Addressing Pelvic Floor Dysfunction in Female Athletes through Education and Prevention Practices

Dr. April Dominick // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to close the pelvic floor knowledge gap through education in the community, prior to an individual needing formal pelvic PT.

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

APRIL DOMINICKGood morning, PT on Ice. My name is April Dominick. I am Ice Pelvic Faculty and your host this morning. Let's chat about how PTs can close the knowledge gap when it comes to basic pelvic floor education in the community. Essentially, I'm presenting a case for how we can use a prehab framework to educate individuals prior to the onset of pelvic floor dysfunction, or them requiring formal PT. What really gets my knickers in a knot is how uneducated we are as a society about our bodies. It blows my mind, all of the incredible systems that are happening in our body, like breathing, pumping blood to muscles and organs, filtering through nutrients to store stool and urine. All that's happening in the background right now while you're listening attentively to me on this podcast. All is fine and dandy with those processes until one day it's not. Until one day you're listening to your friend who is a singer and she tells you that her pessary, the device that she inserts into her vagina to support her bladder, fell out on stage. while she was singing her solo for her opera. But she's never heard of the pelvic floor muscles or pelvic floor muscle training, which can also support her bladder. Or the baseball coach who's two years post-prostatectomy and now struggles going to work because he leaks pee when he's yelling out plays to the players. or when he's demonstrating a new sprinting strategy to the team. Does he know that just because he doesn't have a uterus, he also has a pelvic floor too? An entire group of muscles that he can voluntarily control to help him not leak when he's yelling or when he's running. We are undereducated about our bodies. There is a massive gap in knowledge when it comes to the pelvic floor and treatment options or associated risk factors with pelvic floor dysfunction. This gap in knowledge could be the difference between someone getting surgery or avoiding it due to prior knowledge and doing conservative care instead. Zooming out on a larger scale, I got to thinking, what role do we as PTs have in teaching individuals in our communities about the pelvic floor and any related pressure management systems before they reach the point of needing to come into our office for formal PT or surgery? Given that the rates of pelvic floor dysfunction rise with age, there's so much power to potentially reduce function, such as urinary leakage, simply through pelvic floor education at any age, at any stage in life. So that parents feel comfortable educating their kids in this space. So that grandma Betty can advocate for herself and ask for specific treatment options for painful intercourse that she learned at a talk at her community rec center. And so that Sam feels empowered to talk to their coach about leaking and lifting. One issue that's related to pelvic floor dysfunction is intra-abdominal pressure, or IAP. It's defined as steady state pressure that's concealed within the abdominal cavity, and it's created from the interaction between the abdominal wall and the viscera. It tends to fluctuate with our respiration phase and the abdominal wall resistance. the pelvic floor muscles are essential for the maintenance of this intra-abdominal pressure, as they lock shields with other muscles in the core canister, like the diaphragm, the abdominals, all to support this dynamic pressure system. If you think about it, life is a series of fluctuations in intra-abdominal pressure that affects all humans. One minute, the pressure may rise with a sudden sneeze or jumping, or it may lower to a different level when standing up from sitting, and then it may swing back up if someone is on the toilet pooping. So the ability to manage those pressure changes will differ depending on the human, depending on their relative capacity and knowledge and understanding of this pressure system. It doesn't matter whether they're a young gymnast, an older adult with low energy reserve, or a two-year-old potty training, or a yogi mom of three kids. All of those individuals are subject to changes in IAP, no matter their age or stage of life. The input IAP is the same for all of us, but we have this really beautiful ability to turn it into different outputs. We could use that IEP to manage lifting a grand kid overhead. We could use it to laugh at April's podcast this morning, to score a goal or to nail a note in a song without a pessary falling out. Education on interabdominal pressure management as it relates to pelvic floor dysfunction is not a major focus in performance, in athletics, or in life's education either. So I propose it's time for an intervention or a PT prevention intervention, if you will, So let me use the example of urinary leakage or urinary incontinence, aka UI. I'll use that as an example for pelvic floor dysfunction. UI can arise in the presence of poor intra-abdominal pressure management. A staggering 50% of female adolescent lifters leak when they are doing their sport. And that leakage, can be a barrier to entry or a barrier to continue with exercise or their sport, as well as a distractor during training and competitions. Taking it one step further, the lack of knowledge of the pelvic floor contributes to inadequate management of IAP, as say someone's lifting a heavy barbell. This lack of knowledge influences the development for pelvic floor dysfunction for some. A 2018 observational study by Cardoso and colleagues aimed to determine the prevalence of UI, urinary incontinence, in female athletes practicing high-impact sports. They also wanted to know what's the association of UI with knowledge, attitude, and practice. In their study, they found that 70% of their athletes reported UI, and none of them told their trainer about this dysfunction, and none of them sought PT care. Talk about a missed opportunity. Participants were also unaware of the positive association between high-impact sports and the development of UI. The authors found that an individual had a 2.7 times more chance to develop UI if they practice their sport for more than eight years. And this piece of information is key not only for the short term, but also for the longterm in someone doing athletics for that long. However, there was one saving grace. And that saving grace to the development of pelvic floor dysfunction was adequate knowledge of urinary incontinence. So in the study, if an individual had adequate knowledge of the occurrence of urinary incontinence in sport, then they had a 57% lower chance of developing UI. 57% chance of lowering the development of UI if they had adequate knowledge and that's just education alone. What a huge difference that can make. So in the conclusion, the authors, they called for a greater dissemination of knowledge and preventative practices for UI in sports in order to decrease the prevalence of urinary incontinence and increase adherence of young athletes to sports practice. So many individuals, some of us included, avoid talking about urinary incontinence with teachers or coaches due to shame and embarrassment, coupled with a lack of knowledge about the condition and treatment options that are available. Instead, individuals will suffer in silence. They'll spend a ton of money on protective pads, they'll restrict hydration, and some will even avoid exercise altogether. Y'all, this, this is a coaching problem. This is a teaching problem, this lack of knowledge about pelvic floor dysfunction. When the athletes in the Cardoso study were asked about whether trainers should discuss the topic of urinary incontinence, a majority agreed that the trainer should encourage prevention. But how? How can they do that if trainers or coaches aren't even educated on pelvic floor dysfunction? Research supports positive effects of education alone when it comes to improving pelvic floor outcomes. So what's needed? I believe education is needed at the community level. PTs have a unique role in teaching about the pelvic floor and intra-abdominal pressure management that could be directed either to trainers or to fine arts teachers like vocal coaches or to athletic coaches or even to the athletes themselves. This could potentially allow for the reduction of instances of pelvic floor dysfunction, as well as maybe some PRs because now they understand, oh, I have this whole group of muscles to help me, or more efficient performances where the person, the singer, the theater major isn't fatigued because they know how to optimally utilize their IAP system. Athletes and performers are not the only individuals, though, who deserve this basic pelvic floor education. The general population does, too, as it relates to their IAP management with daily functions like we talked about before, lifting the grandkid, running, sneezing, we need more pelvic floor community workshops and in services at music or dance classes in the community, in collegiate team meetings, or silver sneaker programs. These programs could potentially reduce urinary incontinence and pelvic floor dysfunction at any age or stage to allow for improved quality of life and a shame-free environment in which folks are encouraged to discuss pelvic floor dysfunction with their teachers, their providers, their friends. Furthermore, PTs can also educate on an instance that may come up, which may signal, hey, I think pelvic floor PT would be more dialed in and you could get some gold standard pelvic floor muscle training because this general education didn't work. So in a 2018 systematic review, Fonte et al and colleagues identified five risk factors for lack of pelvic floor knowledge. Number one, educational level. Number two, access to information. Number three, socioeconomic status. Number four, age. And number five, race. So community talks could focus on these populations in order to narrow the knowledge gap. I urge you to consider the role of educating your community, whether it's the grandma buddies, the baseball bends with the prostatectomy, as well as performers and athletes at any age on the pelvic floor, particularly as it relates to management of the intra-abdominal pressure, something that we all experience changes in moment to moment. SUMMARY So if you're looking for more opportunities on how to optimize your pelvic, your client's pelvic floor or folks in your community through breathing and bracing strategies, check out our upcoming live courses. We've got two I'll talk about. One is April 6th and 7th in Windsor, Colorado. That's gonna be with Alexis Morgan and myself. Come on out and learn with us. Another opportunity is the following weekend, April 13th and 14th, and that's gonna be with Christina Prevett and Rachel Moore down in Houston, Texas, my home state. And our next available 8-week online cohorts that aren't sold out yet, but you can still sign up for, are Level 1, it starts April 29th, and then Level 2, that one starts August 19th. Head to PTOnIce.com to sign up for those courses. Thank you all so much for listening, and I will see you all next time!

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