Birth Prep: Pelvic floor therapy as preventative care
It’s common for clients to view pelvic floor physical therapy or occupational therapy as something that’s only necessary when there’s a “problem” that needs to be “fixed.” This focus on management after an injury isn’t surprising, considering how much of our medical system in the US is focused on symptom management, rather than preventative care.
What if we started shifting our perspective, so that pelvic floor therapy acted more as preventative care for a more empowered birthing process? The more educated you can be about evidence related to interventions and birth outcomes, the easier it will be for you to approach labor and delivery with a sense of confidence and peace. Additionally, starting pelvic floor therapy as a pregnant person is helpful for beginning to consider some aspects of your early postpartum healing and recovery.
So how can pelvic floor therapy support you in preparing for birth? Here are 7 ways a pelvic floor physical therapist or occupational can help improve your birthing experience.
Core control and body mechanics during pregnancy
Hip and spinal mobility
Connecting to your pelvic floor
Breathing and pushing mechanics
Birthing positions
Pain science and childbirth
Perineal massage
Preparing for early postpartum
Core control and body mechanics during pregnancy
As you’re nearing your due date, you may notice that your center of gravity has drastically changed, making it difficult to do many daily movements such as walking, cleaning, bending over, squatting, etc. Your pelvic floor therapist will teach you how to connect to your core in a functional way in order to minimize back pain, diastasis recti, and pubic symphysis dysfunction. Learning how to stabilize your core during pregnancy will benefit your postpartum recovery, as you will have already practiced engaging these muscles and made them a part of your sense memory.
Hip and spinal mobility
You don’t need to be overly flexible in order to have a successful birth. But starting to work on hip and spinal mobility may be helpful for the stages of labor when the baby is moving through the pelvis. Being able to move in and out of hip internal and external rotation, as well as finding mobility throughout your whole spine, may be beneficial for reducing birth injury and increasing options for different birthing positions.
Connecting to your pelvic floor
Although there’s now access to so much more information about the pelvic floor, you may find yourself lost in a sea of suggestions and advice. Working with a pelvic floor therapist before birth can help with not only getting educated about what the pelvic floor is and what it does, but how to actually feel this group of muscles. And no, we’re not going to tell you to do 100 kegels!
Breathing and pushing mechanics
Being able to sense into the pelvic floor will benefit you as you learn about the mechanics of pushing during labor. Practicing what it feels like to actually use your breath to effectively lengthen the pelvic floor will allow you to feel more prepared for when you’re actually laboring.
Birthing positions
There are other ways to labor besides being on your back! Your pelvic floor therapist will go over the research backed positions that will hopefully help you prevent tearing and increase ease of pushing. We’ll talk about positions appropriate for a medicated and non-medicated birth, and help you practice these positions in your body in order for you to feel confident about how to move in and out of them.
Pain science and childbirth
Many pregnant people are concerned about how painful labor may be. Your pelvic floor therapist can help educate you on some of the science around pain, and the role of the brain and nervous system in pain processing. This can help with creating a plan regarding pain management during childbirth.
Perineal massage
Starting perineal massage at about 34-36 weeks postpartum can be helpful for reducing the degree of tearing that can occur during childbirth. Your pelvic floor therapist can help you feel confident that you’re performing the massage correctly, as well as teach partners how to perform the technique as well.
Thinking about early postpartum
Although it can feel empowering and relieving to consider how to best prepare for labor and delivery, it’s just as important to consider how you’re going to feel in the early postpartum period. Your pelvic floor therapist can help you think about stretches, breastfeeding or chestfeeding body mechanics, breathing techniques, and pain relieving measures to ensure that the early postpartum period is as comfortable as possible.
Pelvic floor physical therapy or occupational can be an essential part of your pre and postnatal prep and recovery. I can help guide you towards a birth where you feel knowledgeable, confident, and secure every step of the way.
It’s not a UTI???!!!
Picture this-it’s been weeks of urinary urgency and frequent urination and pain while peeing. You’ve tried every over the counter supplement and old wive’s tale remedy, and nothing is helping. You finally make it to your doctor, and he tells you that your test came back negative for a urinary tract infection. What is happening?!
Symptoms that can look very similar to a UTI, including urinary frequency and urgency and pain with urination, can sometimes be caused by pelvic floor dysfunction and impaired bladder/brain connection. With a little bit of help from your pelvic floor physical or occupational therapist, you may find relief from your symptoms. You’ll feel empowered if these symptoms ever return, knowing that you have tools in your toolbox to address the discomfort.
Bladder irritants: You are what you drink
If the inner lining of your bladder detects urine concentrated with certain irritants, it will try to release the urine as quickly as possible, leading to the sensation of increased urgency. Common bladder irritants include coffee/caffeine, carbonated beverages, and alcohol. Note! “Carbonated beverages” include seltzer! If you need your spicy water to stay hydrated, try creating a “water sandwich”: have a little bit of water, then some seltzer, and then some more water. This will help dilute the seltzer, as well as any other bladder irritant you might be consuming.
Additionally, dehydration can be a bladder irritant. It’s common for people experiencing urinary urgency to cut back on water intake in an attempt to control frequency of bathroom visits. It’s important to keep hydrated, however. Working with a pelvic floor physical or occupational therapist will help you to create strategies on how to better manage the uncomfortable sensation of urinary urgency.
Pelvic floor hypertonicity
If the fascia around the bladder and urethra is overactive, or hypertonic, this can confuse the signals between the bladder and the brain, leading to sensations of urgency that aren’t caused by a full bladder. Additionally, inability to lengthen the pelvic floor can result in more difficulties in emptying the bladder. Urine will then be retained, which could then increase the likelihood of feeling urgency again soon. A pelvic floor physical therapist can help assess if the discomfort you’re feeling might be connected to over recruitment of the pelvic floor musculature.
Bowel Habits
Your GI system health can be intimately connected with feelings of urinary urgency, frequency, and pain with urination. If you’re someone who experiences chronic constipation, this can lead to hardened stool building up over time in the rectum. Because of the proximity of the rectum to the bladder, this can place pressure onto the bladder, contributing to the sense of urgency.
Additionally, experiencing chronic diarrhea can also lead to general inflammation and irritation of the pelvic floor tissue. Because one of the main functions of the pelvic floor is to ensure you don’t leak urine or feces, the pelvic floor muscles can overrecruit when they sense liquid stool in the rectum. This over-recruitment of the pelvic floor musculature can contribute to higher tone of the musculature surrounding the urethra, which could lead to feelings of urgency and pain with urination, as described above.
Interstitial Cystitis/Painful Bladder Syndrome
Interstitial Cystitis, or Painful Bladder Syndrome, is a diagnosis that may include inflammation of the bladder, urinary frequency and urgency, pain with sex, and bladder pressure. Often, these symptoms can be caused by or contributed by pelvic floor dysfunction and over-recruitment. If you have IC or PBS, and you present with hypertonicity in the pelvic floor, it would be helpful to seek out support from a qualified pelvic floor occupational or physical therapist. A trained specialist will help teach you how to lengthen these muscles overtime, hopefully decreasing urinary urgency and frequency.
If you have UTI symptoms with no discernible UTI or other medical cause, it may be time to consider pelvic floor physical therapy or occupational therapy! Using manual techniques, bladder retraining exercises, breathwork, and stretches, your pelvic floor therapist can help guide you towards reducing symptoms and gaining your life back.
Endometriosis
What is endometriosis? Why does it happen?
Endometriosis is a condition in which tissue similar to the lining of the uterus starts growing outside of the uterus. It is most commonly diagnosed in people assigned female at birth (AFAB) ages 25-40. This tissue mostly attaches to pelvic organs, but occasionally can grow to other visceral structures as well–it has been found as far away as the nasal passages. It affects about 1 in 10 people assigned female at birth. Common symptoms include pelvic pain, heavy and extremely painful periods, spotting between periods; and GI issues. Pelvic pain due to endometriosis is typically cyclical and is worse right before menstruation starts.
There are several theories about the cause of endometriosis, though more research is needed.
Endometriosis needs to be formally diagnosed through laparoscopic surgery, although ultrasound or MRI may give your doctor some initial insight.
What are my treatment options?
There is no cure for endometriosis, just management. Medical treatment options may include: hormonal management via oral contraceptives, GnRH-analogues, or progestins; laparoscopic surgery, a minimally invasive surgery used to remove adhesions and scar tissue; and NSAIDS/pain relievers.
If this is a medical condition, why can pelvic floor physical therapy or occupational therapy help?
Pain neuroscience education and central sensitization-In chronic pain conditions, the autonomic nervous system can produce a hypervigilance that perpetuates pain cycles. This is called central sensitization, and it can make pain relief feel elusive. Pelvic floor therapy aims to educate clients about current research in pain science; this education can feel validating and empowering, and studies are suggesting that understanding pain science can help clients with pain reduction.
Self-care around menstruation-If you have endometriosis, you know that your menstrual cycle can be extra challenging. Your pelvic floor therapist will work with you to create a plan around your period pain, which might include brainstorming about lifestyle changes to support pain relief and relaxation; gentle stretches; or breathing exercises.
Pelvic floor relaxation-Many people with endometriosis experience pelvic floor hypertonicity, or overactivity in the fibers on the muscle. This may perpetuate some of the pain or discomfort they are feeling, and contribute to pain with sex. Your pelvic floor therapist will teach you tools for ongoing pelvic floor muscle relaxation.
Pain with sex-If you have endometriosis and you’re experiencing pain with penetrative intercourse, you’re not alone. Through the use of stretches, exercise, breathwork, and therapeutic tools such as a pelvic wand or dilators, your pelvic floor therapist can help address your pain with intimacy.
Endometriosis can be really challenging to manage. Pelvic floor physical therapy or occupational therapy can help educate and empower you, mitigate some of the effects of the condition, and assist in the return to the activities you’ve always loved.
What are hemorrhoids? How do I know if I have them?
Hemorrhoids are swollen blood vessels found internally in the rectum or outside of the anus. These blood vessels cushion the area and protect your anal sphincter and help with closure. Nearly 75% of adults will have hemorrhoids at some point in their lives, often caused by increased pressure in the pelvic region. Causes of this increased pressure may include the weight of your baby during pregnancy, pushing during childbirth, and straining to pass stool. You may also experience hemorrhoids postpartum, as you’re now increasing pelvic pressure by constantly lifting and holding your child. Common symptoms of hemorrhoids may include: blood in your stool, and/or a hard lump and discomfort around your anus. It’s important to check in with your doctor if you’re experiencing any of these symptoms.
Pelvic floor hypertonicity
Maybe you’re already seeking out pelvic floor therapy for vaginismus, dyspareunia, or any other kind of pain with sex. If so, it’s possible that you have a hypertonic pelvic floor. This means that your pelvic floor muscles might hold some overactivity throughout the day. These chronic holding patterns can lead to constipation, which can increase your risk for hemorrhoids. Working with a pelvic floor rehab provider on learning to intentionally relax your pelvic floor can help to decrease some of your habitual patterns, hopefully leading to better stools and decreased hemorrhoid prevalence.
Coordination is key…
Pelvic floor dyssynergia happens when our body unconsciously contracts our pelvic floor when it’s supposed to relax. Ideally during bowel movements, our pelvic floor muscles should lengthen and open, rather than contract. Constantly contracting your pelvic floor muscles while you’re trying to defecate will cause straining and increased pressure on the rectum, possibly leading to hemorrhoids.
Chronic constipation
Chronic constipation impacts 15-20% of the population. Although many people experiencing chronic constipation have pelvic floor involvement, the condition can be caused by a myriad of other factors including not getting enough fiber, movement, and water throughout the day; slow GI motility; chronic stress or trauma; and more. Managing stool consistency through proper evacuation techniques (including using a squatty potty or stool!), diet, exercise, and self-care are some of your best tools in the prevention of hemorrhoids. A pelvic floor therapist can help you parse out and manage some of these factors.
Managing intra-abdominal pressure during defecation
Our entire abdomen is basically a pressure canister that we can use to our benefit or to our detriment. Most of us don’t habitually think about the way we’re passing stool. You may be unconsciously gripping your abdominal muscles and increasing pressure on your pelvic floor. A pelvic floor therapist can teach you methods for reducing this pressure, and for passing stool in a more easeful way.
Hemorrhoids are a nuisance at best, and quite painful at worst. If you live in Jamaica Plain, seeking out pelvic floor physical therapy or occupational therapy can help address the underlying causes of your hemorrhoids, focus on management strategies for the present, and develop preventative treatment for the future.
Pelvic Health Tips for Going to the OB
Going to the OBGYN can feel vulnerable. Here are some tips to make it a little easier:
-Deep 360 degree diaphragmatic breathing. Feel your belly, ribs, back, and pelvic floor expand on the inhale, and let everything relax towards midline on the exhale. Try lightly extending exhales for more parasympathetic nervous system response. Exhaling on a low vowel sound can also feel pleasurable. (You can even just imagine the vowel sound in your head).
-Dancing/intuitive movement. Put on some music that makes you want to move and follow your intuition. See if you can incorporate inner thigh stretching movements, like a deep sumo squat, as well as movement through your rib cage. Elongating the inner thigh muscles (adductors) may help with pelvic floor lengthening, and moving dynamically through your rib cage can help with releasing tension around the diaphragm. Studies show dancing may release more endorphins than regular aerobic exercise, and is great for reducing cortisol levels related to stress.
-Tell a friend. Having someone to pick you up from the doctor, or text when you’re feeling scared, can help alleviate the stress of an appointment.
-Restorative yoga poses. Laying in child’s pose on a bolster or pillows helps bring more proprioceptive input into your stomach. This can help facilitate more relaxation and ease in your abdomen. Sensing into your sit bones moving out towards the sides of your body on the inhale, and back towards midline on the exhale, can help facilitate pelvic floor relaxation.
-Push-open breathing for when you’re at your appointment. In addition to diaphragmatic breathing, it may help to do push-open breathing at your appointment. As the OB or midwife is inserting the speculum, try a diaphragmatic inhale, and on the exhale, keep your belly round and allow your pelvic floor muscles to relax down and out.
-Building a neutral or positive relationship with a speculum. If you’re someone who is concerned with pain or discomfort regarding a speculum, ask for a pediatric one, which is smaller in size. Ask if you can bring one home, and begin to build a relationship with it. This could mean touching it, noticing and naming its objective qualities, practicing having the speculum make contact with your vulva/front hole, or inserting it yourself. Over time, with small simple acts, you can rewire your brain to make neutral or positive associations with the speculum. (I just want to add that it’s okay if you never get there. The speculum has a messed up, racist history, and is baseline uncomfortable for most people. I personally wish we had other tools readily available. I like the look of this redesign.)
-Use a hot water bottle or heating pad for afterwards if you’re feeling any residual discomfort.
What do you do to take care of yourself before or after an OB appointment? Pelvic floor physical therapy or occupational therapy can be a great way to support making OBGYN visits a little easier.
Pelvic Health in the Menopause Transition
Pelvic health physical therapy and occupational therapy can help prepare and support you as your body changes
First: We can help you gain control of your bladder.
As we age, our pelvic floor muscles can weaken, especially during and after the menopausal transition. Some common pelvic floor challenges during this life stage are: urinary and fecal incontinence, urinary urgency and frequency, as well as prolapse symptoms. Your pelvic floor therapist can help you coordinate, strengthen, and relax your pelvic floor and deep inner core so you can participate in the meaningful activities in your life without fear of leaking. And if your bladder is the culprit for nightly wakings, pelvic health physical therapy or occupational therapy can support you to develop useful bladder habits so you can get the rest you need.
Second: We can help with pelvic pain during intimacy
Hormonal changes during menopause can cause vaginal tissue to become dryer and thinner, which can lead to pain with sex. Pelvic floor therapy can help by teaching you how to coordinate and relax your pelvic floor musculature so you can feel more at ease during intimacy.
Third: We can help keep your bowels moving smoothly.
Constipation becomes more common as we age. For optimal bowel functioning, we need the pelvic floor muscles to open and coordinate correctly with the breath. Pelvic PT/OT can help you correctly relax these muscles, and learn better bowel habits to keep you regular.
Fourth: We can help keep you moving and exercising.
After the age of 50, bone density begins to decline. Physical therapists & occupational therapists can also help you maintain and gain overall strength so you can keep doing the things you love. We can collaborate with you on a realistic program to keep your muscles and bones healthy and strong.
Diastasis Recti Rehab
What is diastasis recti?
Your rectus abdominis muscle is the traditional “6 pack” abdominal muscle, and it connects on either side of your body through a piece of connective tissue called the linea alba. During pregnancy as the belly expands, the linea alba stretches and thins, resulting in an increase in the separation between each side of the muscles. Studies indicate that the prevalence of diastasis in pregnancy can vary between 30-70% of pregnant people. Many people recover without any rehabilitation during the postpartum period, although some people may benefit from pelvic floor physical therapy or occupational therapy. Diastasis can occur in people who have not been pregnant as well, due to habits that place increased pressure on the linea alba, including poor core mechanics or straining to pass stool. A functional diastasis is two finger widths apart. If your diastasis is wider than two finger widths, or you’re still feeling disconnected from your core postpartum, it can help to see a pelvic floor physical therapist or occupational therapist.
Why seek help?
Connecting a strong and dynamic core allows you to move through postpartum life with a decreased risk of pain and dysfunction. In early postpartum life, you’re suddenly “strength training” many times a day by picking up, holding, and putting down a ~6-10lb weight (your baby :) ) many times a day. Postpartum rehab will help teach your body to activate more of your deepest abdominal muscle, your transversus abdominis, which will put less strain on your diastasis, and will allow you to feel not only confident in performing your new day to day tasks with your baby, but will give you the support and coordination you need to return to exercise.
What to do?
Many people associate “core exercises” with things like crunches, v-sits, or planks. Ideally, people in early diastasis recovery are not performing those exercises, as they put more pressure on the linea alba. Your pelvic floor therapist will teach you simple ways to use your breath to activate the transversus abdominis muscle, facilitating increased strength. Besides working on deep core strengthening, there are many other important aspects of a person’s lifestyle that are important to address for diastasis healing.
Posture
Posture can play a big role in diastasis rehab. Many pregnant people compensate for the new center of mass by leaning backwards, which can place an increased stretch on the linea alba. Other postural habits that can create more tension on the linea alba are flaring the ribs, excessively anteriorly or posteriorly tilting the ribs, rounded shoulders, and forward head posture. Body mechanics throughout the day, including always holding your baby in one particular way, can also place stress on your rectus muscle. Finding dynamic postures and body mechanics throughout the day can help the abdominals activate more effectively,
Breath holding/Pressure management
Many of us tend to hold our breath when we’re doing something that requires a lot of strength, including picking up something heavy, pushing a heavy stroller, or even putting away groceries. Breath holding can put excessive strain on the linea alba due to increased pressure in the abdominal cavity. It’s important to try to “blow as you go” or “exhale on exertion” and make sure you’re not breath holding when you don’t need to be.
Exercise
Returning to exercise too quickly postpartum, especially heavy weightlifting, can put a strain on your diastasis. Diastasis healing is also about taking the time you need to recover proper core functioning. For some people this is 2 months, for others it looks more like 18 months. Returning to exercise slowly and with the guidance of your pelvic floor physical therapist or occupational therapist will help you know which exercises you can do with confidence and control, and which exercises you need to build back strength for.
Constipation
Managing chronic constipation can become a very important part of diastasis management. People with long term constipation may be used to straining or using breath holding to pass stool, which puts excess pressure on the linea alba. Your pelvic floor therapist can work with you to build better bowel habits to ensure that you’re not straining to pass stool.
So what next?
Diastasis healing is multifactorial, involving proper muscle recruitment and coordination, spinal and thoracic mobility, breathing mechanics, posture and functional movement training, and managing bowel habits.
Is it “too late” to see a pelvic floor physical therapist or occupational therapist?
It’s amazing to see the larger cultural trend of increased numbers of pelvic health providers. There’s more widespread education about pelvic health, pregnant people have more access to preventative care, folks with pelvic pain have more resources to experience pleasure. The list goes on! This is how it should be. But what if your pelvic floor challenges began when you had a baby 10, 15, 30 years ago? Your doctor might have sent you home with some highly prescriptive information about kegels, and maybe that was it. Maybe you were forced to accept that leaking or weakness was just going to be a part of your life forever. Maybe you’re resentful that no one was talking to you about the pelvic floor when your specific challenges began. You might be thinking, “Is there even a point to see a pelvic floor therapist now?”
The answer is: YES! It is NEVER too late.
Will your rehab look different than someone coming in with newer challenges? Yes. Your body may have developed compensatory strategies for dealing with core weakness or incontinence. You may have more ingrained motor patterns that are causing you to walk, sit, or stand in a certain way that exacerbates dysfunction. Although the neural pathways that support motor learning may decrease with age, there’s great research to suggest that continued motor learning is beneficial for cognitive and physical functioning. So attending pelvic floor physical therapy or occupational therapy might be beneficial for your body AND your mind.
In a typical session, your pelvic floor therapist may look at posture, gait, and functional movements like sitting down, standing up, or squatting. We may look at your breathing mechanics, and evaluate the muscle strength of your hip and pelvic floor muscles. We assess more restricted or tense muscle groups and may use manual therapy to support lengthening of the muscle or relaxation.
It’s never “too late” to go to pelvic floor physical therapy or occupational. You don’t have to accept pelvic floor dysfunction as part of your life. You deserve easeful and meaningful participation in the activities that matter most to you, at any age. If you need pelvic floor therapy in Jamaica Plain or Roslindale, give us a call.
Casual Sex with Pelvic Pain
If you’re someone who experiences pelvic pain, vaginismus, or vulvodynia, it probably influences how you approach sex. Often times clients come in experiencing pelvic pain, and they’re in long term, monogamous partnerships. If this is the case, I often spend time asking questions about the dynamic between my client and their partner, and how their partner can help co-create a context where pain free or less painful sex can occur. Within this kind of conversation or intervention, there’s an assumption of the possibility for ongoing communication and difficult conversations. There’s an assumption around an inherent foundation within the relationship built on trust and understanding.
Other times, folks come in, wanting be able to date and sleep around in a more casual way. When this happens, it can be helpful to think about what the expectations around treatment can look like, and how to best proceed. When someone wants to be slutty with pelvic pain, I tend to think of it in three options, that can always feed into each other:
Be open and vulnerable about what you’re experiencing; see if the person can hold the complexity of that
Don’t engage in casual sex until you are having pain-free experiences, either in the clinic or on your own
Engage in sex that does not trigger your pelvic pain
Option 1: Being vulnerable
This is a great option if you a) want to practice being open and honest without shame, for the sake of practicing those skills #badass b) if you’re with someone that you feel you can trust, even if it’s just casual or c) if you’re having sex with someone who might become a longer term connection, even if it’s still casual.
It’s hard to state our needs and to practice setting boundaries. It places you in a position where you might feel more at risk for getting hurt. BUT it can feel empowering to own your experience and try to communicate that to another person. ESPECIALLY if you’re having sex with someone who’s a decent person and who makes it clear that they care about your experience.
Once you decide whether or not this person can hold your experience, you can also discern if you want to try engaging in the kind of sex that might trigger a pain response. Having discussions around safe words and after care can also be part of this disclosure. Additionally, if you end up not being able to have the kind of sex that you want to have, how do you and this other person want to manage potential disappointment together? Can you hold disappointment while pivoting to some other kind of sexy connection? Or do you need space to process and feel your feels on your own? This can be helpful to think and talk through, especially if you’re not trying to develop too much emotional intimacy with someone!
Option 2: Don’t have casual sex until you’re pretty sure it won’t be painful
This is a great option if you’re someone who likes have feel more in control over their experience. If the thought of being vulnerable with a stranger makes your stomach turn, you’re definitely not alone. In pelvic floor physical therapy or occupational therapy, you can work on reducing your pelvic pain, as well as on your own. Tools that can be helpful are movement, dilators, breathwork, nervous system settling, sex therapy, and manual work. As you progress in your journey, you will hopefully feel more confident that you can have the kind of sex you want. Once this feels true, having casual sex might feel more accessible.
Option 3, which can definitely feed into option 1: There’s a million ways to “have sex”
It can feel hard to undo the cultural hierarchy around sex that most of us have inherited to some degree, where sex=some form of penetration. When penetrative sex is placed as the pinnacle sexual experience, and everything else is just foreplay or second tier, it may feel hard to take PIV sex off the table. I think it’s really helpful to question the assumptions we have about what sex should look or feel like. It may be helpful to go through a Yes/No/Maybe list by yourself first to start to envision what a sex life that decenters penetration could look like. This might allow you to approach your sexual encounters with a new found empowerment and understanding around what you want and how to communicate it.
I always say: having pain with sex requires creativity, which can make it more fun! But reflecting on what you want out of casual sexual encounters as someone with chronic pain can definitely help to create a sense of empowerment and safety. Try pelvic floor physical therapy or occupational therapy can definitely help you figure out what tools are right for you!
A pain in the butt
Did you know as embryos, we briefly have tails? Around the 8th week of intrauterine life, the tail disappears. We’re left with a tailbone or coccyx, consisting of 3-5 vertebral segments, sitting below the sacrum at the very end of our spine. The coccyx is integral to the pelvic floor, and vice versa, because some of our pelvic floor musculature attach to the coccyx. Because of these attachment sites, trauma to the tailbone can cause referred pain to other parts of the pelvic floor. And a tight or hypertonic pelvic floor can make it difficult for a coccyx injury to heal.
Coccydynia, or tailbone pain, can occur for a variety of reasons. Difficult childbirth, especially forceps delivery, seems to have higher associations with coccydynia¹. Direct trauma to the coccyx (someone needs to do a study on coccydynia and roller derby players) can also be a common cause. Sitting slumped while feeding your child can also put pressure on your coccyx, exacerbating any pain you might have from the birthing process.
The prevalence of coccydynia, or tailbone pain, is unknown, although it seems to be more common in AFAB (Assigned Female at Birth) than AMAB (Assigned Male at Birth) people, most likely due to birth injuries. The good news is that conservative treatment, including pelvic floor therapy, can be successful in treating up to 90% of cases².
How do you know if you have tailbone pain? You may experience discomfort or pain with prolonged sitting or standing–especially if you are feeding a little one or sitting at work. People with coccydynia commonly experience pain when moving from sitting to standing. Finding the right chair might feel like a nuisance for you: hard chairs are too hard, soft chairs are too soft. It’s challenging to find that “just right” fit.
Pelvic floor physical therapy or occupational therapy can help. Through a combination of postural retraining, manual therapy techniques, breath and pelvic floor coordination, and learning to optimize your core functioning and stability, a pelvic floor OT or PT can support you with alleviating tailbone pain. We can help you strategize about proper adaptive cushioning (don’t use a donut!) and managing constipation. In the meantime, limit your time sitting, stay hydrated, and call us to set up an appointment today.
Lower Back Pain Postpartum
Many people come see a pelvic floor physical therapist or occupational therapist due to lower back pain postpartum, having never experienced lower back pain before. Why are they only now experiencing this? There can be many drivers to lower back dysfunction, especially as a new parent. Here’s some of the things we would look at:
How is your core functioning: Most postpartum people could benefit from some core rehabilitation after pregnancy. A strong core helps support good body mechanics to prevent lower back pain. If you are experiencing diastasis rectii and/or had a c-section, you may need even more support activating your core in order to protect your other muscles from overcompensating during harder movements.
How are your glutes functioning: Many people experience some glute weakness due to postural changes during pregnancy. In order to protect the low back when lifting your baby, your glutes need to fire effectively.
How are you breathing: Did you know the diaphragm, our main respiratory muscle, connects to the front and the back of your body? This means that when the diaphragm is working optimally, we should have 360 degree expansion of our torso. True diaphragmatic breathing can help restore range of motion and lengthen tissues in your back body. Most of us are shallow, chest breathers, which can restrict range of motion in the low back.
How are you lifting? Think about the literal movements your body made throughout the day before your baby was born. Maybe you went for walks, occasionally lifted groceries to the counter, occasionally bent down to pick up some trash on the floor, worked out a few days a week? When you’re newly postpartum, your body is making repetitive movements that it might not be used to, especially when it comes to lifting. How many times a day are you picking your baby up and putting them back down? You’re suddenly a full-time athlete in a sport that you might not have trained for! Most of us don’t naturally coordinate our posture, core, and breath in order to optimize lifting strategies to prevent low back pain.
How is your posture? Most newly postpartum people are understandably tired and newly adapting to the baby’s routines and rhythms. Depending on your labor, different parts of your body may be sore or tender, resulting in new postural patterns. Additionally, your body may still be accommodating postural changes that occurred as compensations during pregnancy. Think of your new daily routines–are you suddenly sitting on the couch way more, without a lot of lumbar support? Are you rounding your back more when you feed your baby? Posture throughout the day can have a big impact on the lower back overall.
How is your pelvic floor? Did you know that parts of the deep pelvic floor attach to the sacrum and coccyx, aka the bottom of the spine? A hypertonic or overactive pelvic floor is very common, and can contribute to lower back pain.
How often are you having a bowel movement? Constipation in the early postpartum stage is very common! A distended, impacted rectum can irritate the muscles of the pelvic floor and low back.
How is your nervous system? The transition from pregnancy to labor to postpartum can be wonderful, but also challenging. If you find the newly postpartum period stressful or tiring, you’re not alone. Our nervous system plays a huge role in how we manage and interpret pain signals from our bodies. Additionally, stress can manifest as tension in the muscles of the low back.
There are so many understandable reasons why you may have low back pain postpartum. Pelvic floor physical therapy or occupational therapy can be a great resource for getting you back to functioning.
Can I just journal my way out of chronic pain?
There are so many ways to work with chronic pain, and there’s research to support many different modalities. Expressive arts therapy, acupuncture, listening to music, meditation, and spending time in nature, all have studied benefits for reducing chronic pain.
If you’ve been in chronic pain long enough, at some point or another, you may have come across a well-known and controversial book, Healing Back Pain by John E Sarno. Sarno theorizes that folks with chronic back pain who, after repeated testing, have no discernible pathologies, are suffering from what he calls Tension Myositis Syndrome, also known as TMS. Sarno suggests that chronic pain is a manifestation of the subconscious mind in response to repressed emotions, especially anger. The pain is meant to distract you from feeling these intensified emotions. This results in an autonomic nervous system response that slightly deprives oxygen to the tissues, contributing to the feeling of pain.
TMS healing protocol involves some degree of education about how pain is processed (aka pain is created by the brain, not the body). It involves a return to “normal activity,” encouraging mindset shifts around the psychological nature of pain. And a large part of the healing is…journaling.
Sarno and his proponents think that your pain will only resolve when you deal with your unprocessed and unresolved emotions. There seem to be a few TMS-based journaling techniques, but many involve writing a list of all the things that cause stress or anger in your life, past or present, and taking the time to write about them. Others just suggest writing about your day, and about the challenges and emotions associated with the day. The point is to find a safe space to express unprocessed emotions.
So if you’re asking, is TMS an evidence based theory? The answer is…no. I found one study that showed a positive effect when 51 patients used a TMS protocol, but that’s too small of a study from which to glean large scale conclusions. Is there evidence to support expressive journaling for chronic pain? Most certainly. Do we know that the mind-body connection contributes to the perception of pain? Definitely! But I don’t buy the physiological underpinnings of Sarno’s theory, and I don’t buy a one-size-fits-all pain resolution approach.
Is it for everyone? Why the vast appeal?
From my research, it seems like a lot of folks who are interested in TMS are now applying the concepts to research around pain neuroscience. So even if the theory in and of itself is ~off~, people are justifying it in certain ways by talking about biopsychosocial approaches to pain, and nocioception (see past newsletters if you’re not sure what I’m talking about!). The Curable App, which many of my clients have found useful, is founded on principles of TMS.
Ableism and self-healing
There’s this certain strand of ableism that can be embedded within TMS theories, where if you just work hard enough, you can cure yourself. This doesn’t take into account many social determinants of health, how bad healthcare is in this country, and how hard it might be to work on healing your trauma if you live in an environment without clean water, air, food, and relative safety and stability. The rugged individualism of ~self-healing~ leaves so many folks out of the equation. Healing is relational, and most of us need more support in order to develop more skills for working with pain, chronic stress, and illness.
No one size fits all approach
Do you love to journal? Maybe you should do it then! It’s associated with decreased stress and pain scores. But do you open a notebook and feel dread, guilt, fear, boredom? Then let’s try something else that maybe fits your needs better. To prescribe a one-size-fits-all approach to healing chronic pain only further isolates folks for whom these these protocols don’t work. I encourage my clients to do the kind of nervous system work that brings them pleasure. I enjoy writing, but I certainly don’t want to wake up every morning and spend 20 minutes writing about the worst and most stressful parts of my life, as some TMS experts suggest. Doesn’t feel very trauma-informed to me.
Expectations matter
So why do so many people swear by TMS? EXPECTATIONS MATTER. Evidence shows an association between expectations around treatment and treatment results.
When you’re in chronic pain, and a very confident person tells you they know EXACTLY what’s going to make you feel better, what do you have to lose by buying in?
I prefer living in a murkier world, where we can hold the complexity of the mind-body connection without reducing it to something as simple as TMS. Everyone could benefit from some nervous system resilience, sure, and also unions, fair wages, more time off, and more connection to supportive people and the earth, etc. I’m never going to tell a client that I know precisely why they have chronic pain, and I know exactly how to fix it. Let’s honor the fact the healing is often a windy journey of trial and error, and that you get to discover what works best for you.
Learning to Breathe Again Postpartum
After your child is born, you may find that you suddenly have to readjust to many new body mechanics, including learning to breathe again. Many pregnant people can struggle to regain control over their breathing mechanisms, and can find it difficult to reconnect to their diaphragm–muscle that helps us draw in air even when we aren’t conscious of its hard work.
The “Why”
Many people develop a rib flare during pregnancy to compensate for core instability and to feel like they have more “room” to breathe. With ribs in this hyperextended, position, it becomes harder to engage the full range of motion of the diaphragm. Many pregnant people develop a ribcage positioning pattern in which their ribs can feel a little “stuck,” making it harder to feel like you’re taking the deepest breath possible. This hyperextended “stuck” rib cage also makes it more difficult to engage your core, as you are putting the core muscles on a stretch. Additionally, your rib cage often widens during pregnancy by 2-5 cm. The combination of this new, widened rib cage, alongside a more flared rib position, may make it difficult to feel like you’re taking the deepest breath possible.
Postpartum Breathing
You’ve just had your baby, you’re exhausted and adjusting to one of the biggest transitions in your life. Maybe you’ve noticed that your body feels a little awkward, and returning to the breathing pattern you had pre-pregnancy feels challenging or impossible. What can you do?
Find the bucket handle and the pump handle
The motion of the ribcage is often discussed in terms of a bucket handle and a pump handle. Your bottom, floating ribs tend to move out towards the side of your body on the inhale, similar to a bucket handle. You can feel this more by cupping your rib cage in a C-shaped grip, with your thumb towards your back body and the rest of your hand cupping your ribs in the front. You can also use a band to wrap around your ribcage as well. Can you feel the ribs expanding out towards the side on the inhale? Accessing more of that lateral breathing will help support diastasis healing and postpartum core rehab.
The other movement of the ribs is more of an up and down movement, like a pump handle. It’s important to note that this motion comes from both the front and back body. It sometimes helps to pay attention to your sternum, connecting both sides of your ribs. Can you feel it rise like a pump handle on the inhale, and then fall back down on the exhale?
Ideally, diaphragmatic breathing looks like this 360 degree expansion, with the ribs moving laterally as well as up and down.
What could be impacting your ability to find full rib cage expansion?
If you’re early postpartum and feeling like you cannot access this sensation of 360 diaphragmatic expansion, you’re not alone. There are many things that are occurring in early postpartum life that could make it hard to access full range of motion of the diaphragm, including:
-Fatigue/exhaustion
-Postural dynamics, including forward head and rounded shoulders
-Pelvic positioning (either anterior pelvic tilt or posterior)
-Lack of core stability
What can you do
Finding an expansive diaphragmatic breath is an important part of postpartum rehab. It impacts the ability to find your core strength, as well as support proper pressure management techniques in order to support your pelvic floor. So what can you do?
Sometimes it’s helpful to go into exaggerated postures in order to develop a felt sense of their impact on their body. Here’s one common pregnant and postpartum posture: bring your pelvis all the way forward so that your lower back arches. Extend your rib cage up and open. Try to take a deep breath here. You may find that your abdominal muscles feel too stressed, and that there’s no room for the diaphragm to expand.
Now play with a more optimal posture. In sitting, find pelvic neutral, with the sensation of your sit bones connecting to the chair or the ground. Your front hip bones and your pubic bone should be sitting on the same frontal plane, with neither too far forward or back.
Come sense into your ribs. Align your rib cage over your pelvic. Tuck your ribs down, and sense into a heavy sternum. You may find from just this adjustment that you can feel your core a little bit better.
Now, try to take a deep diaphragmatic inhale. Go slowly, through your nose, and count to five. It sometimes helps to look in the mirror to see what’s happening. Do you see a lot of movement in the shoulders and neck? Try to soften it. Find that lengthening quality in your front, sides, and back body, right underneath your rib cage. Hopefully you’ll now find that it feels like there’s more “room” for your breath.
Neuromuscular patterns that got codified in pregnancy are sometimes challenging to unlearn. Playing with posture and 360 degree diaphragmatic breathing can make it easier for you. If you’re finding that certain areas of your body feel “too tight” to find that 360 breath, you benefit from pelvic floor physical therapy or occupational therapy, which will help you strengthen, lengthen, and coordinate the right muscles in order to access the deep breath you’re looking for.
What if time plus effort doesn’t always equal progress?
What if time plus effort doesn’t always equal progress?
There’s a longstanding assumption within rehab fields that with concerted practices, exercises, or ~work~, over a distinct period of time, change and success will flourish. A lot of this (I think) is derived from some of the pitfalls of how scientific studies work in a profit-driven society. Universities and research groups only have a certain amount of money to perform a certain set of interventions over a certain period of time. So we’re left with an assumption that these interventions and time periods are translatable to the person standing in front of us, which often robs the person of their unique complexity.
A theme that’s come up in my work with several folks lately is something we all know innately: healing is non-linear. But I want to break that down a little more to identify some of the assumptions we can make when trying to move towards goals in rehab, especially regarding pelvic pain, trauma, or any other kind of pelvic floor dysfunction.
When effort has a sympathetic charge
There’s a high correlation in pelvic pain research between anxiety and/or trauma, and pelvic floor dysfunction. What happens if/when the subject of a person’s sense of hypervigilance is their own healing? Especially in such a time-scarce culture, healing can feel like another part-time job required to feel better. There are times when I think this is can be necessary. But when our movement towards some kind of change in our bodies is driven by the same stress that contributes to the pain in our bodies, how can we reorient towards another approach?
As we have moved towards more commodified wellness industries, what are the ways our expectations of perfect health and wellness, often fueled by hyper-individudalism and ableism, reinforce a sense of fight and flight in the body? That’s why I’m so focused on accessibility in my work: how can we make this as easeful as possible? Our lives are hard and complicated enough. What is that one small, bite sized thing that you know you can commit to? How can we work towards some level of consistency, rather than only trying to do our home program when we feel like we have a full 30 minutes available?
What’s your relationship to effort? When you think of working towards a goal, does it feel all or nothing? How do you ask for support, whether through friends, therapists, or other resource, to guide you in your goals?
The body often clings to what it knows, even if it’s not serving the person, because it feels safer. How do we continue establishing safety in order to move towards something different?
Healing and Time
I’ve written about this before, but as Americans, we are obsessed with linear time. The calendar and the clock drives our actions, the way perceive change, and what we expect out of seeking help.
We have this idea that if we can apply enough effort towards our goals over time, that we will inevitably seek success or progress. But what if there are so many unpredictable factors that impact how our body integrates any change work? When I worked in early intervention, it was quite common that a family would go on vacation and suddenly see a strong growth spurt in terms of motor and language skills in their little ones. There could be so many factors influencing this, but it was a great example of how we can’t always control how and why work integrates. What does it look like to trust the non-linearity of healing? Here are some examples of “random” life changes that could positively influence a person’s pelvic healing timeline:
-An important conversation with a friend
-A small dietary change that leads to pooping more
-Moving to a different department at work
-Walking a lot on vacation
-Wearing a sleep mask
-Joining a choir
-Getting more childcare
-Taking an art class
-Weather changes
-Getting a dog
-Reading a validating book
-etc.
We don’t know and can’t say how many factors, contexts, or other influential practices could impact us. When you go to pelvic floor physical therapy or occupational therapy, the home program is just one container of healing, and your life is the rest. I’ve seen expedited changes in healing journeys come from a person moving homes, starting a new trauma therapy, changes in work/life balance, relatives coming to live with a person, a new romantic relationship, etc. We have to make room for life to unfold unpredictably so we can develop the kind of relationship with progress that doesn’t see it as something we’re entitled to, but rather something that unfurls with grace and messiness if we give it enough gentle attention.
A relational approach to chronic pain
What could a relational approach to chronic pain look like?
There are so many methods and approaches to working with chronic pain/pelvic pain. One that I’ve found particularly useful for clients is actually learning about the biological mechanisms of pain, and then learning how to relate to the pain differently overtime. If you’re someone who suffers from chronic pain, I think it’s always helpful to ask-What are my assumptions about what pain “means” or how it acts in my body? What thoughts, feelings, and behaviors come up when I think about my pain? As we start to elucidate some of these associations with pain, we can get clearer about what’s actually happening in the body, and have more agency in terms of how to work with it.
When I start asking clients questions about their assumptions about pain, it’s often assumed that pain is a result of something bad in the body that needs to be “fixed.” For many years, rehab clinicians and manual therapists have said “the issue’s in the tissues,” but we know that’s only part of the truth.
Pain is not just “in your head” but it’s not just “in your body” either/Pain Science 101
Take a moment to pause and consider what you understand about pain. It’s really easy to think that pain is something that comes from the skin or tissues when we consider a paper cut. There’s a painful stimuli that shows distinct damage to some part of the body, followed by unpleasant sensations.
The body itself does not have pain neurons. The body itself does not “detect pain”. We have what are called nocioceptors, which help detect danger. These neurons then send this signal through the spinal cord, and into the brain. The brain then interprets, based on many factors and associations, whether or not to make this stimuli “pain.” We’re talking about memories, contexts, social factors, past experiences of pain, etc. In a split second, the brain can then “decide” to send neurochemicals back down to the body, which we then experience as pain.
With chronic pain, the central nervous system becomes more intensely attuned to these danger signals. Chronic pain is thus an evolutionarily protective response, designed to help protect us from experiences that could threaten our lives.
So once we understand that pain does not necessarily mean distinct tissue pathology, that something is “wrong” or “broken”, we can get really curious. It may help to redefine chronic pain. What if we defined chronic pain as a mind-body system habitually and automatically attuned towards protecting us from uncomfortable and negative stimuli?
We know through neurobiology research that we are hardwired to notice and remember negative stimuli/memories more than positive stimuli/memories. This is why, although research is still burgeoning, I’m interested in somatic approaches to chronic pain. If we can orient the nervous system towards pleasure or neutrality, can we build more positive associations with sensation and embodiment, thus shifting some of the brain’s interpretive networks around pain?
This is where I’m working on developing a relational approach to working with chronic pain/chronic pelvic pain. When folks hear about embodiment or somatic approaches, I think there’s often shame or confusion about “how much” or “how often” a person is “supposed to be” embodied. I think this can create its own kind of hypervigilance about this way of being in the world. But when we think of embodiment as an output of curiosity, creativity, and relating, more space opens up.
I sometimes give the analogy of building a budding friendship. Consider questions like, what makes me feel drawn to this person? How does that interest show up in my nervous system?
And making a new friend can feel vulnerable. So when you’re thinking about reaching out, maybe you delay it when you’re in a weird spot, have increased stress, or have family in town.
And think about pacing when building a new relationship. Most people don’t decide to be friends with someone and then start texting them all day. It takes time, and it’s a dance of connection and disconnection, space and togetherness.
And when we’re developing a new friendship, it’s often easier when we have older, easier relationships to return to. This helps us remember who we are and how we like to be with others.
So how can we similarly think about building a somatic relationship with chronic pain? You can get really curious about the pain. Build a slow rapport with your dynamic felt sense over time. Give it space and allow yourself to disconnect. Gradually develop more easy access to pleasurable resource within the nervous system.
We can then start to think of relating to sensation in the body as part of a larger ecosystem or community. When pain flairs, what else is there to support you? Finding new, felt-sense ways to build relationship with this web of support can bolster you when pain inevitably arises, and possibly change the brain’s perception of pain overtime. We can then also consider our wider webs of support outside the body, which could include: the relationship you have with a therapist or rehab professional, social supports, spiritual resource, and more.
Understanding pain management as relationship building can give us the opportunity to learn new, gentler ways of approaching chronic pain. This can allow us find organic ways of “being with” our pain that doesn’t overextend or deplete us. We can learn to follow our subtle impulse in connecting to our body, expanding our capacity to stay embodied when pain inevitably arises. When we can access the creativity and curiosity that relating requires, it can bring us out of our stress responses associated with a pain flair, and into a space where there might be more agency over our direct experience.
What it means to be a dissociation friendly provider
I’ve been reflecting a lot on the moniker of “trauma-informed” and wanting be really specific about what that means and how it shows up in my work. As a pelvic health provider, there are so many reasons why a client might be experiencing some level of dissociation in our work together. Whether that be related to gender dysphoria, sexual trauma, or religious upbringing, many folks come to see me who are disconnected from their pelvis.
Tune into your hands and try to feel them. You might find that there’s a vast array of sensation that emerges. That’s because the brain's sensory map for your hands is quite large (and seems to be larger for folks like violinists #yayneuroplasticity). The sensory map of your pelvic floor is verrrry small. For many folks, trying to tune into this small muscle group can feel hazy, fuzzy, less specific. Add in a history of trauma and chronic pain, and this map in your brain becomes even more smudged.
So what does it mean to be a dissociation-friendly provider? We know there’s a high correlation between sexual trauma and pelvic pain, yet most of the interventions taught in traditional pelvic rehab curriculums assume that it’s safe for the client to connect with their body, as well as receive manual therapy. Although I’ve always seen consent for internal work highly emphasized in these teaching environments, I’ve found throughout my clinical experience that consent needs to be a much more present part of a client’s whole rehab experience. So what does that look like?
Identifying if someone is experiencing dissociative symptoms
Most folks don’t use clinical words to describe their experiences. I have many clients that tell me about their dissociation using that word specifically, and I have other clients who use other words, like feeling numb or disconnected. I try not to ascribe the word “dissociation” to a person’s experience, but rather provide some education on dissociation as a common trauma response and see if that resonates with them.
Many times when working with someone, I start to get curious if they’re moving towards dissociation if they start to get suddenly very sleepy, if they close their eyes, or if they start talking a lot and intellectualizing their experience. These aren’t necessarily indicators that someone’s dissociating, (i.e. someone might close their eyes because they’re trying to focus or relax) but something to track throughout a session.
Use education as validation
Many people experience shame around their dissociation, so I like to provide nervous system education as a form of validating their experience. One of the first things I usually say is that dissociation is an ADAPTIVE COPING RESPONSE, so we can’t change it by shaming ourselves out of it or by forcing ourselves into a more embodied state. We have to work with it collaboratively.
Provide Options
Breathwork, restorative exercise, and manual therapy can all contribute to dissociation. So if someone is experiencing dissociation, I like to give 2-3 options for alternative interventions. It helps to be really concrete, without overburdening the person with too many choices to consider. At this point, instead of focusing on interoceptive or felt sense-based ideas, I offer things related to nervous system settling that relate either to visually orienting to the environment, connecting the body to another object (tactile-based exteroception), sensing into gravity, or sensing into the distal extremities (especially feet).
Be mindful of facilitator vs fix it mentality
I think working with dissociation as a pelvic health provider is a great opportunity to challenge our “helper” identities as clinicians. If you start to have thoughts like “this person is going to think this session is pointless” or “are these interventions even relevant to this person’s goals” (even if you know in your evidence-based and client-centered heart that they are), then it’s possible you need to challenge some of your beliefs around how you think you’re supposed to perform as a clinician. I think for rehab clinicians, because our work tends to be more concrete than say psychotherapy, we can place ourselves in boxes in terms of how our work should look. I think this limits creativity, takes energy and agency away from you as a clinician, and saps confidence. Ask yourself: Am I trying to “fix” this person’s experience, or am I trying to collaborate with them to make their experience more easeful? Notice how each of those approaches live in your body.
Embrace divergent treatment plans rather than linear approaches
This is connected to the above point, but I think it’s really important to let go of how we think a session is “supposed” to look. We tell our clients that healing is not linear all the time, but how can we grant ourselves the permission to “go off course” a bit, for the sake of establishing trust between you and the client, and between the client and themselves? Rather than always prioritizing moving towards the person’s goals at all cost, what if we allowed ourselves the flexibility to prioritize that person’s moment-to-moment needs, knowing that they’re always changing? This helps establish consent between client and clinician as a more active process, rather than only using it as a tool when connected to internal work.
Dissociation is common, normal, and part of our bodies’ natural wisdom. If you feel confused and nervous about acknowledging when dissociation is happening in your clinic, then I highly suggest connecting to folks with more training or expertise around this topic.
Somatic consent for pelvic floor therapy-finding your full-body “yes”
Many folks with chronic pelvic pain have experienced medical trauma of varying degrees, especially for queer & trans folks/people of color/folks with historically marginalized identities.
Maybe you’re considering pelvic floor therapy because a doctor suggested it. Maybe you’ve tried lots of other creams, nerve blocks, medications, even surgeries, and things haven’t helped.
It’s useful to consider at this point in your healing journey--what’s my relationship to healing? How do I define it for myself? In what ways is my healing journey creating further stress and tension in my life, and where am I finding new ways to self-advocate, be kinder and gentler to myself, etc?
It’s really challenging to feel empowered in your healing journey when you’ve tried so many things with little success, so it’s important to check in with yourself when you’re starting to feel some healing burn out. If pelvic floor therapy is feeling like your “last resort,” like it does for many people, how can you still ensure that you’re listening to your body’s need for consent and trust?
For many people with chronic pelvic pain, an internal pelvic floor assessment can feel daunting, stressful, and retraumatizing. Maybe you feel like you need to just “push through it” so that your pelvic floor therapist can get “as much information as possible.”
An internal assessment can only give a clinician so much information. I learn a lot by listening to the tone of the tissues of the lower abdominals, and doing an external musculoskeletal assessment. I look at where your breath falls in your body. I learn a lot through asking questions, like do you experience one-sided hip tightness? How are your bowel habits? If you menstruate, do you use tampons, menstrual cup, or pads?
For folks with chronic pelvic pain, I would never start treatment at the level of the deep pelvic floor muscles, because I presume that there’s already a high-guarding pattern and tension. So I don’t need to assess here initially.
If you’re working with a pelvic floor therapist who seems rushed, unfocused, or unattuned, or if you’re going into pelvic floor therapy with a fully clenched jaw and a “no pain, no gain,” attitude, I invite you to try to tune into your body’s way of communicating consent.
How can you tell if your body is ready for internal treatment? What bodily cues help you realize that you can access a sense of safety? What information do you need to know before you can book an appointment? Making space for a clear “yes” or “no” from your body can help you gain clarity about what kind of therapeutic approach is right for you.
A somatic exercise for finding a “yes”
Orient to the room around you. Let your eyes wander where they want to go.
Let your eyes rest on something pleasurable or satisfying. Maybe it’s a picture, a plant, the window, or the way the light hits at a certain angle.
Tune into your body. How has it signaled this satisfaction or pleasure? Without trying to analyze it, can you just sense 5% into what this “Yes” feels like?
Let go of this object, orient to pleasure, and sense again.
Taking small sips of pleasure throughout the day can help support your nervous system in differentiating between wanted and unwanted sensations. From here, listening to your body’s cue for consent is hopefully easier and clearer.
Developing a relationship with your pelvic pain
“Killing the Pain”
From a pain science perspective, those with chronic pain, (including pelvic pain, endometriosis, interstitial cystitis, etc) can have a heightened sense of imminent danger as their body attempts to protect them from new experiences of discomfort and suffering. This guarding can create added patterns of muscle bracing, tension, and holding. Learning to work with chronic pain is a process of trusting your body’s capacity for neutral and pleasant sensation. Sometimes this means that it’s not necessarily the pain itself that changes or “goes away,” but rather our relationship to it that evolves over time. As a practitioner, I can’t promise that we’re gonna “kill the pain” or “destroy the pain” (I don’t abide by these metaphors, because I see pain as a necessary protective mechanism that deserves respect), but I can promise that we can shift the relationship to it.
That’s why when I give out exercises and homework for clients, we work collaboratively to see how it can fit into their everyday routines, and how much capacity they have for different practices. I use words like “play” or “experiment” instead of giving out prescriptive routines. Engaging in the “work” of healing in a way that supports curiosity rather than resentment or guilt for not “doing your exercises” helps folks engage in a new orientation to listening and taking care of their body.
Define a healthy relationship for yourself. Some key ideas that come to my mind are: collaborative, attentive, honest, warm, fun, patient. Developing this orientation to our relationship with healing, as well as the sensation of pain, can help support us to take care of ourselves in a different way. When “healing” becomes relational, even within one’s own body, it allows us to take on a more expansive meaning of the term. Rather than bullying our chronic pain, which will most likely only reproduce patterns of bracing, tension, and discomfort, we can see healing as an ongoing process of listening and responding with care.
Is “Wellness” ableist?
How do we define “wellness” in an oppressive society?
Often when I close emails, I write, “Be well.” And I mean it. I imagine the person filled with joy, energy, and a sense of abundance. But I struggle sometimes with what “wellness” really means in our culture, who gets to define it, and what it means for the world of pelvic health. What does “wellness” mean in a culture that’s foundationally built on the violence/exploitation of marginalized populations? Where is the line between taking personal responsibility for your wellbeing and recognizing the consistent toxic and unhealthy messaging we’re all enculturated with? “Wellness” in our culture is built on the success of the individual to develop healthy habits and behaviors, rather than on systems and relationships that allow people to flourish organically. The “wellness influencer” emphasizes their disciplined habits, intense fitness regimes, “clean” eating, etc. The picture of “wellness” is often portrayed as a thin, white, able-bodied person. We develop this static, unattainable image of what health and “wellness” looks like. This can negatively add to other extreme material barriers people face.
As a healthcare professional, I am very careful to balance a person’s capacity to grow and change, with the acknowledgement that the barriers to joy and fulfillment are very tangible and heavy.
What does “wellness” mean when healthcare is unaffordable, food deserts are abundant, and people need to spend their “free time” on a second job, rather than resting or feeling nourished? When “wellness” is only portrayed through a series of habits and products, rather than liberatory systems and relationships that can hold the complexity of all of our experiences, it becomes something taunting rather than a goal to strive for. Wellness to me means access to housing, prison abolition, and thriving art spaces. It means universal healthcare and disability justice. As healthcare professionals, it’s our responsibility to acknowledge the limitations of our services in the face of larger oppressive structures. This offers me hope rather than despair, because it allows me to feel more expansive and creative about what “wellness” looks and feels like for each individual. This humbles me and allows me to see each person in their own unique complexity, rather than projecting a constructed idea of being “well” onto them.
How do you define wellness for yourself? Where do you draw inspiration for images of “wellness”? How do you see “personal responsibility” amidst collective experience?
For further reading, I recommend the works of Fariha Roisin, Jenna Wortham, Bayo Akomolafe, Leah Lakshmi Piepzna-Samarasinha, and Tricia Hersey.