Bladder Frequency and Urgency

Do you find yourself running to the bathroom more often than you think you should? Have you always been the person with the “small bladder” that goes to the bathroom three times at a restaurant when your friends don’t go at all? When you have to go pee, is it an urgent urge that makes you uncomfortable to wait?  Do you sometimes not make it to the bathroom on time?

If you experience some or all of these signs, you are not alone and can absolutely improve this. The best news is that the solution is pretty simple!

How is your bladder supposed to work?

Let’s pretend your bladder is your child, your brain is you (the parent) and your child wanting a snack is like your bladder wanting to pee.

We all know that some kids are very chill & relaxed while others can be quite high maintenance (but we still love them!). If your child (aka bladder) is calm and wants a snack (needs to go pee) they will ask “can I please have a snack?” and you (the brain) are able to respond appropriately.

Maybe the answer is “sure, it’s been a while since you have had a snack, absolutely you can have a snack.” Or maybe your answer is “you know what, we just ate lunch and I don’t think you need a snack right now.” If your child/bladder is calm they can usually accept the answer and go on their merry way for a while.

Eventually they’ll feel hungry (need to pee) again, and they will come back to you to ask for a snack again. And once again you can decide if it’s a good time for a snack. If you wait for longer periods the child might get more persistent or ask you more frequently but you are still very much in control of the situation. At the right time, the child gets their snack and everyone is happy.  

This goes very much to the heart of how things are supposed to work: your bladder sends signals to your brain as it’s filling up and it’s up to your brain to decide when is the right time to go pee.

What causes urinary frequency and urgency?

There are many reasons for urinary frequency and urgency. In my experience, the top two factors that we can influence and improve are:

1. Undesirable learned habits

2. Dietary factors

Undesirable Learned Habits

Let’s go back to that example and replace that lovely, polite child with a cranky one. Do cranky children ask for anything nicely or politely? I don’t know about you, but when my children are cranky they are definitely not polite. When cranky children think they need a snack they go “I WANT A SNACK RIGHT NOOOOOOOOOOOW” (even if you happen to be in the middle of the grocery store).

You are then in the precarious position of having to choose between:

1. giving into the tantrum and giving them a snack even though they don’t need a snack, or;

2. telling them “no, you cannot have a snack”.

If you give in, your child learns that tantrum equals guaranteed snack time, leading to more tantrums. If you hold your ground, you get to deal with the potential wrath of said cranky child (for most people, the wrath of a bladder can be in the form of a urine leak, fear of leaking, abdominal discomfort, etc).

This is where the habit starts to form. In general, if you give a kid a snack every single time they ask for a snack they are going to start asking for snacks more often (because snacks are delicious and they are clever little humans). The same applies to your bladder - if you go pee right at the moment you think you have to go and rush immediately to the bathroom, you are reinforcing a bad habit.

Your bladder has a bigger capacity than you think. You can go for hours upon hours at night without going pee. Why do you think you need to go pee before you leave the house when you literally just went pee 15 minutes ago? Did your kidneys magically turned superhuman and filled your bladder up to full capacity in 15 minutes? Probably not! You probably just have a habit of going pee before you leave the house. You might also have a habit of going pee as soon as you get home and maybe that has escalated into you needing to drop your groceries and sprint up the stairs to go pee as soon as you get home even though you didn’t need to pee while at the store.

They’re all learned habits. It’s important before you go pee to ask yourself:

Do I HAVE to go pee or do I just WANT to go pee?

The same way you would ask yourself “do I want a snack or do I need a snack?”. You should be in control of your bladder rather than your bladder controlling you.

I really think of the urge to pee kind of like a hunger cue. Most people do not drop everything they are doing and rush to the kitchen and stuff their faces with food at the first sign of hunger. So why are we sprinting to our bathrooms at the first realization that there is urine in our bladder?

It’s not an emergency, it’s just information. That bladder of yours is sending a friendly neighbourly signal up to your brain that says “FYI, getting kind of full, might want to think about that sometime soon.”

Dietary Factors

To make matters more complicated, you might be making your “child” crankier than it needs to be by eating certain foods and drinks. If your bladder is extra irritated, it’s going to make its presence known a lot louder and more often than you would like.

Foods that may irritate your bladder include:

• Coffee (decaf is better but still not perfect)

• Tea

• Alcohol

• Chocolate

• Carbonated beverages (yes, even plain soda water)

• Artificial sweeteners

• Citrus (oranges, lemons, etc).

• Tomatoes

What can I do about it?

There are several things you can do to take control of your bladder health. Some are fairly self-explanatory like decreasing or moderating your intake of the irritating foods listed above.

One of the main things you can do: drink more water. It’s counter-intuitive, but drinking more water more often than not helps you pee less frequently. I’ll say that one more time for the people in the back:

You can go pee less frequently if you drink more water.

Want to know why? If you are dehydrated, your urine will be very concentrated. Concentrated urine can really irritate the inner lining of the bladder and will want to get rid of that fluid ASAP. Your bladder is much happier to hold a larger amount of dilute fluid rather than a small amount of concentrated or irritating fluid.

There are also cognitive and physical techniques known as urge suppression techniques. They can help you deal with a strong urinary urge, avoid leaking and rushing to the bathroom, and normalize the number of trips you make to the bathroom. These should be taught to you on an individual basis by a doctor or pelvic floor physiotherapist that knows your individual situation and can determine which techniques are best for you.

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Your Takeaway Points!

If you suffer with urinary frequency and urgency, please remember these key points:

• Needing to go pee should not feel like an emergency

• Foods and drinks such as coffee, alcohol, and chocolate can irritate bladders

• A significant amount of urinary frequency and urgency is behavioral and can be modified

• Ask yourself if you have to go pee or you just want to go pee? Is the signal coming from your bladder or your brain?

• Drinking more water can decrease urinary frequency and urgency

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If you would like to know more about these or have an evaluation by one of our pelvic floor physiotherapists please feel free to contact the clinic at 778-630-8800 or clinic@ladnervillagephysio.com to book an appointment.

Meet Sofy!

Our newest orthopaedic and pelvic floor physiotherapist, Sofy was born in Taiwan before moving to Kimberley, BC at a young age. She eventually ventured down to Vancouver to complete her degrees and now calls this beautiful city home. Growing up in the East Kootenays introduced Sofy to many sports and outdoor activities, where she spent most of her time in the mountains or at the golf courses. Besides being a physiotherapist, Sofy is also an artist. She loves oil painting and everything art! 

What is something totally random that people won’t know about you?

I moved to Kimberley because I had terrible eczema and allergies living in Taiwan and Kimberley was the only place that magically made my symptoms disappear (after exploring several countries and cities).

When did you decide you wanted to be a physio? 

I wanted to become a dentist since I was 8 years old. It wasn’t until 3rd year university when I realized that I couldn’t talk to people if I was working inside of their mouths. I love talking and getting to know people as well as learning about how the human body works. After exploring a few different professions, physiotherapy seemed to be the perfect fit!

Which sports are you into? 

Golf, golf, and golf! Tennis in the summer, squash in the winter. Rock climbing, spikeball, and volleyball are pretty fun too. 

Where did you grow up?

Taiwan and Kimberley BC. 

What is your favourite orthopaedic condition to treat?

I like them all! Each body part is fascinating in their own ways in my opinion, hard to pick a favourite. I took a special interest in hands and the upper extremities early on in my career, but now I like to treat everything. 

What makes you happiest? 

Camping on top of a mountain or painting away in my little studio. 

LIGHTNING ROUND!!!!!

Cats or dogs? Dogs

Favourite food? Thai food

Favourite dessert: Tiramisu 

Favourite Junk food: Instant noodles

Beach or mountains: Mountains

Favourite colour: Baby pink

Favourite music: Pop

Favorite day of the week? Sunday

Nickname? Sof, Meng (but I really don’t like it)

Would you rather be able to speak every language in the world or be able to talk to animals? Speak every language

Favorite holiday? Christmas

How long does it take you to get ready? 30 mins

Invisibility or super strength? Invisibility

Is it wrong for a vegetarian to eat animal crackers? No

Dawn or dusk? Dusk

Do you snore? I “breathe loudly” 

Place you most want to travel? Nepal, South America

Last Halloween costume? Cannot remember the last time I dressed up

Favorite number? 3

Have you ever worn socks with sandals? Whenever I’m too lazy to put on shoes

Would you rather cuddle with a baby panda or a baby penguin? Baby panda

Would you want to live forever? No

What's for dinner tonight? Turkey burger with yam fries

Yep, she painted that.

Diastasis Rectus Abdominis 101: All About The "Mummy Tummy"

Abdominal diastasis, diastasis rectus abdominis, diastasis recti, abdominal separation, ab gap, “mummy tummy” ….. it has a lot of names. But whatever you call it, I want you to know a little bit more about it so you can be better equipped to manage it.

What is it an abdominal diastasis?

Diastasis Rectus Abdominis (also known as DRA) is a common occurrence where the linea alba (the line of connective tissue between your six-pack muscles) gets stretched. Note that I said stretched, not torn. Think of pizza dough - stretching the pizza dough is a diastasis, but there are no holes or tears in the pizza dough (which would be a hernia).

DRA most commonly occurs during pregnancy but can also occur in people who have never been pregnant, such as people who lift really heavy weights with poor abdominal engagement and technique.

DRA is considered a normal change in pregnancy!

Your body stretches to accommodate the growing baby and honestly, stretching is kind of the name of the game when it comes to pregnancy. Did you know that uterine capacity increases from 4ml to 4000ml at term and abdominal length increases by an average of 115% at 38 weeks gestation? Can you imagine how uncomfortable pregnancy would be if your stomach didn’t stretch? I can only imagine the heartburn.

So I hope we can all agree that the stretch is a good thing and we are on team stretch - yay for stretch! But unfortunately, as with other body parts faced with a sudden increase and then decrease in size (RIP pre-baby boobs), it is also quite common for that stretch to remain after pregnancy.

How common is DRA?

Way more common than you think! Here’s the research from Mota et al and Sperstad et al showing how common DRA is in pregnancy:

• 33.1% of women at 21 weeks pregnant

• 100% of women at 35 weeks pregnant

• 60% of women at 6 weeks post-partum

• 32% of women at 12 months post-partum

How do I know if I have a diastasis?

There are a few ways to tell! The most obvious sign that people notice is the presence of an abdominal “dome”, “cone” or “triangling” of their stomach when they exercise or during daily activities (like getting up from the couch or straining on the toilet). This is a protrusion or bulge down the center line of your stomach when you attempt to use your muscles without correctly preparing or stabilizing first.

Some common movements which can cause doming are crunches, “V” sits, Russian twists, pull ups and getting up from bed or a reclined position.  This picture is someone with a diastasis doing a double leg lift without any preparation for the movement. Can you see the peak down the middle of her tummy? This is what we are talking about when we say “the dome.”

Avoiding the dome is one of the biggest considerations for proper DRA management.

If you haven’t noticed a dome you may also be able to feel the increased space between your abdominals.

To test yourself for DRA:

• Lie flat on your back and press your fingers into your midline right underneath your sternum.

• Press again a few inches down and keep going all the way down to your pubic bone.

• When you press you might feel that some places feel firm and springy while in other places your fingers might sink in deeper. This could indicate an area that has stretched.

• You can confirm this with a head lift test: with your fingers in the soft spot do a mini crunch and lift your head and shoulders off the ground, does the soft spot narrow? If it does that is another indication that you likely have a diastasis (the narrowing is a good thing, don’t let it freak you out!).

Need a visual? Check out this youtube video for a guide to assessing your own DRA.

Still not sure if you have a DRA? A pelvic floor physio, midwife or OB could also tell you right away if you have a diastasis and give you further direction.

Is it my fault?

This is a question I hear a lot and the answer is usually a resounding NO. Women often say to me “maybe if I didn’t gain so much weight” or “maybe if I was younger then my gap wouldn’t be so big” but according to the research this simply isn’t true.

According to a wide body of research, here is a list of things that are NOT risk factors for DRA:

• Age 

• Ethnicity

• Height 

• Pre-pregnancy weight

• Duration of labour  

• Method of delivery

• Weight gain during pregnancy 

• Baby weight at birth

• Gestational age 

• Exercise training before, during and after pregnancy

• BMI before pregnancy or at 6 months postpartum

Some things that we think might contribute to a diastasis are:

• Having multiple pregnancies close together

• Being pregnant with multiples

• Heavy lifting using a Valsalva technique

• Genetics

Will it go away?

While some natural recovery can occur in the first 8 weeks postpartum a large number of women will still have a DRA and need to learn how to properly manage it going forwards.

How do I manage my DRA?

Management will include learning proper movement and abdominal techniques so you can exercise without worsening your diastasis. You will need to avoid the dome. I know I mentioned that earlier but it needs to be repeated.

Exercises and movements which cause a dome will need to be modified until you are strong enough to maintain control throughout the entire movement.

Take a look at the pictures on the right hand side. You can see the doming in the DRA in the top picture. Through proper technique, this doming can be controlled - this is demonstrated in the bottom picture. This person has properly activated the rest of her abdomen and is in control of the movement. Can you see how her stomach remains flat even when she lifts her legs?

(For what its worth, this lady deserves a lot of credit because that move is really hard to do properly and I’m sure it took some time and practice to get to this level!)  

The most important thing to remember:

AVOID THE DOME. Say no to the dome. You are now a dome-free zone.

A pelvic floor physiotherapist will be able to assess your abdominal diastasis, teach you correct abdominal control techniques, give you exercises to increase your abdominal strength and endurance, and help you transition back to your preferred type of exercise.

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If you suspect you have an abdominal diastasis and want to investigate further, please feel free to book with Nicole at Ladner Village Physiotherapy by booking online or calling us at (778) 630-8800. She will be happy to help!

What Is A Pessary?

Nicole Coffey is our resident pelvic health guru and expert on all things related. Read as Nicole answers a Q& A about what exactly a pessary is and who could benefit from one.

What is a pessary? I get this question a lot.

A pessary is an internal vaginal support device typically made of medical grade silicone. They are generally used by women who experience bothersome symptoms from prolapse (when one or more of the abdominal organs including the bladder, uterus or rectum descend and decrease the space within the vaginal canal - find more information in my earlier blogs Part 1: What is Prolapse? and Part 2: I Have A Prolapse! Now What?). This can lead to symptoms such as vaginal heaviness, pressure, a sensation that something is “up there”, or noticing tissue protruding from your body. There might also be bladder and bowel symptoms such as incomplete emptying. Pessaries can also be used to treat urinary stress incontinence, which is accidental urine leakage with activities such as coughing, sneezing, jumping, running, and so on. The pessary acts like an internal shelf to hold the organs up, keeping them away from the entrance of the vagina.

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Typical Pelvic Floor Anatomy

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Uterine Prolapse

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Inserted Pessary

For some people, surgery is an option. For people who do not want to have surgery or who are not surgical candidates, a pessary can be a fantastic option for treatment. (For the record, pelvic floor exercises are also awesome and can help as well, but we are talking about pessaries today).  

So what holds people back? Pessaries can be intimidating. But have no fear, I am here to show you that they aren’t so bad after all!

Take a look at the most common questions I get about pessaries:

1.       Do they hurt?

No! The best thing about a pessary is when it is inserted you can’t feel the pessary and you can’t feel your prolapse! This is why they are so magical. Some women who have a history of vaginal pain (such as pain with intercourse and tampon use) might have discomfort while inserting and removing the pessary. Other women report an initial discomfort when inserting and removing the pessary until they get the hang of it but the majority of users report no pain.  If you do feel pain when inserting and removing the pessary and you are post-menopausal you might benefit from vaginal estrogen cream (this is an excellent conversation to have with your doctor).

2.       Are they hard to get in and out?

Not really. Some styles are trickier than others and require a little bit of skill, but with a little bit of practice you will be a pro at managing your pessary.

3.       When do I wear it?

This is mostly up to you. Some women only wear their pessaries during high intensity exercise. Some women insert it every morning and remove it every night. Others wear theirs for 3-5 days at a time. If a gynaecologist fits you with a pessary there is an option to wear it for longer periods (up to 3 months at a time), but this again is a conversation to have with your specialist.

4.       Can I have intercourse when I am wearing my pessary?

Usually no. There are some types (ring pessaries) that would allow for penetrative vaginal intercourse, but the majority of pessaries need to be removed for intercourse.

5.       How soon after having my baby can I be fit with a pessary?

I personally do not fit people with pessaries before 12 weeks post-partum because your body is still healing and changing. I also do not fit people who are currently pregnant. Again, if you see a gynaecologist they will be able to work with you in these situations as needed.

6.       I don’t have prolapse but I leak urine, can I still use a pessary?

If you leak urine due to stress incontinence (coughing, running, jumping, etc.), a pessary absolutely can help. It will probably just be a slightly different type and you likely will only have to wear it at times that you leak such as while at the gym. A pessary will not help with urge incontinence (leaking due to a very sudden and strong urge to pee).

7.       How do I know what size and type I need?

This one is unfortunately a little tricky. Fitting a pessary is a combination of experience, art, and some trial and error. During your appointment I discuss with you which type of pessary I think would be best for you to try first and why. Then we proceed to try a few different sizes and shapes as needed until the perfect one is found. Sometimes this happens right away and sometimes it takes a few tries. It might take more than one appointment but it is worth it in the end to have a pessary that fits properly.

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If you have any further questions about pessaries or would like to book a pessary fitting, book online, send us an email at clinic@ladnervillagephysio.com or give us a call at (778) 630-8800.

How Do We Learn? Neuroplasticity, Of Course!

One of the biggest myths about physiotherapy is we only work on bodies. It’s true, we do that a lot! We use manual therapy, soft tissue massage, modalities like LASER, ultrasound and dry needling (aka IMS - intramuscular stimulation) - all to help your body heal and perform at its best. However, the most important thing we do is prescribe exercises. Why?

The number one thing we are trying to change is your brain.

Whenever we learn a new skill, be it playing a guitar or performing the perfect squat, we need to start with activating the right muscles in the right sequence to get the right outcome. And that, dear reader, doesn’t happen at the muscle level - that all starts from the brain.

So what is this brain change we speak of? How does it work? More importantly, how do we make it work for us?

Neuroplasticity is the brain’s ability to change. This change can be harnessed for good (that guitar chord progression is amazing!) or evil (stop leaning over to pick up that box - squat it out!!).

As a physiotherapist, we harness the power of the brain’s ability to change itself through specific exercises. If I want you to improve the range of motion of your shoulder, I’m going to give you exercises that force your brain to engage a specific muscle and build on top of that. Those silly movements we ask you to do? There’s a method to the madness, we swear!

So what makes for good neuroplastic change? Kleim and Jones wrote THE paper on neuroplasticity back in 2008. This became the guidebook with how we influence neuroplasticity for the forces of good. Here are their ten principles and how we relate this to our exercises:

1. Use It or Lose It - want to still be able to squat in 20 years? Squat now. Your brain is very good at eliminating circuits that aren’t being used. If you want to keep a skill at a certain level, you need to practice it regularly.

2. Use It and Improve It - when you practice a task, your brain becomes more efficient at that specific task. It strengthens the neurons and their synapses, prunes off the inefficient pathways and creates a faster circuit.

3. Specificity - if the goal is to improve your golf swing, working on your tennis form isn’t the best way to do it. Sure, some of the muscles used are the same and you’ll see a cross training effect. But to get the best results for your golf game, we need to focus on your golf swing - break down those movements, improve them and put it all back together.

4. Repetition Matters - how many times does an baby fall before they master the art of walking? Almost 14,000 times! (Thanks, Dr. Lara Boyd, for that nugget - I’ve been keeping that number in my head for 10 years!) Keep this is mind if you’re getting frustrated - “brains are stubborn, but so am I”.

5. Intensity Matters - when you’re working out or practicing a new skill, work hard and make it count. Sweat! Fail! Make it hard! The more you push it - either physically or mentally - the faster you’ll see change.

6. Time Matters - we know we get faster neuroplastic change if we start rehabilitation shortly after an injury. The sooner we start, the better.

7. Salience Matters - you need to care about what you’re doing to get change! You know that adage, “You can’t make a person change”? It’s true for the brain, too! If the person doesn’t care, they will not see neuroplastic change. This is why we ask you what you love to do - we need to make sure the exercises we are prescribing relate to something that matters to you and helps you get to your end goal. Otherwise, what’s the point?

8. Age Matters - younger brains are better at neuroplastic change. We used to think younger brains were the ONLY brains that could change, but research has blown that out of the water. Older brains change, too - here is no age limit to neuroplasticity!

9. Transference - this is the cross training effect. Let’s go back to the golf/tennis example. Both games demand good shoulder control, a strong core and good hand/eye coordination. If we focus only on your golf game, your tennis game will improve a bit as well.

10. Interference - I’ll use a personal example with this one. I have spent so much time playing ultimate frisbee that I cannot play tennis without flicking the tennis racket. I can’t do it! My wrist just flicks every time I hit the ball. The neuroplastic change I have developed to throw a frisbee has interfered with my ability to hit a tennis ball properly. I could put in the effort to induce enough neuroplastic change and separate these circuits if I wanted to, but it’s not salient for me (see what I did there?).

Want to have more neuroplasticity in your life? There are two things you can do to make your brain more efficient at neuroplasticity: aerobic and mental exercise. Both have shown to increase the brain’s ability to adapt and change. All the more reason to get out for that bike ride and rock that crossword puzzle!

As always, if you’d like to see one of our physiotherapists, give us a call at (778) 630-8800, email us at clinic@ladnervillagephysio.com or book online.

Happy learning!

Pelvic Floor Physiotherapy - It's a Thing!

So often I am treating people and all they say is “I wish I knew about this sooner, I did not know pelvic floor physio existed.”

Well I’m here to tell you that it does exist and below I have answered some of the most common questions I get asked about pelvic floor physio. I hope it can help shed some light on this often-overlooked topic. If you have any questions about your own pelvic floor function I would be more than happy to meet with you and answer your questions. 

Pelvic Floor Physiotherapy is a thing??

Yes! It’s a thing! And I am here to help! Pelvic floor dysfunction is COMMON. Significantly more common than you could imagine. You just don’t know that because no one likes to talk about it. “Hey, I can’t go swimming with my grandchildren anymore because I’m afraid I might have an accident in the pool” or “I sometimes get skid marks in my underwear, do you?”  is not a common topic of conversation for most people. But it happens to a lot of people, and if you would prefer it stop happening to you please be brave and have that conversation with your family doctor or come in for an appointment. 

What can Pelvic Floor Physiotherapy help with?

Glad you asked! Here is a list of some of the conditions I can help with:

• Urinary incontinence (accidental urine leakage)

• Fecal incontinence

• Pelvic organ prolapse - read Part 1 and Part 2 of Nicole’s previous blog on prolapse

• Dyspareunia (painful intercourse)

• Constipation

• Coccydynia (painful tailbone)

• Pregnancy-related hip, low back, or pelvic pain

• Urinary frequency and urgency

Do you treat men?

Yes! Men have a pelvic floor as well. I commonly treat stress incontinence (eg. after prostatectomy or a TURP procedure) among other things such as pelvic pain. 

What does a typical assessment look like?

On your first visit, you will arrive at the clinic and be shown to one of our private treatment rooms. I will then take a detailed history (ask you a bunch of questions about your bowels, bladder, sexual health, general health, exercise habits, etc.) to get a clear picture of who you are and what you are dealing with.

I will then educate you EXTENSIVELY on the condition you are dealing with, why it happens and what we can do about it! Next comes the objective part of the assessment. This generally involves observing your pelvic floor while you contract and relax your muscles to ensure you are doing so correctly. I also, when needed and with your consent, will complete an internal exam that allows me to assess for pain, prolapse, and the strength of your muscles.

I’m not comfortable with an internal exam. Can I still come? 

Absolutely, please do! Although the internal exam adds valuable information to the assessment I can provide treatment based on pelvic floor observation and the history you provide. If you would prefer no observation and just discussion I am more than happy to do that as well. Whatever makes you the most comfortable is what works best for me. 

I am also able to minimize internal work because I have an external EMG biofeedback machine which can help tell how strong you are and how well you are contracting your muscles, which can be extremely helpful.

What is a biofeedback machine and why is it helpful?

One of the biggest things about doing pelvic floor exercises is that most women believe they are doing their Kegel contractions correctly when in fact they are not. The biofeedback machine works by attaching stickers to your pelvic floor (kind of like a heart monitor) and then we get direct and immediate feedback visually on the screen when your muscles are contracting and relaxing. This is extremely helpful for people to confirm that their muscles are doing what they think they are doing. (Or maybe it’s a wake-up call that the muscles are not contracting nearly as strongly or being held for nearly as long as thought, and that person was completely unaware that the exercise they were doing was ineffective). The machine helps to ensure you are getting the maximum benefit from the home exercise program by increasing your awareness of what your muscles are doing and how to control the contractions. That way you can be confident that you are doing the exercises correctly!

When should I come for pelvic floor physio?

Anytime you like! You may have been having issues for a few months or a few decades, it doesn’t matter, you can still make a ton of progress! If you have just had a baby I recommend waiting until 6 weeks after the birth in order to give things time to settle. If you are looking for a pessary (I’ll save more explanations on those for another post) you must be minimum 12 weeks postpartum.

Can I bring my baby in?

Please please please pleeeeease bring your adorable tiny humans! I LOVE BABIES. I don’t want the lack of a babysitter to be the reason you don’t come in. So if you need to come with your child please do so. We can make it happen.

If you’re interested in booking an assessment with Nicole, book online or give us a call at (778) 630-8800. 

Chronic Pain

Want to know what truly fascinates me? Chronic pain. There are lots of definitions for chronic pain, but most sources agree on this one:

Pain that is persistent and lasts longer than 12 weeks can be classified as chronic pain. 

With most injuries (let’s say a sprained ankle) you injure yourself (tissue damage). There is an inflammatory reaction (your foot becomes swollen and looks like a balloon with toes sticking out) and you probably feel some pain with certain movements (if you try to run or jump). But body is on the ball and starts working to heal the tissue injury (building scar tissue). You find that slowly but surely your range of motion and activity tolerance improve, the pain and swelling dissipate and you’re back to playing soccer in 6-8 weeks. Yay!

But what if the pain doesn’t go away? What if the tissue is healed but you still feel pain? What if the pain you feel is way out of proportion to the severity of the injury? What if the pain is still there six months later? What if you still can’t put weight on that foot, it hurts to touch it gently and you can’t stand putting a shoe on because it feels like too much pressure?

This is the realm of chronic pain and it can have major implications on physical and mental well being. People start to get told “it’s in your head” and “suck it up” and “it should be better by now”. The reality is that we are only just starting to understand the complexity of chronic pain.

There is no “set” pain response.

A certain injury does not cause a pre-calculated level of pain. Everyone’s experience of pain, even with similar injuries, vary greatly.

How we act and react can depend on many factors such as stress and the “threat level” of the injury.

We have lots of receptors throughout our body (in our skin, joints, etc) that recognize lots of different things such as sharp vs dull, hot vs cold, light vs firm pressure, etc. When that input is noxious (irritating or damaging) those signals are sent by nociceptors. When enough of these signals get sent to the brain all at once the brain interprets them and decides how to act.

Some different scenarios for you: maybe your brain feels like something tickles and so it sends a signal to you that you should squirm, maybe you are getting a massage and it “hurts so good” but you decide to keep still even though it’s not comfortable, or maybe you stepped on a a nail and your brain decides that the situation is dangerous and immediately moves your foot away from the nail. In each instance, your brain got a nociceptive input but decided to react in different ways depending on the situation. That interpretation of danger and threat level is important and helps determine how you feel about the input you are experiencing.

How you perceive your injury and how it impacts your life has a huge role in how you feel pain.

A classic example is a paper cut. It is small, it is mighty, and it is a total pain (pun intended) for everyone. But who do you think will feel more threatened from that paper cut - a violinist who has a concert tonight or to a soccer player who has a game next weekend? If I was a betting woman (I’m not but let’s pretend) I would guess the violinist will panic - “oh my gosh can I play? Will I have to miss the concert? Is everything ruined?” - and that paper cut will probably throb all day long. Switch to the soccer player who probably thinks “Yup, that sucks, but as long as I’m careful reaching into my soccer bag I’ll probably be fine” and then goes on with his day and forgets about the paper cut. Those two people had very different reactions to the same injury.

The amount of tissue damage cannot predict the amount of pain experienced.

I know this seems strange. If you have pain you assume it’s because something is injured right this very moment, but in chronic pain this is not always the case.

Let’s start with amputees who have phantom limb pain. If someone’s foot is gone it’s impractical to think that they can have an itch on their big toe or an ache in their ankle because there is literally no remaining tissue, so how could it be damaged and send signals to the brain if there is nothing there to be damaged? And yet there are many reports of amputees feeling pain in their lost limb.  On the other extreme, some people have severe life threatening injuries and feel no pain at all. Soldiers with gunshot wounds will sometimes report not realizing they were hit until after the situation calmed down. Their body was so busy in survival mode that it didn’t have time to stop and worry about a major wound.

This also happens with knee arthritis. Some people have “brutal” X-rays that show severe knee degeneration but report only minor stiffness in the morning and no impact on their daily function. These folks can still walk, garden, etc. Other people report debilitating pain that stops them from doing simple daily tasks such as standing and walking for more than a few minutes at a time but their x-rays show only mild degeneration. We cannot rely on X-rays or MRI’s as a way to determine how much pain someone is in. The longer you have pain the weaker the correlation between pain and tissue integrity.

The longer you have pain, the more efficient your body’s pain warning system becomes.

It’s like it has practiced and practiced and practiced sending those signals up your spinal cord to your brain and it becomes really good at it. This starts to get more complicated but to oversimplify we start to call this system “sensitized.” It’s like your body has turned up the volume button on the radio - a simple input on one end (light touch) is over-represented and feels overwhelming and loud at the other (which gets interpreted as extreme pain). The brain is being told there is more danger at the tissue than there actually is. This often leads to pain avoidance behaviours (it hurts when I move so I’m going to move less) even though the joint and muscle are completely physically capable of moving. 

Chronic pain is not “all in your head”.

There are legitimate physiological processes that lead to chronic pain. The good news? Your body did this as part of a protective response for you. There was a real or perceived threat and your body said “Not on my watch! I’ve got your back.” Your body is not silly - it wants to keep you safe.

The other good news? If your body wound up this much in response to a need it can also down-regulate when that need is no longer present. That means going back down to pre-pain levels! It means feeling like you are in control of your pain instead of it controlling you.

You just need the tools so it can get the message “thank you for your help but your services are no longer required. Chill out.”

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If you would like to do some more learning here are some awesome resources:

• TedTalk by Lorimer Moseley, who is absolutely brilliant and it really explains a lot of how interpretation of stimulus can influence pain. Honestly it’s one of my favourite videos.

• Here is another good intro that I like - “Tame the Beast”

• If you prefer to do some reading anything by David Butler or Lorimer Moseley is great. They have a book called “Explain Pain” which is a great read.

• Neil Pearson is a local (B.C.) man who has done a ton of work with chronic pain. His resources are also quite good.

Okay friends, I’m outta here for now. Happy reading!

Prolapse Part 2: I Have a Prolapse! Now What?

OK, so you have prolapse. What do you do about it?

Treatment for prolapse depends on a few different factors including (but not limited to):

• Which structure(s) is/are prolapsed? (Anterior wall, posterior wall, uterus?)

• What is the extent (grade) of the prolapse?  (I covered the grading in my previous blog, but for a brief refresher Grade 1 = mild, Grade 2= moderate, grade 3 = large).

• How much is it bothering you? (Depending on the type of prolapse some things you might notice include sensations of vaginal heaviness or pressure, incomplete bladder emptying or trouble initiating a bowel movement).

A pelvic floor physiotherapist can help guide you as to which exercises and precautions are most appropriate for you and your specific situation.  

The three primary treatment options for vaginal prolapse are:

Pessaries

1. Pelvic Floor Exercises. Pelvic floor exercises are fantastic because they are easy to do, inexpensive, non-invasive, and fairly effective. I often say that running with prolapse might feel a bit like running without a bra on (not my favourite feeling in the world). But with a little strength and skill your pelvic floor musculature can become the sports bra. It can be strong and work to support the prolapse throughout the day, maybe even provide a little bit of lift. While pelvic floor exercises are useful and helpful, they are not a quick fix, nor are they magical. They are often more than enough for women with only minor bother symptoms or mild/moderate prolapse, but they cannot turn a prolapse that is protruding outside of your body (grade 3) into a “barely there” grade 1.

2. A Pessary. If pelvic floor muscles are the sports bra then a pessary is a sports bra with underwire! If you have never heard of a pessary you aren’t alone. Essentially, they are silicone vaginal support inserts (maybe like an ankle brace, only for your vagina) that work to lift and support the prolapse. I get that this sounds intimidating, but here is the thing…. When a pessary is inserted (and fits correctly) you can’t feel the pessary and you can’t feel the prolapse! You read that right. It essentially takes your prolapse bother symptoms away (whatever they might be, such as feelings of vaginal heaviness, pressure, etc). Pessaries come in many shapes and sizes and have different wearing patterns. Some women only wear a pessary while exercising. Others insert it every day and take it out every night. Some people wear the pessary for several days at a time. There is some upkeep involved such as cleaning the pessary and follow up visits to ensure the pessary fits correctly. They are a successful long-term management tool as an alternative to surgery.

3. Surgery. This is the only “true fix” that is not just supporting from below but actually “re-stringing” from above. It is also obviously the most invasive procedure. Each gynecologist and surgeon will have their own protocols so I suggest having an in-depth conversation with your specialist if you are considering the surgical route. Surgical recovery times and potential complications such as re-occurrence rates are all important questions to ask.

One big consideration, no matter which treatment route you choose, are steps you can take to help prevent further progression of the prolapse. These can include avoiding chronic constipation, minimizing high impact activity, being mindful of correct lifting techniques to name. Or maybe you have no sensations of vaginal heaviness but do experience symptoms such as incomplete bladder emptying or trouble initiating a bowel movement. These could also be a sign of prolapse.

If you have any questions about prolapse or would like to book an assessment please feel free to email us at clinic@ladnervillagephysio.com or phone the clinic at 778-630-8800.

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Wondering where to find Part 1? Right here - Part 1: What is Prolapse?

Prolapse Part 1: What is Prolapse?

Whenever I am doing an initial intake interview with a client who has come in with concerns about their pelvic floor I ask about prolapse. The most common answer I get when asking if people have any concerns about prolapse is simply “what the heck is prolapse?” Well, let me tell you.

You have various organs within your abdominal cavity, the lowest of which include your bladder, your uterus and your rectum. They are all strapped into place and held in the correct position with connective tissue, like a marionette being held upright by strings. But sometimes those strings get over-stretched (like during childbirth). So instead of having nice upright puppets you now have puppets with extra long strings, which means you now have droopy puppets. These “droopy” organs then begin to collapse downwards.

It’s like your vagina is a tent (yes, like a camping tent), and then a big old bear (aka one of your organs such as your bladder) comes and sits on the edge of your tent. The bear is not physically inside your tent, but he’s leaning on it and squishing it, and making the space inside your tent smaller. This can lead to a “bagginess” or “sagging” within the vaginal canal which is also known as prolapse!

Women who have a prolapse (that they are aware of) generally describe sensations of vaginal heaviness, pressure, of something being inside of their vagina (like a tampon or a “bubble”), or a general feeling of their “insides falling out.” This can occur all day every day or occasionally. Often activities such as coughing, sneezing, carrying something heavy, or being on your feet all day can increase awareness and sensations of the prolapse. That being said, many women have a prolapse and have no sensation of it at all. This applies to small, moderate, and large prolapses. Some women have tissue protruding outside of their vagina for the majority of the day but if you asked them to stand clothes-free and hands-free they would have no awareness that their anatomy was different or changed.  

The name of the prolapse will depend on the structure causing the issue. I have listed a few of the more common terms below:

• Anterocele/cystocele/anterior vaginal wall prolapse: these are all generally names used for when the bladder is the offender. When the bladder decides to droop, it collapses into the empty space of your vaginal canal. This can sometimes lead to symptoms such as incomplete bladder emptying.

• A rectocele is also known as a posterior vaginal wall prolapse. This is when the back wall of your vagina (the wall between your vagina and rectum) is pushed forward due to external pressure from the rectum. Please note that a rectocele is not the same as a rectal prolapse. This is when tissue is loose inside the rectum resulting in excess tissue bulging out of the anus. A rectocele can cause, among other things, difficulty initiating a bowel movement.

• A uterine prolapse is pretty straight forward. If your uterus is dropping it’s more like the tent is collapsing from above. It can sometimes “drag” the front and back walls of the vagina down with it and seems to be the most noticeable type of prolapse.

You can usually tell which structure has prolapsed with a brief self exam. If you put your finger inside of your vagina and it feels squishy in the front, it’s a cystocele. Squishy in the back is a rectocele. If the extra tissue feels firm like the end of your nose you are feeling your cervix and it means that your uterus is the structure that has dropped.

The grade of a prolapse will depend on how much “droop” there is. If the bagginess is happening in the upper half of the vaginal canal it’s a grade 1. If the bagginess is in the lower half of the vaginal canal it’s a grade 2. If there is tissue protruding out the entrance of the vagina the prolapse is a grade 3.

Treatment options for prolapse vary and the right option for you will depend on a few things such as A)which structure is prolapsed? B) how big is the prolapse? And C) how much does it bother you?

I will discuss treatment options for prolapse in my next blog, but if you have any specific questions or would like a consultation please feel free to contact the clinic or book an appointment and I would be more than happy to help you out!

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If you’re looking for the second half of this blog, check out Part 2 - I Have A Prolapse! Now What?

Time to Stop Leaking

Do you cross your legs before you sneeze?

Do you avoid jumping jacks?

What about jumping on a trampoline?

There are two basic types of accidental urine leakage: The first type is called stress incontinence. If you leak urine when you cough, sneeze, laugh, jump, run or lift something heavy you are not alone. In fact, 1 in 3 women who have given birth suffer from this condition. (Side note, men who have had their prostate removed also suffer from stress incontinence, but I will save that topic for another day).

The second type of leakage is known as urge incontinence. This is when you get an urgent urge to urinate, rush to the bathroom, and maybe you don’t make it on time. I will also talk about how to address this at another time!

Why does stress incontinence happen?

Essentially, if there is a strong downward pressure (such as increased intra-abdominal pressure from a cough), and that downward pressure is stronger than the closure pressure provided by your pelvic floor muscles, then the stronger force wins and a leak will occur. It’s not that your pelvic floor isn’t there anymore, it just means that it wasn’t strong enough to resist that force and was overpowered in that moment. That lack of closure pressure is usually due to muscle weakness and could be due to a number of things, but the most common culprits are childbirth, a chronic cough, obesity, pelvic floor surgery and age.

Okay, so now what?

Here’s the thing…stress incontinence is very fixable. Not in the “okay I feel more confident but I’m going to wear a pantyliner just in case” kind of fixable, but the “I’m going to have a contest with my kids to see who can do a better star jump” kind of fixable, the “oh my goodness I’ve been walking around all day and moving furniture but my underwear is still completely dry” kind of fixable, and the “I’m going to skip the aisle with all of the absorbent products because I don’t need them anymore” kind of fixable. You do not have to accept the leaking as your new level of normal. You do not have to live with this for the rest of your life. You can do something about this! You can have confidence and control over your bladder again.

I want that! How do I get that?

 I’m not going to lie, there is a little bit of homework involved. The strength, endurance, and skill level of your pelvic floor need to improve. That’s where pelvic floor physiotherapy comes in. A pelvic floor therapist can make sure you are contracting the correct muscles in the correct way and give you a treatment plan to suit your current skill level and your specific situation. If this is something you are interested in learning more about, please feel free to contact me or book an appointment and I would be thrilled to go over it all with you one on one!