can comfortably hold”. Harvard Health also states that bladder training is a support treatment for both urinary frequency and overactive bladders in both men and women, alone or in combination with medications or other techniques.

Harvard Health recommends the following step by step guide to retraining your bladder

1. Keep track. For a day or two, keep track of the times you urinate or leak urine during the day, how much fluid you are taking in and how long your urinations are (count in “mississippis”).
2. Calculate. On average, how many hours do you wait between urinations during the day?
3. Choose an interval. Based on your typical interval between urinations, select a starting interval for training that is 15-30 minutes longer. If your typical interval is one hour, make your starting interval one hour and 15 minutes.
4. Hold back. When you start training, empty your bladder first thing in the morning and not again until the interval you’ve set. If the urge hits first, remind yourself that your bladder isn’t really full, and use techniques to delay going. Try gently contracting and relaxing your pelvic floor 10x, sit down and perform 10 deep breaths, distract yourself with another activity.
5. Increase your interval. Once you are comfortable with your set interval, increase it by 15-30 minutes. Over several weeks or months, you may find you are able to wait much longer and that you experience far fewer feelings of urgency or episodes of urge incontinence

Another tried and true tip from a pelvic floor physiotherapist:

If you suffer from stress incontinence, leaking when you cough sneeze, laugh run or jump, practicing and re-training your “knack reflex” can be highly effective. Read more about the “knack reflex” and how to practice here.

A reminder that the contributing factors to urinary incontinence can vary person to person and a individualized assessment and treatment plan from a pelvic floor physiotherapist is recommended.