Exploring the Challenges of Defining Normal in Pelvic Health

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett takes a pragmatic approach discussing variations we see in practice and physiology and acknowledges where we still have work to do.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE daily show. My name is Christina Prevett and I am one of our lead faculty in our pelvic health division and I'm coming to you from a cottage on my 35th birthday because I had a Wonderful husband who surprised me but that does not mean that I'm not gonna get excited talking about all things pelvic health so We had a really interesting conversation come up over the last several weeks, and it's funny because it's come up in a variety of different circles around defining normal. What is normal when it comes from a pelvic health perspective? Because when we are trying to make diagnoses of different conditions, urinary incontinence, pelvic organ prolapse, diastasis recti, we have to know what the realm of normal is so that we know when we deviate from it. And so we had a question come up in our app about, what is the amount of normal voiding, the number of normal voiding episodes that an individual should have during the day? Because some of our literature says 5 to 8, and some of it says 8 to 13. And then if you leak a little bit when you're really tired, does that actually consider you to have a condition? Do you have urinary incontinence? If you have a kind of a spasm in your shoulder, you wouldn't say that your shoulder was injured, but you would say that you have urinary incontinence. And it's such an interesting question, and I kinda wanna dive into it a little bit today. So last week, as many of you know, I'm a postdoctoral research fellow at the University of Alberta. And so what I am looking at in my research, I am an interventional researcher, specifically looking at resistance training and its impact on health. And what my studies are looking at specifically right now is on resistance training in pregnancy and its impact with pelvic floor dysfunction. What I was doing was I was learning from physiology researchers. I was looking at individuals who were looking at pelvic floor assessment and measurement. And up in Ottawa, I was at Linda McLean's lab, they are doing data taking on what is normal force production of the pelvic floor and what are things that we can expect to see as differences in the pelvic floor on ultrasound, on EMG force activation, and on dynamometry, which is force production. in a younger cohort of individuals and an older cohort of individuals. And this sparked a lot of conversations because we know that with age, for example, pelvic floor dysfunction goes up, but what are normal wrinkles on the inside of the pelvis? And what are things that we would consider abnormal or needing to seek some intervention for? So I'm gonna try and take you through a couple of different examples in the literature of what we know, what we don't know, and what we have to acknowledge is just areas of gray. So we're gonna talk about the bladder first. So some of our literature is saying, you know, five to eight Ps during the day is normal. Some individuals have pulled that up to eight to 13 as a top end of normal. And then some people will say that you shouldn't ever have to pee at night, or it should be rare, like you shouldn't be getting up consistently to pee at night. And others say that that is true if you're under the age of 65. But if you're over the age of 65, getting up once to pee is considered within the realm of normal. So let's talk about why there is that variability. When we are looking at data sets and we are trying to incur where that normal distribution is. So we think we have an average if it's normally distributed and 95% or 97.5% of our data is going to swing within plus or minus two standard deviations of the mean. And I'm getting kind of in the weeds of statistics here, but that's kind of our normal distribution. And our P of less than 0.05 on a two-tailed test are the ones that are below that two standard deviations on either side. And what that's saying is like when we have this big group of individuals who are kind of distributed across this arc, and we are seeing that this other group of individuals is well below that, then we can say that these are probably different populations or there is something different going on. When we are looking at trying to characterize normal, There is so much that comes into human behavior that creates differences in a person's lived experience. And when we're trying to capture that descriptive data, it depends on a lot of things, right? If we are looking at normative data and we're trying to describe it, it is going to be very specific. to the data set that we are capturing that information from. What do I mean by that? I mean, if we have an individual who's an athletic group of people who are very conscientious of hydration, their normative values for how often they're going to pee is probably in that higher end between eight and 13. If I am working with a sedentary population who doesn't take a lot of care in their hydration, or it's not something that they think about, five is probably on the top end of that. And so we know that this hydration status is largely going to dictate frequency of urination. Similar to things that we know cause liquid to filter through the kidneys a lot faster, things that we call bladder irritants. So if I am working with an individual who has a higher caffeine or alcohol intake, right, that's gonna make it flow through the urine. Caffeine is not a diuretic, it's a mild diuretic. It does make us have to pee, but in the morning, we're oftentimes drinking caffeine that's simulating that the kidneys and the bowels to start functioning. We are peeing more in combination with having caffeine. Alcohol is another one where it increases filtration rate because alcohol is a toxin, our body is trying to get rid of it, and so it can change our frequency of urination. timing of when we drink water can dictate are you a person who gets up every night to go to the bathroom or not. So all of that can be in the realm of normal variation and that makes it extremely difficult then to diagnose things like nocturia or frequency issues where urination is over a threshold where we consider this to be a quote-unquote pathology or a condition. And so what that has done in our bladder consensus statements is that we have added a second part to this. We have said that when you're thinking about healthy bowel and bladder habits, you should be able to defer going to the bathroom as needed. Your urge to go to the bathroom should increase as the amount of bladder filling hits a more critical threshold. We're getting to the top of our bladder fillage. and we should be able to empty our bladder when going to the bathroom and have complete emptying of our bladder. And frequency of urination, we have like, you know, multiple studies that have tried to characterize normal, but the big asterisk sign on this is that frequency should be at a level that feels okay for you. You should not be stressing about your bladder. You shouldn't have anxiety about bathrooms because that's showing that there is issues with being able to defer going to the bathroom, being able to hold going to the bathroom, or you're going to the bathroom so often. that it's disrupting the cadence of your day, right? But that's really difficult because we can't necessarily say there's this cutoff, right? Where if you're going to the bathroom less than five times, you're probably dehydrated. That's pretty consistent. But if you're going to the bathroom six times versus 10 times, It depends on you and on how you are feeling, and if that is okay for you, or if that's something that is all right for your day. And so we don't really have these normative values, and it's why there's inconsistency in the literature about it, and we can't really give you a hard and fast number, and we really don't want to, because you're a human being. It depends on your day. You're not doing the exact same thing every day. So these healthy bladder statements that we have that are in our research and that are in our course are trying to give an idea, right? So if you have a person who's really underneath that or really above that, then it can almost introduce the conversations around frequency and work on things like urge suppression to potentially bring that frequency down or modulate liquid intake to maybe help with some of those concerns. A second example where we're not really sure about normal is when it comes to diastasis recti and pelvic organ prolapse. And this I actually see as almost a bigger problem because it really bottlenecks our research. It actually makes a huge difference in terms of the way that we are educating on normal conditions and normal changes, and how we create a threat response oftentimes when potentially we don't need to. Let me kind of dive into what I mean. When we are looking at our frequency of pelvic organ prolapse, so pelvic organ prolapse is a movement of one or more of the vaginal walls towards the vaginal opening, and it is assessed on a Valsalva Beardown Maneuver, which is done on a relaxed pelvic floor. Okay, that is where we are doing our assessment. We know that our vagina is not a hollow tube, our bits touch, and we do not have our vaginal wall as a cartilaginous ring, right? It is smooth muscle. And therefore, it should be moving, right? We should see some movement, but it is the degree of movement that we have tried to create a cutoff score for in order for us to have clinical care pathways that give us some idea about what is the next step for individuals who are experiencing signs and symptoms of pelvic organ prolapse, right? We can have individuals who have high amounts. So where are some of the issues come up? We can have individuals with high amounts of movement and low symptom burden and vice versa, right? We can have individuals with high symptom burden with low movement. So here comes the first hole in our argument is that there's discordance between subjective complaints and objective symptoms of prolapse. The second concern that we have with using our grading system as it is currently is that depending on, again, the study population that we are pooling data from, and this is gonna be especially true with our individuals who are post-menopause, we can have over 50% of individuals studied in a normal data set where individuals may not even have signs or subjective complaints of prolapse experiencing grade two movement. So not at or past the level of the hymen. And so they can have that movement. And so if greater than 60% or greater than 50% rather of individuals are experiencing grade two movement, can we truly say that this is an abnormal finding? Because that would mean that 50% of our female population or 25% of our population in general is experiencing a condition. and in combination with the fact that they're lacking symptom burden is a concern. The third thing when it comes to prolapse literature, and this is something that I've been thinking about a lot lately, is that so many of my clients who have really high symptom burden are most concerned with their standing and resting position of their pelvic organs. So for some of my clients with higher grades of prolapse, thinking stage three, stage four, it's standing and feeling that bulge around the opening of their vagina in the introitus. And our assessment is on an active bear down, which really is something that other than birth, we should not be doing a max bear down. So the clinical, the jump to this is how we assess pelvic organ prolapse to this is where my symptoms are most prevalent is missing. We're missing a step. And that is why in our pelvic division, we are such huge advocates for the standing assessment, right? We're not doing a max bear down, but I'm seeing where are your tissues resting especially for some of my postmenopausal individuals or those who have a larger vaginal opening, it's very easy for me to appreciate and I get a much clearer picture of the posterior wall at rest in a standing evaluation. And so when we were doing some of our work up in Ottawa, it was really interesting because when we look at individuals who are parous, those who have given birth vaginally, what we see is that our perineum is going to have more up and down movement. We are going to see post-delivery, an increase in range of motion, and it's been most characterized in the anterior wall. And we are going to see a shift in some of our pelvic structures, right? This is normal physiology. And so when we haven't done a great job of characterizing normal variation and then add in individuals who have had multiple vaginal births who have now gone through menopause, some of that shift in structures are wrinkles on the inside that we maybe don't need to pathologize. And so because we have so much of this variation of normal, again, now our definitions for pelvic organ prolapse are an objective sign of descent in combination with subjective symptoms and subjective complaints. And that's wonderful because what it means is, is that people are gonna have different range of motion. Just like some of our individuals from a musculoskeletal perspective are more bendy and can bend over and their elbows can touch the ground. And some people, they can barely get their fingertips to touch because of hamstring length. We're gonna see variations of normal in vaginal wall length. And this is not something that we need to pathologize. It's the combination with subjective complaints that is going to be our important distinguishing factor to potentially modifying or working on the anatomy, whether that's conservatively with pelvic floor muscle training and pest reuse, or that's surgically with a vaginal mesh type of surgery going into prolapse repair. The third where we don't have a very good understanding of normal is with diastasis recti. So two years ago was the first time that we had taken a big representative sample who were not coming in for core complaints and giving them an idea of what is a normal interrectus distance, right? And over 50% of individuals coming in had greater than two centimeters, which is typically our cutoff score for diastasis recti. And what that shows is again, this bell curve of normality is centered around two centimeters. So if our average is two centimeters or 50% of individuals on this normal distribution are experiencing a two centimeter gap, then again, we've had a failure to recognize normal variation when slapping on layers of pathology or conditions. And again, this is alarming because what it does is it halts a lot of our progress. Because until we've been able to characterize what is normal, recognize when subjective complaints come in, and then be able to create care pathways and algorithms that allow for normal changes, but acknowledge and treat the subjective complaints, it makes it difficult for us to take the next step forward. And that was something that I've learned so much from the researchers that I was working with last week who were doing so much work on the basic science level to characterize normal variations and look at anatomical differences between those that have complaints of pelvic issues and those that don't. And what this does is it allows us in pelvic health to understand the physiology and etiology of the conditions that we are treating. And we do a really good job in other areas, like in cardiovascular complaints. But honestly, it's frightening sometimes how little we know about why individuals are leaking. I did a reel where we talk about exhale on exertion, about how that reflexively gets our pelvic floor to work, because our pelvic floor kind of pumps in and out with inhale and exhale. And on EMG, for me, when I was exhaling on exertion and doing an isometric lifting task, my pelvic floor activation was the exact same as when I was balsalving. And this makes a lot of sense, right? Because what the biggest thing the exhale does is it brings down inner abdominal pressure by about half. And so it makes sense that it works for us when we're trying to get people to have a lower threshold before they start leaking, but we have used physiology that is based on anatomical plausibility and we do not have the evidence to back us up, right? So anatomical plausibility is when we take theoretical thoughts about how things work and use them to justify our outcomes. That is where we start. But until we create this bridge where we understand variations of normal and then understand from a physiology perspective what our interventions are doing, we're always going to be a little bit behind in our creation of these care pathways. And so it made me think a lot about my research in resistance training in pregnancy. because we have some acute studies on what the Valsalva Maneuver does, but we have nothing on bracing mechanics when it comes to a female pelvis and heck no on a pregnant female pelvis. And so it really did create so many conversations that were so fruitful and so incredible. And I'll leave you with the final example. So we know that there are some people who are going to experience urinary incontinence a lot more readily or a lot sooner than other individuals. And what we are starting to see is that some individuals have more urethral hypermobility than others do. And it tends to be a non-modifiable anatomical risk factor for incontinence with exercise. What that means is that yes, we can absolutely see improvements with pessary management. It's going to tack up the urethra, prevent some of that hypermobility. We're definitely going to see improvements, right? But we may have a subset of individuals that are not going to have a complete resolution of symptoms because of their genetics, because of the way that their anatomy is. And that to me, like just learning about this physiology research, it makes so much sense for me as an interventional researcher, but also as a clinician, that I have some people where I have hit them with everything and I still can't completely resolve their symptoms. They get a lot better. But it's okay to have those conversations that there is going to be some individuals who have small amounts of leakage. And then the next part of that is when do we actually consider that a problem, right? When is that becoming an issue? And we don't have that answer. Like I can squat and I can have a cranky hip before I warm up, but I'm not injured. I just need to warm up, right? So maybe if I have a drop or two of urine linkage, I don't have incontinence, my body just needs to warm up. And so we just have so much more that we need to understand in terms of normal variation and genetic makeup and anatomical differences between individuals of different parity states, different ages, stages, different disease history, different injury history. And when we do that, it's really going to open up from a research perspective and a clinical perspective to us to get truly a better understanding of what it is we're trying to modify, how we are doing what we're doing, and it's going to get us to gain credibility in a lot of different spaces. All right, that is my rant for today, 20 minutes. Alan's going to be like, yep, this is Christina, she's on the podcast. But I hope that makes a lot of sense to you. I get so passionate talking about this because I think it's so important and it has been a blind spot for me. And so it's very cool to fill up a known blind spot and just work to think about things a little bit differently, which is really neat. If you all are trying to come and see us live on our two-day course, we have two courses left for the summer. I am in Cincinnati this weekend, July 20th and 21st. Alexis is in Wyoming next weekend, the 27th and 28th. And then our live courses start up again in September. If you are looking to get into our online cohorts, September 12th is when our next L1 starts. If you have already taken our L1 online and you wanna jump into our level two cohort, that is starting August 19th and it is filling up very quickly. All right, have a wonderful week, everybody. I'm gonna ring in 35 by the lake and I will talk to you all soon.

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