When HOW matters more than WHAT:  TIIPPSS – A Framework for Changing Symptoms

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 was born.

TIIPPSS 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!