We include very specific neuromuscular re-education to bring balance of muscle strength and length, improve postural alignment, and increase daily function without pain. We not only address the area of pain, but also track the mechanical breakdown in the body that created the condition in the first place. By diagnosing the mechanical cause of the pain/discomfort, we are able to develop a program that is individualized for each patient. Now, combine that background with our knowledge of treating the pelvic floor and how different regions of the body can actually contribute to pelvic floor related conditions. It's the perfect combination to ensure that the whole body is treated to result in the best and long lasting outcome. By educating the patient in the anatomy and biomechanics of their condition and the relationship to other regions of pain/discomfort, the patient is an active participant in their care.

As the abdomen grows and weight is gained, increasing stress is placed on the spine and lower extremities. Any deficits in strength, stability, or range of motion will be exacerbated throughout pregnancy. The earlier the problem is addressed (by the 20th week), the greater the chances of success in eliminating the condition. Although it is still effective to address these conditions in the later stages of pregnancy, the goal becomes primarily one of pain relief and maintenance of current function.

Often times, pain develops due to a muscle imbalance that was present prior to pregnancy and only now presents itself with the increasing stress of weight gain and postural changes of a growing abdomen. Once the mechanical stress of the injury is addressed, increased pain relief and greater ability for successful function in daily activities and work requirements can be obtained. Immediate pain relief through hands on treatment is the first goal of physical therapy. As the initial pain is under control, we then continue hands-on treatment in conjunction with appropriate exercises geared toward maintaining function. Patient education is important for injury prevention through proper body mechanics with typical daily activities such as sitting, bending, squatting, and walking. We assess the expectant mother's mechanics with these activities and offer alternative ways to accomplish her daily activities without creating injury or increasing pain.

Common prenatal conditions that can be addressed in physical therapy:

• Sciatica
• Low Back Pain
• Mid and Upper Back Pain
• Plantar Fasciitis
• Knee Pain
• Groin Pain
• Early Stress Incontinence (prior to 8th month)

What the patient can expect:

• A comprehensive evaluation of the condition to determine why she is experiencing pain.
• An assessment of the patient's body mechanics for her activities of daily living.
• Hands on treatment to relieve pain and spasm.
• Specific exercises targeted for maintaining function.
• Education of the condition and contributing factors that may have helped to cause the condition.
• Home maintenance program.

If you think you would benefit from an assessment from a licensed physical therapist that specializes in prenatal care to help you develop an appropriate fitness program tailored to meet your needs, ask your OB/GYN if you are a candidate for our 3-visit pregnancy fitness program.

How do I sign up for the 3-Visit Pregnancy Fitness program?

• You must obtain clearance from your OB/GYN prior to your assessment.
• Once you obtain clearance from your OB/GYN, just call our office to schedule with one of our licensed physical therapists.
• Be sure to mention that you are coming in for our Pregnancy Fitness Program as opposed to an evaluation for an injury or condition.
• Your insurance may cover the cost if you have a referral slip from your OB/GYN.
• Cash rates are available.

What should I expect from the Pregnancy Fitness Program?

• A comprehensive assessment of your posture, body mechanics for daily living, history of exercise and fitness goals during pregnancy.
• Education on prevention of potential injuries that could occur based on our findings.
• Specific exercises targeted toward established fitness goals with handouts for reference.
• 1-2 follow up visits to add or modify your program to meet your changing body's needs.

Pregnancy Fitness: Myth vs. Truth

Myth: You cannot recruit your abdominals after the 4th month of pregnancy.	Truth: No sit-ups after 4 months (not recommended ever).
Myth: Walking is the only exercise recommended to pregnant women.	Truth: Modified Pilates, Yoga, and modified exercises are all great ways to stay in shape throughout pregnancy.
Myth: My energy level will be lower if I exercise.	Truth: Fitness at delivery will help the pushing phase of labor.
Myth: I should not begin exercising during pregnancy if I did not exercise prior to getting pregnant.	Truth: Exercises need to be modified and specified to each individual during pregnancy.
Myth: It is safe to continue my pre-pregnancy exercise routine.	Truth: High aerobic activity is not recommended due to chance of increasing womb temperature.

Your shoulders start to roll forward from all the bending, lifting, feeding, bathing, laundry and then because you have no abdominal muscles to hold your trunk upright you start to slouch. The body does follow the path of least resistance after all. We often hear women say that when they were talking to other moms at a mommy exercise class someone told them that it's normal to have a little incontinence when they cough, sneeze, or laugh a year after they had their baby. Or that they will never get rid of the muffin top (or in some cases more than a muffin) so just accept the bulge. Both are UNTRUE. You should have full continence after 8 weeks, and there is no reason that you cannot engage your lower abdominals and loose an immediate 2 inches off the waist without losing a pound. The key is to increase your Body Awareness and take the time to take care of yourself so that you can take care of your family.

How do you know if physical therapy can help you? Ask yourself a few of these questions and if the answer is YES, you may benefit from asking your physician if treatment by a licensed physical therapist that specializes in women's health is appropriate for you. Don't be afraid to give your OB/GYN a call even after your 6 week check up; they will be able to determine if they need to see you again, refer you to another physician, or perhaps prescribe physical therapy over the phone if they think it is appropriate.

• Do you have stress incontinence when coughing, sneezing, lifting, or laughing?
• Is your C-Section incision hard, not movable and/or causes pain to touch?
• Do you feel like your insides are going to fall out when walking or while exercising?
• Is intercourse painful?
• Do you have to get up at night frequently to urinate?
• Are you constipated much of the time?
• Are you unable to perform a Kegal while holding your abdominals in?
• Do you NOT know if you are performing a Kegal correctly?
• Do you have unresolved low back pain or sciatica since delivery?
• Do you have neck pain while breastfeeding?
• Have you lost your awareness or ability to recruit your abdominals?

The earlier you address the above symptoms by finding the mechanical cause, the quicker full resolution can be obtained so that you can get on with life. More chronic conditions as listed in our Pelvic Floor Dysfunction section may develop over time if left untreated.

Common Post-Natal conditions that can be treated in physical therapy:

• Cervical Pain - most often created by straining to look at the baby while breastfeeding or poor posture while holding your child.
• Low and Mid Back pain - can result from constant forward bending over various surface heights such as, the changing table, crib, car seats, floor, bouncies...
• Sciatica - if sciatic was not addressed soon enough during your pregnancy; it can result in continued problems after delivery.
• Bladder Dysfunction:
  • Stress Incontinence - urinary leakage with coughing, sneezing, laughing, or lifting.
  • Urge Incontinence - having the urge to urinate immediately with feeling of the inability to control or to hold urine for any length of time.
  • Urinary Frequency - having to urinate frequently either during the day or at night.
• Post C-Section Rehabilitation - scar restriction that inhibits the ability for abdominal recruitment.

The abdominal wall consists of four main abdominal muscles - the external obliques, the internal obliques, the transverse abdominus, and the rectus abdominus. The abdominal wall is stretched and elongated as your baby grows. After delivery the elasticity of the tissue is compromised, leaving you with the feeling of overstretched flabby tissue. The time frame for the return of elasticity of the abdominal muscles depends on age, weight gain during pregnancy, time frame between pregnancies, awareness of you abdominal muscles before and after delivery, as well as proper recruitment of the abdominal muscles during daily activities and with exercise.

Try this exercise.

1. Place your hands below your belly button as if to cradle your stomach.
2. Take a large breath in, allowing your belly to fill up with air.
3. On exhale bring your belly up away from your hands in an upward and inward motion using your abdominal muscles.
4. Do not tuck you buttock or pelvis under.

Can you do it? Think of putting on your "skinny jeans" if you have a hard time visualizing. Now remember your abdominal muscles are postural muscles and should be engaged slightly all day with all activities, but should not be engaged so hard you cannot take a full breath. If you have difficulty with this exercise or are not sure if you are performing it properly, you may benefit from out 3-Visit Post-Natal Physical Therapy Program.

Based on our in-home outcome studies, data indicates a majority of women have positive results within 3 visits. At Body Awareness, we have developed a 3-visit program designed to address the needs of the post-natal patient. However, if it is determined by the therapist that the patient would benefit from continued physical therapy, the patient and physical therapist work collectively to determine a feasible treatment plan to meet each woman's individual goals. The initial evaluation, recommendations, and goals are communicated to the physician in the written plan of care.

• A comprehensive evaluation and written plan of care.
• Hands on treatment to address pain and dysfunction in order to normalize mechanics.
• Education in proper body mechanics and postural alignment.
• Neuromuscular re-education for proper recruitment of the pelvic floor (Kegal's) and abdominal muscles.
• A home exercise program designed to meet individual needs.

• Our patients will be able to demonstrate proper body mechanics for lifting, bending, squatting, and breastfeeding.
• Our patients will be able to perform a Kegal properly in supine, standing, sitting, and with activities.
• Our patients will be able to demonstrate proper abdominal strengthening exercises to promote stability of her core muscles.
• Our patients will demonstrate understanding of the importance of continued self maintenance to counteract the excessive forward bending position involved in childcare.
• Our patients will gain a source of information and support regarding their changing body and the physical demands of childcare.

The pelvic floor is a complex structure that not only allows the passage of urine and stool at appropriate times, but also preserves continence daily. Bowel and bladder functions are controlled by contracting and relaxing these muscles. These muscles must relax to allow for urination, bowel movements, and, in women, sexual intercourse.

Muscles of the Pelvic Floor:

• Levator ani - comprised of 3 muscles. It is comprised of 30% type II (fast twitch) and 70% type I (slow twitch)
• Puborectalis
• Pubococcygeous
• Iliococcygeous
• Pirifomis
• Obturator Internus - runs along the obturator

Other notable structures:

• Gluteus Maximus
• Gluteus Medius
• Iliopsoas
• Transverse Abdominus
• Lower portion of the Rectus Abdominus
• Mulitifidi

These structures in combination with the pelvic floor form the support structure for the pelvic ring.

The length and strength of these muscles will contribute to the presence of trigger points, hypertonia(excessive muscle tone), or hypotonia (lack of muscle tone) of the pelvic floor.

Pelvic floor dysfunction occurs when the muscles are unable to properly contract and/ or relax. Typically what we have found is that the pelvic floor muscles have a combination of tone, strength, and control. Pelvic Floor Tone means the density of the tissue. This is very different than the strength which means the power of the muscle. Control is referred to as quality of movement. When the any of these three aspects of the pelvic floor is disrupted, pelvic floor dysfunction will occur.

The pelvic floor is what I consider the gateway. If its function is disrupted, then all that is attach to it, or systems that use it will eventually be affected. Here are some examples. Hip, back, abdominal, pelvic, or vaginal pain may result from improper muscle length/ tension of the pelvic floor (levator ani). If the pelvic floor is in spasm, the bladder may not void urine properly due to the urethra opening passing through the pelvic floor. The bladder will then tell the body it has to urinate more frequently because it can't void completely. If the bladder retains a residual amount of urine, the toxin may reabsorb itself into the bladder wall causing a breakdown in the lining (Interstitial Cystitis). A spasm of the back portion of the pelvic floor can cause a similar disruption of the bowel system. If the body cannot rid itself of waste it will continually back itself up the systems of the viscera. Constipation may result. Reflux may also result as the food cannot go down; the body pushes it back up. Irritable Bowel Syndrome (IBS) may result from the gall bladder trying to figure out a way to allow the waste to pass. The gall bladder secretes bile into the intestine so that food is broken down and waste can be formed after the body takes the nutrients from the food. If the body cannot pass the waste, the gall bladder may change the amount of bile it secrets in attempts to allow the pelvic floor to let the waste pass, creating IBS.

There are four main categories of pelvic floor dysfunction. These can occur on their own or in conjunction with one another.

Supportive Floor Dysfunction: The muscles of the pelvic floor do not have enough integrity to support the pelvic organs. This may result in loss of urine with coughing, sneezing, or lifting. Pelvic pain may also occur with walking or exercise.

• Stress Incontinence - The inability to control urine leakage or flow with stresses such as a coughing, sneezing, laughing, or exercise.
• Pelvic Organ Prolapse -
  • Cystocele - Bladder prolapse into the vagina
  • Rectocele - Rectal prolapse into the vagina
  • Uterine Prolapse - Uterine displacement into the vagina

Incoordination Dysfunction: The muscles of the pelvic floor work in a specific order and timing with other muscles to carry out bowel, bladder, and sexual functions. Improper timing of muscle contraction may result in constipation or urine leakage with activities of daily living.

• Stress Incontinence - Inability to control urine leakage or flow with stresses such as coughing, sneezing, laughing, or exercise.
• Constipation
• Pelvic Pain
• Detrusor Sphinctor Dyssynergia - incoordination resulting from a problem in the spinal cord.

Hypertonia Dysfunction: The word hypertonia refers to muscles that "tighten up" or "fire" more than usual. This dysfunction may result in pelvic pain with lifting, sitting, walking, intercourse, bowel/bladder voiding, or when wearing restrictive clothing.

• Levator ani Syndrome - spasm of the pelvic floor muscles
• Coccydenia - Pain on or around the tailbone
• Vestibulitis - Pain in the space between the labia minor into which opens the urethra and the vagina.
• Chronic Pelvic Pain
• Dyspareunia - Painful intercourse.

Visceral Dysfunction: The internal organs of the abdomen or pelvis stop moving or functioning properly. As this occurs, the surrounding muscles may become irritated and pain may occur. Surgical scarring may also play a role.

• Endometriosis
• Pelvic Inflammatory Desease
• Dysmenorrhea - Pain with menstration
• Irritable Bowel Syndrome
• Interstitial Cystitis - Chronic inflammation of the bladder

PFD can be diagnosed on physical examination by a physician and further assessed by a physical therapist that is specially trained in treating pelvic floor dysfunction (PFD). Using "hands-on" or manual techniques to evaluate the function of the pelvic floor muscles a physician or physical therapist can assess the strength, tone, and control of the pelvic floor as well as note compensatory patterns of movement (what the patient may be using instead of their pelvic floor). Typically an internal exam is done to assess tone, presence of trigger points or restriction, pain, and quality of a Kegal with the pelvis in neutral as well as in a relaxed position. The main considerations in determining what the underlying cause is so that a proper treatment plan can be established are in the proper assessment of the pelvic floor muscle tone, strength, and control. For example, the physical therapist may find the presence of trigger points along one side of the pelvic floor, but once they have been eliminated the therapist determines poor ability to relax after initiation of contraction. In this case it would be inappropriate to prescribe Kegals as an exercise as it might make the symptoms worse.

It is important to note that a comprehensive external examination of the lumbar, pelvis, abdominal, and hip regions are completed in order to determine associated weakness, muscle restriction, and faulty movement patterns that may be contributing to the dysfunction of the pelvic floor. Full resolution of systems may not result unless this is incorporated into the treatment plan.

At Body Awareness Physical Therapy, our licensed physical therapists have been trained to complete an internal examination of the pelvic floor as well as a comprehensive orthopedic examination so that the big picture can be assessed and a treatment plan can be developed to ensure that all contributing factors are addressed for the best possible outcome and return to function. We have found that most women's health programs fall short of identifying contributing faulty movement patterns at the hip and back, or making sure that the re-education of the system is in place. This must be included so that the symptoms do not return and the patient can be an active participant in the management of the condition. We have also found that programs that are orthopedic/exercise based do not incorporate the importance of the manual treatment of the pelvic floor or stress manual biofeedback to ensure proper sequencing of muscle recruitment is taking place. We have come up with a unique program that can be considered a marriage of both women's health and orthopedics. Our program looks at the body as a whole. We assess how each region of the body is affecting the other (it is all connected after all), with the goal being to restore optimal alignment, muscle balance, proper sequencing of muscle recruitment and most of all function.

Pelvic Floor dysfunction is treated best by obtaining a detailed medical history so that a possible line can be drawn as to progression of symptoms to the patient's current presentation at the time of evaluation. It is important that the patient disclose any emotional or physical trauma incurred including strains/sprains, surgical procedures, or instances of high anxiety, stress, or abuse. Once a complete history is obtained and an evaluation has been completed, we treat the whole person. Many different treatment techniques are available to help the physical therapist effectively deliver a plan of care. A combination of the following treatment techniques are used each visit. At each visit the physical therapist will determine what is appropriate for that particular session based on the subjective and objective findings. Patients are encouraged to remain consistent in attendance of their treatment session as each session builds upon the last to continue to peel the layers of the 'onion' away. One session of physical therapy generally lasts about one hour in length. Most women will need to commit to attending physical therapy 2 times per week for up to 12 weeks for optimal results and return to function.

Common Treatment Techniques may include but may not be limited to:

Commonly Asked Questions About Kegal's

What is a Kegal?

When is appropriate to perform a Kegal?

What if I cannot perform a Kegal?

Have a Question? Feel free to email us and we will respond to you within 24 hours