Keepin' it on the down low

Recently someone emailed me with a question to clarify a term that I use quite frequently. I apologize to anyone else who has had this confusion, and realize that just because I say something over and over, doesn't mean that it will make more sense each time - anyway, here is the question, and the reply.

"Hi Molly,

I was reading your web site about Pelvic Floor Dysfunction and had a question.

I have had serious pelvic floor problems. I have had two major repairs and an ileostomy. I have had the ileostomy reversed and PFtherapy. I did pretty well for a while, then started having more difficult evacuation. I have changed therapist, which is not easy. I live in Massachusetts, and PF therapists are not easy to find, especially someone good.

I am wondering what "down training" is? I want to ask my therapist, but would like to know first.

Thank you,"

Down training: Using biofeedback as a tool to relax, rather than strengthen, the pelvic floor muscles

There are several ways to go about this, all of them a little frustrating, which is why most of my patients use a home-unit, so at least they get to be in familiar surroundings while trying to relax.

EMG (biofeedback) measures the electrical out put of the muscles. That's it. If the muscles are "high tone" or contracting, there is more output, if "low tone" (weak), or if contractions are very weak, there is less output. When strengthening the pelvic floor, we set a goal to tighten the muscles to a certain level, when the level is reached, there is a noise or some other indicator that you have reached your goal.

When down-training, we set the goal at, or slightly below the resting tone (threshold). Here is where I differ from a lot of therapists. You can set the tone to go off when the tone drops below threshold. When this happens, you know you have achieved your goal of relaxation. I tend to work the other way, and have you work on turning the sound off (when you relax the muscles, the annoying noise goes away) - it just makes more sense to my way of thinking that if you are trying to relax, you really don't want the machine to beep at you every time you finally get there.

soft lights, relaxing music, meditation, maybe a hot pack, at first - whatever it takes to get your whole body to relax. As you get more practiced, then the goal is set to a more challenging level, and perhaps you allow a more functional surrounding, getting your pelvic muscles to relax on demand.

You may be asked to occasionally contract the muscles during a session - this OK, it gives your eyes, ears, and body a reference point between contracted and relaxed. You should not be asked to continue contracting the muscles if you are completely unable to get them to relax afterward.

There are whole protocols on contracting the muscles to fatigue in order to achieve relaxation, and some evidence that it works. For those that it doesn't work on, the effects can be devastating. This method does not fit my treatment philosophy at all, and I refuse to do it, even when specifically ordered by the doctor. To clarify a little more here: If you have tight muscles in your neck, and were asked to do repeated exercises until the muscle could not lift even the weight of your head, you would consider that pretty extreme - especially for an area that has to be active during normal daily function. Your pelvic floor is active whenever you are in an upright position, fatiguing these muscle to exhaustion will give temporarily relief, and some people respond well enough to have lasting effects. Others can't get all the way to fatigue, or the muscles bounce back with uncontrollable spasm, reinforcing the tight, unrelenting contraction and shortening of tissues that causes so many of the imbalances in pelvic floor dysfunction.

Anyway - I hope this clarifies things for some people, and please - ask questions! If I don't know the answer, I will try to research it, or throw out an opinion, or maybe add a different perspective to the subject.