The National Association for Continence estimates that bladder or bowel control issues impact 25 million Americans – about 1 in 13.
It also estimates that only about 1 in 12 who struggle with such control issues seek help.
Sarah Capodagli aims to improve those numbers, at least here in Greater Buffalo.
Capodagli, 29, a physical therapist profiled this weekend in the In the Field feature in WNY Refresh, has forged a career to help people of all ages try conservative, non-surgical ways to prevent and address incontinence, frequent urination, pain with intercourse and related issues.
“Just because symptoms are common doesn’t mean they have to be your normal,” she told me earlier this month. “And It’s so much easier to prevent symptoms than to chase them. That’s not an effective way of living.
“Pain shouldn’t be normal. Leaking shouldn’t be normal. Commercials try to normalize that with pads but wouldn’t it be nice – more convenient, less expensive – to not have to purchase things to deal with it and instead take the steps to start improving?”
Capodagli opened her own business, CorrEra Physical Therapy, in November 2013 on Youngs Road in Williamsville, just south of Wherle Drive near Erie Community College North.
Several questions that didn’t make the print edition focused on how her business runs and what patients who see her can expect.
Excerpts are below.
Q. Talk about common urinary issues.
If it’s urinary leaking, a lot of times it’s stress incontinence and urge incontinence. We end up doing a lot of figuring out where the muscles are starting, if we need to strengthen them or if we need to get them more coordinated and work on some behavioral or habitual things that people do. So a ton of what I do is a lot of coaching to get your body going in the right direction, along with the manual therapy.
Q. Are there any preventaive tips you have for people who are getting older and starting to worry about these things?
It would be wise to see exactly where you’re starting from, whether it’s seeing a pelvic floor therapist or gynecologist or uro-gynecologist and asking, “Can you feel to see if I’m doing a contraction the right way?” I’m specifically trained to assess the muscles. If you have some pelvic pressure, you have symptoms of prolapse, knowing that there are options, that surgery doesn’t have to be the first step. There are things like this kind of therapy. There are pessaries which are something Dr. (Tova) Ablove places all the time. (Ablove and her partner, Dr. Teresa Danforth, were featured last fall in Refresh) Knowing the conservation options, knowing your baseline and knowing what you can do from an exercise standpoint that will improve or worsen your system is important. It’s hard to assess your own muscles if you don’t know where they are.
I want everything within a patient’s comfort level, taking something potentially embarrassing and difficult to talk about and pointing out, “Like anywhere else in the body, they’re just muscles.”
Q. Can you explan the pelvic floor?
If you were looking down at your pelvis, you have a pubic bone and and tailbone. It really the whole pelvis, the pelvic bowl. If these muscles were not there, we would have a big hole in the bottom of our pelvis. The muscles serve as support. There’s a lot of pressure in this area. Everything in my abdominal cavity is essentially putting some pressure on these muscles. The pelvic floor has three different layers.
Q. Talk about contracting the pelvic floor.
The kegel – a contraction of the pelvic floor – is the bicep curl of the pelvis. ... Some people will say do your kegels while you have a baby or are pregnant. If you’re already walking around with a tight pelvic floor, why on earth would you do more “bicep curls?” So some people do not need to do them. Some people shouldn’t. It’s not all abou strengthening. The pelvic floor is really your base of support. If it’s too tight, that’s a problem. If it’s too weak, that’s a problem. If it doesn’t have great endurance, that’s a problem. If it doesn’t have coordination, that’s not great, either. I always say happy muscles have good strength, good flexibility and are coordinated.
Q. What are kegel exercises? Can men do them?
It’s a contraction of the pelvic floor. It’s lifting up and letting go. And yes, for men. They have a pelvic floor, too.
If you know where the muscles are, the best way to activate them is to exale, so if you take a deep breath in, nothing happens, and as you exhale, you draw up and in, almost in a way like you’re stopping gas if you were standing in line in a grocery store and someone came up behind you in line and was invading your personal space. You wouldn’t tighten up so they’d know what you were doing. You’d gently pull up and in. Another way is you stand, and turn your toes in and squeeze your butt, when you rotate your hips you knock the glutes out of it and as you tighten you’re forced to engage that group of muscles.
Q. So these exercises are important to men and women? How often should you do them?
Yes. It depends on a person’s pelvic floor. If someone has a healthy pelvic floor and are not symptomatic, and are looking to maintain strength, 10 reps a day is fine. If you have pain or have symptoms or the urinary, bowel or pain symptoms, it’s really important to figure out where your starting point is. If you’re starting off as someone who has a lot of urgency and frequency and constipation, kegels could be detrimental. So it’s important to know where to start.
It’s kind of like the commercial where if one piece of broccoli or one pushup sufficed, that’s how we'd treat these kegels. If you say, “I’ll do it once in awhile, when I remember,” that’s me expecting to have great biceps if I do one curl every once in awhile. There should be some consistency. They are just muscles, but they’re muscles. If you stop using your right arm for 10 years, it would be hard for you to pick up a pencil.
Q. As we age, do muscles change?
Yes. But the good news is that 70 percent of these muscles are slow-twitch fibers. They’re your endurance muscles. Thirty percent are fast-twitch muscles. They conk out a lot faster. If we take the time to train our pelvic floor, then, as we age those slow-twich muscles can last longer for us, so incontinence doesn’t have to take place when we get older.
I love the holistic approach of really seeing the person as a person and not just a diagnosis – being able to look at the different aspects of what might be coming into play that affect their symptoms. Your pelvic floor knows your every thought. The NSA is starting to use pads during lie detector tests to sense what people’s pelvic floors do.
When we talk about pain, if someone has anticipated pain or is experiencing stress – instances of anxiety – then your pelvic floor is going to respond the way that if you were stressed the way your shoulders might elevate.
Pain can affect intimacy. It can affect a relationship. It goes so much deeper than the physical piece. It comes down to breaking a pain cycle. If you’re always having pain, then we have to break that so there isn’t this anticipation of pain every single time. It’s really about resetting the pelvis in almost every case, resetting those muscles and getting symmetry again.
Q. How can you reset the pelvis for urinary issues and for pain-related issues?
With pain, a lot of times it’s trigger point release. It’s manual stretching of the muscles – a home routine where they are continuing stretching and relaxation and only using the muscles when they need them. It’s learning when to use those muscles and not to let them tighten all the time with you.
With urinary symptoms, if someone has a lot of urgency or overactive bladder, I end up doing more relaxation and coordination training with them instead of strengthening. More often than not, people who have a lot of urgency and are up a lot at night, most of the time their pelvic floor tends to be more tight than weak. Sometimes they’re both. We work on any symptoms of pain or tightness first before you start strengthening.
Q. It sounds like there are a variety of ways to treat these issues. Can you talk about that?
What I have found is that there is a place for medications where they might help to springboard someone into going the right direction. Sometimes it’s the answer because the doctor might not have anything else to offer. With my male patients, if there is nothing that comes back on a test that’s positive, they’re prescribed an antibiotic. Longterm use of antibiotics can cause symptoms of IBS. Then we’re affecting the pelvic floor. My approach is thinking, “Let’s consider everything, every variable. What can we take out? What can we not take out." Diet affects the pelvic floor for sure. Food intake. Bladder irritants. There are different massage techniques that will help with bowel dysfunction. There are stretching and circulating routines that I give. I do a ton of manual therapy in terms of releasing trigger points in muscles. I have a biofeedback unit that I use sometimes. I use sensors externally. I want you to have longterm improvement. For someone who’s having a hard time figuring out where these muscles are, biofeedback can be a really useful tool. You can’t train what you don’t communicate with.
Dietary, talking about pain of the pelvis, I really think about four different areas and deduce where symptoms might be coming from. With pain, it could be some kind of infection or disease process, which we want to make sure that we rule out. The medical community will check through blood testing and imaging. There could be some sort of trauma, surgery. Childbirth is a beautiful thing but it is traumatic to those muscles. Most of those changes occur during pregnancy, not delivery, so it doesn’t matter if it’s vaginal or Cesarean.
Other two areas are musculoskeletal imbalance: bringing balance to the pelvic floor; some area may be too tight, another area too weak. We want to bring that area back into balance.
Another area is inflammation. Inflammation, which Time magazine called a “silent killer,” is unbelievable. If we can start talking about gut health, that may be where we find a lot of our answers. Where there’s poor gut health, there’s a battle going on, and that’s close to the pelvis, too. Issues with pain, you might have musculoskeletal imbalance, there might have been some trauma. There’s almost always some level of inflammation involved, and inflammation takes up space where joints and muscles want to move – which can add to pain. If something’s inflamed and angry – say it’s your bladder or your prostate – that can be uncomfortable. Then the muscles respond to try to help but it’s really looking at those four areas.
… If someone is eating an inflammatory diet, that’s something we need to address. Sodas, sugars, those kinds of things, are going to be inflammatory.
Q. Can you talk about what it would be like for a new patient to come in to see you?
I like to talk to patients on the phone while scheduling so I can get an idea if I can help them. If someone has questions, I do consultations instead of a full visit, so they can jump in when they’re ready.
As far as starting with a patient, I have them fill out their history but I also have them fill out a quality of life questionnaire to see what areas are impacted. It address urinary, bowel and sexual function so if there are areas that maybe they weren’t looking to address, it helps me to know if they’re also having a symptom somewhere else that makes sense. This therapy is going to help all those areas.
Then they come in and we sit and talk through that. The first time they come, depending on their comfort, I will do an evaluation assessing the muscles, assessing their alignment and looking to see what is going on with muscles outside and inside the pelvis. Then we start a program that day.
For urinary symptoms, if I’m not releasing muscles – if there’s mostly weakness – then we spend a little more time going through the routine to uptrain muscles. If they have pain, I find trigger points the day they come and start treatment that day, too.
We can only go as far as the muscles are going to allow us. It’s not right to push past them. At least in this setting, we’re treating the muscles, so I don’t use a speculum like you can find in your gynecologist’s office. … I’m assessing the muscles so I don’t hae to use those tools.
Q. How do you break the ice and deal with the boundaries some people put up?
They’ve had a conversation with me on the phone before they’ve even set foot in the office. I tell them what it entails, so they have an awareness. People have to take everything off and get into a gown. It’s personal and I have to be able to assess the muscles to treat the muscles. The whole thing is to make everyone feel they’re just muscles to me and I want to help you. I have my degrees but I’ve done a lot of continuing education through Herman & Wallace. In order to do their courses, it is a peer physical examination, which means everything I have learned to do I have had to have done to me. When you go to these courses, you are a patient and examiner...
When they come, I don’t say, “We’ve got 15 minutes, here’s your gown.” I show them pictures of the pelvic floor and I help them better understand their body so that they’re also motivated if they see what’s possible. I make them a real important part of the process. I have a saying: “You can’t start where you want to be. You have to start where you are, and progress to where you want to be.” If they want to progress, usually people are fine. Usually people are nervous. Some have had pain, so I go at their pace. It’s not ripping off a Band-Aid because that would lead the muscle to react rather than respond. It’s hard to treat a reactive muscle. It’s a lot easier to go with what the muscle’s allowing you to do so.