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.. →

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. 

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A few years after I started treating pelvic floor dysfunction, Steven Covey published the book titled Seven Habits of Highly Effective People. Covey’s philosophies include self-mastery, seeking to understand and working with a team to achieve your goals, all messages applicable to anyone interested in maintaining pelvic and bladder health. Bladder health requires healthy habits that mirror many of Covey’s philosophies. It’s important to understand that the bladder is a trainable organ. What we do and the self-talk we use around bladder function make a difference!
November is Bladder Health Month and to celebrate that, I’ve outlined seven easy and healthy habits for your bladder.

First, a Word on Normal Bladders

An average bladder can hold about two cups of urine before it needs to be emptied. A person with a healthy bladder urinates 6-8 times each day or once every 3-4 hours. In reality, most people urinate (pee) a bit more during the day and less when sleeping. People urinate once every 2-4 hours on average. As you age, bladder capacity can decrease, which means you might have to pee more often, but not more than once every two hours or once a night.
The bladder sits in the front of the pelvis. The female bladder has the uterus above it, the male bladder has the prostate underneath it. This anatomical difference means the male bladder has more support. The female bladder can change position after childbirth, surgery or trauma.
The muscles at the bottom of your pelvis (pelvic floor) contribute to bladder support, control and position. If the pelvic floor muscles are overactive, they can contribute to bladder and pelvic pain.

Seven Habits to Maintain a Highly Effective Bladder

  1. Understand your bladder’s normal schedule. Avoid “just in case” peeing. Urinating more than every two hours can teach the bladder to send a signal to your bladder that it should be emptied even before it is full. Don’t’ ignore the urge to urinate (pee) for too long. “Too long” is generally considered more than four hours. This can be convenient for you but isn’t healthy for your bladder. This is bladder self-mastery.
  2. Learn about all your pelvic floor muscles (often called Kegel muscles and Kegel exercises).
    The pelvic floor consists of several muscles with 3 layers that span from side to side and from the front to the back of the pelvis. These muscles help support the bladder, uterus and rectum in the proper place, shut off and initiate the urine stream and contribute to sexual function. The muscles can be underactive or overactive. Not all people need to strengthen the pelvic floor muscles. Learn to soften and release the muscles, (reverse Kegel) as well as strengthening them.
  3. Let go of your pelvic floor muscles when urinating. Don’t start or finish with a push or strain. For females, when you urinate, sit on the toilet and after you empty your bladder, do some rocking back and forth rather than straining or pushing to empty your bladder completely. For more information see the book Below Your Belt  written to educate young women on information all ages should know.
  4. Learn what might irritate your bladder and use your diet to control your bladder symptoms. Limiting the amount of caffeine, chocolate, coffee, spicy foods and other highly acidic foods like tomatoes, citrus and vinegar can help control urgency and frequency and decrease bladder pain. Drinking fluids without carbonation or artificial sweeteners is the best, as some people are sensitive to these. Also, avoid constipation. A full bowel can press on the bladder, causing irritation and urgency or obstruct the bladder’s ability to empty.
  5. Use your pelvic floor (Kegel) muscles for controlling the bladder. Contraction or relaxation of the muscles can help with urinary urgency and frequency. Performing Kegels when you experience urgency sends a message to the brain telling the bladder to relax. If this is not helpful or causes pain, you may have overactive muscles that need to release and soften (relax) rather than contract to help your bladder symptoms. Over time, practicing Kegels will help strengthen the pelvic floor muscles, which has been shown to decrease symptoms of stress incontinence—accidentally peeing when you cough or sneeze.
  6. Keep the skin around the urethra and outside the vaginal opening (vulva) clean and dry. This can help decrease skin irritation caused by urine leakage. Regular soap can irritate the sensitive vulvar skin and bladder, so use mild natural soap and warm water outside not inside the vagina. Use pads specifically designed for incontinence and a moisture barrier cream if irritation occurs. (Some examples are Bag Balm®, Vaseline® or A and D ointment®, but please talk to your doctor or pharmacist about the best options for you.)
  7. Speak freely and get help for your bladder problems. Talking about bodily functions is not easy for most, but keep in mind there is help and support available. Work with a team of health care providers and physical therapy specialists that will help you understand your problem. Often simple lifestyle changes and proper exercise programs increase bladder effectiveness.

If you struggle with bladder control, bladder position changes known as prolapse, bladder or pelvic pain learning effective habits is a must.

Lifting Techniques for POP

Do you find it challenging to find educational material that will encourage patients to stay engaged in their activities and discourage them from becoming overly cautious?  I have found lifting education to be an important simple first step in the rehabilitation of POP. Some lifting techniques naturally increase the downward pressure on the pelvic organs more than others. Patients need to learn breathing techniques, body positioning and activation of the pelvic floor muscles.

This lifting with POP education handout focuses on the effects of technique and breathing on lifting activities.  The strategies described come from reviewing the literature and working with POP in my clinical practice. The patient education handout was developed as part of an independent study project with Heather Bridgham SPT, University of Washington Department of Rehabilitation Medicine, Department of Physical Therapy.

Women presenting with Pelvic Organ Prolapse (POP) are frequently told many exercises and activities are unsafe and therefore should be avoided. Often, little information is provided about the specific techniques to be used in these exercises or activities. For example, a lifting technique can be done with either a squat or a lunge position, and breathing patterns used to do the lifting can strain the pelvic floor muscles or incorporate them into the task. Without specific information about technique, many exercises and activities are put on the “avoid or harmful” list.

When exerting while lifting or exercising, there is a natural increase in intra-abdominal pressure (IAP). The key is to understand which activities naturally increase IAP more than others and to use breathing patterns and pelvic floor muscle activation during these pressure rises.

Let’s use an analogy to better understand IAP.

Think about an upside-down ketchup bottle. Hitting the bottom of the bottle increases pressure (similar to IAP) and empties out the contents. But if the cap is on, no ketchup comes out. Similarly, during an increase in IAP caused by lifting or exercise, a healthy (non-POP patient) using her pelvic floor muscles is like keeping the cap on her pelvic contents.

ketchup bottle photo

Now, back to the ketchup. Sometimes the ketchup won’t come out even when the cap is off and pressure is applied, and then suddenly it does come out. Why? Because disrupting the surface tension and integrity creates an easier flow. Disruption of the surface is like a pelvic floor dysfunction seen with POP because of muscle and fascia integrity changes. Research shows that in healthy women, using the PF muscles during increases in IAP supports the continence mechanism and the pelvic organs. These concepts are explained in a research looking at the differential effects of Valsalva and straining maneuvers on the pelvic floor.  For the complete IAP literature review add the complimentary download to your cart.

Photo by .dh
Photo by drocksays

Pelvic floor muscle training (PFMT) is used to improve strength, endurance, and coordination of the pelvic floor muscles. There are two hypotheses regarding the use of PFMT for prolapse: (1) that strengthening these muscles can improve the structural support for the pelvic organs, and (2) that women develop a “knack” for consciously contracting their pelvic floor before/during increases in intra-abdominal pressure.

What research currently says about pelvic floor exercise training.

Within the available literature, there is general consistency regarding prescribed dosage comprising of 3 sets of 8-12 max pelvic floor muscle contractions per day. The duration of specific pelvic floor muscle training should be conducted over a 3-6 month period on the basis of muscle physiology, necessary for muscle hypertrophy. However, strength is not the only measure of muscle function and unfortunately there is a lack of research comparing muscle training, or looking at sub maximal pelvic floor exercise in conjunction with motor control training.

Consider an individualized exercise program

Administration of PFMT is more beneficial for the patient when the supervised training is given individually rather than in a group. This accounts for individual strength and activity differences. Further research is needed to identify the characteristics of patients that predict positive/negative treatment outcomes. The majority of the literature reviewed focused on short duration effects of PFMT; therefore, longer duration follow-up studies of PFMT are warranted.

This complimentary literature review download includes 14 articles addressing exercise science and pelvic organ prolapse.

GPostpartum women have lots of questions and need patient education for pelvic organ prolapse. My clients often think they are alone with the symptoms, reporting a feeling of isolation or “feeling different” than other women. One patient asked, “Does my vagina have stretch marks too?” Another reported, “It feels like I’m growing a testicle!”

Most of these women first consulted the internet when looking for answers about what they were feeling in their bodies. Internet searches for prolapse are plagued with what I call "doom and gloom" information, especially if you are a postpartum mom. Prolapse symptoms often cause women to stop or change exercise, daily activity routines and/or sexual activities. They report feeling less feminine and more self–conscious about their bodies. A new mother adjusting to changes in her body and trying to return it to its pre-pregnancy state needs to know all of her recovery options.

I'm delighted to provide a free informational handout on pelvic organ prolapse that introduces physical therapy as a first line of treatment. Please feel free to share it with your patients, physicians and fellow therapists.

Photo by Sangudo

It's not always easy to look at your sexuality issues head-on. Sometimes medical conditions create limitations or cause pain with vaginal penetration.  Your healthcare provider may have suggested a vaginal dilator. What are they and who uses them?

This is the first in a series of posts designed for women that have been advised to use a dilator or are currently working with a vaginal dilator. Dilators can be used to keep the vaginal tissues pliable and healthy or to help return the vaginal opening and canal to a size that is functional for the patient’s sexual activity preferences.

Vaginal dilators have been used in my practice since the late 1980’s as a component of pelvic floor rehabilitation therapy for sexual function. Also known as vaginal trainers or spacers, vaginal dilators are designed to stretch or expand the vaginal opening, tissues and musculature. They have helped hundreds of patients return to or begin penetrative sexual activity, a common goal for many women. This tool can help improve comfort during vaginal penetration, and this can translate into an increased quality of sex life for women and their partners. Physical therapists trained in Women’s Health are ideal health care providers to work with dilator introduction and progression. We have the ability and time to evaluate and treat the pelvic girdle and vulvar regions, and the pelvic floor muscles.

Women who suffer from several categories of medical conditions benefit from the use of vaginal dilators. I have categorized the conditions into 4 types based on my clinical experiences using dilators.

The first group involves women with conditions that have created anatomical changes within the pelvis. This includes genetic conditions, (Mullerian Agenesis or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome), a surgery (after hysterectomy, prolapse repair, or gender reassignment surgery), a response to medical treatments (Graft-versus-host disease -GvHD) and cancer patients with sexuality issues after radiation, breast cancer treatments, and surgically induced menopause.

The second group includes women with medical conditions that can cause painful or restricted vaginal penetration or intercourse. This category includes but is not limited to, Vulvodynia, Vestibulodynia, Vulvovaginal atrophy, Vaginal Stenosis, Lichens Sclerosis, Painful Bladder Syndrome, Interstitial Cystitis, perineal tears, episiotomy and pelvic pain after childbirth.

The third group includes women with chronic pelvic pain who have either pelvic girdle (the SI joint, coccyx, pubic region) and/or bladder and bowel symptoms. Often in this case, the dilator is used as one way to stretch the pelvic floor muscles.

A fourth group includes women who have not been able to have a pelvic gynecological exam, wear a tampon during their menses, or be sexually active with vaginal penetration despite desire and multiple attempts. This condition is known as vaginismus. Often women with vaginismus need to learn to control muscle responses, focus on insertion techniques and understand the neuroscience of pain, fear and anxiety. Those women have additional needs address in the blog Vaginal dilator tips and overview for vaginismus patients by physical therapist Tracy Sher, MSPT.CSCS.

When working with patients where dilator techniques have been recommended, I frequently encounter many patient emotions. Knowing which dilator to use and having clear directions supports women in their process of recovery. With the support of physical therapy they frequently move from being embarrassed, confused and discouraged to confident, inspired and empowered. Many women reach their goal of pain-free vaginal penetration.

For more information, download Types of Vaginal Dilators , a free educational handout which describes several dilator types, sizes and features.

The first step is choosing the right dilator for your condition. If you have been advised to use a dilator, I suggest you seek the help of a physical therapist. We have the knowledge and skills to support you to meet your goals!

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In memory of Mom

May 27, 2015, would have been my mother’s 100th birthday. She was born in Russia and came to the US during the Great Depression.   I remember her stories about learning English, going to college to study microbiology and serving in the US Navy WAVES. She had a good friend in the Navy, a physical therapist who loved her job, and mom was always impressed with her passion for the profession. I was strongly encouraged to consider a career in physical therapy. I am so glad I did!

Mothers are special and to acknowledge them all I am doing an eBook countdown discount promotion (from 80% -30 %) this week, May 27- June 3, for Reviving your Sex Life after Childbirth, your guide to pain-free and pleasurable sex after the baby.

I believe it is of critical importance that once and for all the pelvic floor musculoskeletal issues of the post-partum woman are acknowledged and treated. This book provides the first steps for real solutions from over 25 years of practice.

Please share this with the mothers you know.

Photo by A.Davey

Your guide to pain-free and pleasurable sex after the baby

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This book helps post-partum women restore pain-free and pleasurable sex after childbirth. It offers practical physical therapy instructions and self-treatment tips on exactly what to do if sex hurts before you start, during, or after you are done.

The graphics and instructions provide an easy to implement step-by-step approach. The book also addresses a root cause of postpartum sexual pain and provides proven long-term strategies to help you restore normal pelvic floor sensation and tone -- a key component for pleasurable sex.

A must read for all post-partum women, their partners, and the clinicians who care for them.

...Perhaps we can prevent considerable chronic birth related vulvar, pelvic, and sexual pain this way, thanks to Kathe!

Deborah Coady, MD, FACOG
Author of Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Painful Sex

Book Resources

Downloads, links and references in the eBook can be found at

Reviving Your Sex Life After Childbirth - Resources.