Check out this great online conference with featured speaker, Scott Hann!

He will include success stories and explain the importance of adequate Vitamin D levels.

Tuesday, Nov. 17th
8 pm Central
$25 (members)
​$40 (non-members)

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Help us reach our ideal audience. Contact Ann Marschel at amarschel21@gmail.com.

by Heidi Giroux, P.T.

My interest in Pelvic Floor Physical Therapy came shortly after the birth of my first son. I had third-degree tears and significant swelling; recovery was slow. Although the birth of this baby was surrounded by excitement, the aftermath induced a bit of fear.

I remember being in the parking lot approximately five weeks postpartum and carrying my son in the car seat. I had a full bladder, and the car seat pressed against my abdomen. I lost complete control of my bladder and had a full episode of incontinence in the parking lot. I remember crying and wondering what just happened. I had been a practicing physical therapist before the birth of my son, and I remembered reading information about how this problem can be helped.

This kind of treatment was relatively unknown 25 years ago, but there were therapists assisting patients with these issues. I decided to order the level one home study course to learn techniques and exercises to help my condition. Thankfully, the incontinence resolved itself through exercises and techniques (which are much more than Kegels).

However, after the birth of my fourth and fifth children, I again noticed leaking when I coughed or sneezed. The problem also happened when running after my children.

It was interesting to notice that it was most pronounced during the luteal phase of my cycle. This discovery piqued my interest in how hormones affect the pelvic floor muscles, reproductive organs, and supporting structures.

As I continued to study, and as I learned and understood the reproductive cycle taught in the Billings Method™, I was able to assist many patients and Billings clients with practical advice in the physical rehabilitation of the pelvic floor.

What is Pelvic Floor Physical Therapy?
Pelvic Floor Physical Therapy is a specialized area of physical therapy that involves evaluating and treating musculoskeletal and neuromuscular dysfunction related to the pelvis.

The pelvic floor is made up of muscles and other tissues that form a sling from the pubic bone to the tailbone. They assist in maintaining an upright posture, supporting abdominal and pelvic organs, and help to control the bladder, bowel, and sexual activity.

Pelvic floor dysfunction refers to a wide range of problems that occur when the muscles of the pelvic floor are not functioning normally and are often too tight or weak. Typically, there are related impairments of the abdomen, sacroiliac joint, low back, coccyx, and/or hip joint that accompany this condition, and can contribute to pain and loss of function.

Pelvic floor issues are rarely isolated. It is common for symptoms to emerge together or for one problem to cause a cascading effect and should be treated comprehensively to resolve the symptoms.

In my physical therapy practice, I schedule each patient for a one-hour session. I work to treat a wide variety of conditions but predominately urinary incontinence and pelvic pain.

On average, for urinary incontinence, patients require 6 – 8 sessions. However, many times there are other orthopedic issues. Sometimes these are combined with pelvic pain, so, for those patients, they average more like 10 – 12 sessions.

How many types of urinary continence are there?
​
There are three categories of urinary incontinence: urge incontinence, stress incontinence, or a combination of both. Urge incontinence, in particular, can be triggered by such seemingly innocuous things as cold, running water, or putting a key in the door.

All three types are treatable with physical therapy that includes behavioral techniques and lifestyle changes, and physical retraining.

When treating Urge Incontinence, we apply these seven steps:

Step 1: The patient keeps a diary over a 72-hour period that includes the number of voids, the volume voided, incidents of leakage, potential food irritants, and fluid intake.

Step 2: Bladder retraining is achieved by increasing the amount of time between bathroom visits. The optimal is to void every two to five hours. However, a patient with urge incontinence voids every hour or more often. I will ask the patient to increase that by minutes or hours. When the patient has increased time between voids with ease, and there are no accidents, we consider this success.

Step 3: The patient focuses on healthy fluid intake. That means slowly sipping throughout the day, 40-50% of body weight.  She also will be encouraged to avoid bladder irritants, which are found in fluids that are more acidic such as coffee and sodas.

Step 4: We initiate the goal of completely emptying the bladder during each void. Often during this step, breathing techniques or double voiding are discussed and practiced.

Step 5: Now we are at the point where we incorporate urge control techniques:

• Sit down when the urge comes
• Do Kegel exercises 5 – 10 times to inhibit the bladder
• Put pressure on the perineum
• Do diaphragmatic breathing
• Try to distract oneself to avoid emphasizing the immediate urge to void,
• Raise the heels or walk on your toes (my favorite and easiest)

Step 6: We discuss optimal voiding postures, such as avoiding a hunched over position.

Step 7: Avoid “just in case peeing” because when voiding for no reason, only “just in case,” the brain becomes trained to go all the time. 
These steps can be taught at any age, even during the later years. We have found that staff in nursing homes can help patients with cognitive impairment by getting them to void at intervals, such as every two to three hours. It often improves urge incontinence.

Stress Incontinence can happen during physical activity such as coughing, laughing, sneezing, running, or lifting something heavy, which puts pressure on the bladder causing urine to leak.

When treating stress incontinence, we apply these four phases.

Phase 1:  We start therapy by discussing breathing techniques. When we inhale, the pelvic floor drops. When we exhale, the pelvic floor should lift and the deep abdominal muscle contracts. Effective breathing is extremely important for continence because it gives proper pressure control.

Phase 2:  The second phase has the patient working on pelvic floor muscle and abdominal contractions coordinated with breathing. The goal would be for a patient to contract the pelvic floor with the abdominal muscles for 10 seconds 30 times per day. Caution is advised for post c-section or those athletes who tend to have very tight abdominal muscles.

Phase 3:  The patient is then taught about getting the pelvic floor muscles to work synergistically with the hip, gluteal and abdominal muscles with proper breathing patterns.

Phase 4:  During this final phase, we work on functional movement combined with proper pelvic contraction coordinated with effective breathing. Movement practices are going from lying to sitting; sitting to standing; bracing with coughing/sneezing, reaching, squatting, climbing stairs, lifting, walking, jogging, and other impact exercising.
Whether my patients are postpartum or menopausal, I take them through these phases. They help women throughout their reproductive life as well as post-reproductive life.
 
 
Some conditions treated by pelvic rehabilitation physical therapists include:

Women:
Urinary Incontinence
Pelvic Organ Prolapse
Fecal Incontinence
Constipation
Urinary Urgency/Frequency
Voiding Dysfunction
Vaginismus
Vulvodynia
Vestibulitis/Vestibulodynia
Painful Bladder Syndrome/Interstitial Cystitis
Chronic Pelvic Pain
Chronic Abdominal Pain
Levator Ani Syndrome
Coccydynia
Pregnancy related issues

Men:
Urinary Incontinence
Fecal Incontinence
Constipation
Urinary Urgency/Frequency
Chronic Prostatitis (non-bacterial)
Post-Prostatectomy Urinary/Bowel Dysfunction
Chronic Pelvic Pain
Testicular/Penile Pain
Coccydynia

​Physical Therapy Treatment:
Postural education and functional training
Education on dietary irritants and bowel/bladder diaries
Manual Therapy: soft tissue mobilization, trigger point therapy, connective tissue manipulation, dry needling, myofascial release
Movement and Exercise Training
Relaxation Techniques, breathing, down training, chronic pain education
Modalities: biofeedback and electrical stimulation

​Q.  Tell us about your family and where you grew up.
 
I was born and raised in Guadalajara, Jalisco, also known as the “City of Roses” and the cradle of many iconic things associated with Mexico such as the mariachis, tequila, the Mexican Hat Dance, and the sombreros. My father was an army surgeon, and my mom was a biochemist; I only have one brother who is a computer engineer.  We grew up having both of our parents work full time, so my dear aunts and grandma often helped, and I became very close to them. I think on those days and immediately smell my grandma’s kitchen and hear the beautiful voices of ten people talking about their daily activities. 
 
When I got older and moved to Mexico City to pursue my career, I was very fortunate to not only accomplish professional dreams but to find the extraordinary person with whom I have walked, ran, and flew for the last 21 years.  At that time, Fernando was a general surgeon resident, and currently, he is an ear, nose, and throat physician. As in any marriage, we have many stories to tell, and the best of all is about welcoming our three children: Sofia, Jose Fernando, and Natalia.
 
Q. How old were you when you knew you wanted to become a physician? Where did you study medicine?  
 
Because of my father, I was exposed to medicine from an early age. He worked in a public hospital in the evenings, and in the mornings, he had his medical consult in our home. So, quite often, I booked appointments and greeted his patients. I first had a hint of becoming a physician/researcher when I was 14 years old. My grandmother, who was like a second mother to me, was diagnosed with a rare variant of lung cancer. I remember the day when she came back from a doctor’s appointment, and she asked me to read her the pathology report. Since I had no clue what it meant, I searched for the terms in a book. What I read was devastating! I remember telling her that everything was going to be all right, even though I had a knot in my throat. She died within a year after diagnosis. Four years later, I was accepted to the University of Guadalajara, School of Medicine, and later, I moved to Mexico City to do my specialty in Internal Medicine.
 
Q. How did you end up in Durham, NC?
 
It started around 16 years ago when we started a subspecialty at the University of Alabama. At the time, I was 36 weeks pregnant with our second child, and all our belongings were inside four suitcases. We were coming only for two years, but two years became four, and so on. Because of my husband’s job, immigration policies, and educational opportunities, we have had to move several times, making Durham, NC, our most recent move, but not the last one. We are pleased to share that we are moving to Houston, TX, in a few weeks, and we hope that this will be the last one!
 
Q. How do you mix your Catholic faith with being a physician/scientist?
 
To me, being Catholic is part of who I am. It sets the values and standards that guide me. It was that feeling that inspired me to take the Certificate in Bioethics offered by the National Catholic Bioethics Center a couple of years ago. It was beneficial and a great learning experience. I appreciate having the benefit of Catholic sources to guide me in making informed decisions following the values that I cherish.
 
Q. When did you first hear about the Billings Method™, and what led you to become a teacher of Billings?
 
I heard about the Billings Method™ for the first time when I was a 4th year medical student. At that time, we were required to teach contraception to our patients. Because that conflicted with my Catholic faith, I decided to explore the methods of natural family planning that were available. That way, I could speak with my patients about these natural methods as well. The Billings Ovulation Method® caught my eye, not only for its simplicity but for the science behind it. Therefore, I decided to take the course at my home parish, and I loved it! While I did not teach the Method at that time, I talked about it to my patients. I remember women getting excited and surprised to know that a reliable, natural, and healthy method of family planning, such as the Billings Ovulation Method (BOM), existed.
 
In 2013 the priest of my local parish in Virginia invited me to teach NFP. It was at that time that I came across with the Billings Ovulation Method – USA Association (BOMA-USA). I took the teacher training course. Since then, I have been involved in different levels within the association: as a Board Member (now finishing my 3-year term), as part of the Education Committee, and as Chair of the Hispanic Committee.
 
Q. Why do you think medical students typically are not taught about NFP?  And, what can be done to change that?
 
I think there are many factors at play. Usually, among the scientific community, NFP methods are seen with skepticism and underestimated because they are perceived as unreliable and ineffective. This misconception might be due to the lack of knowledge of the various NFP methods, their differences, and their effectiveness rates. For example, the CDC, in one of its pages, lumped together all the Fertility Awareness-Based Methods and, in another, gives an incomplete and vague description of them. At least they have recently updated their website and now mention a current systematic review about the effectiveness of NFP1. That’s a small milestone! Also, within the CDC, the National Center for Health Statistics conducts the National Survey of Family Growth. This organization estimated that only 0.2% of “all women” were “current” users of NFP between 2011-2015 2; however, upon careful reading of the survey, it seems they only included users of the Sympto-Thermal method 2. These are just two examples of how the information about NFP is represented to clinicians, scientists, and the public. Misconceptions need to be clarified, so that accurate evidence about NFP is used. More well-designed research studies about NFP published in peer-reviewed journals will translate to more evidence being accessible to clinicians and the scientific community, in general.  
 
Q. As a member of the Education Committee and Chair of the Hispanic Committee, you have a lot going on in addition to your life as a wife, mother, and physician. Tell us about some of the plans the Hispanic Committee has in the works.
 
Navigating current times has been challenging, but it has opened opportunities for adaptation and growth both in professional and personal life.
 
As part of the Education Committee, and in our efforts to build evidence-based information, we have been putting together a focus group study on women users of the Billings Ovulation Method through the University of North Carolina, Chapel Hill.
 
Concerning the Hispanic Committee, it has been a unique and fulfilling experience coordinating it. We are a small committee born about 18 months ago in response to the needs of the growing Hispanic community within BOMA-USA. Since we had our first meeting, we have reviewed translated materials, training sessions, and worked to implement best practices. We are also working hard to get to know our community via fellowship hours and webinars. Currently, we are happy to be working on the first Spanish Remote Training that began on July 25. As a new committee, we have many other projects and goals that we would like to achieve and will do so one step at a time. We hope we can keep growing and getting more people interested in joining the committee.
 
 
 
 
1 Peragallo Urrutia R, Polis CB, Jensen ET, Greene ME, Kennedy E, Stanford JB. Effectiveness of fertility awareness-based methods for pregnancy prevention: A systematic review external icon. Obstet Gynecol 2018;132:591-604
2 Centers for Disease Control and Prevention. (2017, July). National Center for Health Statistics. National Survey of Family Growth. URL: https://www.cdc.gov/nchs/nsfg/key_statistics/n.htm#natural