This blog post is an open email to all physiotherapists interested in helping women who leak during exercise, especially skipping and box jumps.
I wrote this email to some women's health PTs but all patients and health professionals are free to respond.
Please comment below if you have suggestions or want to be included in the discussions as it will give me your email address privately.
Please share this to those you know who help those who have stress incontinence.
Ok, I had some interesting patients in LA which led to some interesting findings. Some background first.
From the survey I did on CrossFit and peeing (which has issues: acknowledged) 73% of those who answered as leakers cited skipping as an issue. About 50% cited box jumps then running I think in 33% (from memory - it is nearly 5am here). Dead lifts was the worst weight lifting one and came in at 13% and anecdotally, it is when they go close to 1RM ie HEAVY. In the 'other' column, they reported some pull-ups, rings dips, trampoline and star jumps/jumping jacks as non listed exercises. Not many had signs of prolapse.
So my thinking is:
1. Crossfitters who leak are probably ok in normal ADLs and don't prolapse - have to check the stats. This is obviously a subgroup of the incontinence population
2. Vertical Visceral Load (VVL) - have I just made up a new term? - seems to be the major contributing factor by far. Heavy dead lifts is to do with massively high IAP. Out of interest, 1994 study that included hoping estimated 9kg visceral load with vertical visceral displacement between 5-8cm. Have to read whole study for population stats etc. interesting though... 8cm I believe is the amount a b-cup moves during running unsupported? ? Berlei study - wearing their bra cuts it to 4cm from memory? But anyway, that amount of displacement seems to fit.
3. Pull-ups and ring dips is high intrathoracic pressure so it got me thinking about that too.
Of the patients I saw in LA, only one had given birth or been pg - 40's, 2 kids, nvd, episiotomy for forceps, no leakage on ADLs (incl cough, sneeze and laugh) but will lose/squirt urine on really heavy dead lifts to the point of going thru underwear and tights/shorts to form a puddle type of squirt. Skipping singles is ok for her but doubles result in drip loss type of incontinence. Apart from minor aches and pains, nil other sig findings.
The other girls were in a group and were drippers on double unders. No pregnancies or births. No issues with cough, sneeze, laugh, just double unders.
The common factor in this small group of 4 was rigid thoraces during double unders, and poor technique. Different for each person. One was a "stamper". I have video of her skipping and deadlifting. Her deadlift at 40kg (light) is quite good.
All of them tended to hold their breath somewhat and had trouble going more than 3 double unders (du) in a row (novice at double unders).
So I did breathing coordination and high singles with them and it helped sig with one girl getting 12 in a row without leaking and setting a PB for consecutive DU.
Just want to acknowledge Julie Wiebe here. I have always taught the beginning of pf squeeze on exhale but hadn't linked "relax" on breathing in before. Have taught low level pelvic floor hold throughout breathing cycles etc etc. Julie's discussions with me about the relaxation cycle was a key factor in influencing my thinking here...and it was the key for these girls.
So I got them to time their "zip" cue that I taught them (gentle back to front with lift) with relative relaxation on breathing in and squeeze on breathing out. It helped! I also taught then to relax their thorax and not "grip" so hard during their DU but to allow their thorax to be more responsive during skipping.
The theory was to time their contractions with breathing, decrease excessive intrathoracic pressure and allow a more global, adaptable response to VVL, IAP, ITT and the weight of the body on the MSK system. They understood the cues really quickly which I tested using isometric arm contractions.
So the next stage in my mind is to see if I can classify responders to my program (they did NOT do my program, just one aspect of it) and have some baseline measures taken. Eleanor Bognar Lee is a local WH PT I am hoping to be working with who can do the internal examinations.
I will be offering free assessment and progression through the program for up to 20 women who leak during DU.
I need your help in determining what YOU would want to know about these women from an internal point of view as well as a history and usual examination point of view. Eleanor is an experienced WH PT but I would like your input as well so I can ensure we capture the information others want, not just what we want to collect.
If this goes well, it might be worth studying properly.
So, your thoughts, opinions and suggestions on subjective and objective / examination information are most welcome.
Thank you all for reading. I don't mind if you pass on this email to others so long as it is in its entirety and you cc me so they and I can introduce ourselves 🙂