Today was my first workout after hurting my back a few weeks ago.

Yep…after 6 years with no significant back pain, I lost my balance while trying to put pants on half-awake in the dark 🤦 and found myself suddenly with back pain & spasm. What did I do next?

I stayed calm.
I kept moving in ways that felt OK.
I avoided movements & positions that didn’t.
I respected my pain and let the dust settle.
And as it did, I kept moving & respecting my body.

I said no to certain things – even when I wanted to say yes – like when my husband suggested taking our girls skiing (they are just learning so likely lots of helping/lifting them back up on their skiis, all while not being a confident skiier myself). I also took a complete break from the gym.

And after feeling great, today was my first day back…So WHAT DID I DO?

I made “DO LESS THAN YOU THINK YOU CAN” my mantra & kept it on repeat with each decision I made.  I did this is to ensure early wins which I can then keep building on.

I warmed up appropriately, listening to my body.

I kept the load low.

When my brain wanted to say “GO!”, I reminded myself “SLOW.” I substituted movements, even if that meant doing something completely different from what was on the board.

I reminded myself that SOMETHING > NOTHING.

I accepted that right now, INTENTION > INTENSITY.

I respected my NOW body, so I can keep moving forward.

Because I can always add a bit more load/intensity/ROM/any other exercise variable tomorrow, IF today goes well.  But doing too much, too soon will set me back.

Because, you can’t rush it.

Instead:

Let the dust settle, then build it back up.

Identify your pain triggers & then avoid them (for now, not forever) – this may mean moving differently or it may mean avoiding something altogether.

Be assured that in the absence of any red flags (which should be screened for), you are going to be OK.

Respect your NOW body, while also applying intentional, progressive overload in a manner appropriate for YOU (and everything that comes with that). Need some help navigating your way back to the gym or whatever activity you love?
Need some help understanding the WHY & HOW?

I’m here.

Teresa Waser, RX Physio

Originally published on Jan 4, 2020 at Teresa Waser – RX Physio (@rxphysio) • Instagram photos and videos

In short, no.


And if you are telling women that their diastasis rectus abdominus (DRA) is going to cause pelvic floor issues, please don’t. I know you are well intentioned but we don’t have evidence to back that up and doing so can add more unnecessary fear onto their plate.

But seriously, if at some point you read the Spitznagle study (2007) that appeared to link DRA with pelvic floor dysfunction or someone has told you this, it’s important that you also read Kari Bo’s study (2016) which disputed those findings and discussed some of the methodological issues with the Spitznagle study.

If you don’t have time to read the article, here’s what Bo et al found: – Pelvic floor muscle (PFM strength) and endurance was BETTER in women with DRA than in women without during pregnancy. – There were NO significant differences in PFM function between women with or without DRA at 6weeks, 6months, and 12months postpartum. – At 6 weeks postpartum more women WITHOUT diastasis were diagnosed with POP stage 2.
In summary, during pregnancy and the 1st postpartum year, those with DRA were NOT more likely to have urinary incontinence or pelvic organ prolapse (POP) than those without. They were also NOT more likely to have weaker pelvic floor muscles.

With more research, things could change but until that time, we should not claim associations between DRA and pelvic floor dysfunction.


Find the Bo et al (2016) article, “Pelvic Floor Muscle Function, Pelvic Floor Dysfunction, and Diastasis Recti Abdominis: Prospective Cohort Study” here:
https://onlinelibrary.wiley.com/doi/abs/10.1002/nau.23005

#diastasisrecti #DRA #diastasisrectusabdominus #postpartum #pregnancy #prolapse #POP #incontinence #leaking #pelvichealth #pelvicphysiotherapy #pelvicfloor #womenshealth #femaleathlete

Y’all know how much I LOVE coffee.

Coffee is nectar to my soul, the elixir that promises that together we can accomplish ALL the things, and the comfort that I crave each morning.

BUUUUT……. Coffee is also a bladder IRRITANT.

It’s sad but true.

It can make you feel like you have to go pee more frequently, make the urge to go pee stronger, and it can worsen leaking.

Now I’m not hear to tell you to stop with the coffee. You get to make your own decisions and trust me, I get your love for that liquid black gold.
But I want you to be informed so that you can make your own decisions as to what is best for YOU.

Try abstaining from coffee for a week as see if your symptoms change. If they improve, well now you know!

Maybe that will mean that you stop drinking coffee (crickets chirping 🦗🦗🦗)
Maybe that will mean that you have just 1 cup rather than 2.
Maybe that will mean you switch to a lower acidity decaff coffee (which though still an irritant may be less so for you).
Maybe that will mean that when you look at the WOD and see double unders, you will skip your cup ‘o joe for that day, or just push it back until after your WOD.

For me personally, one cup is fine. But any more than that and my bladder is definitely irritated. This means that after 2 cups, I feel like I need to pee during double unders. For others, it might mean a leak. Everyone’s threshold is different. You might do better with none 😱. But once you know, then you get to make the choice based on that knowledge.

And coffee is just one of many potential bladder irritants. This is small part of what we often go through (amongst LOTS of other stuff) when dealing with concerns such as urinary urgency, frequency, bladder pain and leaking.

Need help with an unhappy bladder? Give me a call.

Teresa Waser, RX Physio

Sometimes well intentioned health and fitness professionals hurt people with their words.

They say things like…
“You have prolapse so you shouldn’t run anymore.”
“If you do those exercises, your diastasis will get worse. Only do the “safe” exercises.”
“You leak when you jump? Well that’s normal after having kids.”
“Why do you need to lift that heavy anyways?”
“You should just bike or swim, or take up yoga.”

The underlying message is that you are broken and if you aren’t careful you could end up more broken. Do less. Be less. Accept it.

Except that it’s bullshit.

Sometimes restrictions ARE needed. But even then, it’s often temporary and with appropriate modifications and progression, we can move forwards towards what you want to be able to do. We can find ways to manage and progress.

A lot of the time though, that well intentioned fear mongering restricts people unnecessarily – holding them back from pursuing the athletic endeavours that make their hearts sing, the ones that we know are best for optimal bone density, the ones that drive wondrous adaptation in our cardiovascular and musculoskeletal systems, and the quite frankly, the ones that keep many of us sane.

Athleticism brings us JOY.


And I’m ready to fight for that – for everyone who (good intentions aside) has been sidelined from life and from themselves, by unnecessary restrictions.

If you are looking for a physiotherapist who will work WITH you to help you do the things that bring you joy, give me a call.

Teresa Waser, RX Physio

The picture above is a throw back to August 2018, when I was at my leanest.

I had worked with a nutrition coach, measuring and tracking every macro, to get to a goal of “shredded” for a photoshoot. I wanted to “look the part”. I wanted to prove that I could do it. I wanted to be comfortable in my skin. I expected that being lean would mean I would have more credibility, more respect, and just maybe, more self love.

I got a lot praise at my leanest and – I won’t lie – the compliments felt great. I loved wearing whatever I wanted without worrying about my squishy bits showing. It felt good to have strangers approach me and ask what I did for fitness – as if I was suddenly more knowledgeable or credible based on my appearance. But aside from that, there was a lot that being leaner DIDN’T do for me.

Did it ACTUALLY make me more credible and respected? Nope. Being leaner didn’t make me more qualified to teach a deadlift, write an effective running program, or even to inspire my athletes or patients. They are more interested in hearing what I have to say than judging my waistline. And any that ARE judging? Well that has a lot more to do with their own baggage than it has anything to do with me.


Did it make me more loved? Nope. My little girls see me as the most beautiful, strong and awesome Mom in the world, no matter what. And bless his undiscerning heart, my husband thinks I’m sexy any day at any size. And my friends? My real, true friends don’t give a flying F how lean I am. They just want me to be happy. They love me for who I am, not what I look like.

Logically, this makes sense (duh). I don’t love or respect anyone else less based on their weight – so why should it be different for me? Oh… but it is, right? Don’t we hold ourselves up against different standards? Aren’t we often the harshest critics of ourselves, even while we bestow kindness, love and acceptance to those around us? I can’t be the only one!

Now, months later – I’m a bit heavier. I’m not as lean. I have noticed that I don’t get all the compliments anymore – and that’s OK. But other than that, nothing has changed. My family and friends still love me the same – perhaps more as I’m happier when I eat the damn chocolate. Maybe you are too.

If you have weight loss or body composition goals, I will NEVER shame you for that. Trust me, I get it and your body = your choice – ALWAYS. If you are like me, you were brought up in a society that tells us that as women, smaller is better. We have been programmed to believe that how we look matters more than it actually does and certainly more than it should. That programming doesn’t change overnight. We can’t just wish those beliefs away. They are interwoven into our values, our attitudes, and our concept of ourselves and our place in the world. But we can work on them.


My beliefs and the power that I give to my appearance in defining my self worth – those are things that I am working on every day. Some days I have all the self love… and other days, the dialogue in my head when I look in the mirror is not cool. It’s a process. So, wherever you are in this, I’m with you.
Perhaps losing weight is something that you are pursuing for health reasons, based on medical advice. If that’s the case, you have my full support in your journey towards a healthier weight if that’s your goal. And if you have these goals for other reasons including aesthetics, I will hold space for you. You are still welcome here.


But if you already ARE a healthy weight (whatever the hell that is – a conversation for another day as size does NOT dictate health!), perhaps it’s time you gently challenged your own beliefs regarding what defines your self worth. Perhaps it’s time you realized what being leaner DOESN’T do for you. And maybe then, you might be just a little more accepting of the person in your mirror as well.


Because you are so much more than your appearance.
You are more than your 6-pack abs or lack thereof.
You are more than the number on the scale.
You are amazing. You are beautiful. You are worthy.
Just as you are.

Originally published May 6, 2019 at Teresa Waser – RX Physio (@rxphysio) • Instagram photos and videos


#imwithyou #selfacceptance #selflove #ongoingprocess #notperfect #imperfectlyperfect #amazing #beautiful #worthy

I like to think of the analogy of heading out for a road trip, where knowing your risk factors is kind of like knowing what the road conditions are. If the roads are clear and dry, your risk of crashing is less than if it’s raining, foggy or icy, but there’s no guarantee. We might want to know the road conditions so that we can control what we can to help manage our risk (for instance, adjusting our speed, our level of attention to the road, maybe threw some winter tires on, or in some situations maybe even choosing to delay our trip), but we shouldn’t stay home every day because we are scared of crashing.

In the world of pelvic health, it appears that pelvic floor measurements are like the road conditions – they help us assess your relative risk for pelvic organ prolapse. Having a favourable gh+pb (<7cm) and great pelvic floor muscle function indicates that the roads are dry, but it doesn’t mean you are invincible. Just like HOW you drive matters, HOW you exercise matters! The road conditions are just ONE factor of MANY that will determine whether you end up in the ditch or not.

Just as you might want to check the road report before heading out on a roadtrip, you might consider getting a pelvic health check so that you can best manage your risk. The truth is, we don’t have all of the answers. We can never say that we can prevent POP, just as we could never say we can 100% prevent car crashes. But there are certainly things we can do to keep you safer on the road.

Maybe you want good brakes, grippy tires, and traction control in your car (improve your pelvic floor strength and coordination)… Maybe you will control how fast you drive and how you take your corners (manage how you exercise, your strategies and the loads/intensity that you use)… Maybe you will keep your eyes on the road (self monitor for signs and symptoms)… Maybe you will even put on some winter tires (use a pessary)… But you should still get out there and drive. Because out there…that’s where life happens. And I want you to live the fullest life imaginable, harnessed with knowledge that empowers you.

– Teresa Waser @rxphysio

Originally published April 30, 2019 at Teresa Waser – RX Physio (@rxphysio) • Instagram photos and videos

#pelvicorganprolapse #POP #pelvichealth #pelvicfloor #womenshealth #postpartumfitness #prenatalfitness #physiotherapy #physioswholift #fitmoms #femaleathletes #girlswholift #crossfit #fitness #physiosincrossfit

What if what we actually needed to do was to cue for LESS tension?

Often times with pelvic floor symptoms, we may focus on cueing to contract the pelvic floor, to INCREASE the tension. Sometimes this works and often it doesn’t.

Do we check to see if the cues and strategies we are using are actually working for the person in front of you? And if we don’t check, how do we know that it’s actually helpful?
#testretest

And if your cueing isn’t working, what do you do? Do you tell them to keep working on it anyway? Do you try another cue to add tension elsewhere such as TA? Or do you try to incorporate an exhale?

What if the issue is that they already OVER-recruit relative to the demands of the task at hand?

Our pelvic floors need to be dynamic and responsive. They need to provide adequate support – not too little, but also not too much #goldilocksprinciple
The strategy matters because #tensiontotask matters.

Your pelvic floor may indeed need more tension but it might also need less. Check if the cues you are using are actually working and if they aren’t then #dosomethingdifferent

If you are a PT or coach working with women and you aren’t sure how to do this, let’s chat. Or better yet, come on a @physiodetective course such as The Female Athlete Level 1, 2 and Masterclass that I act as a Senior Teaching Assistant for, or come on my TIIPPSS-FC course with @reframerehab where we cover tension amongst many other factors that can optimize how we approach pain, pelvic symptoms of leaking and prolapse, and performance concerns.

If you are someone dealing with pain or pelvic floor issues , I’m here to help. Send me a DM or come and see me in clinic @rxphysio

Originally posted April 30, 2019 at Teresa Waser – RX Physio (@rxphysio) • Instagram photos and videos

#pelvichealth #pelvicfloor #pelvicorganprolapse #stressurinaryincontinence #incontinence #leaking #postpartumfitness #womenwholift #fitmoms #crossfitmoms #femaleathletes #physioswholift #physiotherapy #rxphysiotherapy #physiosincrossfit

“Oh Mommy…I’m so sorry,” my 6 year old said as her little fingers traced the long scar across my lower abdomen. “Why are you sorry, honey?” I asked, taken aback.

“Your scar…it must have really hurt…. Did it hurt to have your babies?” She looked up at me with her sweet blue eyes, conveying concern under her furrowed brow. “Well it did hurt a bit at the time,” I answered, “but it doesn’t hurt at all now. And I’m not sorry about it. I would have a hundred scars if that’s what it took to have my girls.” I smiled at her reassuringly.

She smiled back and planted a gentle kiss on my tummy, kissing me all better of course. And then she danced off to play.

I looked at myself in the mirror. I had stepped out of the shower moments ago and stood in my underwear and sports bra in front of the bathroom mirror. Along my tummy, a thin scar was strung from hip to hip, with a midline vertical extension of a few inches – as if pointing towards my odd-looking belly button. I looked at it and realized that I truly was not sorry for it. And yet, why then did I hide it?

I wear high waisted leggings – heck I even wear high waisted bikini bottoms. I wear cover-ups at the beach and one pieces at the swimming pool. I hide it so others don’t see. I hide it in case they feel that it is ugly…in case, the view makes them think that I am less. I don’t want their judgements to steal or dampen the acceptance and pride that I have in my journey.
But the truth is that hiding it to protect myself and my story from judgement, also means that I cover the triumph that my scars represent. It means that my daughter sees it as something to hide, something that I am sorry for and that is not what I want.

My scars are my reminder of my journey through motherhood – my reminder that my body carried my beautiful twins earthside. They remind me that my tummy grew and stretched as it held onto them, answering my prayers that they would not arrive before they were ready for the world. With this, my connective tissue gave way to them, accommodating their growth as nature intended.

I was brave in my journey, but I have not been fearless in the aftermath. I have hidden my scars and only shared my story with those that I trust. But in recent months, I have been reminded that we acquire courage by practicing our bravery. Sharing our stories – as raw and vulnerable as that can feel – can allow others to step into the light that our bravery creates, so that they may feel less in the dark.
So in case you haven’t seen my scar…here it is.
And no, I’m not sorry.

Originally published March 16, 2019 at Teresa Waser – RX Physio (@rxphysio) • Instagram photos and videos


#diastasisrecti #diastasisrectirepair #diastasis #twinmama #physiotherapy #postpartum #restore #strengthen #journey

When HOW matters more than WHAT:  TIIPPSS-FC – A Framework for Changing Pain, Pelvic health symptoms and Performance

Perhaps you are a CrossFit athlete who leaks during double unders,

or a mother who feels bulging in her perineum when she lifts her toddler,

or a runner who becomes symptomatic during longer runs,

or an athlete experiencing back pain during Olympic lifts,

or a senior suffering knee pain when going down the stairs.

or perhaps you are a healthcare or fitness professional working with individuals who are limited by such symptoms.

What can you do?

In all of these situations, there exists a good possibility that we can change the individual’s symptoms with a task or activity by changing HOW they do it.  As my friend and mentor, Antony Lo (aka The Physio Detective) would put it, we can do this by getting them to #dosomethingdifferent.  But WHAT?  How do we find the difference that will make the difference?  How do we know where to begin? And if that doesn’t work, what else we can try?

Travelling around and teaching alongside Antony, it occurred to me that these questions were coming up pretty frequently.  Additionally, I would sometimes hear from healthcare & fitness pros who were trying to #dosomethingdifferent with a client but had gotten stuck – out of ideas and unsure to do next.  What I heard was that we needed a framework.  And out of that, TIIPPSS-FC was born.

TIIPPSS-FC is a handy acronym that I came up with to help us consider all the categories for potential variation that we may try as a means to change someone’s symptoms and/or performance with a given task. 

Let’s break it down…

T – Tension

I – Impact

I – Irritability

P – Posture/Positions

P – Pressure

S – Strategy

S – Sensitivity

Ideally, we want to optimize the TIIPPS and then consider FC (Fatigue and Capacity).  More on FC later…

So what do we mean by these?  Let’s elaborate a little…

Tension

This is all about having the right #tensiontotask – not too much, not too little.

Are we overcooking the tension in the pelvic floor musculature?  If so, what if we cued the person to relax or “soften” the pelvic floor during the activity?  Or to imagine the pelvic floor as a trampoline that yields as it’s loaded with impact?

Or if we are undercooking, what happens if we dial up the tension in the pelvic floor (whatever that means to the person)?

What about full body tension?  Are we tensioning ALL the things?!  Think of the athlete who is tensing every muscle in their body as they try to squeeze out one more double under.  What would that level of tension potentially do to the dynamic responsiveness of our pelvic floor?  To the intraabdominal pressure?  To the demands on the pelvic floor and our continence mechanism?  To our athletic performance overall?  What if we let that go?  Try to relax that tension – letting the cheeks jiggle as we run or jump (yes, all the cheeks!)?

What is the potential impact of emotion on tension?  For instance, fear of falling when running downhill?  Or fear of leaking when skipping? Or fear of injury?  How could we potentially change fear or emotional state to alter tension?  Perhaps distraction? Visualization?  A positive memory? Foot in the door technique?  Changing context, environment or equipment?  Music? Our tone of voice and the confidence (or lack thereof) that we display as their care provider?

What about from a pain standpoint – can we potentially alter pain by modulating tension?

Aside from #allthetension, what if we have focal tension in one area of the body?  And if so, what if we tried to take that tension and dispersed it around the whole body, as if to #spreadtheload?  As if taking a glob of paint in the area of focus and then spreading it out to paint over the whole of our body?

Impact

Modulating impact can change symptoms.

Close your eyes and listen to the footfalls – whether running, skipping, jumping or in the catch of an Oly lift.  What is the impact like – an elephant or a ninja or somewhere in between?  Can we make that impact softer?  Can we reduce vertical excursion?

What about other impacts such as the Oly lifter who sustains vertical loading onto the torso when catching the barbell in a squat clean?  Or the equestrian who is symptomatic when landing in the saddle as the horse is cantering or landing a jump?  Or the softball athlete who’s bat connects to the ball? There are various impacts to consider depending on the athlete and the activity.

Irritability

Bladder and gastrointestinal irritability can really impact pelvic floor symptoms.  Dietary factors such as the consumption of bladder irritants can exacerbate urinary leaking and urgency and, anecdotally, POP symptoms as well.

If you tick off your bladder with a pre-workout drink, energy drink or diet soda (those three are aka bladder irritant soups), coffee, sparking water or any of the other common bladder irritants, the muscular bladder will contract more frequently and forcefully, making it harder to stay dry.  Other bladder irritants can include spicy foods, acidic foods such as citrus, artificial flavours/colours/sweetners, caffeine and, potentially, dairy.  Even dehydration can result in bladder irritability as our more concentrated urine can act as a bladder irritant.

Ignored food sensitivities and anything leading to gastrointestinal irritability can mean the pelvic floor has a harder time managing gas and fecal continence.

There is also some indication that other dietary factors such as the amount of sugar and processed food in one’s diet can have a potential influence on inflammation.

Hormonal influences can also impact the irritability of our symptoms.  Whether this is something amenable to change or not, understanding the influence of these factors on the irritability of our symptoms can be empowering.

Posture/Positions

In my mind, “posture” refers to relatively static alignment – as in sitting or standing, or trunk posture while running or walking on a level surface where there tends to be fairly minimal deviation in alignment, whereas “positions” refers more to dynamic movements where one moves through a series of significantly different positions such as during a snatch or clean and jerk.

What if we change the alignment of ribs over hips?  The inclination of the torso?  Could a slight forward lean from ankles to provide bony support for bladder? Perhaps.

While we subscribe to the notion that there is no ONE “right” or “perfect” posture, changes in our alignment, either statically or dynamically, can change symptoms. 

Additionally, I think that while we tend to do a decent job of moving people towards postures and positions that fit with what are traditionally seen as the “right” postures, there tends to be hesitation or resistance in moving people away from these “good” postures, even though doing so may be a way out of symptoms.

Of course, biomechanics matter and the rules of physics apply, particularly at higher load and intensity.

Additionally, while these changes in posture/position may be helpful long term, they may also be something that we employ temporarily. #fornownotforever

Pressure

Intraabdominal pressure (and how we manage IAP) can influence symptoms.

What if we modulate breathing to change IAP?

What if we exhale through the movement?

What if we breath hold?  What if we breath hold on a smaller volume of air?

Are we taking shallow breaths under a shield of tension?  What if we took larger breaths?

What is the impact of wearing a weightlifting belt or not?

How can we modulate the distribution of pressure with muscular activation of various components of our inner core and trunk?  How can our alignment influence pressure and it’s distribution?  How can tension influence pressure?  As you may be beginning to see, these categories overlap and interact with one another – they are categorized not as separate entities but rather to categorize our thinking and our potential approach to changing their experience (whether that means changing pain, symptoms such as leaking or POP symptoms, or changing athletic performance).

Strategy

Strategy really refers to the HOW of the movement – the technique and all the variables of the task that we can play with.

For instance, I can change running technique by changing cadence (which will also change impact and vertical excursion among many other things!)

Strategy can also include HOW heavy, HOW fast, and other variables of the task that can be altered.

In the example of running, strategy may also refer to pace, terrain, incline, footwear, arm swing, thoracic rotation, etc…

Sensitivity

Both pain and sensation are outputs of the central nervous system.

Consider that right up until I mention it, you are likely unaware of the sensation of your clothing resting on your body.  Or consider how you may initially feel a tampon or well-fitting pessary that you just inserted but then later forget that it’s even there.  Or consider how someone with a mild grade 1 prolapse may have debilitating symptoms while another with more significant structural descent, say even a grade 3, may not be bothered at all.  Consider how poorly medical imaging findings correlate with clinical presentation (symptoms and function).  Perhaps you can recall a time that you noticed that you were bleeding or bruised without recollection of pain, perhaps unable to even recall when the injury occurred.

The fact is, your central nervous system (brain & spinal cord) is constantly receiving messages from your body and environment.  The tissues are always talking.  So how does it decide WHAT you need to pay attention to, and how much attention you should pay?  This is sensitivity – and it can be ramped up or ramped down.

Context, history & past experience, emotional state, beliefs, sleep deprivation, stress & anxiety, and many other players on the field will together determine the outcome of the game – what symptoms you experience and to what extent.

What if we can alter the symptoms of pelvic organ prolapse by addressing the individual’s beliefs about their POP?  What if rather than being told not to lift anything greater than 10lb for fear of their ladybits falling out, they were counselled in appropriate loading within a context of progressive overload to harness adaptation and improved function?  What if rather than focussing on DANGER and FEAR, we bolstered feelings of safety, connection, empowerment and strength?  Similar to Lorimer Moseley and David Butler’s application of DIMS and SIMS for pain, could we not apply this same approach to symptoms of POP as well?  So many exciting questions that we can discuss with respect to sensitivity, but what I’d like you to take away from this is that sensitivity can impact an individual’s symptoms in a real way and we can impact that sensitivity.

So with all the TIIPPSS that we can change, how do we know if it’s a change worth keeping?  How do we know if any of these are useful to the person in question?  We test them.  #testretest

As a result, not just anything different is required, but rather, the difference for that person in the given situation at this given moment in time.  We keep the difference that makes a difference – improvement in the parameter that we are wanting to improve (pain, symptoms, performance).

Now remember when I said we’d come back to FC…here we are.

We want to aim to optimize the TIIPPSS, which in reality is likely an ongoing process in some cases, but we also need to consider the Fatigue and Capacity.

Fatigue

In any situation, fatigue can play a role.  In the short term, such as during a run, a workout or a day in our lives, the more fatigued we are or the more fatigued the weakest player is (which may in some cases be the pelvic floor), the more likely we are to become symptomatic.

As a result, someone may be fine to do 200 double unders staying dry and happy at the start of their session whereas as the end of a gruelling workout, they may not. 

We can consider fatigue in determining rest & recovery needs, as well as programming decisions for those who are symptomatic, in order to optimally match tolerance with demands.  This also gives us a place to further discuss sleep, in addition to energy balance – knowing that RED-S is a risk factor for pelvic floor dysfunction, and that frequency of SUI and urge incontinence has been found to be significantly higher in eating disordered athletes compared with healthy athletes.

Capacity

Whereas fatigue is a consideration over a shorter time frame, capacity refers to changes in tolerance over a longer term. 

Sometimes we optimize all the TIIPPSS and we get to a certain level of symptom-free performance, and then we may just need to build capacity – building strength and endurance over the long term with progressive overload that is matched to the individual’s current tolerance and in keeping with the individual’s goals.  Load and volume management matter in the short and long term!

So there you have it – optimize the TIIPPSS, consider the impact of Fatigue and then build Capacity.                                                                        

I hope this post has given you food for thought in all the ways that you can help yourself or others change symptoms.  This is an ever-evolving framework so I welcome your feedback – both good and bad – as well as any questions or comments that you may have.

In addition, I would like to add that TIIPPSS FC is no substitute for a good assessment – if you are experiencing pelvic floor symptoms such as leaking urine, gas or feces, pressure/heaviness/bulging, or pelvic pain, see a pelvic floor physiotherapist – ideally one who also looks at your movement and helps you with the HOW as well.  And if you are having issues with pain elsewhere in your body or looking for performance improvements, a qualified physiotherapist can help!

 

As physiotherapists, I think the vast majority of us enter into the profession due to a strong desire to help people. That was certainly the case for me. In fact, the main reason why I decided to go into physiotherapy rather than medicine was the allure of human connection – to have more time with my patients, a greater opportunity to connect with them, to educate and empower them, and to help restore function and performance in multiple facets of life. I couldn’t imagine a better job. 

Fast forward several years, and I found myself working in a busy private orthopaedic clinic. I still loved my job and embraced the privilege of working with my patients every day. But there were days when at the end of my shift, I would reflect back and wonder if there was more that I could do. 

Specifically, I observed that a lot of my older patients were having difficulty maintaining their strength and function as the years went by. In some cases, they felt afraid or reluctant to get active and unsure of what to do, particularly those who had diagnoses such as osteoarthritis, osteoporosis, joint replacements, metabolic syndrome or other chronic diseases. Additionally, there was a lack of safe, appropriate and effective exercise programming for older adults in our community. As a result, these older adults would often remain or become more sedentary. Unfortunately, as we can imagine, this only accelerates the decline over time. Bone density and muscle mass drop, strength and mobility deteriorate, balance suffers, fall risk climbs, and a multitude of psychosocial factors can be negatively impacted. Sadly, this is often just chalked up to “aging”, as if there is nothing we can do. Fortunately, that is far from the truth.

Strength Training as a Solution

Recent years have brought about some practice-changing research which has demonstrated that high intensity strength training is both safe and extremely effective in older adults, including osteoporotic patients. For instance, the 2017 LIFTMOR trial demonstrated that in osteoporotic patients, bone responds very well to progressive strength training (back squat, deadlift and overhead press) and impact loading (jumping chin-ups with drop landings). Additionally, they recorded improvements in functional performance and even thoracic kyphosis. Groups around the world are also demonstrating successful models of delivering just this type of intervention. Some examples include The Bone Clinic in Australia, Stave Off in Ontario, Greysteel Strength and Conditioning in Detroit, and a growing number of Masters programs in CrossFit gyms across North America.

The Longevity Program

The desire to do more for my patients led me to develop a program called Longevity, which was launched in CrossFit Leduc in the Fall of 2016. Held twice per week, this hour-long group training session for adults over 50, is coached by myself and the head coach and owner of CrossFit Leduc, Brad Bendfeld. We begin with a group warm-up, then work on resistance training and, finally, a WOD (“workout of the day”), which typically involves some interval training. Participants undergo an intake assessment prior to entry to the program, and all workouts are modified as needed to be safe and appropriate for each individual, while still delivering a challenge.

Our participants laugh, smile and encourage each other as both a sheen of sweat and a sense of accomplishment appear. I see that, in most cases, the decline in their function is not only slowed, but reversed. They are getting stronger, fitter, moving better than they have in years and they are having so much fun doing it. But there is more to it than getting stronger and building denser bones. We all want that, but what really makes me happy is when I hear a patient say that she can now play with her grandkids because getting on and off of the floor isn’t so hard anymore, she can now pick up her grandchild, go up the stairs much more easily, and so on. 

We have a number of participants in their 70s, some with joint replacements, many with osteoarthritis and osteoporosis, and they are all making gains. We have participants who are now deadlifting 200lb with impeccable form and blowing their own expectations out of the water. The goal is not to deadlift 200lb – although those who can are incredibly proud of their progress to achieve that! The goal is to maximize function and to build resilience, with the overarching goal of maximizing and preserving quality of life. Isn’t that what physiotherapists strive to do?  It certainly is what drew me to the field many years ago.

A New Career Path

What started out as a solution to fill a need in our community, ended up changing my career path. In falling in love with Longevity, I decided to leave my position as Clinical Lead at that busy private clinic. I now continue to program and coach Longevity on an ongoing basis but, additionally, I opened RX Physiotherapy, my own practice within CrossFit Leduc. In this setting, a new model of care has become a reality, one where strength training is integrated into treatment in a capacity that is not typically seen in traditional clinics, and where the lines between rehabilitation, preventative care, and physical performance are appropriately blurred.

In our field, I feel there is so much potential to continue to do more for our patients in this capacity. Let’s strive to deliver care that goes beyond traditional confines. Let’s explore partnerships with those in the strength and conditioning world – we can be tremendous allies, rather than competitors, and we have so much to learn from one another. Let’s challenge our beliefs regarding exercise and rehabilitation in the older adult and embrace appropriate loading in this population. Honestly, I cannot convey how rewarding this can be.

Reference:

Watson, SL, Weeks, BK, Weis, LJ, Harding, AT, Horan, SA, Beck, BR. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research (2017) 1–10.