To Kegel or not to Kegel?

     Without fail, whenever I explain to people that I treat people with incontinence and pelvic pain issues they say, "You mean like doing Kegels?"   The answer is usually no, at least initially.  The idea that kegels are the ultimate answer to incontinence and pelvic pain issues is a dangerous misconception. 

     Most people are somewhat familiar with the Kegel pelvic floor exercise.  A Kegel is an exercise where one voluntarily contracts the pelvic floor as if trying to stop the urine stream.  If there is TRUE WEAKNESS in the pelvic floor, performing Kegel exercises is a place to start, but just because you have some urinary incontinence doesn't mean you have isolated weakness in your pelvic floor.  Also, in my practice I have found that many people think they are performing Kegels and they are really contracting their abdominals, or their hip muscles, or simply holding their breath. 

    What I find most commonly when someone has pelvic pain or incontinence issues is that there is some spasm or areas of trigger points in muscles of the pelvic floor.  This Mayo Clinic article does a great job of explaining this phenomenon, how it can present, and how physical therapy can help:

 http://www.mayoclinicproceedings.org/article/S0025-6196%2811%2900024-3/fulltext

    The Nonrelaxing Pelvic Floor

The pelvic floor could be in spasm for a number of reasons. This is often seen after childbirth with tearing or episiotomy.  It's also seen after a pelvic or abdominal surgery or any medical issue with the pelvic organs.   In response to these irritations or traumas the pelvic floor responds by tightening up, just like other muscles in the body respond to pain.  Some issues that can result in pelvic floor spasm include fibroids, interstitial cystitis, kidney or bladder infections, constipation, endometriosis, pelvic inflammatory disease, and polycystic ovarian syndrome.  Likewise, many pelvic or gynecological diagnoses are actually primarily or partly due to pelvic floor spasm.  These include vaginismus, dyspareunia, vestibulitis, vulvodynia, coccygodyia or tailbone pain, and pudendal neuralgia.  Incontinence and pelvic organ prolapse can occur as a result of the weakness associated with a spastic pelvic floor as well. 

Unfortunately, the public and even the medical community is still quite unaware of this issue.  As a result, the spasm or tightening in the pelvic floor often goes unaddressed, resulting in sometimes years of pain or incontinence.  Patients often go through unnecessary surgeries with poor results.  And more surgeries can result in even more pelvic floor tightening, ultimately worsening the pain or urinary incontinence. 

The thing NOT to do in these situations is the first thing that comes to the mind of many medical professionals and much of the public - KEGELS.   The pelvic floor is a muscle and behaves much like any other muscle in the body.  When a muscle is in spasm it is weak.  If you had a spasm in any other muscle that was causing you pain, what do you think would happen if you went around contracting that muscle several times a day?  The spasm would get worse.  The pain would get worse.   And the weakness would get worse, which would result in any incontinence to worsen as well.  

What a pelvic or women's health physical therapist would do is assess the pelvic floor muscle to check it's tone.  If the tone is too high, or the muscle is in spasm, we would do gentle massage and instruct in relaxation techniques to first normalize the tone.  We would also address any other muscle imbalances in the hips, legs, and trunk.  Weakness and limited mobility in these related areas often results in overuse and spasm of the pelvic floor.  In this way we are addressing the ultimate cause of the pain, not just the source of the pain.  If this rings true for you or someone you know, please refer them to a women's health or pelvic physical therapist.  Please feel free to contact me with any questions as well.  I can't tell you how many patients I have seen who get relief quickly after finally having physical therapy for these issues after years of unnecessary pain and embarrassing incontinence.

Conley Physical Therapy in Decatur, Georgia can help!   
www.conleyphysicaltherapy.com
info@conleyphysicaltherapy.com

I hope this post will help to bring awareness to a very common problem and that people will find the help they need!

Warmest Regards,

Kelly Conley, PT, DPT, OCS

Exercises for activating gluts and progession to single leg squat

Hello again,

Are you ready to get your gluts firing?  As you recall in a recent post - Are your gluts working when you work out - we discussed the single leg squat and how to learn if you are performing a single leg squat correctly and whether you can self correct to have the proper form.   Today I will be discussing some exercises to try if you are unable to perform a single leg squat properly.

To review, a proper single leg squat should look like the figure on the left and not like the figure on the right.  The center of your knee cap should be aligned over your second toe, and your pelvis should be level, not tilted or rotated.  Also your trunk should be straight, not rotated or with your trunk leaning forward.   Knowing how this activity should look, you can try to perform it correctly.  If you aren't able to do so, you shouldn't be running or jumping or stair climbing for exercise.  If you don't hurt already, you will eventually due to uneven forces and wear and tear on your system.

Now, what can you do if you aren't able to properly perform the single leg squat?  
You look at your double leg squat.   First let's look at the proper form of the squat.

The alignment of the legs should be similar to that of the single leg squat.  The center of the knee cap should be in line with the second toe.  I tell my patients that if you look down, you should be able to see your big toe on the INSIDE of your knee.  In the image above, this would be true on the squat being performed on the left. In the squat being performed on the right, the knees are inside of the foot completely.  If he were to look down, his toes would either be on the outside of his knees or he wouldn't be able to see his toes at all because his knees would be blocking them.  This type of squat puts unequal and dangerous forces throughout the foot, ankle, knees and hips.  If someone who could only squat like this were to try to run, these dangerous forces would likely not only result in knee, hip, and ankle issues, but they would translate up the body to the back, shoulders and neck causing pain and injury in any of these areas as well.  

SO, how can we correct this and reinforce gluteal activity? 
There are some squatting type exercises to help activate your gluts where your weight is on both legs.   Let's look at a few of these.  


For this exercise you take a loop of resistance band and fold it in half or double it.  Then put it around your legs or step inside it.  Position one part of the resistance band below the knees and one part above the knees.  Pull the knees out into the band as you do your squat with proper form, with the center of the knee cap aiming towards the second toe.  The toes should point straight ahead and not out to the side.  Within a few repetitions you will feel your gluteal muscles working.  Try not to lean your upper body forward.  It should remain fairly upright or vertical.  A very slight forward lean at the hips is ok, as is shown in the picture.  Also, make sure your lower back isn't rounding out.  There should have a slight arch, or lordosis, in the lower back.  Sometimes to maintain this it feels like you are "sticking your butt out."

Often times it is difficult for people to keep their trunk upright.  If that is the case, I would recommend the ball wall squat, keeping a resistance band just above the knees to pull against in order to recruit the gluteal muscles.  The same alignment of the leg is correct - middle of the knee cap over the second toe, so that you can see your big toe on the inside of your knee.  The toes still point straight ahead.

 If you did find that you had a lot of difficulty keeping your trunk upright in the regular squat and your shoulders wanted to move forward - your core and back muscles may be weak or inhibited.  If that's the case, I would move to another exercise seen below. 






This exercise is an over head squat.  The resistance band helps to activate the back muscles and keep your upper body vertical.   The alignment of the legs is similar - although you can move the feet slightly wider than the hips and point the toes slightly outward.   Be sure the knees don't go inside of the toes.  Also, you should only bend or squat as low as you can WITH PROPER FORM.  As soon as the hands and trunk move forward in front of your hips - stop bending and return to upright.  As you get stronger and/or the inhibited muscles become activated, you will be able to squat lower.

Remember, no exercise should cause you any pain.   The only discomfort you should feel with any of these activities is the burn of the muscle working and fatiguing.   If you do experience any pain, you should consult a health professional to help you with your problem.

I hope this has helped you to understand how to progress to be able to perform a proper double leg squat and to activate your gluteal muscles during your exercise and weight bearing activity.  Remember, Conley Physical Therapy in Decatur, Georgia can help! Feel free to contact us with any questions.

www.conleyphysicaltherapy.com
info@conleyphysicaltherapy.com

Now go and get those gluts firing!
Kelly Conley, PT, DPT, OCS 

Conley Physical Therapy at New St. Festival in Decatur

This weekend Dr. Kelly Conley, PT, DPT, OCS was spreading the word about Conley Physical Therapy at the New Street Festival in Decatur, GA.  It was a great day to tell people how physical therapy can help eliminate their pain!