Constipation; Big Picture Therapy

Author: Susannah Haarmann, PT, WCS, CLT

You made an appointment with a pelvic therapist to address urinary urgency and now they're asking you questions about your bowel function? Invasive or awkward much? We get it, but we need to know. Let me explain; there are 3 outlets sharing a tight space within your pelvis. The bowel, bladder and reproductive pathways are intimately related and a malfunction of one might cause some compromise in another. Just think about how much satisfaction is tied to your ability to poop, pee and have sex! It's our job to hear your full story, pair that with your body story (our exam findings), and connect the dots to treat the problem! Here are a few scenarios explaining how constipation relief can help solve the problem for which you seek treatment:

Urinary Urge      

Nerves relay information. When your bladder gives you a SUDDEN pang that you need to pee and you don't know if you can hold it, there is likely a neurological reason. The sacral feedback loop maintains urinary continence and makes the bladder contract when you want to urinate. The switches for that feedback loop are located inside the pelvis just in front of the sacrum, and what structure nestles nicely into the curve of that sacrum? That's right, the rectum! If the rectum is full (maybe even distended because you haven't pooped in 3 days) it could be pressing on the sacral nerves. The signals then sent to the brain can be misinterpreted as 'I have to pee,' not 'I have to poop.' So, pooping might actually be one of the keys to calming down the bladder. Tricky pelvis!   

Painful Intercourse   

When the pelvic floor contracts it lifts up and closes the openings to the vagina and rectum. We want to drop down and lengthen the pelvic floor muscles in order to receive comfortable penetration. If you are having pain with intercourse it may be because your pelvic floor muscles are short and have difficulty relaxing to open. You also want to relax these muscles to pass stool. Additionally, holding more tension in your pelvic floor throughout the day than is needed can inhibit the defecation reflex. The defecation reflex works to move stool through the bowel. A tight pelvic floor shuts the door to the anus and says 'not now.' Eventually, the defecation reflex with quiet down making you have to work much harder to have a bowel movement in the future. And let's be real, who feels their best sexy when they are constipated anyway?                                                                                                  

Back pain during pregnancy

Progesterone levels rise to maintain a pregnancy, however, this hormone can also be constipating. Many women experience intermittent back and sacroiliac joint pain during pregnancy; a pelvic health physical therapist can help you relieve these symptoms and we might ask you about your bowel health! Why? Well, one reason is when people are having difficulty pooping, some bear down or strain to nudge the stool closer to the rectum. This will increase your intra-abdominal pressure which can also put pressure on the discs of your spine. A pelvic floor physical therapist can assess what your pelvic floor muscles are doing when you simulate pooping and look at your breathing patterns with functional activities. And the best part of if all? What we teach you during therapy might even help you have an easier and more empowering labor experience!

So, there you have it; a few common scenarios explaining why your pelvic floor therapist asks seemingly unrelated questions about your bowels. We're not really an awkward lot, we just have a mind for comprehensive care and want to help you LIVE YOUR BEST LIFE! :)



Family or work? The importance of value clarification

By Richard Harvey, PhD and Erik Peper, PhD

In a technologically modern world, many people have the option of spending 24 hours a day/ 7 days a week continuously interacting via telephone, text, work and personal emails or internet websites and various social media platforms such as Facebook, What’s App, Instagram, Twitter, LinkedIn and Snapchat. How many people do we know who work too many hours, watch too many episodes on digital screens, commute too many hours, or fill loneliness with online versions of retail therapy?  In the rush of work-a-day survival as well as being nudged and bombarded with social media notifications, or advertisements for material goods, we forget to nurture meaningful friendships and family relationships (Peper and Harvey, 2018). The following ‘values clarification’ practice may help us identify what is most important to us and help keep sight of those things that are most relevant in our lives (Hofmann, 2008Knott, Ribar, & Duson, 1989; Twohig & Crosby, 2009;. Peper, 2014).

Give yourself about 12 minutes of uninterrupted time to do this practice. Do this practice by yourself, in a group, or with family and friends.  Have a piece of paper ready. Be guided by the two video clips at the end of the blog. Begin with the Touch Relaxation and Regeneration Practice to relax and let go of thoughts and worries, then follow it with the Value Clarification Practice.

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New postpartum guidelines urge '4th trimester' treatment for mom after baby

By: Vikki OrtizContact Reporter Chicago Tribune

As mothers around the world marvel that Kate Middleton went home from the hospital mere hours after giving birth to her third child Monday, the largest group of women’s doctors in the U.S. is urging a major shift in the way physicians care for mothers of new babies.

Instead of waiting six weeks for a mother’s first postpartum checkup, the American College of Obstetricians and Gynecologists now recommends a “fourth trimester” of ongoing treatment for mothers of newborns. The care, which ideally would begin within three weeks of giving birth, would improve the health of both mother and baby by offering continual assessment of the woman’s physical, social and psychological well-being, according to the new recommendations released Monday.

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PTJ Special Issue Podcasts: Physical Therapy for Pain May Reduce Overall Costs, Opioid Use

PT in Motion

April 25, 2018

For some patients, physical therapy can both decrease overall health care utilization and save money down the road—especially if delivered sooner rather than later. These were the takeaways from 2 articles in a May 2018 special issue on nonpharmacological management of pain published by PTJ (Physical Therapy), APTA's scientific journal. PTJ Editor-in-Chief Alan Jette, PT, PhD, FAPTA, interviewed authors of each of the studies via podcast.

One study, coauthored by Xinliang “Albert” Liu, PhD, examined the effect of timing of physical therapy on downstream health care use and costs for patients with acute low back pain (LBP) in New York state. The patients were categorized by whether and how soon they received physical therapy after seeing a physician for LBP: at 3 days, 4–14 days, 15–28 days, 29–90 days, and no physical therapy. Patients who received physical therapy within 3 days (30%) incurred the lowest costs and utilization rates, while those who didn’t see a PT at all saw the greatest of both.

In the PTJ podcast, Liu observed that among those who did not receive physical therapy there was “greater variety in health care utilization and costs," pointing out that factors influencing costs include age, living in nonmetropolitan areas, type of insurance coverage, comorbidities, and whether they were prescribed opioids or other medications. He cautioned that “we don’t have the evidence” yet to say that all patients with LBP should be referred immediately to physical therapists, but he hopes that future research can “identify subgroups that would potentially benefit from physical therapy and lower their health care utilization and costs.”

separate study explored downstream health care utilization and costs for Veterans Affairs patients who received physical therapy, opioids, or both after hip surgery. After 2 years, patients who received only physical therapy had lower overall health care costs than those who only received opioids and had fewer return visits for surgical fixes or replacements. Among the 56% of patients who received both, those who received physical therapy first had lower costs, had fewer opioid prescriptions, and were less likely to use opioids long-term.

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Do feminine hygiene products actually lead to a higher risk of infection?

By Maria Cohut

Fact checked by Jasmin Collier

The ladies' personal care aisle in any drugstore is bound to offer a wide array of intimate hygiene products — from gentle washes to wet wipes for your on-the-go needs. We use these products on a regular basis, but are they likely to cause harm?

A recent study finds a worrying correlation between the use of feminine hygiene products and the risk of vaginal infections.

Market studies indicate that, this year alone, United States revenue from feminine hygiene products sales amounts to $2,729 million so far.

Some products — such as tampons and sanitary pads — are necessary for most women, who will need to continuously invest in them for a large portion of their lives.

Other feminine hygiene products, however — such as intimate washes — aren't necessarily something we couldn't do without.

Still, many of us buy them in the hope that — unlike regular soaps, which are sometimes abrasive or irritating — they will promote intimate cleanliness without harming the health of this sensitive area.

However, a new study conducted by researchers from the University of Guelph in Ontario, Canada, seems to tell another story.

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Pelvic Physical Therapy: The Reality Behind the Curtain


By Carrie Pagliano, PT, DPT, OCS, WCS

There can be a sense of mystery behind pelvic physical therapy, not only from the point of view of the patient, but from professional colleagues in the medical community.  Perhaps this has to do with the fact that pelvic Physical Therapists (PT) are often tucked away in physical therapy clinics behind a closed door. But let’s be honest; most of the mystery comes down to the internal (vaginal or rectal) muscle examination as a potential component of examination and treatment. That said, simplifying pelvic physical therapy down to an internal assessment or a vagina therapist is akin to saying the late Stephen Hawkings studied donut holes.  There is so much more to pelvic PT and the conditions we treat.

The beauty of practicing in pelvic physical therapy lies in the culmination of so many areas of expertise.  It requires an integrative understanding of the human body, finding the right clinical hypothesis and treatment direction in an area of practice where research is still evolving.  Pelvic physical therapy has the unique privilege of being truly wholistic.  Our patients have issues ranging from pelvic organ prolapse, chronic pelvic pain, pain from oncologic or dermatologic issues, urinary and fecal incontinence, issues related to pregnancy or surgery, pain or difficulty with orgasm or intercourse, and the list goes on.  Our patients are female, male, intersex, and transgender.  Our patients are adults and children.  Our patients are referred to physical therapy from ObGyn, Urology, Colorectal, Neurology, Orthopaedics, Pediatrics, Psychology and Dermatology.  Our patient’s problems range from simple to complex.  Our examination includes the entire person, from a comprehensive subjective examination, where the patient can share their story, to a thorough objective assessment which includes the spine, pelvis, hips, etc.  The smallest part of the exam focuses on the internal assessment; either vaginal, rectal, both, or not at all.  For many patients, this portion of the examination is the first time which a medical provider identifies their pain or problem after seeking advice from multiple practitioners.  Pelvic PT’s are often the first provider who has listened to their story for more than a few moments and acknowledged that as a patient, they are not broken, and there is hope.

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Physical Therapy Keeps Hips Healthy for Post-Retirement Activities

Pain, soreness and weakness in the hips can interfere with desired activity levels, particularly for men and women 65 years old and older. For active Americans trying to enjoy their retirement years, poor hip health simply isn’t part of the plan—but that doesn’t mean they’re destined to miss out on life’s many pursuits. The good news is that physical therapy can help seniors remain physically active by addressing small issues before they grow. Many are surprised to learn that when it comes to hip pain, the answer is closer than they think. According to Harvard Medical School, strengthening the surrounding muscles—including the quadriceps, glutes and hamstrings—can take some of the stress off of the hips. Learning to take care of our hips as we age means recognizing when a new pain or limitation arises, and making

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Ladies: Dos and Don’ts for Vaginal and Pelvic Health

Women are taking their pelvic health seriously today, and that’s a great thing. Especially considering that most will experience at least one issue with their lady parts at some point. It could be bladder leakage, recurrent yeast infections, uterine fibroids, heavy periods, or something else.

But, while some pelvic health trends are making the taboo topic of your vagina mainstream, others are at best useless and at worst harmful. Read on to see our dos and don’ts for vaginal and pelvic health.

Click below for full article

5 Ways to Manage Your Child's Constipation and Bedwetting Treatment on Vacation

By Steve Hodges, MD

For children prone to constipation, travel almost inevitably leads to clogged pipes. And if your child is on the Modified O’Regan Protocol (M.O.P.) for bedwetting and accidents — well, a spring break visit to Grandma’s or a summer camping trip poses a whole range of challenges and concerns.

As one mom in our private Facebook support group posted: “If we skip enemas for a week but continue laxatives, will that set us back to square one?”

Another mom, whose daughter is on M.O.P.+ (large-volume enemas) for bedwetting, wrote: “The thought of trying to do this discreetly is freaking me out. I think my extremely old-fashioned mother-in-law would claim child abuse if she heard we were giving our daughter enemas.”

A dad whose 7-year-old is on M.O.P.+ for encopresis asked: “Is there a simpler method we could substitute for a few nights? She’s had 5 or 6 accident-free days and we don’t want her set back while we’re away from home base.”

There’s no easy answer to these questions. Some families, despite tremendous vigilance on the road, do experience big setbacks.

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Can a healthy diet fix constipation?

Steve Hodges, M.D.

Associate Professor of Pediatric Urology, Wake Forest University School of Medicine

The other day a patient’s mom asked me, “Why is my daughter so constipated? She’s been on a ‘real food’ diet since birth. She’s gluten free and does karate or ballet every day.”
Most folks assume that when a child’s pipes are clogged, the culprit is highly processed, low-fiber diet.

But that’s not always true, and trying to fix constipation with “clean” diets may only frustrate families without actually solving the problem.

Always treat constipation aggressively!

Most folks assume that when a child’s insides are clogged, the culprit is highly processed, low-fiber diet.

But that’s not always true, and trying to fix constipation with “clean” diets, prune juice, or fiber supplements may only frustrate families without actually solving the problem.

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How Physical Therapy Helps Retirees Keep Dreams Alive During the Golden Years

Private Practice Section, APTA

Are you among the millions of Americans who have high aspirations for how you’ll spend the extra time during your post-retirement years? Whether you plan to travel the world, pick up fly fishing, spend more time woodworking or sign up for a golf league, your physical fitness level will be a factor.

A 2010 study suggests that the fitness declines we typically attribute to advancing age are largely caused by living sedentary lifestyles—which are on the rise due to the prominence of desk jobs in the workplace and activity-limiting personal technologies including smart phones and voice-activated remote controls in the home. Still, this runs contrary to the widely held belief that any declines in our physical abilities are caused solely by biological aging. Do we really have control over how active we’ll be in our “golden years”?

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Want to Fix Your Child’s Bedwetting? Avoid These 5 Mistakes

By Steve Hodges, M.D.

Shoulda, woulda, coulda. If I had known 10 years ago what I know today about treating bedwetting and accidents, I could have saved countless families from anxiety, frustration, and embarrassment, not to mention tons of laundry.

But you can’t dwell on your mistakes. You can only learn from them, adjust accordingly, and pass on your knowledge.

That’s what I remind parents who beat themselves up over their children’s bedwetting struggles. Plenty of parents have told me: “I can’t believe all the useless treatments I wasted time on. My daughter could have been dry a long time ago.”

As one mom of a bedwetting teen emailed me, “I am beside myself with guilt, as this has been going on for years. I knew something was wrong, but didn’t do anything."

To parents like these I point out: At least now you know what to do! That alone puts these families way ahead of most, given how poorly the medical community serves kids with enuresis (wetting) and encopresis (poop accidents).

In this post I will share a list of mistakes commonly made in the treatment of bedwetting and accidents. Some are mistakes I, myself, have made; other items on the list come from parents of my patients or parents in our private Facebook support group.

I take the term “medical practice” seriously. The way I approach accidents today is radically different from — and more effective than — the approach I advocated 10 years ago. It’s even different, in more subtle ways, from how I treated the condition a year or two ago.

You can’t resolve a child’s bedwetting and accidents overnight, but by avoiding these mistakes, you can save your family months, even years, of distress.

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Fascia—What You Should Know

by Cinthia P. Cable, L.M.T.

What is fascia?

Fascia is a body-wide, protective, supportive, flexible, soft tissue network. It has been found to be the most abundant tissue in the body. It looks much like a three-dimensional spider web that surrounds and separates muscles, nerves, arteries, veins, and organs. It attaches one body element to another and stabilizes and supports structural components with its connective ability.

Fascia exists just below the surface of the skin but also penetrates deep within the body, surrounding the organs and filling the space between the organs and other components. Scientists have identified three types of fascia. The first is superficial fascia, which lies just below the skin and gives the body its shape. The second is visceral fascia, which surrounds and suspends the organs. The third is deep fascia, which surrounds muscles, bones, nerves, and blood vessels.

The web-like fascia fibrils are composed mostly of collagen, which makes them strong, and elastin, which makes them flexible. But there is another component within the fascia—slippery proteins—which makes the collagen fibers moist and slippery. This moisture gives the fibrils a dewy sheen and facilitates movements between the various bodily components.

Fascia is one continuous network that extends from the top of your head to the soles of your feet. The word for this quality is continuity. Fascia has the quality of plasticity as well, which means it has the ability to soften, lengthen, and separate—to become more pliable. And finally, fascia has the quality of sensitivity due to the many nerve endings and mechanoreceptors contained within it. This sensitivity gives us the ability to be physically aware enough to control and coordinate our movements. Perceived sensations within the body are felt via the fascia, starting just under the skin.


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Comparing Treatment Options for Bladder Leaks: Pads vs. PeriCoach

You’re already running late for work when, halfway into your commute, you realize you didn’t restock your purse with bladder pads. “Great—and no time to stop by the pharmacy,” you think. You resign yourself to creating makeshift “pads” out of toilet paper or awkwardly asking any sympathetic female coworker you can find to spare a couple of pads to get you through the day.

This is an all-too-common scenario for women living with bladder leakage, known as urinary incontinence (UI). In a previous post, we compared how prescription drugs stack up against the PeriCoach Kegel exerciser for addressing the symptoms of bladder leakage. In this post, we’ll compare bladder pads with PeriCoach. Before we do, let’s revisit just how common bladder leakage is among women.

Bladder Leakage: A Problem for Millions of Women

The numbers are striking: Nearly one in three women will experience some form of UI in her life. Stress incontinence—leaking a few drops or a stream of urine when you laugh, cough, sneeze, or physically exert yourself—is the most common type.

UI does not discriminate by region, race, age, or fitness level—women in every corner of the world experience bladder leakage. While it’s more common in menopausal women and those who have been pregnant and given birth, it can also affect younger women who haven’t had children.

Many women turn to pads to deal with their bladder leakage. Yet, at best, this is a temporary solution. Pads don’t address the root of the problem, which, in many cases, is weakened pelvic floor muscles—more on that later.

First, let’s look at the cost of bladder pads and their impact on women’s daily lives.

Pediatric Incontinence and Pelvic Floor Dysfunction

“What's wrong with children?”

By Dawn Sandalcidi, PT, RCMT, BCB-PMD

As pelvic health physiotherapists it would be safe to say most of you are treating adults with bladder and bowel dysfunction and pelvic pain. I was in the same place when I was approached over 30 years ago from an urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” I will never forget the whirlwind of learning since that day.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, by 5 years of age, over 90% of children have daytime bladder control (NIDDK, 2013) What is life like for the other 10% who experience urinary leakage during the day?

Bed-wetting is another pediatric issue with significant negative quality of life impact for children and their caregivers, with as much as 30% of 4 year-olds experiencing urinary leakage at night (Neveus, 2010). Children who experience anxiety-causing events may have a higher risk of developing urinary incontinence, and in turn, having incontinence causes significant stress and anxiety for children (Austin, 2014; Neveus, 2010).

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Nope, Deep Sleep Doesn't Cause Bedwetting

Steve Hodges, MD

 At my pediatric urology clinic, just about every parent of a bedwetting child is convinced that “deep sleep” explains the wet sheets.

Parents tell me, “She’s such a deep sleeper that you could blast Motorhead in her room and she wouldn’t budge.”

Or, “When he’s out, he’s out — there’s no chance of waking him up.”

In many cases, the child’s pediatrician has confirmed this theory or suggested it in the first place. And when families search online, they find additional support for the idea that deep sleep causes bedwetting.

For example, under the heading “Causes of Bedwetting,” the American Academy of Pediatrics (AAP) states: “Your child is a deep sleeper and does not awaken to the signal of a full bladder.” This statement tops a list of 8 bedwetting “causes.” And in an article titled "Nocturnal Enuresis in Teens," the AAP lists among the “contributing” factors to teenage bedwetting: “a deep sleep pattern that can be part of normal adolescent development, inconsistent sleep schedule and limited hours sleeping.”

On its website, the Enuresis Treatment Center calls bedwetting “a treatable sleep disorder” and claims that “targeting treatment to changing the sleep pattern will not only end the bedwetting, it will allow the bedwetter to experience better night’s sleep.”

There are two problems with the deep-sleep theory: 1.) it makes no sense, and 2.) no evidence supports it.


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Exercising During Your Second and Third Trimester

Dr. Kristin Anderson ,PT, DPT, OCS, CLT

As your baby continues to grow, you are going to be experiencing more wonderful changes in your body. Your abdomen is growing, meaning that the abdominal muscles are no longer in a prime position to work or help support you. Hormones are creating increased laxity of your joints to prepare to make room for the growing baby in your pelvis. Your diaphragm (breathing muscle) is rising, meaning there is less room for you to expand your lungs. You may notice that it is easier to get out of breath, even just walking up the stairs! To top it off, your heart is having to work harder because it is working to circulate 50% more blood volume then it normally does!

Our bodies are amazing and we need to appreciate the changes that our bodies are going through. Here are some guidelines for exercise in your second and third trimester. Please refer back to our article on exercise in the first trimester in our blogs!

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Comfortable Sex Positions for Women with Pelvic Floor Disorders

Life can take its toll on your lady parts. Pregnancy, childbirth, menopause, and even chronic constipation and obesity can weaken your pelvic floor muscles. These important muscles act as a hammock, stretching across your pelvis and holding your organs (bladder, bowel, uterus, vagina) firmly in place.

When the pelvic floor muscles are weakened or the connective tissues of the pelvic area are damaged—whether from a rambunctious baby doing somersaults in your belly, or hormonal changes during menopause—you can develop a pelvic floor disorder (PFD).

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Has Your Constipated Child Achieved the "Spontaneous Poop"?

Steve Hodges, MD

Has your child achieved the vaunted “spontaneous poop”?

That’s a hot topic in our private Facebook support group! “Spontaneous poop” is a term I mention in The M.O.P. Book but don’t explain in detail. It’s worth further discussion.

By “spontaneous poop” I mean a bowel movement that is not preceded by an enema — one that the child feels coming on and “just happens.”

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Sleep Health

By Dawn Sandalcidi, PT, RCMT, BCB-PMD

One third of the US population suffers from sleep disorders. Sleep disruptions occur across a person’s lifespan, for example:  erratic sleep patterns during teen years, new babies, work or kid stresses, hormones and pain are all big culprits when it comes to having difficulty falling asleep, staying asleep or getting sufficient sleep. 

Getting good sleep is necessary for optimal health and poor sleep impairs function. 

Quality sleep is imperative for the function of your body systems including:  immune system function, healing, pain management, cognitive function, learning, memory and cardiovascular function.

Sleep is a basic human need. Without adequate sleep, people can experience:

·         Increased pain perception 

·         Loss of function

·         Decreased quality of life

·         Increased depression and/or anxiety

·         Attention deficits

·         Disruption in ability to process information

·         Memory impairment

·         Decreased ability to learn new motor skills or exercise putting people at risk for balance issues and falls 

·         Decreased functioning in work related and recreational activities, as well as self-care


The cost of insomnia is over $100 billion per year! 

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