And remember to hit her up on twitter because she loves to talk about her passion!!
5 Myths about Pelvic Floor Dysfunction by Ann Wendel
Ok, the cat’s out of the bag. Crossfit HQ recently released a video where women admitted that they sometimes “pee during workouts.”
I want to believe that the video was made with the intention of increasing awareness of Stress Incontinence. I think it’s a great thing that a community as large and as dedicated as the Crossfit community would bring attention to this issue. Yet, there were multiple erroneous and misleading statements made in the video, even by a gynecologist from the crowd. And, more disappointing, no follow up effort has been made by Crossfit HQ to provide correct information or resources for the women who viewed this video and thought, “That’s me!”
Several other women’s health physical therapists have written excellent blog posts about this topic since the video was released. My purpose in writing this article is to dispel 5 Myths about Pelvic Floor Dysfunction, and point men and women to resources to address this issue.
Myth #1: Leaking during exercise (or sneezing or coughing) is normal.
Truth: Leaking urine during exercise is common, but not “normal.” In the U.S., the national average of women who experience incontinence is 1 in 3. A study done by Thyssen et al (2002) surveyed 291 elite female athletes competing in a variety of sports from basketball to ballet, regarding their history of urine loss during participation in their sport or day to day activities. 151 reported leakage of some kind. Of the 151, five discussed it with a medical provider, and only six got pelvic floor training. (1) Can you imagine only 5 out of 151 athletes with an ACL tear seeking treatment? That would never happen! The responses in the Crossfit video show that incontinence is very prevalent in the athletic community, and that most women do not seek treatment because they are either embarrassed or they assume it’s normal because everyone else they know has the same issue.
Many of the women interviewed in the video stated that they “leaked urine every day” and that they always leaked during box jumps and double unders. One woman stated “Two kids, it’ll do it to you.” While it is true that childbirth can be one of the factors that contribute to pelvic floor dysfunction, not all women experience incontinence after childbirth; and, it can be treated if it occurs.
Sadly, the “interview” with the GYN did little to help these women – this healthcare professional stated that it was her professional opinion that “it’s ok to pee during double unders.” THIS IS NOT O.K. (It is not your fault, but it is also not o.k.) Any women’s health physical therapist will tell you that it is not o.k. to leak urine when working out (or coughing, or sneezing). It is a sign that the whole system is breaking down, and the pelvic floor is just the place it shows the most at the time. This brings us to Myth #2.
Myth #2: It is perfectly fine to keep doing the activities that cause incontinence.
Truth: Julie Wiebe, PT, does an excellent job of addressing this myth in her blog post stating: “Incontinence is just one way of identifying a pelvic floor insufficiency. It is a signal that an imbalance in the deep core exists. The deep core is a closed pressure system, and insufficiency in any component will impact the capacity of the whole. A female athlete may not be incontinent, but do they have any hip pain? Or low back pain? How about osteitis pubis? Pain, joint instability and incontinence are all just signals that the system as a whole needs attention.”
In my own practice, I rarely have a patient that comes to me specifically for incontinence. Many female patients come in with complaints of low back, hip or knee pain. As part of my initial evaluation, I ask every woman if they ever experience any incontinence. Over half of the women will say no, until I press, and then they admit that they do. What they don’t understand is that pain in the knee may be related to weak and/or uncoordinated pelvic floor and hip muscles. Chronic groin strains, IT Band Syndrome, Trochanteric Bursitis and Patellofemoral Syndrome are a few of the common diagnoses that female patients seek treatment for – an integrated approach is necessary to identify the root cause of the issue and to successfully treat the problem.
If you experience incontinence with running, box jumps or double unders, STOP. Seek help from a qualified women’s health physical therapist, even if your GYN states that you don’t need physical therapy. Be an advocate for yourself and seek treatment. The Section on Women’s Health of the American Physical Therapy Association has an index of providers.
Truth: Many coaches mistakenly say that none of the women at their box has this issue. To that I say “Most of them wear a pad. Every single workout.” The reason that the issue came to light twice at high level Crossfit competitions in the past few years is that those women either didn’t wear a pad that day, or they soaked right through the pad. The majority of women I treat tell me that they wear a pad to every single WOD because they know (or are afraid) they will leak. These are fit looking women that no one would ever suspect have this issue. These are women of all ages – from their 20’s to the Masters Division.
Other behaviors reported by my patients that can clue coaches in to the issues include:
- Avoidance of certain exercises (they say “I can’t do double unders, or burpees, or box jumps”).
- Limiting intake of water to keep the bladder empty (bad strategy due to possibility of dehydration and the fact that concentrated urine/dehydration can irritate the bladder and increase urgency).
- Running to the bathroom immediately before box jumps or double unders begin (need to completely empty the bladder one last time before attempting these exercises).
Women may not feel comfortable discussing these issues with coaches; however, it is possible to include questions about incontinence on your intake forms along with providing resources in your area (coaches can reach out to local physical therapists and even sponsor a local physical therapist to come in to give a talk on the issue). Your goal is to keep every one of your members strong and healthy.
Myth #4: Doing more Kegels is the only way to treat incontinence.
Truth: This could be an entire blog post right here. In fact, Julie Wiebe, PT has done multiple posts with videos to address this myth. The truth is that the pelvic floor is part of a system and all of the parts need to work together to prevent problems. Some women do have weak pelvic floor muscles, and learning to properly activate the pelvic floor as part of the system during exercise is beneficial (learning to contract the pelvic floor as you exhale during exertion in a lift). Other women have an overactive pelvic floor (what Julie calls a “high, tight pelvic floor”). In this case, the muscles may be overactive/weak or overactive/strong but still not coordinated with the respiratory system. Either case can lead to leakage.
Julie explains this well (quotes and photos from Julie’s website used with permission):
Central stability (commonly communicated as core stability) requires a balance of all the muscular contributors and the capacity to create a subconscious neuromuscular strategy for graded engagement to meet the demands of the task at hand. Incontinence and lack of lower quarter control are both signals that the balance of the strategy and/or strength of the central stabilizer muscles are off.
Balanced pressure system
Imagine squeezing the balloon in the middle, just like the pressure a sustained abdominal hold would create. The causes the air in the balloon to shift up, out the top, and down, out the bottom.
The pelvic floor may not be able to match the excessive pressure from above, which can lead to incontinence.
Julie has an excellent video on her You Tube channel explaining this.
I will cover this topic in greater detail in future posts.
Myth #5: This isn’t my problem; women have doctors to help with this stuff.
Truth: As a coach, you spend infinitely more time with the women at your facility than any doctor ever will. Most members attend two or more sessions a week, adding up to over 100 hours spent in your facility per year. Contrast this with the 15 minutes women spend with their gynecologist per year. You have the ability to address incontinence in your facility by talking about it, asking questions, integrating proper central stability into your programming, and directing women to local resources such as women’s health physical therapists and gynecologists who understand the issue. Please do not assume that women are receiving the care they need. We can train the pelvic floor and central stability mechanism just like every other muscle group in the body. This will take a coordinated, team effort from coaches, physical therapists and gynecologists; physical therapists are here to help. Let’s start a dialogue in the comments section!
1. Thyssen H H, Clevin L, Olesen S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J. 2002;13:15–17.