#PTonICE Daily Show – Monday, October 16th, 2023 – Valsalva: what does it even mean?

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore takes a deep dive into the Valsalva Maneuver from 3 different lenses: the scholarly research, the pregnancy & postpartum patient, and the strength & conditioning world.

Take a listen to learn how to better serve this population of patients & athletes.

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Good morning PT on ice daily show. My name is dr. Rachel Moore. I am here with Representing the ice pelvic division. I’m on faculty with ice pelvic division. Whoo. Sorry. I need to drink my coffee um i just got back in last night super late night flying from a course this weekend our pelvic live course in um wisconsin it was so much fun we got to see some leaves change which is exciting for me because in houston we don’t really have that happen um so really awesome super great weekend awesome and engaged group that we had. If you are looking to join us on the road to catch our live course, our live pelvic course, there are still so many opportunities this year. In that course, we are doing so many things. We are talking about pelvic floor considerations. We’re talking about the internal assessment and actually going over and practicing it on your back and in standing. We’re talking about pelvic girdle pain which is such a huge topic in the pregnancy and postpartum and just pelvic world in general and then day two we’re diving into the actual fitness side of things where we’re doing squats and we’re learning how to brace and we’re using weightlifting belts and we’re getting up on the rig and doing gymnastics moves it is a blast every time I come home from a course I’m hyped and there are four more chances of in 2023 to catch this course on the road. So October 21st, we’ve got a course in Corvallis, Oregon. November 4th, we’ve got one coming up in Bozeman, Montana. November 18th, we’ve got one coming up in Bear, Delaware. And then December 2nd, we’ve got one in Nova Scotia, Canada. So tons of opportunities to catch this course live on the road. Our online course will pick up again in January. So if you’re interested in joining us in the ice pelvic division, that’s what we got coming up.


This morning we are here to talk about Valsalva. So the word Valsalva is kind of a term that nobody really knows what it means or everybody thinks they know what it means and they all have their own separate camps of what it could mean because it’s described so many different ways in the literature. So what we’re going to do this morning is clarify what the different definitions of this one word are, talk about the history of it a little bit more, where this term really even came from in the first place. So this topic is really near and dear to my heart. Recently, Christina Prevett and I recently just wrote a clinical commentary on Valsalva and on the nuances of Valsalva. and how as clinicians we can take this term and how we need to take this term and understand the lens, especially when we’re looking at research, but when we’re talking to patients about what this term even means and what we’re actually looking for in our strength training fitness world when we say the word Valsalva. So let’s kick it off with the history of Valsalva. The term Valsalva is actually named after a physician from the 18th century. So he was an otolaryngologist. Anyway, he worked in ears and throat, ear, nose and throat doctor. And he created this maneuver essentially as a way to push infection out of the ears. So, the maneuver that Dr. Valsalva described actually doesn’t even look like the Valsalva that a lot of people talk about today. His maneuver was plugging your nose and blowing out, but not against a closed glottis. And when he created this maneuver, the purpose of it was to flush infection out of the ear by having that tympanic membrane push outwards to, in theory, push pus out of the ear. That is where this term was created. So when we look at Valsalva in the research lens, when we talk about diving into the specifics of research on this topic, if we’re looking in the ENT world, autolaryngological world, we’re thinking about this maneuver as a plugged nose, closed glottis, now push out in order to push that tympanic membrane out. When we’re looking at this word in the urogynecologic world, it has a very different emphasis or purpose. So when we think about pelvic organ prolapse and the diagnosis of pelvic organ prolapse, that’s where we see the Valsalva, quote unquote, being useful, I would say. So the Valsalva in a urogynecologic world is an intentional bear down and strain with a closed glottis. in order to measure the descent of the pelvic organs, particularly during that POPQ or that assessment for pelvic organ prolapse. So on the ENT side, we have the focus of plugging nose, blowing out, pushing tympanic membranes out. In the urogynecologic world, we’ve got this strain down through the pelvic floor in order to descend the pelvic organs and measure what that descent is.


In the strength and conditioning world, the term Valsalva means something completely different. In the strength and conditioning world, the Valsalva is a maneuver that is advantageous, particularly if you’re a competing athlete in the strength training world, where we need a little bit extra spinal stiffness in order to hit a lift to PR. so in the strength training world this is an inhale into the belly and then a brace of those core muscles that anterior abdominal wall and all of those muscles within the core in general in order to increase that intra-abdominal pressure and spinal stiffness to be able to lift heavier. So when we do the Valsalva, we have a 10% increase in that spinal stiffness and that carries over or translates into pounds on the barbell. So when we’re again thinking about our competitive athletes who are maybe trying to like edge somebody out, the Valsalva is an incredibly useful and productive maneuver. Even if we’re not a competing athlete, if we’re talking about just getting stronger and we’re pushing ourselves to the capacity that we want to push ourselves to in order to make those strength gains, the Valsalva is likely utilized in order to increase that capacity to lift heavier. The confusion here comes from that one word having many different definitions. And when we look at the urogynecologic world versus the strength training world, they really are truly opposite. When we’re thinking about straining and bearing down, we’re pushing down with our abdominal wall muscles, we’re pushing down with our pelvic floor, and we expect to see that descent. I 100% agree that we shouldn’t put a heavy barbell on our back and then strain and push down through our pelvic floor. That is not beneficial and it is going to put a lot of strain through the pelvic floor. Absolutely. However, when we talk about Valsalva in a strength training capacity, that’s not what the Valsalva is. The Valsalva in a strength and conditioning world is that intentional inhale into the belly and brace of that anterior abdominal wall muscles. When we do that brace of those anterior abdominal wall muscles, we don’t want to see a descent of the pelvic floor. That would be an improper brace that would need training to improve that coordination. What we expect to see with a valsalva in the pelvic floor world is a matched degree of contraction for the demand that’s placed on that system. So if we’re thinking about somebody who’s lifting a heavy lift, a one rep max, We expect that pelvic floor to kick on, but we’re not necessarily volitionally thinking about lifting pelvic floor and doing that pelvic floor contraction. As that core canister is engaged and we engage that proper brace, the entire core canister should kick on to a relatively equal degree. So in the strength and conditioning world, that Valsalva is advantageous. In the urogynecologic world, if we’re taking that concept and applying it to lifting, it is the opposite of advantageous. So when we’re looking at recommendations for our strength training athletes and our patients, we need to understand the language that is being used and what the definition of that language is. So from the standpoint of our OBs who are telling our patients, don’t ever do a Valsalva, in their mind, they’re saying, don’t ever strain and push your pelvic floor down when you’re lifting. Totally. We agree. 100%. Don’t do that. It’s not going to be great. But the disconnect is that this one word has so many different definitions. So we really have to dive in and break down what was that recommendation specifically. So when we’re with our patients, that looks like breaking down the definition for them.


But if we’re looking in the research world and we’re trying to read literature, read the newest evidence about what recommendations are for our pregnant and postpartum athletes, we need to go into the article itself and look at how they define Valsalva. Because we can easily read the abstract and the conclusion of an article that says Valsalva is not recommended, but if we’re, looking at this article and it’s actually meaning the bearing down, then we’re not getting, we’re not able to extrapolate that to the strength and conditioning side. So really with this term, it’s one word named after a man who the original maneuver isn’t even what we’re talking about anymore anyway. Across the board, we have to either figure out different words or different ways to describe this, or it really falls on us as providers to break down what it is we’re talking about. So rather than just telling your patients, do a Valsalva, maybe we don’t use that language at all, and we just talk about bracing. When we do a brace, we can manipulate breath. If we’re gonna take that intentional inhale and then brace, that is a Valsalva, But in order to eliminate the confusion across the board, we can just call it a brace. This makes a lot more sense to patients than being told by one person to never valsalva and then by another person to valsalva. And when we lay it all out and explain what all of these differences are and how it’s all one term, but it has different meanings, and none of these meanings necessarily are the same. And in fact, in the urogynecologic world, in the strength and conditioning world, they’re literally the opposite. It starts to click with patients, why it’s okay that my physician told me not to do this Valsalva, but you’re telling me that I can, because I understand that these are two very different physiologic mechanisms. Our clinical commentary over this that dives into all of this and so much more comes out in the spring. So keep an eye out. We’ll be sending it out in the ice pelvic newsletter. So if you are not signed up for that newsletter, head to PT on ice.com, go to the resources tab, sign up for that newsletter, not only for our clinical commentary in the spring, but for all kinds of resources. in the pelvic floor world. Stay up to date on the newest evidence and also just check out some cool stuff that we find along the way. I hope you guys have an awesome Monday and I hope we see you on the road soon.


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