Author Archives: Kathe Wallace

Kathe Wallace

About Kathe Wallace

Kathe Wallace has practiced physical therapy since 1976, focusing on pelvic floor rehabilitation since 1988. As a nationally recognized leader in the pelvic floor specialty of physical therapy, she evaluates and treats many types of conditions referred to her by medical specialists in orthopedics, physical medicine and rehabilitation, urology, gynecology, gastroenterology and colorectal surgery. Full Bio.. →

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A physical therapist is best suited to assess, treat and help a woman manage the musculoskeletal and urogenital changes of the postpartum woman in the 4th trimester and beyond.  This review of postpartum exercise literature will assist the therapist in understanding current guidelines and recommendations that support the timing and requirements for returning to fitness, exercise and sport.   The seven articles reviewed discuss current strategies for abdominal wall, general strength required for injury prevention, and return to sport activities.

Some women, including high level and recreational athletes face a balance, learning how to care for a newborn and the desire to restore her fitness to prenatal health status.  For people who have to return to competition, physical jobs or those who use exercise for stress relief, this timetable may be accelerated. These needs exist alongside the challenges of sleep deprivation, a physical changes from pregnancy, and recovery from childbirth  that can require rest, and rehabilitation. Exercise goals in postpartum women vary, as do the current evidence based recommendations for returning to sport.

Photo by Ronnie George on Unsplash

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Registration is Now Open!

The Birth Healing Summit is a free on-line opportunity for practitioners to learn from experts who discuss how to help moms  heal their body, mind and/or spirit more completely after birth. You can listen from the comfort of your own home or wherever you may be!

The summit takes place April 8 -16, 2019. 
Join the summit with this link. Registration is FREE!

I'm delighted to be part of this Summit. I'll be covering the Clinical Pearls of Prolapse Examination and providing a list of free access references regarding up-to-date examination of prolapse and levator ani avulsion. 
Here is the link for the full list of Birth Healing Summit 2019 presenters and topics.

Don't miss the opportunity to learn more about postpartum recovery.

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Terminology and Technique for Pelvic Floor Rehabilitation

The time has arrived to correctly describe and effectively use the Valsalva maneuver--and the all-important Vaginal Vacuum that can accompany the maneuver--in pelvic floor rehabilitation. How one performs the Valsalva breath holding technique is an important consideration in pelvic floor health and rehabilitation. The Valsalva maneuver was introduced as a medical procedure in 1704 by an Italian physician to expel pus from the middle ear. Over the years, the Valsalva maneuver has been used in medicine for everything from changing cardiac rhythms to testing for disc herniation. 

Valsalva vs. Strain Maneuvers and the Pelvic Floor (PF)

First, we need to define Valsalva versus Strain from a pelvic health and rehabilitation perspective. Clarifying these definitions is a beginning, improving the understanding of the effect of managing Intra-Abdominal Pressure (IAP) in pelvic floor dysfunction (PFD).

The Valsalva maneuver is a moderately forceful attempted exhalation against a closed airway. The 2017 International Urogynecologic and Continence Societies (IUGA/ICS) joint Terminology Report for the conservative and non-pharmacological management of female pelvic floor dysfunction defines the Valsalva maneuver as "the action of attempting to exhale with the nostrils and mouth, or glottis closed. Valsalva is usually performed with digital closure of the nose, as when trying to equalize pressure in an airplane." Properly used, the term “Valsalva maneuver” does not address the pelvic floor.

In contrast to the Valsalva maneuver, the strain maneuver is a forceful bearing down which can cause excessive perineal descent. We use a strain maneuver to test for pelvic organ prolapse, but it is otherwise discouraged in most of our patients with prolapse or incontinence. Straining/bearing down as defined in the above IUGA/ICS terminology report “may have a similar meaning to Valsalva; however, in practice, straining/bearing down may be interpreted as meaning pushing downward and trying to relax the pelvic floor, as when defecating.” A strain maneuver therefore does address the pelvic floor.

In reality, the Valsalva maneuver does affect the pelvic floor. During the Valsalva maneuver the pelvic floor elevates. I term this elevation the Vaginal Vacuum. For more information on pelvic floor elevation during the Valsalva maneuver, see Talasz et al., 2012 which states that “the Valsalva maneuver reflects an expiratory pattern with diaphragm and pelvic floor elevation, whereas during straining the pelvic floor descends.” Also see Baessler et al., 2017, who demonstrated that Valsalva maneuver is associated with better bladder neck support and a stiffer pelvic floor.

Vaginal Vacuum Technique (VVT)

I consider using the Vaginal Vacuum breath holding technique when the primary presenting pelvic floor muscle diagnosis (Spitznagle et al., 2017) includes a force production deficit with or without movement pattern coordination or IAP impairments. In my practice, patients with some pelvic floor muscle awareness and without pelvic floor muscle overactivity respond the best to the VVT.

Most pelvic rehabilitation practitioners are familiar with coaching a pre-contraction of the pelvic floor (termed the “Knack”) prior to a symptom-provoking cough. The Vaginal Vacuum Technique is designed to be a symptom reduction breathing technique.  It is a short duration Valsalva breath hold used with a symptom-provoking activity like a lift or a push. The VVT can be accompanied by pelvic floor activation either reflexively or with coaching pelvic floor cues.  

To identify if the patient has a reflexive Vaginal Vacuum effect, instruct the patient in a brief, sub-maximal breath hold on exhalation to be directed upward against a closed throat and mouth, (clearing your ears on the airplane-- Valsalva maneuver) and observe for the response of stiffening or lifting of the pelvic floor.

Non-responders may need coaching. I suggest adding a contraction cue for the pelvic floor or providing more training in the coordination of this technique. Patients with significant PFD may need to use both the Knack and the VVT to manage IAP. For some, this Valsalva breathing technique may never produce an elevation of the pelvic floor.

Management of IAP with the Vaginal Vacuum Technique

Management of IAP is an important treatment consideration in patients with PFD.  Breath holding, often unavoidable when pushing or lifting heavy loads, can be performed with different pelvic floor responses.  The Valsalva maneuver can be of value in pelvic floor rehabilitation. Terminology is important, and I encourage you to reverse the trend of using Valsalva as a term to describe a straining/bearing down maneuver in clinical practice. I also encourage you to perform terminology fact checks: look closely at research publications for their specific descriptions of the Valsalva maneuver.

Finally, try the VVT during your initial patient assessments and use it as an additional self-care behavioral strategy to manage IAP.  Clinically, many patients have reported improved quality of life--an ability to lift or push with fewer symptoms. I hope your patients do too.”

To learn more about advanced pelvic floor examination and the importance of managing IAP visit my  professional continuing education teaching  page.

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Physical therapists are in a unique position to evaluate and treat pelvic organ prolapse with movement, exercise, and breathing assessments. Some women want to get to the top of the stairs, others to the top of Mt. Rainer without symptom aggravation. The physical therapy goals are to minimize symptoms, continue activity and maximize functional performance.  We assess pelvic floor muscles and prolapse stages, evaluate global muscle/joint function, breathing patterns, and functional activity patterns.  The articles reviewed reinforce the fact that no single solution will be effective for every patient. A comprehensive approach should consider patient goals, current scientific evidence, and examination findings.

Although these studies provide information about functional activities and Intraabdominal pressure (IAP), differences in the way IAP was measured make it difficult to compare results. They also address the utilization of behavioral interventions such as the “Knack” maneuver and breathing pattern terminology. My goal is to keep women moving and exercising to their maximum potential. Keeping current on the research is a vital component of patient care.

I hope you enjoy these literature reviews. If you are a physical therapist, I offer continuing education training in comprehensive prolapse examination and up-to-date treatment strategies in my Boost Camp Series.

These literature reviews were developed with Thanh-Thao Truong, SPT as part of an independent study project at the University of Washington, Department of Physical Medicine, School of Physical Therapy.

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The term “The Fourth Trimester” has been described for years, relating to a new baby’s first three months. You can find scores of articles about meeting a baby’s needs in the fourth trimester, with advice on everything from swaddling to feeding to sleep.

But what about the women?

For years, the primary focus has been on the health of the newborn, which is only one part of the package deal of childbirth. Historically, the women received a 15 minute postpartum checkup at six weeks, a screen for postpartum depression, and maybe, if they were lucky or persistent, referrals for physical therapy or other resources.

With the introduction of the fourth trimester for women, that’s beginning to change. New guidelines from the American College of Obstetrics and Gynecology (ACOG), increased information about the potential for long-term changes to a woman’s body after pregnancy, and a call from women themselves for better care is leading to a push for improved postnatal care.

What Kind of Care Should Be Included in the Fourth Trimester?

According to the ACOG guidelines, women should have their first contact, either by phone or in person, with their OB within the first three weeks after delivery. A comprehensive postnatal visit should happen soon after, and include a screening for the woman’s “mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance.”   It also looks at postnatal care as an ongoing process, not something that begins and ends at a six-week visit. It encourages referrals to care providers, like women’s health physical therapists, who can address the woman’s physical recovery from childbirth, as well as lactation consultants, therapists or specialists in postpartum complications and management.

What Does This Mean for Women?

In short, it means more comprehensive care. It means looking at the prolonged health of the woman, beyond the baby. It means addressing and treating the physical changes brought on by childbirth and expanding the ways to help women recover over the next months. It places a focus on physical, mental, social support and access to therapies, including physical therapy for new moms. It means a long overdue focus on the health of the woman.

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In 2017, the American College of Obstetrics and Gynecology reported [1] on The 4th Trimester Project patient engagement meeting, where new mothers were asked, “what issues are not effectively communicated to women?” Women reported a desire for clinicians to ask questions related to pelvic floor dysfunction, back pain and incontinence.  They wanted healthcare providers to open the conversation about these common postpartum problems and to provide resources to treat these symptoms. To help meet this need, there is a movement among physical therapists to provide postpartum women musculoskeletal and pelvic floor screening exams as a standard part of obstetrical care.

Women Lack Information about Postpartum Problems

Women need to be aware of common problems following childbirth. Many women try to return to previous activity levels only to discover that low back pain (LBP), pelvic girdle pain (PGP), urinary or fecal incontinence (UI ,FI), pelvic organ prolapse (POP) or pain with sexual activity limit their function and quality of life. Currently, women may perceive these issues as normal consequences of childbearing and delivery, or be hesitant to start a discussion about incontinence, pelvic pain or sexual dysfunction with their healthcare provider. Unfortunately, this causes musculoskeletal and pelvic floor dysfunctions to go untreated, as women are unaware of the health care resources available. By including pelvic floor questionnaires and screening exams, both during prenatal and postpartum visits, healthcare providers can open the conversation, learn if a woman is having continued pelvic floor problems, and provide a referral for continued specialty care. 

Childbirth is a risk factor for multiple pelvic floor dysfunctions and musculoskeletal problems. Urinary Incontinence and Pelvic Girdle pain occur commonly during pregnancy, with up to 77% of pregnant women reporting symptoms when questioned. Depending on the study cited, UI continues to affect 18-60% of women postpartum. Back pain continues in 4-90% of women after childbirth [2].  Sexual penetration pain or dyspareunia is reported by 44.7% women at 3 months postpartum, 43.4% women at 6 months postpartum [3]. Despite these numbers, there is no systematic approach to address common postpartum symptoms, other than the symptoms of depression. There is a need for education prior to giving birth and comprehensive screenings before and after childbirth.

Using Questionnaires to Empower Women with Knowledge

About one-third of women have urinary incontinence and up to one-tenth have fecal incontinence after childbirth [4], yet these issues frequently go untreated. In her 2018 Doctoral Thesis Pelvic Floor Dysfunction in Women: Tackling Barriers [5], Hedwig Neels reviewed the importance of educating women regarding pelvic floor dysfunction. Her work underscores the need for early awareness and education. Neels demonstrated that women of all ages have a limited knowledge of the pelvic floor and its function. Regular screenings with standardized questionnaires will educate women about symptoms and enable earlier identification and referral to providers.

For pelvic floor conditions, the Queensland Female Pelvic Floor Questionnaire [6] assess 4 areas of common symptoms, (bladder, bowel, pelvic support and sexual function) and their impact on daily activities. The questionnaire provides a comprehensive, condition-specific, self-completion format. Screenings should be provided by OBs during pre- and post-natal visits and can also be administered by, PCPs, physical therapists, midwives, doulas and childbirth educators. It is my hope that women are provided these screening questionnaires once during pregnancy, then again on or before their postpartum checkups (See my related article Redefining the Postpartum Visit). Reviewing the findings of the questionnaire decreases the chance of these problems going undiagnosed and encourages women to seek care for their symptoms.

As a pelvic physical therapist with over 30 years of experience treating postpartum women with pelvic floor dysfunction, I want women to know and seek care for common pelvic floor, pelvic girdle or other musculoskeletal symptoms related to childbirth. I also want to increase knowledge of and access to multidisciplinary resources and treatments available. I would like to see women, and those involved in postpartum care, embrace the 4th Trimester as a time to care for women as much as we do for newborns.

  1. Tully, K. P., Stuebe, A. M., & Verbiest, S. B. (2017). The fourth trimester: a critical transition period with unmet maternal health needs. American Journal of Obstetrics & Gynecology, 217(1), 37-41.
  2. Mannion, C. A., Vinturache, A. E., McDonald, S. W., & Tough, S. C. (2015). The Influence of Back Pain and Urinary Incontinence on Daily Tasks of Mothers at 12 Months Postpartum. PLoS ONE, 10(6), e0129615.
  3. McDonald, E. A., Gartland, D., Small, R., & Brown, S. J. (2015). Dyspareunia and childbirth: a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 122(5), 672-679.
  4. Woodley, S. J., Boyle, R., Cody, J. D., Mørkved, S., & Hay‐Smith, E. J. C. (2017). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. The Cochrane Library.
  5. Neels, H. (2018). Pelvic floor dysfunction in women: tackling barriers (Doctoral dissertation, University of Antwerp).
  6. Baessler, K., O’Neill, S. M., Maher, C. F., & Battistutta, D. (2010). A validated self-administered female pelvic floor questionnaire. International urogynecology journal, 21(2), 163-172.

Thank you to Richard Galindo, SPT, University of WA, Dept of Rehabilitation, Division of Physical Therapy for literature review assistance to prepare this article.

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The American College of Obstetrics and Gynecology (ACOG) Committee on Obstetric Practice is acknowledging a need to change the focus of postpartum care. A committee opinion, just released from the Presidential Task Force on Redefining the Postpartum Visit, supports postpartum care as an ongoing process, rather than an isolated visit. 

To provide comprehensive care, seven components of postpartum care have been outlined.  Physical recovery, one of the seven components, includes referrals to physical therapy. Let’s improve obstetric care by increasing the focus on women and their postpartum care.

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 “It isn’t what you do but how you do it”

John Wooden said that during his tenure as UCLA ‘s most successful men’s basketball coach, leading the team to 10 NCAA championships. His quote has followed me through my career as a physical therapist. Although it was initially targeted at character, I believe strongly it applies to movement and activity. It parallels my approach to treating pelvic floor dysfunction (PFD).

Like athletes, many women with PFD need lifestyle coaching-advice on what activities will improve their symptoms and quality of life. If we want women to be champions of their pelvic floors we need to perform individual assessments, and provide the care and coaching to help them thrive, whether on the basketball court, in the gym, or on a walk with their family.

A physical therapist considers the impact of lifestyle advice on patients with PFD.  A current research topic of interest for physical therapists treating PFD is the management of intra-abdominal pressure (IAP) during activity. This advice as long-term application for an active woman throughout her lifespan.

Physical therapy education (coaching) should focus on re-educating patient-specific activities to minimize large changes in IAP as a means for managing PDF symptoms. For example, a simple tweak in the technique of a lifting strategy, breathing timing or postural habit can reduce symptoms in some women. This strategy focuses on how to do activities correctly rather than avoiding movement altogether. At the Pelvic Health Clinic and in my PFD teaching practice, this is the focus.  I encourage you to see a physical therapist who can help your activity using lifestyle coaching combined with and exercises strategies. We focus on what you can do and how to do it correctly. See you on the basketball court— or wherever your active lifestyle takes you.

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Is Your Pelvic Floor Overachieving, Underachieving or in Balance?

So much in our lives is about balance.  The medical word for that is homeostasis, which is the tendency of the body to stay in balance. Every healthy human has control of the muscles throughout the body.  As a physical therapist, whose professional passion is focused around a group of muscles in the pelvis called the pelvic floor, I think a lot about how to rehabilitate them. One approach is to consider is how a yoga program could work in conjunction with these muscles within the pelvis.  We can learn to be mindful of what we do with these muscles.

What Tips the Balance in the Pelvic Floor Muscles?

When the pelvic floor muscles are out of balance, I think of them as overachieving or underachieving.  An overachieving pelvic floor is usually chronically held or pressured by the body to be used without a break.  This overuse of the pelvic floor muscles is just like the fatigue or burnout that happens if you work overtime, all the time. The pelvic floor takes on an “I can do it all” attitude, and the muscles fire and tighten constantly, losing their flexibility. It becomes difficult to release them at all and it also can cause surrounding muscles to work poorly, or not at all.  This can lead to many painful conditions or a bladder that is stressed by the contestant tension.  Yoga poses and exercises that encourage release and opening of the muscles work best for this condition.

When your pelvic floor underachieves, it can be because of disuse and/or lack of proper understanding about what it can do.  Teaching your pelvic floor to work is like training for a new job. Once you learn how to engage the pelvic floor muscles effectively, they can work with your other core muscles to support your bladder, bowel, spine and internal organs, at the bottom of the pelvis. Unfortunately, the pelvic floor can also “underachieve” when it is overstretched or injured by childbirth, surgery or trauma.  In both circumstances yoga poses and exercises can activate the muscles.

Balance with Yoga and the Pelvic Floor

Yoga focuses on two key areas that can help the pelvic floor. The first tenet of yoga that can improve pelvic floor function is the focus on breathing. The diaphragm and the pelvic floor muscles work together, so improving breathing techniques can improve recruitment or release of the pelvic floor musculature. The second tenet of yoga is engaging an energetic lock, or Bandha, specifically the Mula Bandha. The Mula Bandha engages energy in the pelvic floor. While it is not specifically a pelvic floor contraction or core stability, it is associated with tightening the pelvic floor. You might think of the pelvic floor contraction as the bridge to creating the Mula Bandha.

Do You Want To Learn More?

Power Your Pelvis is a workshop combining information about the pelvic floor anatomy with yoga techniques. It is an excellent resource for those wanting more awareness of the pelvic muscles, looking to balance their pelvic floor, or bring experience to their yoga practice or teaching.  If you live in the Seattle area, consider signing up for Power Your Pelvis workshop to learn the basics.   The next class is Friday evening May 12, 2017.

As always, if you are a potential patient experiencing back or SI pain, pelvic pain, bladder, bowel or sexual problems, please share this information with your health care provider, you may need specific physical therapy evaluation and treatment. Power Your Pelvis is directed towards education, improved function and injury prevention, rather than evaluation and treatment.  This link will help you find a local pelvic floor  physical therapist.  If you live in the greater Seattle area we welcome the opportunity to see you for an appointment at my office.

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Low Back and Pelvic Girdle Pain- Understanding Pelvic Floor Connections

Is the Pelvic Floor Balanced, Underachieving or Overachieving?

In my clinical practice, I regularly screen and evaluate my patients to determine the type of muscular dysfunction occurring in the pelvic floor.  Overwhelmingly I find overactive pelvic floor muscles in my patients with SI joint dysfunction and LBP. In cases like these, practitioners need to teach the patient to release the pelvic floor, rather than focusing solely on strengthening exercises. Understanding the connection between the pelvic girdle and the pelvic floor can improve patient outcomes.

What Does the Research Say?

In 2008, Eliasson, et al, found 79% of women with recurrent LBP experienced concurrent urinary incontinence (UI). This compares with 20-40% of the general population, depending on age. In 2016, Ghanderi, et al, built upon this research and showed that performing stabilization exercises with a focus on the pelvic floor led to improvement in both LBP and UI. Without the focus on the pelvic floor, LBP improved, but patients were still left with UI symptoms.

There is a growth in research supporting the connection between the pelvic floor, low back pain and pelvic girdle pain. New research shows this correlation goes beyond simple muscular weakness and points to a need to differentiate between patients with LBP who have pelvic floor muscle weakness versus an overactive pelvic floor. Ongoing research at McMaster University, School of Rehabilitation Science, in conjunction with Pelvic Health Solutions in Canada is helping to identify the incidence and type of pelvic floor dysfunctions associated with hip and LBP.

Download Questionnaire

There is also a correlation between radicular symptoms and urinary incontinence. A 2016 study by Kaptan, et al, found a statistically significant correlation (p=0.001) between LBP with radicular symptoms and urge urinary incontinence. A relationship between stress urinary incontinence (SUI) was noted as well, however the correlation was not as strong. This was the first study specifically looking at radicular symptoms and UI, and more research is needed in this area.

Researchers have also looked at the incidence of pregnancy-related low back and pelvic pain (PLBP) and pelvic floor dysfunction. Pelvic floor dysfunction occurred in 52% of patients with PLBP, a significantly higher percentage than in the control group. These same women showed an increase in the muscular activity occurring in the pelvic floor muscles compared to healthy controls.

As a Physical Therapist, How Can You Help Your Patients?

First, recognize that many patients with low back pain, SI dysfunction or radiculopathy have pelvic floor complaints. To treat effectively and improve patient outcomes, addressing the pelvic floor component is necessary and beneficial. It is worth noting that unless specifically asked, many patients will not include urinary incontinence or pelvic pain in their initial complaints.

Second, learning to perform an external clothed exam can give a traditional orthopedic physical therapist a tool to assess pelvic floor muscle tone and strength. This allows integration of pelvic floor treatment, including stretch or release of overactive muscles, to help decrease pain and facilitate improved neuromuscular firing patterns. Providing postural education and breathing, and explaining how that affects the pelvic floor can also help.

Understanding the connection between the pelvic girdle and the pelvic floor can improve LBP and SI Joint patient outcomes. It can guide treatment, facilitate referrals if needed and improve quality of life.

Interested in Learning More?

Physical therapists, physical therapy assistants and PT students can register for my 2 day professional continuing education course on April 22-23, 2017  in Seattle, WA.  Early bird registration ends March 17, 2017. Here’s the link to Foundations of the Pelvic Girdle - Pelvic Floor Connections.

References

Eliasson, K., Elfving, B., Nordgren, B., & Mattsson, E. (2008). Urinary incontinence in women with low back pain. Manual therapy, 13(3), 206-212.

Ghaderi F, Mohammadi K, Amir sasan R, Niko kheslat S, Oskouei AE. (2016). Effects of Stabilization Exercises Focusing on Pelvic Floor Muscles on Low Back Pain and Urinary Incontinence in Women. Urology.;93:50-4.

Kaptan, H., Kulaksızoğlu, H., Kasımcan, Ö., & Seçkin, B. (2016). The Association between Urinary Incontinence and Low Back Pain and Radiculopathy in Women. Open Access Macedonian Journal of Medical Sciences, 4(4), 665–669. http://doi.org/10.3889/oamjms.2016.129

Personal communications Carolyn Vandyken, Nelly Faghani from Pelvic Health Solutions.

Pool-Goudzwaard, AL, Slieker ten Hove, MC, Vierhourt, ME, Mulder, PH, Pool, JJ, Snijders, CJ, Stoeckart, R.(2005). Relations Between Pregnancy-Related Low Back Pain, Pelvic Floor Activity and Pelvic Floor Dysfunction, Int Urogynecol J Pelvic Floor Dysfunct. Nov-Dec;16(6):468-74. 

Photo by mdid