#PTonICE Daily Show – Monday, May 6th, 2024 – Most bang for your buck: pelvic edition

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses two different presentations of pelvic floor patients who may present to the clinic.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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Good morning, PT on ICE Daily Show. I hope everyone had a great weekend. It is Monday, so that means that you are live with the pelvic division. My name is Dr. Jessica Gingrich, and today we are going to talk about the most bang for your buck pelvic floor addition. So I’m going to present today two separate presentations. So I don’t want to talk about necessarily a case study or two separate case studies, just different presentations that you may see in the clinic. if you are a newer pelvic floor clinician, you may feel stuck. You may feel, oh, I haven’t seen this or haven’t seen this many combinations of things. Where do I start? And so, that’s what I want to talk about today. So, the first thing or the first patient we have is going to be the person that has pain. That could be back pain, that could be hip pain, SI joint pain, tailbone pain, pain with penetration, and that may be during intercourse, during a vaginal exam, whether that is a speculum or digital exam. They may even have a history of this with tampon use. Even bedroom toys can be an issue. They may also say that they have issues with bowel movements. They have difficulty emptying or they do have a bowel movement, but when they’re done, they don’t feel quite empty. From the urinary standpoint, they may feel like they pee all the time, so they have frequency. Or when they get the urge to pee, they really have to go, so more like urgency. And then this also may present with or without urinary incontinence. On the flip side of that, we have the weaker pelvic floor. And so this is someone that comes in and maybe when you’re talking to them about their activity level, Well, I haven’t worked out all that much or I like to walk. I don’t really lift weights. I haven’t done it in years. And they may also present with leakage. They may even have heaviness in their vagina or dragging sensation. All of these presentations may come with, um, babies or, or no babies, right? Back to our first presentation, that person also may have that type A personality, where they like structure, and they feel like they have to work out all the time. I wanna kinda go off on a little bit of a tangent about that personality. We tend to say that, oh, well, they have that type A personality, and that’s not a bad thing, right? If we didn’t have that personality, what would our world look like? What we wanna do is we want to help that person Um, lean in to how they can best just function, right? And so when it comes to working out for a type a person, it may be a lot of education, right? You don’t need to work out seven days a week, but this is what it can look like. Here’s what programming looks like to really maximize things. There’s a great book that I’m currently reading. It’s called A Guide to Losing Control or Type A, I’ll have to post it in here. I can’t remember the title of it. But it’s a really great book around just the structured Type A personality and how to really lean into that and help that person just feel better and function better, really optimizing recovery, stuff like that. So I’ll drop that in the comments here when I’m done. So what I wanna talk about is where can we start with both of these presentations if we don’t know where to go? So with that weaker person, they need to be loaded, right? They need to get stronger. So that’s the first and foremost. But maybe they’re not ready for that. So what we’re gonna talk about, there’s a thousand different ways to do this, but we’re gonna talk about relaxing, okay? This is not the, well, you need to just relax your pelvic floor. You need to just relax. No, it’s more about knowing how to relax. So, the first thing that I want to talk about, and I know this is everywhere, but is the squatty potty or getting your feet elevated to some capacity. What this does from a mechanical reason, and I love talking about this in the clinic, is give them the reason why they’re doing it. Don’t just say, hey, when you go to the bathroom, elevate your feet. Okay, see you later. Tell them why. So what this does is it decreases that anorectal angle. So when that angle decreases, now we’re not having to fight against natural angles in our rectum to help keep us continent. The other thing that it does is it allows that puborectalis muscle to relax, to just unkink the base of the rectum. So two biomechanical reasons as to why we are suggesting that they get their feet up. Now you may be asking yourself, why are we talking about a squatty potty to relax the pelvic floor? Cause that’s maybe one or two times in a day, depending on the patient in front of you. So that is going to allow the pelvic floor to just work optimally, right? You’re getting the pelvic floor. When the pelvic floor needs to be off, you are helping that to be off rather than sitting and without your feet elevated and your pelvic floor might be on a little bit, or if you’re bearing down, maybe your pelvic floor reflexively kicks on. And so that’s just optimizing your pelvic floor on day-to-day functions. that need to happen, right? Now, I will say that some people don’t feel great with having their feet elevated, and that’s okay. Also, the angle of which their hips are is different per person. Also, I feel like you guys can hear my dogs barking. They’re making their PT on Ice daily show debut. Sorry about that. The second one is a diaphragmatic breath. And we hear this one all the time too. Well, let’s just teach our patients how to diaphragmatically breathe. Yes, that’s a really important thing, really for anyone, but we need to teach this well, right? We can’t just say, here’s how you breathe. Okay, go do it. We need to have them focus on what they are trying to feel. And so when we are diaphragmatically breathing, when we inhale, our pelvic floor should descend. Have them focus on that. Where does your pelvic floor go when you inhale? Focus on that movement. And also just… and have them do this in different positions. You know, they may be on all fours doing it. They may be in a deep squat. They may be sitting on the floor. And this is likely going to be a static thing that we’re doing. So, having them be still really focusing on it. Don’t watch Netflix and do this as you’re starting to learn. Now, different cues that I like to use around where your pelvic floor is, it looks different for everyone. So, does your pelvic floor descend? Some people, they’re like, yeah, it does. They kind of understand that they are aware enough about that. Sometimes people aren’t, and so you have to give them one structure to focus on. One of my favorites, and I know you guys have heard me say this a thousand times, is feeling your butthole open. We know where that is most of the time, right? When we have to go to the bathroom and we are not by a toilet, we know where that muscle is because we squeeze it. That’s certainly not everyone, but it’s a good place to start, okay? Now, the third thing is incorporating that diaphragmatic breath that we talked about after a workout or even before intimacy. And that can be a really powerful thing if someone is having pain with insertion, painful orgasms, painful arousal. And that could work for people who own a vagina and for people who own a penis. So give those three things a shot. But remember, we always want the end of that plan of care to look like that person lifting weights. They also may be doing Kegels, right? They may need to have that base strength of where, or I say strength, Kegels can increase strength for someone, but it’s probably going to be short-lived, right? Because A, it’s really kind of body weight, and B, we don’t function just under body weight, we function under load. And so, ending with your plan of care of teaching this person basic barbell movements, dumbbell movements, Kettlebell movements, maybe that’s where they’re starting and encouraging them to lift weights. This looks different per generation, right? We may have to convince some people that this is a really good thing. And then other times we may not need to, right? People are going to be a little more into it. So, go out and try these three things. We’ve got the Squatty Potty, we’ve got Diaphragmatic Breathing, and we’ve got Diaphragmatic Breathing following a workout or before intimacy. Give those a shot and let me know how they go. I will see you in a couple of Mondays.

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