I’m doing my exercises, but my low back still hurts and I still pee when I sneeze. What am I missing?

Story line: You’re a postpartum woman who is on her game. You’re consistent with your daily exercises, you try to eat well, you manage your stress to the best of your abilities, and you feel like what you’re doing is helping you recover in your postpartum months…for the most part. But there’s this lingering thing. Something doesn’t feel quite right…That nagging low back pain that you struggled with prentally and even before you were pregnant still lingers. It’s gone from an 8/10 to a 5/10 at least. And lifting your child out of the crib is a little easier thank goodness. Household chores are tolerable. But seriously?! What gives?! Do I have to live with this annoying low back pain forever?

This is an all-too-common story that I hear in the clinic from postpartum women. When women come into the clinic with nagging low back pain (LBP) that never seems to fully resolve even after they’ve tried everything, the next logical question is ‘what’s missing here?’ Perhaps the chances of this road block occurring can be diminished if a few simple questions are asked earlier during her course of care or her phases of healing:

  1. Do you ever have accidental loss of urine? Even just a little bit?
  2. Do you have difficulty starting or stopping the flow of urine?
  3. Are you unable to completely empty your bladder?
  4. Do you have insertional pain (intercourse, tampon, annual pelvic exam)?

These questions can lead to further evaluation of the pelvic floor muscles (PFM). There is increasing evidence that supports the connection of low back pain and pelvic floor dysfunction, especially related to stress urinary incontinence (SUI). However, experiencing urinary incontinence is commonly written off by the general population. “Oh, it’s just a part of aging…” “Well, I’ve had babies, and this is what happens…” or even “I’m a high-level athlete and leaking is to be expected…”  (This blog post says it all!)

When women present with low back pain, especially postpartum women, they are typically prescribed core stabilization and Kegel exercises in order to strengthen their suspected weakened muscles. However, a growing body of evidence tells us there is a need for clinicians to differentiate between patients with LBP who have PFM weakness versus tightness. If patients have pelvic floor muscles that are always overworking (ie, tight), their LBP and/or incontinence will usually continue to be a problem until they learn to lengthen and relax their pelvic floor muscles. Furthermore, research shows that even if weakness is the issue, many people are unable to achieve the proper timing and coordination of a PFM contraction with verbal or written instruction alone (ie, some folks need more help, which is offered through pelvic health rehab). Dyscoordination of pelvic floor muscles with the core muscles and/or abdominal diaphragm can also cause pelvic pain, low back pain, and urinary incontinence, indicating that the muscle groups need a little extra help synching up with one another.   

Do you need more strength or do you need better coordination? Are the muscles shortened and tightened, needing more relaxation training? Are symptoms such as LBP, hip pain, and urinary incontinence still an issue for you even after you have been consistent with certain exercises? These questions help guide clinicians to determine your actual functioning prior to implementing individualized treatments. Fundamentally, low back and hip pain can arise from many different sources. Often these sources overlap, and some can be deeply hidden within the base of the core (ie, the pelvic floor). Helping you understand the connection of your lumbar spine, hips, and pelvis can help you a) find reason to push pause and re-evaluate and b) seek the right provider to guide you in the proper treatments to finally being able to drop that 5/10 low back pain down to a 0/10. You don’t have to live in pain forever…

References:  

  1. Urinary incontinence in women with low back pain. Eliasson K., Elfving B., Nordgren B., Mattsson E. (2008) Manual Therapy, 13(3), pp. 206-212.
  2. Why are some women with pelvic floor dysfunction unable to contract their pelvic floor muscles?  Kim S., Wong V., and Moore K. (2013) Australian and New Zealand Journal of Obstetrics and Gynaecology 53: 574–5 79.
  3. The association of chronic back pain and stress urinary incontinence. Bush H., Pagorek S., Kuperstein J., Guo J., Ballert K., Crofford L. (2013) Journal of Women’s Health Physical Therapy. Volume 37, Number 1,  January/April 2013. 11-18.

Published by kacannon

Kelsea Cannon, PT, DPT, PRPC is a physical therapist and pelvic health specialist who feels passionate about helping women restore wellness and balance in their lives. Her dedication lies in merging her comprehensive orthopedic, pelvic health, and Pilates expertise to manage pregnancy-related concerns, such as pelvic & low back pain, pelvic organ prolapse, urinary incontinence, diastasis recti, c-section scars, painful intercourse, and bowel dysfunction. She promotes an interdisciplinary approach and is a believer in helping women establish their ‘dream team’ of care providers. Her main goal is to support and inspire women using an integrative approach to help them be successful in reaching their personal health and wellness goals.

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