Pardox - or conundrum?

It is a riddle wrapped in a mystery inside an enigma: but perhaps there is a key.

         -Winston Churchill

 I recently recieved an email from someone with a question about paradoxical contractions of the pelvic floor.  I'd like to apologize to the person that sent the email.  I inadvertantly erased the email while I mused about my reply - so hopefully she will read this (sorry ;-l).

A parodoxical contraction of the pelvic floor happens when the muscles react inappropriately to normal signals from the brain, or reflexively, from the spinal cord.  For instance: during normal bowell movement, the anal sphincter relaxes and is stretched as the stool moves through the opening, when it passes, the sphincter contracts quickly and strongly, ending the movement.  What happens if the sphincter does not relax? or if  it contracts in the middle of the movement? or if relaxation starts to occur, then spasm, then relaxation, then spasm?  or if the normal contraction that occurs at the end of the movement is instead painful and unrelenting like a cramp?

These contractions are "paradoxical." They can interfere with urination, bowell movements and normal sexual function.  They can be painful, or just annoying.  These contractions are one of many forms of pelvic floor dysfunction, and often one of the more difficult to treat.  

When I first started treating pelvic pain, I was emphatic that EVERYONE needed biofeedback (surface EMG).  Over the years, I have found that with a little coaching, most people can learn to sense the difference between relaxation and contraction, even without biofeedback.  However, people suffering with severe paradoxical contraction seem to respond best to biofeedback training.  Often these people feel like things are relaxed, but in reality the contractions may be getting stronger and stronger.  Having visual and audial cues to help sense what the muscles are actually doing is beneficial. 

As with most pelvic floor dysfunctions that result in pain, it is very important to get the muscles to relax.  I have many posts on this: heat, ice, a warm bath, gentle stretching, massage, meditation, whatever it takes.  When relaxation is established, it then becomes the goal to relax during challenging situations (bowell movements, urination, sex).

Everyone is an individual.  Treating paradoxical contractions require diligent effort, patience, creativity and time.   In my opinion, it also requires an experienced biofeedback therapist.

 

If you can add suggestions for things that may help, please do.

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.

Let's go! Really go!

"The time to relax is when you don't have time for it."
- Sydney J. Harris (1917-1986)

When you have pelvic floor dysfunction, one of the worst things you can do is strain while sitting on the toilet. Normal bladder function includes relaxing the pelvic floor, which sends a message to the bladder muscle (detrussor) to squeeze. When you strain during urination, to force things past the tight, spasming pelvic floor, it confuses the system. Straining during a bowel movement also worsens pelvic floor problems.

I know - you have a life, and sitting on the toilet for 10 minutes every 1/2 hour, hoping to pee, can put a huge rift in that life. As physical therapists, we work on relaxing the pelvic floor muscles (PFM) by down-training with surface emg (biofeedback), I touched on this a little more in the "To Kegel or NOT to Kegel" post. We use manual techniques (see "Trigger Trauma"); we teach you exercises to relax the muscles surrounding the pelvis and pelvic floor; most therapists will either teach some sort of meditation, visualization or "physiological quieting" techniques, or refer you to someone that can.

So here you are, about to learn all of these really great techniques that you know will help you, and you still have to go to the bathroom. NOW! not later, after you have hypnotized your PFM into submission. Now! while your baby is screaming and the phone is ringing and you still haven't loaded the dishwasher or folded the laundry, and what is that weird noise coming out of the cat?

There are a few things you can do while you are sitting there:

• 1st - Breathe! Just take a couple of deep breathes when you first sit down. If you know any of those visualization techniques from your therapist or somewhere else, this is the time to use them.
• Get a stool. A little foot stool to keep in the bathroom to put your feet on while sitting on the toilet. This brings your knees up, similar to a squatting position, relaxing the PFM. This works great - helps with constipation, too.
  
• Passive voiding. This actually works better for people that have trouble emptying, but it can work if the problem is initiating a void: place your fingers just above your pubic bone while sitting up right on the toilet. Press in with your fingers, and lean your body forward over your knees.
• Eat right, with lots of fiber. Avoiding constipation will help to keep the pelvic floor in good shape, and help you avoid the habit of straining.

If any of you have any other tips and ideas - please share. I love comments!