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Pelvic Floor Q & A

What is pelvic floor physical therapy?

Pelvic Floor Physical Therapy is specialized physical therapy aimed to treat pelvic dysfunction and promote optimal pelvic health for both women and men. Pelvic floor dysfunction refers to a wide range of diagnoses pertaining to the pelvic muscles and the pelvis, including urinary/bowel incontinence, pelvic pain, pelvic organ prolapse, and postpartum pelvic girdle dysfunction to name a few. At least 1 out of every 5 Americans will suffer from a pelvic floor dysfunction at some time during their life.

Why would I need pelvic floor physical therapy?

There are a multitude of reasons one may need pelvic floor physical therapy. Pelvic dysfunction occurs when pelvic muscles become weak, tight, or when there is an imbalance within the surrounding joints including, lower back, hips, and coccyx. The pelvic floor is an integral part of your core stabilization system, which works intimately with your organs, bones and joints in the region. It is always working throughout the day and is often overlooked as the cause of many issues related to pelvic pain, urinary and bowel incontinence and lower back pain.

Specialized pelvic floor physical therapists help men and women across the lifespan continuum, including young athletes, childbearing aged women, peri-menopausal women and men with pelvic health complications.

What is the pelvic floor?

The pelvic floor is a group of muscles that attach to the pelvis. Their function is to support your organs, allow for elimination, stabilize your pelvis and hips, and promote sexual function. Remember pelvic floor muscles are just like any other muscles in the body. They contract, relax and function like a bicep muscle would. Because our daily pelvic functions, include urination, elimination and sexual function; it is important to remember your pelvic floor can be influenced by your organs, abdominal muscles and skeletal system and vice versa. For example, urinary incontinence is not “just a weak bladder” as thought by popular belief. But incontinence occurs because of pelvic muscle weakness, altered coordination of bladder, brain and pelvic muscles, as well as poor toileting habits.

Do men have pelvic floors too?

Of course! Even though men do not carry children or go through menopause, men have a pelvic floor which functions similarly to a woman’s pelvic floor. Men with pelvic floor dysfunctions will report a slower urine stream, difficulty or pain with erection, tailbone/lower back pain, constipation, or bowel or bladder incontinence. It is not uncommon for a man to have an increase in these symptoms after having any kind of prostate surgery or hernia repairs.

What can I expect during Pelvic Floor PT Evaluation?

Your first evaluation includes a one-on-one visit discussing your concerns and symptoms related to your pelvis and daily activities. You will have the opportunity to share your past medical history, including pregnancies, abdominal or back surgeries, and gynecological/urinary history. Your exam may include general movement like bending forward and backward, observing your body mechanics and strength testing. A comprehensive review of the pelvic floor musculature, pelvic organ function and normal bladder/bowel habits will also be discussed.

During the follow up visit, an external and internal assessment of your pelvic muscles (through the vaginal or rectal canal) may be valuable, however you have the option to choose or refuse any part of the process with which you don't feel comfortable.

An external pelvic floor assessment includes a visual assessment of the skin, symmetry and color of tissues, and observation of muscles performing a contraction.

An internal pelvic floor muscle assessment includes checking all layers of pelvic floor for strength, mobility, pain, symmetry and control. Therapist will also palpate muscles in all three layers of the pelvic floor to assess the coordination for functional activities like coughing, lifting and relaxation.

What is biofeedback? Does it hurt?

Some physical therapists synthesize more information by performing a biofeedback assessment. Biofeedback assessments are performed by inserting a sensor either vaginally/rectally or by placing electrodes near perineum. The sensor is then connected to a computer program which will guide you through a series of tests. The sensors are used to measure the electrical activity of the pelvic floor muscles at rest and when contracted. From the biofeedback information, the therapist can see if the patient has good muscle activity or an uncoordinated muscle pattern. The therapist can also determine if the patient needs to work on slow or fast twitch muscle contractions or both. This assessment should not be painful or uncomfortable, but is helpful to developing an overall picture of your pelvic floor health.

What happens at additional treatments?

The therapist designs individualized programs depending on the findings from the evaluation. The PT may prescribe breathing and core stability exercises to improve the coordination of all muscles in the pelvis, back and core. They may also recommend relaxation and behavior modifications to improve pain or learn control for your daily toileting habits. Initially, you may require assisted neuromuscular training such as manual feedback via the internal pelvic muscles to improve muscle tone, activation and coordination.

You will be given daily homework to assist your healing and pelvic control.

Do I need a prescription?

Yes! Just like traditional physical therapy you will need a prescription for the treatments to be covered under your insurance. However, the prescription must say “Pelvic Floor PT.” Your primary care provider, gynecologist or urogynecologist may write this type of prescription. Many pelvic conditions have multiple causes and may require a specialist to rule out more serious conditions. Therefore, it is necessary to have your medical provider to help coordinate care.

My gynecologist told me to do “Kegels”. I do them every day, but I am not sure if they help to improve my leakage? What is going on?

Kegels or a pelvic floor contraction are important to strengthen and maintain good function of the pelvic floor including improving incontinence. However, research shows 40% of women perform Kegels incorrectly and can promote more leakage! Many women who have leakage with coughing, laughing, sneezing have an altered pattern of contracting their pelvic floor muscles. Pelvic floor PT can teach you to re-train your pelvic muscles to properly coordinate a contraction to eliminate or minimize most types of urinary incontinence.

How does the Pelvic Floor work with the core?

Remember, your pelvic floor is one aspect of the core. Our core is made up of the diaphragm (breathing muscle), transverse abdominals, multifidus (small spine muscles) and pelvic floor. These four muscles make up the core! They must work together and manage your everyday movements and daily eliminations. They cannot, and should not be addressed independently from each other. The diaphragm and pelvic floor synchronize to monitor the pressure in your abdomen. Think of the pressure that occurs in your belly when you sneeze. Oh gosh! This is scary for some…just thinking of it makes you think, “Squeeze the knees.” If the diaphragm and pelvic floor do not coordinate well, leakage and other pelvic related dysfunction can occur.


Dr. Amanda Heritage, DPT

Help! I’m in pain! But I didn’t do anything?!

Because of the nature of our profession, we regularly see people in pain searching for answers as to why. Sometimes the reasons why are obvious and due to physical trauma. A slip on the ice, too much weight on a barbell or a car accident can be some classic examples of traumatic events that lead to pain and dysfunction. Far more often, people in pain have no such instances to point to, or they can only point to something benign; like bending over and placing a golf ball on a tee or putting laundry in the dryer. Essentially these instances are just the straw that broke the camel’s back.

The reality is that pain is multidimensional, complicated, and can have many contributing factors that don’t include just actual physical damage to tissues. It can be very difficult to discern the origin of the problem, since the site of pain can have very little to do with the actual source of the problem. The brain actually plays a very critical role in the pain process. That is because pain is essentially a conclusion made by the brain from a summary of information that it receives from the body. This conclusion is basically an alarm alerting us to take action and make some changes.

Compensation and avoidance are survival strategies that the brain and body seamlessly utilize to avoid pain or weakness. You twist an ankle, the body adapts and limps to avoid the pain. Your ankle feels better, the body seemingly adapts and the pain goes away. But that protective mechanism and compensation can often persist long after the pain is gone. Our bodies also compensate due to postural stresses, old injuries, or in order to combat our daily repetitive actions from work or play. These strategies are helpful and necessary in the short term to help produce pain free movement. However, when perpetuated for too long, or specifically stressed in a time of weakness, these strategies can overload an adjacent structure and cause pain; essentially sounding the alarm. When the alarm sounds… do something about it!! Often, the more you feel the same type of pain, the more sensitive your body becomes to it, and the more likely you are to feel it getting worse. So the earlier you do something about it, the better.

So what can we do? The good news is that there are many things we can do to put ourselves in better position to avoid pain and be comfortably active! Much of what we can do is intuitive, but many of us could use some guidance. Our bodies are extremely resilient and capable of amazing things when we take proper care of them. Good food, proper hydration, and adequate rest are some important aspects of the process. Learning proper breathing, stabilization, and movement strategies can also go a long way towards addressing or avoiding pain.

Having a good chiropractor or therapist is a very important piece of the puzzle. Because of the complicated nature of pain, we can help to identify the source of the problem and mitigate the severity and incidence of your pain. At Nelson Chiropractic and Pilates Center, due to the nature of our experience, expertise, and processes, we are very good at narrowing down the possible pain generators and treat accordingly. We follow up that treatment with specific exercises that act as both reinforcement to treatment and can serve to improve your confidence in using a painful area of the body. We also act as an important sounding board to help narrow down what might be harming you, how serious (or not serious) it is and give you strategies in what to avoid or improve. Once out of pain, we don’t need to see you often, but a regular check in is a great idea to keep all cylinders firing and can be part of a plan to avoid pain in the future.

Interested in hearing more? Ask one of us at Nelson Chiropractic and Pilates Center! 


By: Dr. David Velez

An Out of the Box Case Study

Recently, I had the opportunity to work with a patient who had traumatically injured her elbow. As many of you know, my rehabilitation style is non-traditional. I use Pilates-based rehabilitation to perform functional movements which focus on coordination of breathing and core stability to achieve appropriate body mechanics. So, you might be asking yourself “How in the world can that style of physical therapy be effective in helping an elbow injury?

Let me give you a little background about the patient. She is a newly married, nurse who enjoys strength training and running. She sustained a substantial strained ligament and nerve injury to her dominant arm when she fell running. Initially, she was unable to perform simple movements like grasping a fork or sleeping without pain and numbness into her hand. She was given a brace by her doctor and prescribed physical therapy.

At the start of physical therapy treatment, the patient was very guarded due to severe pain, so I was not able approach her care as I would for most sprains and strains. I needed to think outside the box. After brainstorming with Dr. Kelli Velez, I decided to focus on other body parts and the brain!
With any injury, the brain will automatically protect and inhibit movement to an injured area thus changing the awareness of the skin, muscles and joints in the region. No matter how small the movement we were attempting to do, the brain would not allow the arm to move pain free.

For the brain to be on board with treatment, we needed to tell the brain something new! We used mirror therapy and started to write numbers on the patient's skin around the injured area. We used the mirror to reflect the uninjured elbow, which would trick the brain to think it was looking at the injured elbow without pain.

To our brains, visual awareness and tactile touch are different sensations than an injury pain. You may have experienced this when the chiropractors at our office, assess your sensory system by using hot, cold, tapping, eye movements, or a toothpick on your area of pain. These sensations are perceived differently to our brain and affect the movement of the area, thus the entire body’s movement. Using this idea, the patient's pain started to decrease and she was able move her elbow and wrist with far less difficulty; thanks to the brain!

If you have ever been injured or sat on the couch binge watching your favorite show for more than three days, muscles start to atrophy. This also happened to the patient’s entire arm. Using my knowledge of stability and strengthening, it was time to use the Pilates equipment and different functional positions to wake up and activate the entire muscular system.

Your arm itself does not move alone. Your deep core system anticipates movement and stabilizes to create a fixed point for the limbs to move from. Many positions on the Pilates equipment are gravity free. This allows the body to gently strengthen while challenging core stability and awareness, as the equipment and your body move in multiple directions.
As weeks went on, the patient’s entire body began to stabilize and strengthen to support the healing elbow. When she could progress to bearing weight through the arm, crawling around like a baby, was the most effective exercise to strengthen the arm and stabilize the elbow functionally. The act of crawling on hands and knees is a precursor to upright activities.

By involving developmental positions, like crawling, the brain participates to normalize upright movement patterns. This is necessary to return to efficient movement without pain or compensation from other body parts. With enthusiasm, determination and out of the box rehabilitation techniques, the patient could get back to work, with the support of an elbow brace, but with the best core stability, postural strength and improved arm function to do the difficult job of a nurse.

Physical therapists do not need to be cornered into treating only one body part, but should always consider the goals of the person, not the injured region alone. Healthcare practitioners need to remain forward thinking; at times break the rules and think outside the box!

Dr. Amanda Heritage, DPT

Burn Your MRI Report

Just kidding…but not really. If I had a nickel for every time I’ve had to talk a patient off the ledge after seeing his or her imaging report, I’d be a rich woman. The story often goes a little like this. Bob, a 54 year old HVAC repairman, comes in to see me because he hurt his shoulder or foot or whatever and the first thing I notice is that Bob clearly also has pain in his back. When I ask him about it, he says that it has been hurt for a while. Once or twice a year, his back “goes out” and he’s laid up for a few days but there’s nothing he can do about it because he has some bad discs. You see, Bob went to his family doc a couple years ago to get his back checked out. The family doc sent him for an MRI and the MRI showed, you guessed it, degenerative disc disease at L4-L5, disc bulges at multiple levels, perhaps a herniation or two, and maybe some foraminal or central canal stenosis. Although Bob is pretty depressed about the state of his spine, he finds some comfort in the fact that at least he knows why his back has been giving him trouble for years. And here’s where my job gets tricky, I have to tell Bob that there’s a pretty good chance that he’s wrong.

You see, Bob has become a Victim Of Medical Imaging Technology (thanks APTEI for the witty, yet disgusting, acronym that I have chosen to omit). While MRIs can be invaluable tools when you need to rule out red flags or when frank nerve root compression signs are present, for the most part, they tend to do more harm than good. Why, you may ask? Two reasons:

Reason #1 - What’s on your MRI report often has NOTHING to do with your pain

According to a recent study by Brinjikji et al, “signs of degeneration are present in very high percentages of healthy people with no problem at all. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”1 The chart below indicates the prevalence of MRI findings in people with NO BACK PAIN.1 It shows that if we MRI’ed 10 pain-free 54 year olds, 8 of them would have disc degeneration findings and 6 would have disc bulges just like Bob but he has 7/10 pain and the others have none. How is that possible? Likely because Bob’s MRI findings aren’t what is causing his pain. Don’t get me wrong, there are certainly times where a degenerative disc issue could be the culprit but in the vast majority of cases, disc degeneration is just a normal part of aging, like wrinkles on the spine.2

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Reason #2 - People who know what’s on their MRI report tend to feel WORSE

Seriously, MRIs for low back pain can sometimes do more harm than good! Several studies have shown that patient knowledge of imaging findings leads to more doctor’s visits, longer lasting pain, more disability, and a lesser sense of well-being.3,4 This is likely because many patients interpret their imaging findings to mean that the back needs to be protected, resulting in unnecessary fear avoidance of movement and activity.5 This type of avoidance can actually make the back pain worse. This certainly lends credence to the idea that ignorance is bliss, at least when it comes to your spine.

So what’s the bottom line? You are NOT your MRI findings. Get evaluated by a competent practitioner (like one of the fabulous docs at Nelson Chiropractic and Pilates) who can help you figure out what’s really causing your pain. And when you’re ready to burn that MRI report, give me a call…I’ll provide the matches.

  1. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
  2. Brinjikji W, Diehn FE, Jarvik JG, et al. MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: A systematic review and meta-analysis. AJNR Am J Neuroradiol. 2015 Sep.
  3. Ash LM, Modic MT, Obuchowski NA, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008 Jun;29(6): 1098-103.
  4. Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005 Nov;237(2):597-604.
  5. Darlow B, Dowell A, Baxter GD, et al. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med 2013;527-34.


Dr. Kelli Velez

Building a Strong Foundation

                Recently, as my wife and I were looking for a new home, we found what seemed to be the perfect house in the perfect neighborhood. As we prepared our offer, we asked a contractor to come over to assess how much it would cost to renovate the kitchen. Interestingly, when he got there, the first thing he did was walk around the perimeter of the house. Then he walked through the basement. Before he even looked at the kitchen, he gave us his assessment: find another house. The verdict? The house had a poor foundation, and fixing the kitchen would do nothing to change that.

                While I was disappointed, I completely understood. His assessment mirrored what I do every day in the office. At the beginning and end of every visit, we guide our patients through a movement assessment called the Selective Functional Movement Assessment (SFMA). We do this to determine our patient’s capacity of the most basic and foundational movements. Can they flex, extend and rotate their head, neck and torso with full range of motion and without pain? Can they stand on one leg without falling over? Are they able to squat? These basic movements lay the foundation for the more complex movement patterns that occur in life and in sport. When the simple movements are dysfunctional, everything built on that foundation will be suspect, and only a matter of time before repetition and load lead to injury. Similar to my prospective home, only time stands in between a problematic foundation and a major problem that needs fixing.

                Thankfully, the basic movements of the human body can be much easier to evaluate and fix than the foundation of a house. To differentiate between the two, let’s talk about why these building block movements might be suboptimal. Every joint, muscle, ligament and tendon in the body has a set of responsibilities, all of which are modulated by the brain. When something isn’t quite working properly, the brain seamlessly creates compensatory survival strategies to help us make up for the deficit. The issue occurs when we perpetuate that survival strategy over time, and adopt that strategy as our new normal. When these patterns become problematic, they essentially require a reprogramming or reboot back to normal. That is where we come in.

For example, the glute max is a strong, powerful muscle. It has a main responsibility to extend the leg- a very important component of every step we take. When the glute max is weak, the brain calls upon helpers to help facilitate that movement. Oftentimes one of those helpers is the quadtratus lumborum, or QL. The QL is a stabilizing muscle in the low back, which can also assist in leg extension. The QL can help the glute max out in the short term, but since the QL is a stabilizer and not a powerful mover, it tires quickly. This compensation strategy often results in a weak, tight and tender low back and QL. This compensation can be a common causes of idiopathic low back pain, and can be very easily uncovered and treated with a movement assessment and subsequent treatment.

This example is just one of countless survival strategies that we see every day in our office. When these strategies have been perpetuated for too long, you are left with painful, weak and tight muscles that alter the function of joints, ligaments and tendons. This altered functionality can most definitely be caught by a movement assessment after an injury has occurred. However, the best part is that this it can be caught by a movement assessment BEFORE it ever turns into a debilitating injury. Screening movement on a regular basis can help to reduce the risk of a previous injury recurring, or an injury ever happening in the first place. Once the building block movements are acceptable, other factors like strength, endurance and coordination become significantly more important. Similarly, a new kitchen in my prospective house would only be acceptable if we had first fixed the issues that presented in the foundation of the house.

As Gray Cook states, “Our bodies are miracles capable of unbelievable durability and resiliency, with an amazing performance and physical capacity.” When our foundational movements are without limitation and pain free, we can fully grasp how truly amazing our bodies can be.


David Velez, DC

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