By Alexa Savitz, DPT, PHRC Pasadena
Reflecting on my previous years as a former professional dancer, I too often heard dressing room conversations with cast members sharing stories of accidents or urinary leakage happening over a few laughs, during partnering, while lifting, or jumping. At that time there was little to no education around what our pelvic floor muscles even were and it was assumed these accidents were normal. Not only are episodes of urinary leakage not normal in any case, but performers tend to also report hip pain, low back pain, pain with sex, constipation, and increased stress/anxiety that may play a role in pelvic floor dysfunction. All people with a pelvis regardless of age, gender, sexual orientation, race, can experience pelvic floor dysfunction. Symptoms of pelvic floor dysfunction are also not limited to dancers but common in gymnasts, circus artists, musicians, vocalists, figure skaters, cheerleaders, and trampolinists.
A little bit about the pelvic floor muscles and function
The pelvic floor is designed to wear many different hats (insert your “A Chorus Line” top hat). It has a role in stabilizing our pelvic girdle and trunk while transferring loads with movement, provides support for our organs, performs sphincteric closure and relaxation for daily bowel and bladder function, sexual function, and acts as a sump pump to move lymphatic fluids through our body. The pelvic floor muscles also interact with our hip muscles including the piriformis and the obturator internus (think of your “turnout” muscles). The pelvic floor is also part of our core and interacts with our low back muscles known as the multifidus, the transverse abdominals, and our diaphragm. With that being said, any performer with low back or hip pain should also be screened for pelvic floor dysfunction.
Why does pelvic floor dysfunction happen in performers?
Teixeira et. al 2018 performed a systematic review looking at the prevalence of urinary incontinence in female athletes. They reported stress urinary incontinence had a 44% prevalence in female athletes described by six out of the eight studies included. Two studies compared female athletes and sedentary women and reported that female athletes are 2.77 times more likely to present with complaints of urinary incontinence. There are many possible reasons why pelvic floor dysfunction is so common amongst performers. Some of those reasons may include habitually over-recruiting or holding the abdominals in, compensation for decreased strength in the gluteals, lumbar spine, or core, over activity of the pelvic floor due to the presence of hypermobility, clenching or repeated holding of the pelvic floor muscles, increased stress/anxiety, and decreased rest days between training and performances. The nature of most performing arts activities include an overall increase in demand on the pelvic floor.
What is the research saying?
Recent research is bringing to light just how common these dressing room conversations may be, and how they are not being discussed with healthcare providers. Research is growing, but continues to be minimal on the mechanisms and pathophysiology in the athletic population. This is not only true for dance, but also for gymnastics (team and rhythmic), cheerleading, and other high-impact athletics. Most of the recent research discusses increased prevalence of urinary incontinence and pelvic floor muscle dysfunction.
From the research that is currently available, dance, gymnastics (team and rhythmic), and cheerleading all place high demand and increased load on the pelvic floor to stabilize the trunk and pelvis while performing high impact activities. Not only is the demand on the pelvic floor greater upon landing, but pelvic floor muscle (PFM) demands also increase when performing the jump phases of challenging leaps, tumbling, and lifts.
Urinary incontinence is the involuntary loss of urine and includes the following sub-categories: stress urinary incontinence being involuntary loss of urine with an increase in intra-abdominal pressure, urgency urinary incontinence which is involuntary loss of urine associated with symptoms of urgency, and mixed urinary incontinence defined as a combination of stress and urge UI. The most commonly reported symptom from the research presented is SUI in performing artists. In addition to PFM dysfunction, performing artists may present with hip or low back pain referred from the pelvic floor which may be associated with reports of urinary or bowel incontinence and/or pelvic pain.
In conclusion
If any of these symptoms sound like you, we are here to help at PHRC. As pelvic floor physical therapists, we have the tools to assess pelvic floor muscle function with a whole body approach and see if it is a contributing factor to that nagging hip pain or the low back pain that has never quite resolved. With the recent surge in education around the pelvic floor and pelvic floor dysfunction, more performers are seeking the care they need to confidently get on stage and into the studio. Pelvic floor dysfunction in adolescence through adult performing artists deeply affects quality of life, mental and physical health, training, competition and performance, and can lead to increased dropout rates from their art or activity. At PHRC, we are here to open the conversation and support performers so that they may continue to pursue their artistic dreams on and off the stage.
References:
Bø K, Nygaard IE. Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Med. 2019; 50:471-484.
Gram MCD, Bø K. High level rhythmic gymnasts and urinary incontinence: prevalence, risk factors, and influence on performance. Scand J Med Sci Sports. 2020; 30: 159-165.
Rebullido TR, Gomez-Tomas C, Faigenbaum AD, Chulvi-Medrano I. The Prevalence of urinary incontinence among adolescent female athletes: a systematic review. Jour of Funct Morphol Kinesiology. 2021; 6 (12).
Skaug KL, Engh ME, Frawley H, Bø K. Urinary and anal incontinence among female gymnasts and cheerleaders-bother and associated factors. A cross-sectional study. Int Urogynecol Jour. 2021; https://doi.org/10.1007/s00192-021-04696-z.
Sorrigueta-Hernandez A, Padilla-Fernandez BY, et. al. Benefits of physiotherapy on urinary incontinence in high-performance female athletes. Meta-analysis. Jour Clin Med. 2020; 9, 3240.
Teixeira RV, Colla C, Sbruzzi G, Mallmann A, Paiva LL. Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis. Int Urogynecol Jour. 2018; 29: 1717-1725.
Thyssen HH, Clevin S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol Jour. 2002; 13: 15-17.
Whitney KE et. al. Low energy availability and impact sport participation as risk factors for urinary incontinence in female athletes. Jour of Pediatric Urol. 2021; https://doi.org/10.1016/j.jpurol.2021.01.041.
______________________________________________________________________________________________________________________________________
Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Do you enjoy or blog and want more content from PHRC? Please head over to social media!
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
I was able to find good advice from your blog articles.