Good morning, everyone. Welcome to our last morning together. It is with my great pleasure to introduce Elizabeth Barkowitz. She's a PT that works in our group, and she's literally my savior. She graduated from Marquette and has been practicing PT since 2002 at Frater, where I'm at. She completed specialty training in pelvic floor PT through Herman and Wallace pelvic rehab and is currently board certified in biofeedback for pelvic muscle dysfunction with biofeedback certification international alliance. She currently holds an adjunct faculty position at Carroll University in the doctoral, doctor of PT program. Her clinical practice at Frater includes a treatment of patients with pelvic floor dysfunction relating to bowel and bladder incontinence, pregnancy, postpartum issues, and pelvic pain. Please help me welcome her. All right. Well, good morning. Thanks for having me. This is my first time at this conference, so I'm very excited to be here, and I've been very much overwhelmed. And so I spoke to a few pelvic floor PTs today, very flattered how much we've been mentioned in all the specialty lectures. So this is a really nice collaboration, and today I think it's going to go pretty fast, but I want to talk to you guys about pelvic floor therapy. I have no disclosures. All right. So we are going to start with anatomy because every physical therapy lecture starts with anatomy. So we're going to start with that, and then I will talk to you about how we do a pelvic floor muscle assessment a little bit more specifically, so you guys can take a look at that. If you've signed up for the pelvic floor physical therapy assessment breakout session, this will be a little preview. If you've done it in the past with Ingrid, great kind of time to review your anatomy, and maybe she'll do it in the future if you didn't get to sign up yet. And then I'm going to talk to you a little bit about how we intervene when we find high-tone pelvic floor dysfunction and how we do some strengthening. All right. So pelvic floor muscles are really divided into three layers. The most superficial layers are more concerned about sexual function. So I'll try to do maybe half and half on either side. So if you talk about the superficial muscles, the first one to think about is bulbocavernosis, which is really running around the introitus here. And then the next one in this area is the ischial cavernosis, which is running right down the pubic rami. And then right here, that's your ischial tuberosity, so your sits bone. Coming from the sits bone, running medial to the perineal body is superficial transverse perineal. So all of those muscles kind of mentioned that yesterday, kind of lie on top of the clitoris. So these muscles are really going to help assist with sexual function. And then the external anal sphincter is in the superficial muscle group. Middle layer, mostly urethral compressor. Really important for PT. This is also the fascial layer. So really nice fascial, excuse me, fascial layer here. And that fascial layer runs ischial tuberosity to ischial tuberosity anterior to the pubic symphysis and starts to integrate with fascia of the abdominal wall. And that will become really important as we treat some scar tissue or pain dysfunction. And I'll talk about that in a little bit. And then the deep layer. So this is kind of the bread and butter of pelvic floor. Those deep pelvic floor muscles really are the levator ani, is the big muscle group there. So levator ani is a group of muscles. The muscles would be the pubococcygeus. I don't want to start doing this, I'm sorry. Pubococcygeus, pubic bone running back to the coccyx. And then fibers of the same muscle become puborectalis. So puborectalis is looping around the rectum. And we saw that yesterday in the GI lectures and those are the muscles that are really important for bowel continence. And then the third muscle of the levator ani is right here, iliococcygeus. So this muscle, those muscle fibers are running medial out lateral to this white line, which is the arcus tendinous of the pelvis. So when you're maybe dealing with your pelvic floor physical therapist, they may be calling out that they're treating more iliop... These are these don't match Oh, I'm not touching anything. Should I be going backwards? Yep. Just one more forward. Yep. Okay. So when you are working with your pelvic floor PTs, they may be calling out that they're treating iliococcygeus or puborectalis or pubococcygeus. It's more important if we're doing something like trigger point injections. You can just be documenting levator ani. We kind of are all in the same area there. Nope. I didn't touch a button. Okay. Next one to look at is the coccygeus back here. So running from the coccyx over to the ischial spine. Posterior part of the pelvic floor. This one, the coccygeus muscle is lying on top of the sacro—excuse me, it's lying on top of the ligament running from the sacrum to the ischial spine. So this one becomes important if you have somebody with a coccyx disruption or a sacral disruption. And the last one to call out in these deep pelvic floor muscles right here is the obturator internus, which doesn't look very impressive in this picture. But this muscle is a deep hip rotator. So it starts in the pelvic floor. The branch of the obturator internus exits the pelvic at the kind of at your ischial tuberosity or sits bone, runs across your behind over to your hip and is a deep hip rotator. It's running with the piriformis, which you might have heard of. So what's going on in the hip and what's going on in the pelvic floor shares an intimate connection through your obturator internus. And then I put piriformis in here too. Piriformis is right here. It's running off the sacrum over to your hip as well. And you can access the piriformis from inside vaginally. It's deep in there, but we can kind of get to it. And the piriformis and the obturator internus, again, are running across your butt over to your hip and are those deep hip rotators. And you know, piriformis, piriformis syndrome kind of is that pain down the back of your leg like sciatic pain. Sometimes we have crossover between pelvic floor pain and sciatic pain and those would be the reasons why. All right. So we'll go through the anatomy one more time when we talk about how we assess it. So when we're assessing pelvic floor muscles in PT, we're using just a single digit and it's not that deep. So the superficial layer of muscles are really just the pad of your fingertip and the deeper layers are maybe up to the second knuckle. So we don't have to go in that deep to assess the pelvic floor muscles. To assess muscle, it doesn't take that much pressure either. So we're not in there having to really do any aggressive assessment. The pressure that we're using is really just fingertip pressure. So how I would orient this to my patients, because it was said yesterday they thought every pelvic exam was a pap smear, they also have no idea there's muscles in there to assess. So usually what I'll tell patients is this is going to be a single finger placed inside the vagina to push right on those pelvic floor muscles, those are the muscles that you kind of squeeze when you're trying to hold in bowel or bladder and make it to the toilet in time. And we're really just assessing for how those muscles feel, if they're tense or tender, and how they're working. We can assess kind of how strong they are and how coordinated they are. I'll take my finger and just kind of press it onto the patient's knee or thigh and say it should just feel like this. Normal muscle just feels like I'm touching you or feels like pressure. If it hurts more than that, then I'm going to ask for a number 1 to 10, and I will let you know when I get on each muscle and we'll kind of assess it that way. All right, so we're going to assess most everything kind of based on the clock, 12 o'clock up towards your pubic bone, 6 o'clock down towards your tailbone. Starting with the superficial muscles. First one is the bulbo. I'll do it on this one now. Hopefully you can hear me. All right. I'm going to start with the bulbo. all of your scars, your episiotomy scars, your obstetric tears, those type of things. And I would bet you a dime to a dozen all those vulvar pictures that Dr. Vaughn was talking, or kind of showing us last time, those superficial muscles are gonna be quite unhappy for those women that have had the vulvar issues for a while. Once you get back to the middle, straight down to six o'clock's perineal body, right? So perineal body is a tough little area. You should be able to manipulate the perineal body. It should be nice and springy. You should be able to push down quite aggressively, and it shouldn't hurt. But as you get into scarring, those type of things, you might start to feel restrictions. They might start to kind of tell you that that's becoming uncomfortable, or maybe that's an area of their pain. All right, so again, that was just using the pad of your finger, just the fingertip and the vaginal canal. To assess the deeper layer of the pelvic floor muscles, we gotta go a little bit deeper, but not that far. So really, second knuckle is all you need, all right? If you got your whole finger in there, you're gonna be all the way to the cervix, right? That is, they're way past the muscle. All right, so with just that second knuckle in there, now we need to use your bony landmarks, otherwise you're not gonna know where you are. So with your finger placed up towards 12 o'clock, straight up is the urethra, all right? If you go to one o'clock and curve your finger, you're going to be right behind the pubic bone, which is where the attachment is for the anterior fibers of levator ani, more specifically, puborectalis and pubococcygeus, all right? So to get to them, you have to be curved, all right? So it's not at 12 o'clock, it's more at one, all right, or 11, you kind of have to do the mirror image on the other side, but it's that curve right behind the bone, you should be on the bone, and then you can kind of go along that bone and feel the anterior fibers or the attachments there. If you continue on that path, if you go to three o'clock, and again, curve your finger around the pubic rami, I'm usually telling patients, like if I'm looking at the patient, I'm like, I'm pushing, my finger's pointed towards the wall, all right? You will be on the lateral sides of the pelvic floor muscles, which is the obturator internus. Now, this one is my savior, because if you are lost in there, the obturator internus moves with the hip. So all you have to ask her to do is move her knee, okay? If you really can't find it, you can place your hand on the lateral aspect of her knee and have her push out, all right? So if she's pushing out laterally, you should feel the obturator move, just like if I'm palpating my bicep and moving, I can feel it move, okay? So if you don't know where you are, go lateral and have her start doing it. A lot of times people are too deep, okay? So kind of come back out, remember you only need to be maybe to your second knuckle and over to the side, and as she's moving that leg, you should feel the obturator internus move. Now, when you're assessing obturator internus, don't move. Okay, so find it with some active hip motion, but then have her stop and then assess if that muscle hurts or how it feels to you, okay? You're gonna get a false reading if she's activating that muscle, obviously it's gonna feel more bulky and tight. All right, from there, so to kind of orient you, obturator would be here at like three o'clock. So then if you continue kind of around, I would go back to six o'clock at this point to find your coccyx. So again, if you can reference yourself off bony landmarks, you're not gonna get lost. So if from three o'clock, you turn your finger down and press down, now, depending or not, if she's constipated, you might have to kind of move some of that rectal kind of tissue out of the way, but straight down, you should feel some firmness. If you can't quite feel the coccyx, you can feel some firmness straight down at six o'clock. And then if you are just lateral to the coccyx, you're going to start to be on the fibers of the coccygeus muscle, which is right back here. So these fibers are running from the coccyx over to here, over to the ischial spine. So you could start from the coccyx and kind of palpate to the ischial spine. If you can find the spine, start there, go to the coccyx, that's a horse apiece. But between the coccyx and the ischial spine is where you're gonna find the coccygeus muscle. And this muscle feels firm because it's sitting on a lot of, kind of sitting over some of those deep pelvic ligaments or supporting ligaments, right? So there's firmness in this muscle at baseline and you kind of know where you are. And then the last one, which is kind of right in the middle, it's a little bit in no man's land. So I feel like that one's harder to really convince yourself you're on. That's gonna be right here. That's gonna be the iliococcygeus, right? So the coccygeus is behind it and it's firm. Once you get on iliococcygeus, there's nothing underneath it, right? So it's spongier or softer at baseline. I usually kind of tell a new piece, it's like putting your finger on the inside of your cheek and pushing out. Like there's nothing really supporting behind it, okay? So your landmarks, again, if you're looking for the anterior fibers of the levator ani, you're at one o'clock-ish, kind of curved behind the pubic bone, right? If you're looking for obturator internus, you're going lateral, curving around and asking her to rotate her hip or kind of move her knee in and out. And you'll feel that muscle working. So you know where that is. You can go posterior to six o'clock and then just lateral off the coccyx and find coccygeus, which feels a little bit more firm at baseline and then pull your fingers a smidge towards you towards like four o'clock and you'll be on iliococcygeus. So hopefully that helps. I would say practice. If you have somebody that has, you know, it's fairly tolerant to a pelvic exam, none of that should be painful. Really there's like pressure, pressure, you know, it should be fairly comfortable. You're not that deep. It's not like you're kind of deep to the cervix or getting any kind of radiating symptoms if they are a normal functioning pelvic floor. So what we're trying to do is assess a couple different things. One was pain. So each time I hit the muscle, I'll just say, does that just feel like pressure or does that hurt? All right, if it hurts, I want to know does it hurt under my finger? Does it radiate pain somewhere or is that their pain that they're coming in with? And just for insurance purposes, then I need a number. One to 10, how bad does it hurt? And we can kind of map that out. I'm trying to feel muscle tension, which everybody, you felt muscle tension anywhere. So what I say to my patients is, if you are coming in with like a shoulder tension, tension in your upper traps, if you went to the massage therapist or the physical therapist or to your partner and they laid one hand on you, they would be able to be like, yikes, that feels tight. Tight muscle feels a certain way. There's resistance there. There's bulkiness. There's fullness. Normal muscle kind of moves around. It's nice and flexible and it kind of moves away from you. So that's kind of what you're looking for in the pelvic floor, which does take a little bit of practice, but we're looking for that kind of full, bulky, kind of radiating pain. Those are your clues that it's kind of a high tone pelvic floor versus someone where you're in there and you feel like you could stretch her pelvic floor all the way down to her knees, not great, but if you have lower tone nerve injuries, stretch injuries, obstetric injuries, you might be feeling really no resistance to any of your palpation, which isn't good either. And in that case, I'd really say, make sure that you're comparing left to right because if it is a nerve injury or an obstetric injury, sometimes you'll feel a difference there. Often it'll be low tone on one side and then someone's got to pick up the slack. It's usually the other side. So you might have a high tone on one side and then the other side's like non-existent. That happens and those would be kind of things to note. And then we want to know, does the muscle work? Can she use it? How strong is it? How you assess the muscle, you can get into this or you can just say she has a squeeze. And I have providers that do all sorts of things. So I kind of split the difference for you here. So we do grade muscle strength, right? Everybody grades muscle zero to five. All right, zero, it's not working at all. Five out of five, tip top. Now, honestly, in the pelvic floor, a five out of five, how many times are we running across that? And sometimes that's not the best. So a lot of your kind of high tone muscle dysfunction, you'll be seeing like maybe that this five out of five isn't the best idea for some of these women, but a nice kind of moderate or good contraction is what we're going for. So what you're looking for when you have a finger inside the vagina and you're asking for a pelvic floor or a Kegel squeeze, you're looking for her to both kind of squeeze and lift. You want your finger to be drawn up into the pelvis. So kind of a squeeze and a lift is what we're looking for. And then you can kind of grade that moderate, good, or strong. A flicker is hard to tell. So a flicker by definition, you're just kind of getting a little contraction there. If you have your finger just sitting right in the middle of the vagina and she's given a flicker, you're going to miss it, okay? So you might need to move your finger more laterally or kind of lie it on those deeper pelvic floor muscles and ask for a squeeze. That's fine. If you're really getting nothing, you can kind of come out a little ways and give a little traction to some of those superficial muscles and see if she can fire those. And then just document what you're doing, okay? But sometimes if it's just right in the middle, I see this a lot, there'll be like no contraction and then the patient's really like devastated. Like, I feel like I'm doing something. She may have a flicker or a one or a two and you're just not feeling it unless we're kind of over to the sides there, so. And then in PT, we'll go a couple better just to really assess what's happening with the muscles. So if you see it in the documentation, we're going to try to time out how long can they hold their maximum squeeze. So we're really looking for an endurance contraction up to about 10 seconds. I mean, a 10 second strong contraction is very rare in my practice, but we'll count how long can they maintain that contraction, three, four, five seconds. And then we'll ask them to repeat that squeeze. So if they were able to squeeze and hold for four good seconds before they started to lose power, then I'd say, all right, I want a four second squeeze, have them do that, and then see, can they relax? All right, relax for a little bit and can they repeat that squeeze? And then I also want to assess their coordination. Can they fire this muscle a little bit more rapidly? So I'll ask for some quick contractions. Can they squeeze and let go, and squeeze and let go? Now, the let go is as important as the squeeze, so they can't just squeeze and hold, I already asked them to do that. So what's the coordination? Can they squeeze it, can they relax, and can they repeat that? That's actually pretty tricky for someone that has either weakness or high tone, that they'll get kind of stuck in the weeds there, and then we can start to make some assumptions about their pelvic floor function or coordination kind of throughout the rest of their day, whether we're working about controlling their bladder or it's causing pain after a while or whatever their symptoms are that brings them to therapy. All right, so for the sake of this is a 40 minute lecture, and I glossed over a lot of things. So in pelvic floor PT, we would assess a lot more things. Lumbar spine, sacrum, pelvis, hips, abdominal wall, scarring, I mean, we've got posture. This can, we can, obviously, we can talk about this for years if you want. But the way I'm gonna kind of structure the rest of this is to say we can treat high tone, and I'll talk a little bit about what we do for that, and then we can do some strengthening. I do want to take a second to say that when people are referred to pelvic floor therapy, I've been doing this for 20 years, and it's not a week that goes by that somebody's sitting in my office saying, I have never heard of this before. This is crazy to me. I cannot believe there's muscle in here. You're gonna teach me how to poop, or what does this have to do with my pain with intercourse? So I do take a lot of time at the beginning of every kind of meeting to go over anatomy, a little bit about what we said, and then options. So my kind of motto in pelvic floor PT is there's no deal breakers. My job's to give all the information and kind of all the options, and we're gonna work together to see what works best for you. So options the first day are to do the internal muscle assessment that I just talked you through, and kind of clear as I can make it, it's a finger inserted inside vaginally just onto the pelvic floor muscles, and I'm gonna kind of press on each one, and we can evaluate together, does it hurt? Does it feel fine? And figure out what's your strength of this muscle, and how well can you coordinate it? That's option. There's another option that we don't have to do anything hands-on, and we can do something called biofeedback. I'll explain that in a minute. That's a little bit more hands-off, but I'll still be able to tell you, are you using that muscle fairly well? What's the coordination? And any of the exercises or stretches I give you, you'll be walking out of here knowing that you're doing them reasonably well. And the third option is we don't have to do any of that. Based on the story you've told me, and based on the referring provider, I can make fairly educated guesses what exercises would be nice for you to start with to try to start to think and figure out if some of this stuff is gonna help you. And you can go and think about this. All right, so there are no deal-breakers in pelvic floor therapy, and there's no rash decisions. So if I can kind of read the room, and she's kind of like, ooh, feeling uncomfortable about any of the assessments, I'll just kind of say, you know what? Why don't we just talk about some exercises that you can start doing at home and thinking about this, and then when you come back, we can talk about it more. So we have lots of options so that we can meet everybody where they are, because this is all of our bread and butter, but it does come out of left field for a lot of people still. All right, so the first treatment I like, because it tells me a lot. One, it's gonna tell me how well they're kind of on board with all this. It's gonna give me an idea of their coordination. And it's really quite beneficial for almost all the diagnoses that I see. So whether you're coming in with urinary incontinence or overactive bladder or constipation or pain, we can get to and influence the pelvic floor quite well through breathing. So the first thing I'll usually ask them to do is kind of give me a, just sitting there in the chair, kind of give me a pelvic floor or a Kegel squeeze. Can you do it? And 80% of the time they're, right? Deep breath in, suck it in. And then I'm like, okay. That's not exactly the optimal pelvic floor contraction that we want. So we'll talk about this. And I know Ingrid alluded to the canister when we were on the panel one of these days. So we kind of think about your core, your kind of trunk here as a canister, the top being your, oh, that was me. The top being the diaphragm, abdominal wall, pelvic floor at the bottom, and then some of the spine stabilizers along the back. Now, if I flip them into supine, we can take the spine out of it. So we can stabilize the spine. So when you take a deep breath in, your diaphragm goes down to make more space for air. And when you squeeze the pelvic floor, it should go up. That is not working with yourself, okay? That would be working against yourself. So we really wanna facilitate the pelvic floor squeeze with the exhale, which is very foreign to people, all right? They wanna suck everything in, deep breath in and squeeze, which is not ideal. So how I would introduce it is flip the whole thing around. And diaphragmatic breathing or yoga breathing works like a charm. So if I have somebody in supine, nice and relaxed, hands on their lower belly, what I'm gonna ask them to do is take a deep breath in, bring the air all the way down to their fingertips and let their belly expand. And that's the time that the pelvic floor should relax. So everything should kind of relax and fill up with air. And then on the exhale, they can kind of add a little bit of muscle tone or muscle activation, I should say, of the pelvic floor and the abdominals as they're exhaling. So that's a great home program. If I'm starting to teach this and it is a hot mess, then I'm already knowing like, we're gonna have to go a little slower here because maybe the coordination has been off for a while or we're just not connecting yet and kind of on the same page. So I'm using this opportunity to really figure out what's gonna work best between my patient and myself in terms of communication. And if they're coming in pain or if they're a little kind of skeptical about this whole thing, you can't injure yourself from breathing, all right? So I cannot be making you worse through breathing. And so this is a real approachable kind of thing to start working on at home. And then I'm a big fan of biofeedback. I think it does the buy-in really nicely because they can kind of see in real time what they're doing and I tell patients, all right, I can see if I'm giving you the right things and then we can both be rest assured that what we're doing together is kind of pointing you down the right track. And again, people in pain are afraid of, are being afraid of that I'm gonna make them worse. So we can start to see how your pelvic floor is responding to the things that I do for you. So there's a couple different options for biofeedback, really three, for pelvic floor biofeedback. I can put a sensor inside vaginally, rectally, or we can use surface electrodes. Surface electrodes are cheap and they go on quickly and nothing has to go inside your vagina or your rectum and you can stay fully dressed. So it's very approachable, especially when we're starting. Where the electrodes go is really just on either side of the external anal sphincter. So they go on the inside of your cheeks, right? So they're down on your butt, but you can stay dressed. They just have to lower the pants down, kind of stick those electrodes on either side of the anus and they pull their pants right back up, cord comes off the top of their pants. It's not the perfect assessment. It's really not a diagnostic assessment. It's just really a learning tool. So if they do a kegel squeeze with the biofeedback, they will see the electricity go up and then when they let go, it's gonna come back down. So picture's worth a thousand words, right? Are you engaging your pelvic floor? Does it go up? When you relax, does it come back down? Because it's surface electrodes, I got to troubleshoot that they're not squeezing their glutes, okay? But we can see your glutes, so I can kind of tell. Like, I see you squeezing your butt. So that's not your pelvic floor. So can you be still or kind of focus in between your sits bones, just medial, kind of the inside. We see it on the screen, but I don't see it on their body. Nothing else down there besides pelvic floor, so then they kind of know they're doing that right. And then we can see, can they squeeze and hold and kind of get these plateaus? Can they do it quickly, squeeze and relax, right? They get caught in the weeds after two or three squeezes, it goes up. Okay, I don't know. This one down here in the corner, you can say they squeeze and hold, but they never quite relax. This one down here. So this one is kind of a nice, relaxed, quiet baseline. This one's a little bit more active. So can we kind of look at that screen and talk about relaxing and do some verbal imagery with all that? There's tons of options. This rose thing, some people really like it. It starts as a rose bud and then it's a down train. So if they're starting out with higher tone, the bud is closed. And then as their resting activity comes down, the rose blooms. So that's nice. There's a classic one to kind of up train for more for kids, but some people like it. The men like it. It's a rocket. So as they are engaging the pelvic floor, it'll dock and like give you an explosion. So. All right, so then if they're high tone, what's the first thing I'm gonna say? You need to relax your pelvic floor and the first thing they're gonna say to me is, I don't wanna pee my pants. So my analogy, we talk, I do this a lot with the patients like, all right. So if you're coming into me like this and saying I have headaches or things hurt, it's not gonna be a huge surprise that I go to push on those muscles and it hurts. And that's maybe what your provider did or what we did during the pelvic exam. So there's nothing that I can do for you until you relax your shoulders. But if I say relax your shoulders, you're never gonna worry that you're gonna let your arm fall out of the socket. Okay, and if I say relax the pelvic floor, you are never gonna be able to accidentally pee your pants. All right, I would have been out of business 20 years ago if I was making people sit there and pee their pants. Also, if you relax your shoulders, no one's ever said to me, now I'm too relaxed, I can't carry groceries because my arms are weak. Okay, relaxing muscle does not make you weak. So relaxing your pelvic floor is not going to make you weak. You're not going to leak more when you cough and sneeze because you're too relaxed. That's not a thing. And I had that off at the pass, right? Otherwise, everybody's coming back to me like, I think I'm leaking more. I'm like, well, you were leaking before. Probably just noticing it, but you cannot over relax. They're neurologically intact. We're not worried about that. So then we're using what's all connected. Obturator internus is part of the pelvic floor. That's that deep hip rotator that runs with the piriformis, so you can stretch that. So I like yoga, hip openers, pelvic openers. Can they be in those positions and relax the pelvic floor, right? We already kind of worked through some relaxing with the biofeedback, maybe with the breathing. Can we combine the breathing and the stretching? All this stuff is good. Can we combine the breathing and the biofeedback with the stretching? Yes, so we're kind of like all working on the same kind of path here to try to get control over those pelvic floor muscles. All right, so superficially, if we need to treat more specifically, then we're doing some myofascial techniques. So going back to the assessment, if we want to treat the superficial muscles because there's some restrictions there causing pain with arousal or pain with kind of entry dyspareunia, I'm just using the pad of my finger onto those muscles and doing some manual release stretching. So myofascial release is kind of the term that we use because massage is not reimbursed from physical therapy, so we don't do massage. So we're finding kind of tightness in the muscle and either holding pressure or working with the kind of muscle fibers and stretching there and doing some scar mobilizations, those types of things superficially. If they feel like they have a urinary tract infection or if they feel like they have to pee all the time, a lot of times it's the second kind of layer, maybe the anterior part of the third layer. So with the finger inside vaginally, not on the urethra, lateral to the urethra. So one or two o'clock hooked behind the pubic bone, we can kind of get to some of those anterior fibers of the levator ani. We're getting some of those kind of middle layer, fascial layer kind of compressor muscles and we're mobilizing away from the urethra on either side to try to get some of that tension off of the urethra. This is an interesting little one too because this fascial layer integrates with the abdominal wall. So all of your abdominal surgeries, any direction, you'll have people that lie down, they feel like they have to pee. Every time they lie down, they have this urge feeling, or they feel like they have a UTI every night. If they have tightness in their abdominal wall and they lie down, it's gonna pull all the way under. So you can kind of do some cool stuff. Obviously we can do manual stuff on the abdominal wall, but sometimes we can do some bi-manual stuff or we start to combine. Can I do some of the myofascial release in the pelvic floor muscles as they're doing diaphragmatic breathing? Okay, I'm just trying to mobilize some of that. And then the deepest part of the pelvic floor, again, bread and butter. This is where a lot of your muscle dysfunction is going to live. These are harder to treat because they're deeper muscles and they're harder to get to, but we can do it in clinic. So I've kind of mapped it out and doing some myofascial release techniques, which is just what you would do to yourself up here, okay? So can you find that tight spot? If you find a tight spot that radiates pain, you just kind of hold there. Can they relax? Can they breathe into it? If it's attached to muscle that moves, like the obturator, all right, if this was tight, I kind of move away from it. So if I'm on a tight spot in the obturator, I'm moving their hip, okay? And I rotate their hip out or flex their knee and their hip and kind of get a good release that way. So lots of different options. And then I can do it for like 20 minutes, once a week maybe. They need to do it more, all right? So if they have muscle dysfunction and muscle pain inside vaginally, I really need them to be doing that on their own at home. Dilators work great. The short ones are sometimes hard to move around. So unless you have somebody with a stricture, which I didn't get into, like a graft versus host or significant scar. High tone pelvic floor dysfunction without a lot of scarring doesn't really need that. I'll take. You can kind of get the trigger points and move around. That's what they're doing with the dilator. Can they find it? Can they angle it over towards obturator or down towards ileococcus aegeus and do some sweeping techniques? They have ones that vibrate, which I love. And now they have ones that are flexible, and they can move around. I like a good vibrator too for desensitizing. So we'll get online and we have a nice sexual health store like an hour and a half away from our clinic. So I get on their website and look up vibrators, which I've had to get special dispensation from the hospital. My favorite day when IT locks me out and I just call and talk to IT about the vibrators. So a G-spot vibrator is curved, right? So you hit the G-spot. So in polychlorotherapy, you just turn that to the side or posterior. All right, I'd say 10 years ago, I was not doing as good of a job now kind of reinforcing that you may have high tone pelvic floor, but we're going to treat that, and then you need to be able to use your pelvic floor responsibly, and that is safe. All right, so I think people kind of got stuck in this, like, I have high tone pelvic floor. I've been seeing pelvic floor physical therapy off and on for five years. I can't exercise or strengthen because I have high tone pelvic floor. That is not accurate. You can strengthen muscle, and it's safe. It needs to be balanced, okay? So now coming through pelvic floor physical therapy, they have the tools to be balanced. They know how to relax the pelvic floor. They know how to combine that with stretching. They know how to take care of some of their internal trigger points. They need to use their pelvic floor appropriately, which is strengthening, and that is safe. So just like relaxing pelvic floor does not make you weak, strengthening the pelvic floor does not make you tense. It's not a thing, all right? If you did Pilates with Carissa, you're probably not still clenching your abs because your abs are on fire that day, right? Actually they probably relax a little bit better, and you feel better because you're nice and balanced. So movement's healthy. They do need to coordinate these muscles, and we really work on coordination with the lowest abdominals, the transverse abdominals, okay? So pelvic floor and transverse abdominals together are those muscles that really start to support your pelvic organs. For continence, if you're leaking with functional activity, that's what we want to do. All of my postpartum moms need this. Every time you have a baby, you need to think about this again because both the coordination of your pelvic floor and your TA are like up in the air, and you just got to go through the motions, and that's what we do. Every time you had a knee surgery, we go back to the basics in terms of your leg muscle function and strength and coordination, and every time you have a baby, we go back to the basics with your pelvic floor and your abdominals. All right? So pelvic floor and abdominals here, can they just get them in supine, and then can they do something with them? So easiest thing to do with them probably is a bridge. So can they engage those muscles as they're lifting their hips? If they don't know, we throw the blind feedback on them. They can see you're doing it, all right? They can palpate their abdominals, and we can kind of, again, we've kind of built up the repertoire. So they have kind of some of those things to fall back on. Can they do it when they're standing? I like a plie or some of the barre type moves. Can they do it in bird dog or dead bug, and we can kind of figure out what they want to do for their exercise routine? And can they use it functionally? So here's where we talk about the breathing. The pelvic floor and the abdominals have to be coordinated with the exhale to manage pressure during the effort. So if I was going to pick something up, all right? blowout, as you're picking that up, you're not going to leave. So retraining that because it's been jazzed up from having the baby or having pain or having surgery, we just have to retrain it. And if they retrain it enough, you get that motor pattern, which is the neuromuscular reeducation, and then they're not having to think about it so much. But that's, they've got to go through the process. And then I live in Wisconsin. So it's cold, and we are known for beer and cheese. Not a healthy lifestyle. So it is, there's almost nobody that comes to my clinic that doesn't get the move your body speech. I maybe would have to be slowing people down, but that's barely my problem. I'm more like, you gotta move. So overactive bladder, urinary incontinence, constipation, pelvic pain, everybody needs to move. into their walking or before or after their exercise. Hey, my name's Amanda, I live in Asheville, North Carolina, and I was just curious what your approach is with someone with vaginismus. Oh, vaginismus, sure. Vaginismus gets the same anatomy lesson, and I think they do pretty well with a few things. One is just the coordination training, so a lot of the breathing that they can kind of start to control the pelvic floor is good. I also like biofeedback because they have yet to really have any good news with the pelvic floor. So with the biofeedback externally, with the surface electrodes, very approachable, and I can kind of show them, you can use your pelvic floor. You can engage it, you can relax it, and that might be the first time they're kind of seeing, like, okay, if nothing's being messed around with inside the vagina, the pelvic floor muscles are acting normally. So that gives them a little bit of reference that, like, okay, these muscles are under my control and working for me, and then with that knowledge, we go really slowly, and either the smallest dilator, or if they just want to use a fingertip or a Q-tip, I kind of have them, sometimes with the biofeedback, say, like, all right, on your own terms, maybe covered up, I can even step out of the room. Can they keep that pelvic floor relaxed with just external contact? So nothing's going inside the vagina, and they're doing it themselves, so we know if I'm coming at them or a provider, it's not working. So can they keep the pelvic floor relaxed with something just right at that vaginal opening? And sometimes in clinic, they'd be able to see that on the biofeedback, and that gives them some good positive. And then once they can kind of contact that, again, can they keep those muscles relaxed if there's something placed just right at the vaginal opening, and then we kind of go from there. The smaller dilators, usually, if they can kind of have some contact at the opening and maintain that relaxing on the biofeedback, that gets the ball rolling for their home program of trying to get something inside vaginally, and I'd say a lot of people are pleasantly surprised if we kind of take those beginning steps really slow. Hopefully it'll fall like dominoes in your favor in terms of the dilators, but knowing that the muscles can relax when there's nothing in there is really not something that they're aware of. They kind of think everything's just closed tight, so I think that helps. Yeah? Hi, I'm Anna from California, kind of the other end of the spectrum. Someone with maybe a mild prolapse and wants to do physical therapy to prevent progression but also enjoys weight lifting. You know, I usually tell patients, like, I don't want you to do weight lifting. protecting their pelvic floor. Oh, I'm sorry. OK, so I would start with some of those supine exercises, really telling her, this is separate right now to get the coordination going. Can she engage the pelvic floor and the transverse abdominals and maintain that during easy, non-weight-bearing movements? Sometimes the answer is no. And you're like, oh, now I see what's happening. So then we'll kind of go from there. But I'm also really not opposed to a pessary. If a pessary works, even some of these kind of over-the-counter ones, and she can be working on my stuff and still doing what she likes, I think that's good. I don't think that those kind of butt heads in any way. Generally, with heavy weight lifting, you're holding a breath in to lift the heavy weight. So would you want to engage and do like a Kegel at the same time as holding in sort of a breath in Valsalva? They have to. Yeah. So that's where I had to phone a friend, because their breathing technique isn't what you would normally be doing to lift the laundry basket. So yes, they have to kind of go one forward. They have to maintain that during their Valsalva. So otherwise, they're going to push it down. And that's where, depending on where she is with the prolapse, she might need some external support, because the muscles are your last line if you've already prolapsed down during the heavy lifting. Usually, I'm sticking something in there so that she can continue to do it. But technique-wise, we've got to start from the basics, because a lot of times, you'll see that their basic technique is not the best, and that kind of got them into the situation. Thank you. All right, so that brings us to the conclusion of all the lectures. We just really wanted to thank you all for, again, making it such a great event. We also want to thank Weiyi and the Augs team, Melissa, who have made this possible. It has been a really amazing couple days. In my opinion, it's so inspiring to listen to all the speakers and learn new things and meet all of you inspiring individuals. So we certainly couldn't do it without them. Do you want to advance the slide? And then we just wanted to make mention, again, our Save the Day is April 16th to the 18th next year in Atlanta for the next APP course. As I mentioned yesterday, the call for volunteers will be the first week of June, so remember these warm fuzzies that you're hopefully having at the end of the conference. And when the call for volunteers comes, we would love to have you join us on the committee and share your new ideas. You'll also get an evaluation with giving us feedback on the program. We want to continue to make it better. And with that, we

pelvic floor therapy

Elizabeth Barkowitz

anatomy

biofeedback

treatment techniques

muscle coordination

manual release

patient education

individualized care