Over 30 percent of women and 10 percent of men in the United States suffer from various pelvic pain conditions at some time in their lives. Pelvic pain (PP) is described as pain in your pelvic region that lasts longer than six months, in the area below your navel and between your hips, sometimes including the vulvar-vaginal and penile area.
Pelvic pain includes conditions such as vulvodynia, vestibulodynia, vaginismus, interstitial cystitis, coccydynia, dyspareunia and chronic prostatitis. Pelvic pain can be a symptom of the medical conditions listed above, or can be a condition in its own right, frequently involving the muscles of the pelvic floor.
These diagnoses are very familiar to pelvic floor physical therapists, but may not be to other sub-specialties within the physical therapy industry. From my clinical experience, many women and men who suffer from PP first go to an orthopedic physical therapist for help. The reason is that many PP patients present with a complexity of problems that not only include pelvic floor muscles (PFMs) but also include many orthopedic and musculoskeletal problems as well.
Targeting the Missing Link
Pelvic floor muscle (PFM) dysfunction can be a major cause of orthopedic pain, and taking the PFMs into account can make your therapy more effective, providing your patients with long-lasting results that include pain reduction, increased strength and endurance, and most importantly, improved quality of life.
The function of the PFMs are fourfold: to support and hold up the organs, to help prevent urinary and fecal incontinence, to enhance sexual function, and to stabilize the lumbar/pelvic and sacral regions.
As clinicians, it's important to understand that the PFMs are a conduit between the lower and upper body, and that the PFMs are interconnected to the hips, lower back and lower extremity via fascia, common muscles, blood supply and nerve pathways.
Sometimes the missing link to your orthopedic patient's success is focusing on and treating the PFMs, since they can contribute to pain. Physical therapists treating orthopedic pelvic, hip and lower extremity conditions cannot deny that these muscles need to be taken into special consideration in treating and evaluating their orthopedic patients, especially if the patient is not progressing under their current treatment plan. PFM issues can directly contribute to pain in other body parts via active or latent trigger points.
Isa Herrera, MSPT, CSCS, specializes in womens health and pelvic dysfunction at Renew Physical Therapy in New York City.
Many times, a trained pelvic floor physical therapist can examine the PFMs internally and can release the muscles directly. The question is, how can an orthopedic PT help these patients with simple and effective pelvic exercises?
The Role of Pelvic Exercise
Many times, pelvic pain patients are prescribed Kegel exercises as part of their rehabilitation program. This is the "go to" exercise for PFM dysfunction and the exercise that most clinicians are familiar with, and know well.
The term Kegel, developed by gynecologist Dr. Arnold Kegel, is used to describe a set of exercises designed to improve the function of the pelvic floor muscles. The problem is that there are subtle nuances to Kegels that, if not taken into account, can actually produce worse results for patients with pelvic pain.
Typically, basic Kegels are prescribed for men and women suffering from incontinence and organ prolapse, and are designed to help strengthen the PFMs and improve coordination, continence and sexual function by reducing laxity and weakness. When I evaluate a patient suffering from pelvic pain, I frequently find that, in addition to PFM muscle weakness, the PFMs usually have excessive tone, increased shortness, extreme tension, spasms and multiple trigger points in them, rather than laxity. I also find a lack of flexibility in the muscles that attach to the pelvis, such as inner thighs, hip flexors, gluteals and abdominal muscles.
Normal PFMs are usually in a relaxed and supple state, and can react to what's happening in the body and mind. PFMs can respond to thoughts, past experiences, physical trauma, visceral problems, and abnormal breathing patterns, resulting in shortened muscle fibers that can create pain locally or elsewhere in the body.
Once the PFMs get shorter and tenser, they usually get weak. However, this weakness is not due to looseness in the PFMs, as in incontinence or prolapse; rather, it's caused by the PFMs being too short and/or hypertonic, restricting the muscle fibers' ability to contract and create force and power. This type of hypertonic weakness in patients with pelvic pain can lead to urinary leaking, frequency of urination, and pain with intercourse, walking, sitting and or positional changes. These complaints are also
common to our orthopedic patients.
Typically when a muscle is weak, physical therapists will prescribe strengthening exercises for the weakened muscles. However, for the pelvic pain patient, doing Kegels (the typical strengthening exercise for the PFM) commonly results in more pain and dysfunction.
A New Take on Kegels
So how can a physical therapist restore function, coordination and strength to a weakened and hypertonic PFM? In my experience, a lengthening exercise I have coined the "reverse Kegel" has been helpful.
For pelvic pain patients to succeed, they must have conscious release of their PFMs, and the reverse Kegel is an integral part of their recovery program. The reverse Kegel must be incorporated daily into the patient's routine.
Reverse Kegels are a lengthening and relaxation exercise for the PFMs. Once the PFMs have less tension, more flexibility and less spasm, they can be strengthened using the typical Kegel exercise. Once the PFMs have had normal function restored, the patient will enjoy reduced pain, improved continence, enhanced sexual response and improved daily function.
Now that we know why reverse Kegels are important in treating PFMs, let's cover how to incorporate this technique into a rehabilitation program. The great thing about the reverse Kegel is that it can be incorporated into your typical orthopedic exercises, such as squats, rows and bridging. The reverse Kegel should be performed with the relaxation parts of your basic orthopedic exercise, and should also be coordinated with the breath.
The reverse Kegel is a conscious lengthening and relaxation of the PFMs that should be performed with the inhalation breath. It may seem counterintuitive to release on the inhale, but this is the key to its power. Coupling the breathing with the reverse Kegel creates a mind-body connection, thus ensuring success.
A great exercise to teach your patients is the rose petal flower release. Have the patient breathe in for 5 seconds, sending their inhalation breath to their PFMs while visualizing and imagining their pelvic floor muscles as a large, tight rose flower that's beginning to blossom in the springtime. Have them imagine that as they inhale, the rose is opening up petal by petal and their PFMs are getting longer and relaxing. It's important to make sure patients don't force the relaxation by performing the Valsalva maneuver.
Getting on with Life
It's critical for rehabilitation professionals to consider PFMs when treating painful conditions in of the body that are intimately connected to the PFMs, as these muscles quite commonly refer pain and symptoms to areas outside of the pelvic floor. By incorporating different types of Kegels into your patients' programs, you will often be able to identify and eliminate a root cause of their pain.
Remember-not all Kegels are created equal, and the PFMs need both the ability to contract and relax for optimal function. These simple yet powerful exercises will set your patients on the road to self-healing, comfort and confidence.
1. Herbenick, D., Reece, M., Schick, V., et al. (2010). Sexual behavior in the United States: Results from a national probability sample of men and women ages 14-94. Journal of Sexual Medicine, 7, 255-265.
2. Herrera, I. (2009). Ending female pain: A woman's manual. Duplex Publishing.
3. Roberts, R.O., Jacobsen, D.J., Girman, C.J., et al. (2002). Prevalance of prostatitis-like symptoms in a community based cohort of older men. Journal of Urology, 168(6), 2467-2471.
Isa Herrera is owner and clinical director at Renew Physical Therapy, New York, NY. She is author of Ending Female Pain, available at www.endingfemalepain.com