Stephanie, a 33 year-old mother who delivered her first child 11 months ago, was buying diapers for her baby, and panty liners for herself. She was incontinent, which Mayo Clinic defines as “the loss of bladder control — a common and often embarrassing problem. The severity ranges from occasionally leaking urine when you cough or sneeze to having an urge to urinate that’s so sudden and strong you don’t get to a toilet in time.” It’s a condition that affects one out of every three new moms.¹
Stephanie’s active pregnancy included yoga, Power Plate and weight training with a personal trainer approximately 3-4x each week. The extent of her incontinence during pregnancy was minimal according to the new mom, “a tinkle at the end of a sneeze,” but it was just the beginning. She delivered vaginally using medications for pain relief as well as for augmentation of labor, which lasted 18 hours.
Post pregnancy, her tinkle turned into a nightmare. “I couldn’t run at all,” said Stephanie. And she would leak urine every time she did jumping jacks, pull ups, sneezed or coughed. “The sensation was persistent,” she recalls. This made working out, going to work or going anywhere in public a potential embarrassment. Research shows that up to 23% of women take time off work due to incontinence. ²
Stephanie remembers how exercising was a big challenge, “Anything requiring a run was stressful. I don’t want to wet myself.” And she couldn’t participate in activities that were part of who she was pre-pregnancy, “I couldn’t run the marathon without becoming wet like I peed on myself.” So she made the decision not to register. Dis-empowering decisions like these combine with the already challenging psycho-emotional stress of incontinence itself, which can lead to bigger problems. “Incontinence commonly leaves the sufferer with psychological morbidity, particularly depression.”³
Stephanie’s incontinence had been steadily worsening for 11 months. After delivery, she took about 10 days off before returning to her exercises of yoga, Power Plate, and strength training with a personal trainer. That’s when incontinence appeared full force. Now, eleven months into it, and with no end to panty liners in site, Stephanie reached out for help.
RESULT AFTER ONE SESSION:
We spent one hour together, assessing her and coaching her on what she needed to know. I then sent her home with ten minutes of corrective exercises that she performed every other day. Ten days later, Stephanie said, “It’s really been working. I think you nailed the problem. It’s fine now when I do pull ups and jumping jacks. Overall, I used to leak once per day, but it’s only happened a couple times when sneezing—and not every time.” She said this even though she was participating in high-level urine-leaking activities like boxing, training, and Power Plate.
Here is what I did with Stephanie in that first session.
Because of the nature of her goals and the manners of her referral, I decided not to require my usual complete alignment assessment, but rather to do a mini assessment and coach her directly for incontinence in the activities that she was performing.
The first assessment I did was for breathing. Stephanie didn’t successfully pass the breathing assessment, but was able to snap into good function quickly when we began coaching (somewhat rare). We agreed that the “belly breathing” of her yoga practice had instilled diaphragmatic access for her. If her diaphragm hadn’t turned on so quickly, she would not likely have gotten such great results in this first session. If it had not stepped up to function this well, I would have spent much more of this first session training her diaphragm, because it is the foundational synchronizer of the Transverse Abdominis (TVA) and Pelvic Floor (PF) musculature.
To assess her pelvic floor (PF), I asked her to perform a pelvic floor contraction (Kegel Exercise), specifically asking her to imagine that she was alternating peeing and then stopping the flow of urine. I had her do this for about ten solid repetitions. I then said, “rest,” and asked her what percentage of “on” she thought that her pelvic floor was naturally. Both standing and seated, her response was about 0%. (To be sure, the pelvic floor doesn’t need to be at 100% when someone is simply hanging out. This process was not meant to create a specific diagnosis for proper PF activation, but was intended to create a connection between Stephanie’s mind and body. What we did here was bring her attention to the fact that her PF can be on or off at any time of the day, as well as the fact that she has control over those muscles.) The point was that her PF was currently operating at a standard of being “off” more than “on.”
It was now evident to Stephanie that her pelvic floor simply didn’t function during various exercises and daily activities. This was the crucial first milestone in her training. Far more important than my giving her exercises was her understanding and experience behind those exercises.
Now that Stephanie was aware of her pelvic floor, I asked her to give me a percentage for its activation while doing a variety of exercises. I asked her to attempt to activate her PF during these exercises, so that we could get a sense of how far she can go today. Some of the exercises were the ones that she was doing and having problems with and some of the exercises were my own suggestions, as I attempted to fill in the gap and create a kind of regression/progression chart for her enriched understanding. Here is the scale that I used:
|2 Leg Squat||1 Leg Squat||2 Leg Jump Squat||1 Leg Jump Squat||Jumping Jacks||Running|
Note that this series of “continued assessment” also functioned as her exercise program for the day. After all, each time that she attempted to engage her PF while performing these reps, she was “practicing” the engagement that she needed most. She was literally reprogramming her neuromuscular system as we went, forming a new program for her formerly non-PF-active exercises.
It was interesting to me that her PF felt more activated during her 1 Leg Squat than for her 2 Leg Squat. I am accustomed to seeing the PF (and core in general) function less as the exercise complexity increases. In Stephanie’s case, having less gross stability on one leg seemed to help her initiate her PF muscles to a greater degree. It was also interesting and exciting to see that she was already able to get a feeling of 90% activation for her jumping jacks. There was a sense right then and there that she had practically already fixed the issue!
This was milestone number two. Stephanie had the experience of feeling her success in the midst of the session.
It was not some list of exercises that the therapist had prescribed for her that required an external belief in the therapist. She had belief in herself.
In my experience, that is the single most important moment in any first session. That is the “aha!” moment that empowers our clients to success. There is a real trust that develops when it is clear that they are being taught “how to fish for themselves.”
This first session was ending, and I suggested that she continue with the following 10 minute daily routine:
- Foam Vertical
- Syncing Extended Exhales and Pelvic Floor activation
- Applying extended exhales and pelvic floor activation to alternating leg lifts
- Floor Glute Bridge
- Holding / Non Moving (Syncing extended exhales to PF activation)
- Moving Reps (Using extended exhales and PF synchronization)
- Application of the Core Breathing Belly Pump™ (CBBP) and PF synchronization to:
- 1 Leg Jump Squats
- Jumping Jacks
Remember, the reason that I was confident using the extended exhales (a Fit For Birth TVA-activation exercise) is because her extended inhales (a diaphragm exercise) was already successful. CBBP refers to a method of ensuring diaphragm, TVA, and PF activation in cyclic pumps; it is also a staple Fit For Birth exercise. For all three parts of her home program, especially portion 3, I told her that it was important that she only repeated those exercises that actually work successfully. In other words, she is free to test all three of the higher level jump squats, jumping jacks and running exercises, but only repeat the ones that she could feel her level of PF activation was rising and improving while performing (so that she would not practice the activity with poor CBBP or PF activation.)
I went on to train Stephanie only a total of only five times. Because of her incredible progress, the last four sessions hardly seemed necessary.
Two months later, I caught up with Stephanie to ask, “How effective was the training?” Stephanie said, “It was life changing and educational. I had no idea I was breathing incorrect and not using my body properly. I just thought incontinence was a pregnancy issue – something I needed to work on.”
I asked how her incontinence is currently. Stephanie continues to do her corrective routine only as needed. She said, “I do notice that if I am running around crazy and not conscious on a daily basis or mindful, one day I will sneeze and tinkle on myself, which reminds me to become mindful again. And then I do my exercises again and it works again.” I told her that she was in what I call the “long stage 2.” Stage 1 is awareness—she got that on our first session. Stage 3 is automaticity—she never needs to think about it because her PF and core work automatically. Stage 2 is that middle stage where she needs to remember to apply the correct muscles at the correct time. I told her that this second stage can take weeks, months or years depending on the extent of re-programming necessary and the mindfulness given each day.
Recently, she has decided to give her body a break, realizing that her busy lifestyle has added stress. She hasn’t gone back to running regularly yet, but she feels confident in her exercise classes and daily life activities. “I feel that I’ve got it under control for the rest of my life,” she said. And best of all, she no longer wears leak-proof undergarments; those are for her baby.
¹Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand. 2010 Dec;89(12):1511-22. doi: 10.3109/00016349.2010.526188. Epub 2010 Nov 5. http://www.ncbi.nlm.nih.gov/pubmed/21050146.
²Sinclair AJ, Ramsay IN. The psychosocial impact of urinary incontinence in women. The Obstetrician & Gynaecologist 2011;13:143–148. http://onlinelibrary.wiley.com/store/10.1576/toag.220.127.116.11665/asset/toag.18.104.22.168665.pdf;jsessionid=164FD4FA7AB2396F206E737B067559F0.f03t03?v=1&t=idujxjjt&s=57e667fd7bc5d3a69e79398988cfc9b85590f7f7
³Sinclair AJ, Ramsay IN. The psychosocial impact of urinary incontinence in women. The Obstetrician & Gynaecologist 2011;13:143–148. http://onlinelibrary.wiley.com/store/10.1576/toag.22.214.171.124665/asset/toag.126.96.36.199665.pdf;jsessionid=164FD4FA7AB2396F206E737B067559F0.f03t03?v=1&t=idujxjjt&s=57e667fd7bc5d3a69e79398988cfc9b85590f7f7