Ask the Expert: Meredy Parker, PT, DPT

Q & A with Meredy, PT DPT - Founder & Clinician, Chicago Physical Therapist, Chicago

I found Meredy because of my amazing pilates instructor, Karin! Not only is Karin the best pilates instructor she is one of the most amazing human beings to talk to. Just like we all chat with our hair stylists, I grew very comfortable with Karin. Sharing about health, family, troubles and celebrations. We got to talking one session about what else I could do to help the healing of my body after I had my preventative hysterectomy. Karin mentioned physical therapy or really pelvic floor physical therapy. She saw this amazing therapist not to far from where we were (Pilates + Coffee in Roscoe Village, Chicago) and she highly recommended the practice- Chicago Physical Therapists.

I remember I reached out and received a response hours later. I spoke directly with Meredy, founder and clinician, and given what I shared with her she recommended I come in and see her and her collegue Sarah who I’ll be doing a Q&A with in August! I started going to this practice almost 2 years ago and it’s been such a healing stepping stone in how I feel in my body.

I’m truly grateful for the lessons I’ve learn, the practices that I continue to do at home and the connection I have with Meredy and her practice! Thank you Meredy for taking the time to do this Q&A with me!

1. What is the pelvic floor and what is its role in the body?
   **The pelvic floor (PF) comprises a group of muscles lining the bottom of your pelvis, running from the pubic symphysis joint near the vaginal opening to the tailbone. Not only do these muscles support pelvic organs and joints, but they also play vital roles in sexual function, continence, and even help circulate lymphatic fluid back to the heart. Interestingly, PF dysfunction often intertwines with hip pain, highlighting the intricate connections within our body. These vital muscles also encircle both the urethral, vaginal, and rectal openings.

2. I was told my pelvic floor was super tight and weak. For those that are not familiar, like I was, what caused these muscles to be so tight?
   **Just to clarify, when I refer to “PFM dysfunction” this can be weakness, tender or trigger points, and both of these issues can be in the presence of a normal length PF or a short/tight PF. Most of the time a short PF is also a weak PF. The causes for an overactive PF vary from patient to patient but it’s more common than you might think. A few examples that might bring on an overactive PF include: Any sort of pain in the pelvic or hip region- could be as extreme as a pelvic fracture from a car accident or other trauma, a tailbone fracture from a fall on your bum, or even stress fractures in your pelvis or hips during intense training. Other associated issues that could lead to a tight PF are hip pain from arthritis, bursitis, gluteal tendonitis, sacroiliac or spinal pain. Scar tissue in the region from radiation therapy or gynecological surgeries can bring about a protective guarding of the whole region and is often associated with PFM tension. Women recovering from gynecological cancers, whether they have undergone localized radiation and/or surgical interventions (hysterectomy etc) that bring about menopause, often have PF tension for many reasons. The estrogen binding drugs all have an extremely important influence on the tissues throughout this region and are also associated with joint pain, bladder symptoms, and painful intercourse. The body can become very guarded and then go into a cycle of pain and more muscle guarding. As a PF therapist, we need to be able to distinguish between PF dysfunction that is more musculoskeletal rooted verses that which is more hormonally driven. In many cases it’s a combination but both of these components need to be addressed. I often send clients back to their doctor to try to get them an approved topical moisturizer and sometimes the doctor will give (even people with a cancer history) localized topical DHEA (which is a precursor to both testosterone and estrogen) or localized vaginal estrogen. These are prescription and of course need to be discussed with your doctor. There are a number of non-hormonal vaginal moisturizers that also should be approved by your doctor but can be very helpful. The practices of topical estrogen have changed in the past few years so be sure to check with your doctor.

3. Can stress add to PFM dysfunction?
   **The PF is very connected to the autonomic nervous system. This is the part of your nervous system that regulates your response to stress. It’s made up of the (SNS) sympathetic nervous system and the parasympathetic nervous system (PNS). There is well established research that the PF responds to stress; the PFM grip and tense in response to stress. The upper trapezius as well as the jaw muscles are also connected to the stress response in a similar way. Often times people with high stress levels hold extreme tension in all or one of these three muscle groups. A constantly overactive or gripping pelvic floor can lead to many symptoms discussed below.

4. Why would someone maybe leak urine when they have a tight PF- Doesn’t that mean they are really strong?
   **Any muscle that does not “let go” or elongate in between contractions, is less resilient. The PFM needs to be able to absorb shock and this actually means having “give” or ability to absorb force. When you land on your feet from a jump or you sneeze or do a sudden sprint, your PF needs to absorb that shock and then contract back up or you might leak urine, gas or fecal material. Imagine trying to jump on one leg with a fully straightened knee with very tight leg muscles- this would hurt and possibly cause injury. In PF Physical Therapy (PT), we do a combination of manual release of the tight or immobile structures but also focus on proprioceptive training and breath work to help the client sustain the manual release work performed. We could manually release a PF every week but, if the person goes right back out into their world with unchecked stress, a poor breathing pattern and does 500 crunches a day, the tension will return quickly. It’s amazing what our bodies can do with some gentle guidance to unlearn the pattern of gripping and tension; it just takes some time and consistency.

5. What are the signs of pelvic floor dysfunction?
   **Top six issues I see in a typical week in my clinic: 1) Painful intercourse or pain with any attempt at vaginal penetration (trying to put a tampon in, PAP smears etc), 2) Difficultly with emptying the bowel or bladder or any persistent bladder or bowel pain 3) Tailbone pain 4) Incontinence 5) Lack of ability to orgasm or pain during or after orgasm, 6) Sacroiliac, Spine and hip pain. The ages of women that present with the above issues range between 20 to 80 years of age. This huge range of age is very significant as these issues present for many different reasons. People recovering from cancer often get thrown into symptoms of menopause on top of all the challenges they face with having cancer. So many women do not feel heard and do not know where to go or who to talk to about these issues. Many are not even aware their symptoms are related to hormone changes. If you have had cancer or are in peri-menopause and you don’t feel your sexual wellness, continence, joint pain, exercise needs (I could go on…..) have been fully addressed, please tell your doctor that you would like to be referred to a physical therapist. If you don’t feel comfortable having your PF checked internally, please know that is NEVER a requirement. There are many other ways we can help. Joint pain, even when one is on an AI, can be influenced and even resolved in some cases by prescriptive exercise combined with manual therapy, taping, needling etc. If you’re having joint pain or PF concerns that are inhibiting your ability to do ALL the things you want to do, I highly encourage you try a few sessions with a physical therapist to look over your hips, back, pelvis and get you started on the best program for your specific needs. Starting with isometric and eccentric strength training can be an ideal way to get you strong and then guide you to a more pain-free path to meeting your ideal fitness goals. Joints and tendons are very influenced by estrogen!!! Working with someone that is knowledgeable on these connections is very important.

6. How can weak pelvic floor muscles impact your body?
   ** The PFM is connected both anatomically but also functionally to the abdominal and back muscles. Weak PFM can impact your ability to optimally engage these muscles and this is why people with PFM dysfunction have a higher incidence of SI, back or hip pain. Weakness can also, as mentioned above, influence sexual function as well as continence. It’s difficult to know what to do if you’re not aware of what exactly your PFM pattern is. Some women really do have full-out loss of strength and low tone of the PFM and need to focus primarily on strengthening. Guidance on the most optimal way to strengthen your PF is super helpful for most women and it’s NEVER just doing “Kegels”.

7. What can you do to support and strengthen your pelvic floor, Pelvic floor exercises or training?
   ** The number one strategy I like to begin with is optimal breathing. This is an excellent way to ensure full elongation of the PF to then optimally contract and strengthen. If you are starting out in a shortened position, it’s nearly impossible to work on the strength. Then, I move into a mix of various PFM strength exercises as well as functional training in various positions. I typically go through daily activities and the exercise of choice for each client to practice and discuss what their PFM are doing in that pose or during each exercise. For example, if someone is doing plank holds, we will practice together and talk over what they feel the PFM doing as they breath. A lot of fitness classes emphasize holding the PFM tight with the core for prolonged periods of time. I try to help the client recognize that, when tensing the PFM fully, it’s difficult to even take a deep breath. Experiencing the PFM and breath in all different positions is often key to the client being able to start to connect with the real function of their PFM and how it’s vitally connected to breathing.

8. You helped me with more than just my pelvic floor. During one of my sessions, I had a decent amount of pain in my hips (side effects from trying the 3 aromatase inhibitors to determine what one I would be lucky enough to stay on for the next 4 years). You suggested Functional Dry Needling, can you share a little bit about this?
   ** Please see above references to hip and joint pain as this is VERY REAL.  I wish every person on these medication would have an automatic referral to a pelvic health PT that is also well-versed in hormonally driven joint pain. Dry needling is an amazing intervention that helps to calm down painful muscles. I think of it as an AED to the muscles. It typically causes a localized twitch response in the muscle that the needle is placed in. This twitch causes the muscle through a variety of processes to release and let go. It has been shown to immediately improve the range of motion of the surrounding joints and it also typically allows the client to better activate as well as release the muscle. The effects are often drastic and very quick so my clients love it. For hip and back pain the muscles I most often needle are the gluts, the piriformis and the lumbar or thoracic multifidus. It works extremely well on the upper trap and jaw muscles too. The needle is very thin (like and acupuncture needle) but it’s not acupuncture which is used by specialized practitioners that are aware of how to influence meridians that I am not trained in. I never suggest dry needling as an alternative to acupuncture as the two are very different and dry needling is not acupuncture.

9. In addition to pain we talked about the Vagus Nerve as well. What is the Vagus Nerve?  One of our most recent sessions introduced me to Sensate. How can stimulating it to function properly impact the way your body feels? Are the Vagus Nerve and pelvic floor muscles connected?
   **The vagus nerve is the longest nerve in the body. It runs from the head and travels down to vital organs. It is key to the mind-body connection you’ve likely heard about. Low tone in the vagus nerve is associated with a huge list of symptoms but a few are: Anxiety, headaches,gut issues, chronic fatigue, pain. As mentioned above, the PFM  is a muscle that actually does have innervation with the autonomic nervous system. The PNS listed above (the “fight or flight “) can be down regulated through various means. This is often referred to as ventral vagal nerve stimulation. This can have amazing influences on our physical and mental health. The “Senate” is simply one of many tools and strategies used to help our system move more into the ventral vagal mode; hopefully leading to less anxiety and pain. Other ways to influence this nerve are humming, deep breathing, meditation/prayer. The “Sensate” is a device that vibrates on your chest and is attached to an app with various calming sounds. Humming or singing you can do on your own vibrates the chest wall and influences the vagus nerve in a similar way. Anyone with chronic stress or chronic pain will benefit from ventral vagal nerve stimulation.