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A New Model of Female Urinary Incontinence

The functional anatomy and physiology of the female urinary continence system remains inaccurately modeled by urology and gynecology, the medical practices that treat the condition of urinary incontinence.

Urologists and gynecologists have looked at the problem of urinary incontinence through an exceedingly narrow lens, and onto a diamond-shaped set of muscles called the “pelvic floor.”

This field of vision arises when a woman is placed on her back in the lithotomy position, on either an exam or operating table, with knees bent and feet held in high stirrups.

From this perspective Dr. Arnold Kegel devised his theory of pelvic floor strengthening in the treatment of urinary incontinence, by way of simplistic and conceptually flawed exercises known as kegels. It is also the position women are placed in for incontinence surgeries, all of which are associated with negative long-term outcomes.

In reality, kegels have no bearing on the female urinary continence system, which develops over the first years of life as we learn to crawl, stand, and walk. When symptoms fail to respond to kegel therapy, women are often told they are not performing them correctly. Surgery is usually offered as a definitive cure.

If Dr. Kegel had widened his perspective to include what he had been taught in medical school about anatomy, biomechanics, and human development, perhaps he would have realized that urinary continence depends upon three essential structural alignments.

A newborn baby girl comes into the world with a straight spine and a flexion, external rotation contracture of her hip joints. In other words, her legs are bent at the hips and turned out to the side. Full external rotation of the hips is the starting point of the urinary continence system, a position in which ligaments and other soft tissues surrounding the urethra and bladder are unwound, or relaxed.

Within approximately six months she has internally rotated her hips so that her limbs are positioned underneath her body for crawling. She still has a predominately straight spine, and the diamond-shaped wall of muscle containing orifices for her urethra-bladder, vagina-uterus, and anus-rectum is at the back of her body. Internal rotation of her hip joints begins to tighten and strengthen tissues supporting her urinary continence system, including the long, strap-like muscles of her inner thighs.

When she stands up and begins walking, her pelvis does not rotate backward into a bowl shape as early anatomists believed. This 500 year-old anatomical error is the reason women are still being taught they have a muscular pelvic “floor” underneath them, supporting the pelvic organs above.

Actually, the child stands up by profoundly curving her lumbar spine. Her pelvis remains in the quadrupedal position with a wall of muscle at the back. Her pubic bones come together underneath her like straps of a saddle forming a strong, bony pelvic floor.

The dynamics of breathing and the force of lumbar curvature move her bladder forward against her lower abdominal wall to form a right angle with her urethra. The 90º urethra-bladder angle acts like a kink in a garden hose to control the flow of urine, while lumbar curvature winds up and tightens all the tissues of pelvic organ support. Bipedal hip alignment and lumbar curvature create a self-locking urinary continence system that lasts a lifetime.

Then why do so many women suffer from involuntary loss of urine? The answer lies in loss of full range of motion of the hip joints and flattening of the lumbar spine. These structural changes compromise the highly developed urinary continence system.

It is widely accepted by urology and gynecology that widening of the urethra-bladder angle causes symptoms of urinary incontinence. Yet, these practices never developed a model for how incontinence emerges, or how to restore the female continence system to healthy function. For over 50 years kegels have been the only conservative treatment offered by doctors and physical therapists.

When a woman lies on her back and contracts her pelvic sphincters she is actually pulling the back of her bladder toward her front vaginal wall. Ironically, her incontinence symptoms may improve, but only at the expense of even greater widening of the urethra-bladder angle. Eventually an uncomfortable bulge may appear in her vagina, known as cystocele, or pelvic organ prolapse. Cystocele is actually the posterior aspect of the urethra-bladder angle, which has ballooned further and further into the vaginal space.

All surgeries for urinary incontinence attempt to create an artificial kink, or angle, in the urethra or bladder neck. Incontinence procedures are among the most devastating of pelvic surgeries, routinely leaving women unable to completely empty their bladder. Life-long self-catheterization, urinary tract infection, and bladder pain syndrome become endemic.

At Whole Woman® we understand how the urinary continence system is restored to health. Whether a woman is experiencing loss of urine when she coughs or sneezes (stress urinary incontinence), or not being able to make it to the toilet in time (overactive bladder), revolutionary Whole Woman® techniques work to stabilize and reverse these common symptoms.

For all the years that women have been kegeling to no avail, a model of urinary incontinence based on bipedal human development has been missing from medical textbooks. That model is now available and helping women throughout the world successfully resolve the symptoms of urinary incontinence naturally.

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This morning’s headline “CERVICAL CANCER KILLING WOMEN AT MUCH HIGHER RATE THAN PREVIOUSLY THOUGHT” made my blood boil. Not because the article had anything new to report, quite the contrary. The worldwide gynecologic industry has known for decades that cervical cancer is not only preventable, but the disease is highly reversible even in cases of severely dysplastic cellular transformation. I’m not referring to the extremely disfiguring chemical and surgical treatments for cervical dysplasia that remain the gold standard of medical care. Nor vaccinations that have never been proven safe or effective in the fight against the second most common female cancer worldwide.

You see, during the HIV epidemic of the 1980s a tremendous amount of research was directed at the human vagina. Researchers were astonished to find that female susceptibility to HIV seemed to be highly variable. Women would be immune to the virus sometimes, yet extremely vulnerable at others.  An American research team would go on to identify and describe a highly evolved vaginal antimicrobial defense system that was especially effective against viruses. Unfortunately, this crucial information never made its way into the public eye, but was concealed by the pharmaceutical industry in favor of the development of expensive and risky antiviral drugs.

It would be another decade before German researchers would describe the control of cervical cancer by this very same antimicrobial defense system. Yet, this invaluable research was also obscured by the medical and pharmaceutical industries, and to this day remains buried in old microbiology journals. I rediscovered this critical information, which I detailed in a public lecture given one year ago today called The Miraculous Self-Healing Vagina.

My grandmother died of cervical cancer at the young age of 39, after a decade of agonizing illness from surgery, drugs, and radiation treatments. My mother was greatly traumatized by her ghastly death, and I grew up terrified of the disease. As an adult I obediently kept my routine appointments with the gynecologist and never missed a yearly pap smear.

My discovery of the truth behind cervical cancer has forever vanquished those fears. Not only do I no longer fear for my own health, but I know my daughter and granddaughter will never succumb to cervical cancer either.

My great hope is that women the world over will hear this message.

You can find the my important lecture The Miraculous Self-Healing Vagina on video by clicking this link.

 

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Escala Medical Device – The Pink Gadget From Hell 

Is it a nail polish dryer? The latest in hair removal? Or a sexy pink hot glue gun?

Unfortunately, this ridiculous looking device will soon be inserted deeply into the pelvic cavity of countless women to staple the vagina to the sacrospinous ligament, a new twist on an old operation fraught with risk and failure.

The device is being ushered to market using the Food and Drug Administration’s 510K process, whereby safety and efficacy studies are automatically waved based on established and equivalent procedures, in this case the sacrospinous ligament fixation (SSLF).

Developed by vaginal surgeons Nichols and Randall in 1971, until recently  SSLF has been an operation reserved exclusively for post-hysterectomy women. During SSLF a midline incision is made in the posterior vaginal wall. Blunt digital dissection is extended deeply behind the rectum and into the coccygeus muscle of the pelvic wall. Connective tissue overlying the coccygeus muscle is removed to completely expose the sacrospinous ligament. Sutures are then placed in both the ligament and top of the vagina. Since the vaginal stump is not long enough to reach both ligaments, unilateral fixation is the standard practice.

SSLF has always been associated with anatomic distortion of the vagina and rectum, chronic pain, and severe and intractable postoperative cystocele. In normal anatomy the uterus pulls the vagina toward the front of the body. As the bladder and uterus are connected at the level of the cervix, the bladder is also pulled forward into its normal position against the lower abdominal wall.

The ill-conceived SSLF pulls the vagina in the opposite direction by tethering it to the back of the body, thus pulling the bladder backward against the front vaginal wall. Sexual disability and bowel dysfunction are also well-known risk factors. The pudendal nerve, embedded between the sacrospinous and sacrotuberous ligaments, can easily be damaged by this surgery, leading to chronic pain and anal sphincter dysfunction. Not a single study in all of gynecologic or orthopedic literature describes the musculoskeletal risks of having the muscular vagina tethered to one side of the body.

Bilateral SSLF without hysterectomy has recently been described, using strips of polypropylene mesh to bridge the gap between cervix and both sacrospinous ligaments. Erosion and exposure of the mesh has been reported in up to 37.5% of subjects during short-term follow up studies*. Often sold as minimally invasive, it is nothing less than criminal malpractice to surgically tether the normally anteverted uterus to the back of the body.

Although Escala Medical states it will “Soon offer an alternative first-line solution for milder cases of prolapse and can help achieve a better outcome in more severe conditions – especially for women who aren’t good surgical candidates or don’t want surgery”, the anatomic realities of SSLF suggest this device will be used post-hysterectomy. Therefore, hysterectomy will likely be offered as part of the operation.

Many pelvic surgeons have abandoned SSLF in favor of abdominal sacrocolpopexy, which tethers the vaginal stump to the anterior ligament of the second sacral vertebra by way of a mesh bridge. A difficult operation also associated with risk and failure, at least sacrocolpopexy results in a more natural vaginal axis and therefore fewer postoperative complications.

Escala tells us, “The potential market adds up to $600 million in the United States alone, where close to 400,000 prolapse repair procedures are performed annually at a direct cost of $1.4 billion.”

It is a very dark side of human nature that pursuit of money often blinds otherwise caring and ethical human beings into the swamp of surgical opportunity and allows them to ignore the lifelong damage done to the patients, especially women.
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* Senturk M Guraslan H Cakmak Y Ekin M Bilateral sacrospinous fixation without hysterectomy: 18-month follow up. Journal of the Turkish-German Gynecological Association. 16(2): 102-106 2015

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newborn pelvisThe naturally wide human foot is essential to maintaining the female pelvic organ support system throughout the lifespan of women.

We come into the world with flat feet and a totally straight spine. Our three pelvic organs, bladder, uterus, and rectum are carried high in the infant torso, and in line with their channels, the urethra, vagina, and anus.

As we begin to crawl, our pelvis is in the quadrupedal position, just like that of four-legged animals. The pelvis is positioned like a ring on its edge, with the pubic bones underneath the body like straps of a saddle.

Figure2.4 copyWhen we stand up and walk, our pelvis does not rotate backward into a “bowl” shape, but stays in the very same position it was in when we were crawling. Unlike non-human primates, who must rotate their spine and pelvis as one unit to stand upright, we humans stand up by profoundly curving our lumbar spine. This means we don’t have a soft tissue “pelvic floor” underneath the body, but rather a wall of muscle at the back.

Human females have a genetically more pronounced lumbar curvature than males. Each time we take a breath in, our respiratory diaphragm comes all the way down to our last set of ribs. In doing so, it pushes the intestines, bladder, and uterus down and forward.

By three years of age we have developed pronounced lumbar curvature, and our three pelvic organs have bent a full 90º away from their channels. Like a kink in a garden hose, these angles act as passive sphincter

mechanisms to prevent pelvic organ prolapse and urinary and fecal incontinence. Lumbar curvature is vital to keeping the pelvic organs positioned at the front of the body, and away from the pelvic outlet at the back. It also positions the center of mass of the body evenly over the  arched, symmetrical roof of the hip joint.

sideviewThe human foot arches are developing through early childhood as well, and are also a critical aspect of female pelvic organ support. The natural range of motion of the foot allows the back knee to straighten while walking. This extension lifts the tailbone, maintains lumbar curvature, and keeps the pelvic organs pushed forward against the lower belly.

When we lose the natural shape of the foot and the arches begin to flatten, the back knee does not completely straighten while we walk. In turn, lumbar curvature tends to flatten and the pelvic organs are pulled backward from the lower abdominal wall.

Over time, the bladder and uterus bulge into the front vaginal wall, and the rectum bulges into the back vaginal wall. Prolapse is not a rare occurrence, but happens in the majority of adult women throughout the modern world.

Lumbar curvature can be diminished by other means, such as sitting in soft furniture, car seats, and by chronically pulling in the abdominal wall. However, loss of the natural shape of the feet is a major contributing factor. The female pelvic organ support system is a postural system, and Whole Woman posture re-creates the natural structural alignment of the female spine and pelvis.

Although evident in young girls, ancient artwork, and women living in traditional life ways, Whole Woman posture is unique in the modern world. Yoga, Pilates, and physical therapy all teach that the abdominal wall should be pulled in, which compromises lumbar curvature and pelvic organ support.

Restoring natural posture is a head-to-toe process, which includes restoring structural support to the feet. The ways in which we restore natural foot alignment is by (1) walking in Whole Woman posture with feet pointing straight ahead, (2) going barefoot as much as possible, and wearing wide toe-box shoes, and (3) wearing Correct Toes® toe spacers.

Correct Toes® restore the wide base  of support the rest of the body depends upon to align correctly under the forces of gravity. As a result, symptoms of pelvic misalignment have a much greater chance of being stabilized and reversed.

We were proud to feature Correct Toes® at the 2016 Whole Woman Conference in Albuquerque New Mexico, and our Whole Woman Practitioners have begun to regularly suggest Correct Toes® to their clients.

Thank you, Dr. McClanahan, for helping women restore their natural posture, and reverse symptoms of pelvic organ prolapse, incontinence, and chronic hip pain.

Christine

 

Christine Kent
Whole Woman

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Structural Disintegration and Dysfunctional Patterns

Has the entire world of physical and movement therapy gone mad? Instead of people moving toward a more natural sense of body awareness, ease and comfort, they continue to be led down the Path of the Hard Body – a cultural contrivance that has replaced chopping wood and carrying water with the vanity of the asphalt jungle gym.

“Biomechanics is going by the wayside” exclaims Thomas Meyers, Structural Integration therapist and author of Anatomy Trains. According to Meyers, the New Biomechanics remains loosely defined. Yet, it seems to have at its foundation the perspective that instead of the body hanging on the skeleton like a suit on a coat hanger, the skeleton floats in a bag of soft tissue. While both views are equally incomplete, at least the Old Biomechanics is based on 500 years of anatomical study about how muscles and bones operate. The New Biomechanics being espoused by manual therapists, trainers, and yoga teachers is as amorphous and mystifying as the structural disorders it attempts to describe.

Take Liz Gaggini’s pelvic Tilt and Shift, “the two positional possibilities that are important in pelvic girdle alignment and function.” Anterior Tilt means the top of the pelvis moves down and forward, while Posterior Tilt means the pelvis moves up and back. According to this arrangement Anterior Shift means the entire pelvis sags in front of the ankle line, while Posterior Shift means the pelvis is pushed out behind. Curiously, pelvic rotation is not included, which the Old Biomechanics considers to be a major cause of osteoarthritis of the hip.

Says Gaggini, “It is always the case in Structural Integration that we must deal with patterns in the whole.” Thus we have the central problem with both the Old and New Biomechanics. What, precisely, is the “whole?” What does a structurally integrated body look like? What are the moving parts and how are they integrated into the whole? The Old Biomechanics rotates the pelvis 45 degrees backward and draws a plum line from the ear down through the load-bearing joints of the body. This integration necessitates pulling the abdominal wall in and tucking the tailbone under.

The New Biomechanics gets around the issue by describing “integrated” as individualized postural patterns that can be freed from their fascial restrictions by the specialized knowledge of trained body workers. Meyers tells his proteges they must “seize the truth” of the New Biomechanics. “If we posit that tilt is the tilt of the pelvis on the femur, such that anterior tilt equals hip flexion, and posterior tilt equals hip extension, and we remember that pelvic shift is either a position anterior or posterior to the line of the ankle, then we get the four pelvic types [described by Gaggini].”

According to the Old Biomechanics, bipedal standing is called hip extension. Drawing the pelvis toward the thighs (by pushing the buttocks back), or the thighs toward the pelvis (by lifting the knees), is called hip flexion. The human pelvis is already tilted all the way forward in the standing position of hip extension. The New Biomechanics has taken the liberty of reversing established anatomic language and understanding of pelvic movement.

Devon 3-years copyEven more bizarre is the New Biomechanical description of the pelvis in early human development as Posterior Shift/Anterior Tilt. Says Meyers, “Favored by toddlers everywhere, the hips are pushed back but the pubic bone pulled down with hip flexion. Normal for a toddler (who has yet to develop balance in the psoas complex and deep lateral rotators), but if you see this pattern in the adult, one can suspect neurological deficiency or somatoemotional immaturity” [emphasis mine]  The absurdity of these remarks cannot be overstated.

A baby crawls with her pelvis in the quadrupedal position. When she stands up, she does so not by rotating her pelvis backward, but by profoundly curving her lumbar spine. Her pelvis must stay in the horizontal position to continue developing (ossifying) the symmetrical arched roof of the acetabulum, which is conserved across species.

Unlike the long, flexible human lumbar spine, the short, inflexible chimpanzee lumbar spine must rotate with the pelvis as one unit to stand upright. Why western science determined the human spine and pelvis are wired up like the non-human primate is an unfathomable mystery. The mistake has never been corrected and continues to inform both the Old and New Biomechanics.

goatgirl copy 2In no way are toddler hips “pushed back” and the pubic bones “pulled down with hip flexion.” Rather, like many other living forms she is unfolding from her center, her sacrum. At first her lumbar curve is very acute, but as she unfolds further she lengthens between chest and pelvis, keeping her head balanced over her horizontal sacral vertebrae.

Nikelle WW posture copyBy adulthood she has fully unfolded into the wide-radius lumbar curvature of natural female posture. Her abdominal wall is still held out – never in – but now the leading edge of abdominal curvature is at her midriff, between breasts and navel.

After childbirth her breasts are slightly lower and her abdominal wall slightly expanded. Due to the spiral nature of the female body, pelvic and spinal dynamics do not change from the pregnant to non-pregnant state.

Two surfers running into the sea with their surfboards

The male spine has only two wedged lumbar vertebrae (and discs), while the female has three. Wedging means the vertebrae are taller in front and shorter in back, which is what forms the curvature. Males have only two horizontal sacral vertebrae (S1-S2), while females have three (S1-S3). These differences result in less curvature in the male lumbar spine, an exceedingly important reality unrecognized by either the Old or New Biomechanics. However, males do have lumbar curvature and a forward placed abdominal wall.

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A strange and destructive body-dysphoria predominates in modern exercise and therapy systems, which I believe has its roots in white male supremacy. It is probably no accident that the physical culture of male body-building coincided with European and American hunters and anthropologists bringing back photographic images of native bodies. The most obvious way to distance themselves from “savages” was to abhor the native belly.

founding fathersPrior to this, men had no problem with the abdominal wall, which was held proudly forward in natural human posture. Like all animals, the human body develops into a particular conformation while moving and breathing naturally under the forces of  gravity.

monksBuddhist monks provide another example of effortless human posture when the belly is relaxed, the chest lifted, and the chin pulled in and down.

Pilatesmummy tummy yoga momYet, by the 1930s control of the abdominal wall was the reigning paradigm in western culture and medicine. While Joseph Pilates proclaimed the value of extreme abdominal exercise, physical therapists Henry and Florence Kendall defined a 90-degree backward rotation of the pelvis as “neutral.” Today, male body-dysphoria continues to reign supreme in  yoga studios, gymnasiums, and physical  and manual therapies. The “mummy tummy” is regarded with disgust, and young mothers are resorting to extreme measures, including devastating abdominoplasty, to achieve the flattened six-pack abs idolized in body-dysphoric culture.

Excessively contracting and chronically holding in the belly has serious implications for female pelvic organ support. The urogenital triangle of the pelvic floor (where the vagina is located) is closed off in the male, so they are not subject to bladder prolapse. Rectal prolapse is another matter however, which may be more prevalent in males than females.

Male body-dysphoria is exemplified by a gut that is chronically contracted and tightly pulled in. When the abdominal wall is flexed in this way, posture 1 (1)the pelvis rotates backward and the pelvic floor becomes chronically tense. A person has no choice but to reverse natural breathing. Instead of allowing the abdominal wall to expand forward on the in-breath and passively fall back on the out-breath, the chest rises on the in-breath and the belly is pulled further in. Over time the muscles of the chest wall and shoulder girdle hypertrophy, leading to the classic barrel chest of the body-dysphoric male.
Importantly, instead of the center of mass of the body being distributed evenly over the arched roof of the acetabulum, it is now positioned over the top, front aspect of the joint, where virtually all adult-onset hip disease is known to occur.

Alarmingly, body-dysphoric males educated in the New Biomechanics are teaching doctors and therapists a distorted and unintelligible anatomy. Hip flexion, which also involves elongation of gluteus maximus, is now being called “hip extension.” While anterior displacement of the entire pelvic girdle (slouch posture) is now “hip hyperextension.”

Posture 2 (1)The deceptive and harmful practices of orthopedic surgery allowed a conceptual vacuum to be filled by alternative anatomic models based on deficient standards and partial  truths. Orthopedics claims ownership to 500 years of anatomical understanding, yet has squandered its knowledge in favor of fallacious imaging technology and reductionist surgical dogma.

Birthing large-headed offspring increased biomechanical function and unfolded the female body further into the human form. Failing to recognize this flowering, and deeming female spinal curvature pathologic, is at the foundation of male body-dysphoria. The New Biomechanics describes natural female proportions as “anterior tilt” and “hip flexion”, when in fact the ability to extend through the hip and knee by fully extending the pelvis and lumbar spine is uniquely and essentially human. The male-dysphoric body has lost its ability to double extend, and is held chronically in hip flexion,  as evidenced by an anterior shift of the head and torso. The resulting shortening and thickening of the iliopsoas tendon is a precursor to degenerative hip disease.

36. golden mean copyIt is a profound truth that humans are horizontal creatures from the hips down and vertical from the waist up. The female of our species has expanded the human design further into the proportions of the Fibonacci spiral. The same Golden Proportion found in sunflowers, galaxies, and inherently registered as beauty by the human eye.

Thomas Meyers also tells us agriculture is dying and that, “We’re not all going back to live on an organic farm and work hard.” Perhaps he is unaware of the current trend in young, physically fit, and happy urban farmers doing precisely that. Meyers asks, “What does a child need to know to make it on this planet in terms of their physical movement?”

Here  is my short list:OLYMPUS DIGITAL CAMERA

  • Beware of male body-dysphoria, which pervades modern culture
  • Ignore the New Biomechanics
  • Perfect your handstand
  • Plant a garden
  • Trust in the natural design of the human body
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Have you heard about the newest vaginal exercise craze? Meet Kim (click here) who lifts weights, surfboards, and bunches of bananas with her pelvic floor muscles.

Vaginal Weightlifting

Vaginal Weightlifting

If you find yourself gasping in horror, rest assured you have good instincts. Yet, consider what a stunning example this is of the marvelous design of the female body! How do you suppose Kim is able to keep the surfboard lifted? Is the pelvic floor really that strong?

I bet you guessed it, especially in light of our recent observations about Judith Aston’s body. What a perfect contrast! While Judith chronically holds her midriff in, leading to all sorts of weakness and malalignment, Kim’s midriff is naturally held out, which sends intraabdominal pressure through her torso in a natural way. She is a Whole Woman goddess!

She is also a performer who has no clue that holding her vagina open with a jade egg is inviting internal pressures to push surrounding organs into her vaginal space. In normal anatomy, when the pelvis is weight loaded from above, the vagina is a closed, airless space. Kim is holding the surfboard, not by squeezing a circular contraction (kegel), but by expanding her lumbar curvature, puffing out her midriff, and closing her pelvic diaphragm side-to-side with such force that she can lift the board. Long muscles are strong muscles. What a miraculous design!

However, it appears that Kim does not always keep natural posture while lifting, and therefore may be unaware of the mechanics of her self-locking vagina. She is young and the natural dynamics of childhood have been largely preserved, which has served her well. There are limits however, and  we do not know what level of bruising and tissue damage is being sustained.

nutation

Pelvic Nutation

In promoting her tricks, Kim gives no explanation about what a “strong” pelvic floor actually is. Conventional wisdom tells us it is a contraction rather than an elongation, but trust your WW eyes! When her abdominal wall is lengthened, her pelvic wall is equally lengthened. Vaginal nutation is occurring, where the back vaginal wall clamps sharply down against the front vaginal wall.

The egg is wedged over her horizontal pubic bones, which are acting like a pulley to change the force vector from vertical to a right angle. This is the only way the mechanics can work! More than anything, Kim gives us an exquisite example of the strength of the circular bony pelvis! She is also proof of the pelvic wall’s amazing ability to manage tremendous internal pressures. It can only do this through stiffening. The body walls stiffen by expanding, not contracting.

As far as vaginal kung fu is concerned, because in certain positions her pelvic wall is not closing completely, she’s having to supplement side-to-side closure with a circular contraction. Some level of vaginismus may be the result. Strong enough to break a penis? Who knows?

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Judith Aston, Kegels, and the “Pelvic Floor”

I have been asked once again for my commentary, this time on a pelvic floor exercise created by Judith Aston, dancer turned movement expert and exercise coach. (http://www.astonkinetics.com/blog) My response is that the exercise is nothing but a glorified kegel, and her basic concepts mainstream. Judith has a lovely, lithe dancer’s body, but from the Whole Woman perspective her posture and movement concepts are very conventional and, shall we say, superficial. By that I mean she uses phrases like “helps with alignment of the trunk” instead of helping us understand exactly how and why.

She seems to understand that a contracted belly is not good for prolapse, yet it is so interesting to watch how she simply denies she is doing exactly that. As she raises her head and knees, and tilts her pelvis back, she is certainly contracting her abdominal wall – in plain sight! In order for the pelvis to tilt backward, the abdominal wall must pull it back by contracting. She can pat her tummy and tell us, “See, I’m keeping my belly soft”, because her skin has loosened with the backward rotation of her pelvis. However, her muscles are tight. This is simple biomechanics, yet people like Aston keep the mystique going by literally fooling us with doublespeak.

The digging in with her fingertips and lifting her bladder will have no effect on prolapse. Our bipedal body develops while moving under the forces of gravity. Importantly, the prolapsed bladder must move forward, not up. This is the danger of coming from a conventional framework. Not surprisingly, her body reveals the very structural problems that lead to  prolapse and incontinence.

Judith has spent her whole life cultivating a small ‘inner corset’ at her midriff. She often wears wide belts just under her breasts. When that area is chronically pulled in, you have no choice but to become a chest breather, which is the opposite of natural breathing. Now, with every in-breath intraabdominal pressure is pushing the pelvic organs toward the outlet instead of pinning them into position at the  front of the body.

JudithAston2I call the stomach and liver “postural organs”.  Where do you suppose her abdominal organs, which have been squeezed out of their positions in her midriff area, have gone?

Hint: Look how large and rounded her lower belly is.

This is a classic prolapse case, which we see time and again. Pelvic organ prolapse is not just about the pelvic organs. In many cases the abdominal organs have been pushed down, and in turn have pushed the pelvic organs back from the lower abdominal wall. I would be very surprised if she weren’t symptomatic.

The midriff cannot chronically be held in without developing kyphosis (curvature in the upper back) over time. Judith has staved it off for a long time through all her lengthening work, but you can see that her head is starting to fall in front of her body, which will continue as she ages.

Aston is very beautiful, charismatic, and has some good ideas. It is unfortunate however, that she is teaching women about pelvic health.

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Barton A Serrao C Thompson J Briffa K Transabdominal ultrasound to assess pelvic floor muscle performance during abdominal curl in exercising women. International Urogynecology Journal 26: 1789-1795 2015

A student from my Whole Woman Practitioner Training course recently sent me the above study for my observations and commentary. Of course there were the usual omissions and misconceptions of poorly designed studies that fill volumes in the urogynecology literature.

Image_011

Figure 1

For example, childbearing (parity) was found to be the only risk factor for stress urinary incontinence (SUI), which 60% of subjects reported as being problematic. Yet, episiotomy was not considered to be a variable, even though midline episiotomy is a known risk factor in the development of SUI, and 75% of subjects with SUI were parous. Additional omissions included hysterectomy, c-section, incontinence procedures, and vaginal surgeries. Far more disturbing, however, is the fallacious “3D” imaging technology being used in these kinds of studies.

Welcome to the virtual reality of 3D medical ultrasound, which uses many of the volume rendering algorithms and technologies developed for the motion picture industry at Pixar Animation Studios in California, USA.

This astonishingly complex computer science is based on how a rendered volume of 2-dimensional images emits, reflects, absorbs, or occludes light. Light propagation algorithms are used to fill in the missing volume data to create a “3D” picture. Shadowy 2D ultrasound images are miraculously re-constructed to reveal fetal faces, heart valves, and bile ducts. Unfortunately, there is a dark side to 3D ultrasound imagining beyond the shadows, noise, and inconsistent data recognized by the industry.

Transabdominal ultrasound (TAUS) for imaging the pelvic floor in “real time” is accomplished by placing a curved transducer at the pubic hairline of a patient who is positioned on her back with knees bent. The transducer sends out an array of high-pitched sound beams through her pelvis from front to back. The raw beam data is captured in 3 polar coordinates, i.e., two angles describing the direction away from the transducer, and the depth of the tissue boundary that is reflecting the sound echo. This data must be converted by software to Cartesian coordinates (x-y axis) in order to be displayed. Multiple 2D images are instantly reconstructed again and again on a graphics card to give the illusion of movement in real time.

US 3

Figure 2

Figure 2 was taken from an industry video of a male contracting his pelvic floor. The ultrasound transducer has been placed horizontally at his pubic hairline. The abdominal wall is at the top of the frame, and the bladder is the large black circle in the middle. The white band at the bottom of the image is described as the pelvic floor. When the patient is asked to contract his pelvic floor muscles the floor appears to elevate, lifting the base of his bladder as well.

However, the image and interpretation are utterly deceptive. When the transducer is placed horizontally on the lower abdominal wall, it is industry standard that the images reflected on the monitor are in the transverse plane. If you were looking up or down through your torso, you would be viewing the transverse plane of your body.

When the transducer is turned 90 degrees to vertical the image is derived from the sagittal plane, or looking through the pelvis from one side to the other. TAUS does not routinely capture images from the frontal plane, which looks at the pelvis from front to back.

US 5

Figure 3

Figure 3 was captured from another  “real time” video of a female asked by her physical therapist to contract her pelvic floor. When she contracts, her pelvic floor and bladder appear to lift up in the frontal plane. This movement is described by the clinician as, “The pelvic floor elevating the base of the bladder.” The patient is told she is doing a “good job” contracting her pelvic floor and lifting up her bladder.

TAUS gives the impression that the pelvic floor is moving up toward the head, and this is how the images are interpreted by physical therapists. In actuality, this structure is moving forward toward the lower abdominal wall. The reason the vagina and cervix cannot be visualized is because the image field has been sliced through a particular volume, and rendered to show only the bladder and pelvic floor. Removing regions that are not of interest in order to gain a clear view of features normally occluded is called “clipping”. Clipping tools are standard features in commercial 3D ultrasound systems.

TAUS

Figure 4

Data registration is the process of transforming different imaging modalities, such as MRI and CT, into the same reference frame to achieve as much information about the underlying structure as possible. Shockingly, much of that data is based on the perspective of the “anterior pelvic plane”, an erroneous orientation of the standing human pelvis institutionalized by orthopedics. Slice and volume rendering for 3D ultrasound has been combined with standard Cartesian medical data from CT and MRI to create what is called “simultaneous, multi-volume ray casting.” The resulting image is based on a 500 year-old anatomical misconception of the actual position of the human pelvis. While this may not be an issue when imaging an ovarian cyst, it becomes nothing less than fraudulent when imaging the “pelvic floor.”

The structure that is “lifting” in Figures 2 & 3 is actually the pelvic wall moving the front rectal wall forward. However, the circular contraction of the vaginal sphincter also pulls the bladder backward toward the front vaginal wall. The net result is a posterior bladder wall that is displaced slightly upward with pelvic contractions instead of moved forward toward its natural position behind the lower abdominal wall.

Figure 4 clearly shows the error of viewing the transverse plane as the frontal plane. Image B even measures the “lift” of the pelvic floor. Yet, notice there is no corresponding movement of the bladder toward the abdominal wall.

Physical therapists are using transabdominal ultrasound to show a deceptive and deleterious view of pelvic anatomy. This is not the only fraudulent imaging technology being widely utilized by the medical system. So-called “3D” CT scans of the pelvis are artificially rendered to reinforce an antiquated and erroneous view of pelvic orientation upon which many orthopedic hip surgeries are based. Physical therapists who teach kegel exercises using TAUS as a feedback mechanism are being hoodwinked by an unconscionable industry, and in return are hoodwinking their patients.

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Dear Cara – or -The Problem of Wiberg

Dear Cara,

My book, Save Your Hips, does talk about dysplasia, a concept first put forth in 1939 by Gunnar Wiberg. By this time, radiology was well established and the practice of orthopedics focused primarily on bones. Throughout the previous century a deep level of understanding had been centered on imbalances in the soft tissues surrounding the joint as the initial, fundamental pathology in common hip disease.

I believe The Problem of Wiberg (I just coined this phrase) to be the tipping point in changing current understanding of chronic hip disease.

Center Edge Angle of Wiberg

Center Edge Angle of Wiberg

Wiberg saw on AP radiograph that some acetabulae provide less coverage to the femoral head than others. Working with impressive 2D images that were easy to manipulate mathematically, he produced a theory stating that at a certain point in his diagnostic parameter, called the center edge angle of Wiberg (CEA), a hip could be considered dysplastic or not.

The CEA contains a large margin of error, however, because it does not take into account the major musculoskeletal movement that positions the acetabular roof over the femoral head which is, of course, sacral nutation (i.e. lordosis). When we lie supine for a standard AP radiograph, the femoral head moves slightly up and out of its socket. When we stand up, the femoral head moves down and medially. The hip joint follows the sacrum in this movement. Therefore, none of the images Wiberg was working with gave a true representation of how much of the weight-bearing joint was actually covered by the acetabular roof. No doubt he saw some very abnormal joints. But his parameter is largely erroneous because it measures spacial relationships in a non-weight-bearing position. This wouldn’t be a problem if the joint didn’t radically change from supine to standing…but it does! Wiberg and all the diagnosticians after him never really knew from an AP radiograph which hips were going to be covered-enough as the lumbar spine extended with standing. There are other imaging technologies today, but no one has wanted to confront The Problem of Wiberg. Therefore the images are digitally manipulated to give a standard AP view of the pelvis (“anterior pelvic plane”).

Crazy, but true. This is what Save Your Hips is all about.

But what were Wiberg and others through the century seeing in a dysplastic acetabulum? That it is “shallow” and “oval-shaped”, instead of more circular (it is actually a spiral, which my daughter, who is also my artist, and I realized at the same moment).

Dysplastic Acetabulum

Normal Acetabulum

The only possible gravitational dynamic capable of creating such an acetabular shape is bearing the center of mass on the front aspect of the joint. One bears the COM in this way by flattening lumbar curvature while weight-bearing. The degree to which the lumbar spine is flattened from its natural, wide-radius curvature, is the same degree the femoral head is moved up and laterally.

It is also true that there is another, far less common, condition where the femoral head has been held slightly out of the joint from birth or early childhood. Thus, we have a true developmental dysplasia, and also an acquired (degenerate) condition. Spinal and/or pelvic obliquity (scoliosis) can also cause the hip joint to twist and elongate.

So how should a thirty or forty-year-old who has new-onset or slowly progressing hip pain with radiologic signs of dysplasia be categorized? You would not be able to determine (other than by history) which hip dysplasia was acquired and which was developmental. The trained eye, however, would be able to tell by subtle differences in the bones themselves. But this distinction is not studied and therefore not mentioned in orthopedic literature. It is all classified as developmental.

Acquired dysplasia causes the anterior aspect of the symmetrical, arched acetabular roof to (1) stretch – as gravity pulls the joint downward, elongating the acetabulum like taffy, and (2) apply bone to what becomes the anterior-superior aspect of the acetabulum in the counternutated position (lumbar curve flattened). This area becomes thickened and protruding as it tries to cover and protect the joint.

Normal Acetabulum

Dysplastic Acetabulum

The process of stretching and bone deposition at the anterior-superior aspect of the joint is probably largely responsible for other popular orthopedic theories, acetabular retroversion and pincer FAI, which describe the same architectural characteristics. This is why I describe in my book how orthopedics creates new diseases out of thin air.

To convolute matters further, the practice of orthopedics believes this dysplastic area to be the weight-bearing roof of the normal acetabulum, due to a 500 year-old misconception of pelvic orientation in the bipedal position.

Orthopedics has used flawed, circular logic to justify the mutilation of millions of hips.

Which kind of dysplasia do you believe you have, Cara?

Wishing you well,
Christine

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PAO – A Devastating Operation

Reciting the words spoken by William Harris in 1986, orthopedic surgeons persist in their assertions that “Primary hip osteoarthritis (OA) is extremely rare.”1 These doctors continue to claim that “Up to 90% of young patients (<50 years of age) that develop OA of the hip have an underlying structural problem, which in half the cases is dysplasia.”2

A diagnosis of developmental dysplasia of the hip (DDH) is based on the center edge angle of Wiberg3, which is calculated from standard anterior-posterior (AP) radiographs. To obtain the CE angle, a vertical line is drawn through the center of the femoral head, and another to the lateral edge of the ‘sourcil’. (Figure 1)
Figure 1

The sourcil, a French term meaning ‘eyebrow’, is a projection of the anterior-superior acetabular wall. It is a 2-dimensional contrived parameter that the practice of orthopedics actually believes to be the load-bearing aspect of the acetabulum. In reality, the sourcil does not exist as reflected on pelvic x-rays. Its lateral edge, often used to diagnose ‘pincer impingement’, is subject to change with the slightest rotation of the pelvis, as more of the arched acetabular roof comes into view. (Figure 2)
Figure 2

Moreover, the entire AP radiograph, taken in the supine position, is a faulty representation of how the femoral heads are actually contained within the acetabulum. When supine, lumbar curvature flattens and the femoral heads move slightly up and laterally. When standing with lumbar curve in place, the femoral heads move down and medially. There is no way to calculate to what extent individual pelvic rotation will change the CE angle, a configuration derived strictly from the supine x-ray. Yet, it does not matter because orthopedic surgeons are only interested in treating DDH surgically.

After a decade of disastrous results treating dysplasia with arthroscopic surgery to “repair” labral tears4, the standard of care has become the periacetabular osteotomy (PAO). Surgeons believe the goal of treatment “should be the restoration of hip anatomy as close to normal as possible.”5 PAO is the preferred technique “because of its balance between minimal exposure, complications, and ability to provide optimal correction.”6

In reality, orthopedics has an extremely inaccurate view of pelvic orientation, and rather than restoring normal anatomy, PAO changes the pelvis to a configuration that does not occur in nature. Drawn from centuries of misperception, orthopedics believes “Two strong osseous columns of bone surround the acetabulum, transmitting the stresses between the trunk and lower extremities.”7 (Figure 3)

Figure 3 The most current orthopedic literature proclaims that PAO “preserves the posterior column of the acetabulum and therefore allows early weight-bearing post-operatively.”8

Actually, in the standing body the pelvic inlet is in a vertical position, and the so-called bony “columns” are horizontal, not vertical. In 1955 it was recognized that gravitational forces are carried around the linea terminalis (circular pelvic inlet) and distributed onto the femoral heads.9 (Figure 4)
Figure 4

Surgeons contend, “The pelvic ring and outlet are not disrupted by PAO”10, yet anyone who has ever seen a post-PAO x-ray knows the fallaciousness of such statements. Another selling point of the PAO is that, “It can be performed through one incision without violation of the abductors, thus enhancing recovery.”11 The following summary of the steps in the soft-tissue dissection and exposure prior to the actual osteotomy illuminates the devastating and irreversible trauma that accompanies PAO.12

  1. External oblique incision and exposure of iliac crest.
  2. Subperiosteal iliacus dissection.
  3. Detachment of sartorius origin and inguinal ligament attachment through anterior superior iliac spine osteotomy.
  4. Incise fascia of tensor fascia lata muscle.
  5. Dissect tensor fascia lata from intermuscular septum.
  6. Exposure of lateral rectus femoris muscle belly and medial retraction to identify distal hip capsule.
  7. Release reflected head and direct head of rectus femoris.
  8. Incise fascia of capsular extension of iliacus muscle and dissect muscle exposing entire anterior hip capsule.
  9. Subperiosteal dissection of pubic root and entrance into iliopectineal bursa.
  10. Insert Hohmann retractor into pubis, flex hip, and retract psoas muscle. Overly vigorous traction may injure femoral nerve.
  11. Complete dissection of anterior hip capsule and interval between psoas tendon sheath and hip capsule.
  12. Incise periosteum of pubis and perform subperiosteal anterior and posterior pubic dissection reflecting the obturator membrane from the inferior pubis.
  13. Reflect iliopectineal fascia from iliopectineal line.
  14. The iliac nutrient artery located anterior to the distal sacroiliac joint should be cauterized and sealed with bone wax.

The next step is the osteotomy itself, whereby the acetabulum is sawn in three places and rotated with the intention of better covering the femoral head by the acetabular roof. The established maneuver in PAO is to turn the acetabular fragment into flexion, lateral tilt, and medial rotation. (Figure 5)
Figure 5

“Every effort should be made to orient the acetabular sourcil in a horizontal position relative to the weight-bearing zone of the femoral head. The anterior and posterior walls of the acetabulum should be positioned so that the posterior wall is lateral to the anterior wall.”13

One of the great medical outrages of the 21st century is that what these surgeons are trying to reproduce is not normal anatomy, but the misconstrued reflection of the 2D pelvic x-ray. In the flesh-and-blood standing pelvis, the posterior wall is medial to the anterior wall, due to the oblique nature of the pelvis from the wide anterior superior iliac spines in front, to the more narrow ischial tuberosities in back. (Figure 6)

Figure 6

It is also a tragic irony that the goal of PAO is to get the “femoral head centered under the acetabular roof”14 when this is the natural biomechanical result of sitting, standing, walking, and running with a wide-radius lumbar curvature.

Reinhold Ganz, the orthopedic surgeon who popularized the PAO, recently reported that a 10-year follow-up revealed one-third of his PAO patients had developed femoroacetabular impingement (FAI) as a result of the operation.15 It is logical to assume this would cause orthopedic surgeons to pause and reconsider the long-term benefits of the surgery. Instead, the prevalence of PAO is increasing exponentially. Only now, FAI surgery is being routinely added as an adjunct to the PAO operation. “[Hips] are routinely examined intraoperatively and a femoral neck plasty is performed to maintain or enhance motion and to prevent post-PAO acetabulofemoral impingement.”16

Another recent source tells us, “The longest follow up of PAO to date shows a survivorship, defined as not yet requiring THR or arthrodesis, of 60% at 20 years.”17 These are terrible odds, yet even post-PAO patients seem to be in denial about the realities of the surgery, often encouraging others to submit to the operation. Online support groups serve as funnels, delivering scores of naive victims into the hands of orthopedic hip surgeons.

The theory of acetabular dysplasia has not been challenged since Gunnar Wiberg published his dissertation on the subject in 1939. No one questions that a rudimentary geometric angle drawn onto a 2D x-ray may have no correlation with the reality of the standing body. Or worse, that the natural depression in the front acetabular rim (Figure 7)

Figure 7 is often mistaken for dysplasia and reduced coverage of the femoral head.18 There is no consensus among orthopedic surgeons whether patients with dysplasia benefit from arthroscopy, and what the exact indications for labral repair should be.19

Too often the progression of surgically managed dysplasia is arthroscopy > PAO > THR. Young age is a major risk factor for revision THR, yet untold numbers of post-PAO patients in their teens and twenties are receiving total hips. Many of these surgeries are being conducted in out-patient settings, for which no public records are required to be kept.

The periacetabular osteotomy should be considered a rescue operation to be utilized in the most severe cases of disease and birth defect. The natural history of mild and moderate hip dysplasia has yet to be defined. Moreover, surgeons know “It does seem possible to live a long and asymptomatic life with mild or moderate hip dysplasia.”20


Notes:

1 Perry K Trousdale R Sierra R Hip dysplasia in the young adult. The Bone and Joint Journal 95-B(11):21-25 2013
2 Ibid
3 Zou Z et al Optimization of the position of the acetabulum in a Ganz periacetabular osteotomy by finite element analysis. Journal of Orthopaedic Research 31: 472-479 2013
4 Jackson T Watson J LaReau J Domb B Periacetabular osteotomy and arthroscopic labral repair after failed hip arthroscopy due to iatrogenic aggravation of hip dysplasia. Knee Surgery, Sports Traumatology, Arthroscopy June 13 2013 [Epub ahead of print]
5 Perry 2013
6 Ibid
7 Callaghan J Rosenberg A Rubash H The Adult Hip Lippincott-Raven 1998 p.57
8 Perry 2013
9 Davies JW Man’s assumption of the erect posture, its effect on the position of the pelvis. American Journal of Obstetrics and Gynecology 70(5): 1012-1020 1955
10 Perry 2013
11 Ibid
12 Zaltz I How to properly correct and to assess acetabular position: an evidence-based approach. Journal of Pediatric Orthopedics 33(1): S21-S28 2013
13 Ibid
14 Ibid
15 Albers C et al Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH. Clinical Orthopaedics and Related Research 471(5): 1602-1614 2013
16 Ibid
17 Perry 2013
18 Vandenbussche E et al Hemispheric cups do not reproduce acetabular rim morphology. Acta Orthopaedica 78(3): 327-332 2007
19 Colvin A Harrast J Harner C Trends in hip arthroscopy. The Journal of Bone and Joint Surgery 94: e23(1-5) 2012
20 Jacobsen S Adult hip dysplasia and osteoarthritis. Acta Orthopaedica 77(324) 2006

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