Rule #76: No Excuses, Play Like a Champion.

"'I don't have time' is the grown up version of 'the dog ate my homework'".

Life is stressful. Student loans, car payments, kids to feed, 50+ hours work, long commutes, boss barking at you, deadlines to meet, etc. Plus, we need to fit exercise into our days in between all the chaos because it's supposed to be good for us right? I've heard every excuse in the book for why one isn't exercise. In fact, I've used every excuse there is to get out of exercising.

Here are some of the common excuses that I hear every day, (and some of which I have used myself) with a rebuttal to challenge these excuses.

Excuse #1: I don't know what to do.
Work out trends are like diet trends, there are so many different types and it can be so overwhelming. How can all these experts have completely different opinions on how to exercise? I get this question from my patients everyday. And as a physical therapist, it is my job to prescribe exercise. Sure there are some extremely general guidelines out there. The Department of Health and Human Services recommends that healthy adults should be getting 150 minutes a week of moderate aerobic activity or 75 minutes a week of vigorous aerobic activity, as well as performing strength training activities twice a week. Moderate aerobic exercise would include activities like brisk walking and swimming, whereas vigorous aerobic exercise includes activities like running and dancing. Use of weight machines, rock climbing, and body resistance type exercises would be considered strength training. That's less than 25 minutes of moderate exercise per day, and 10 minutes of vigorous. Obviously this is very very VERY vague guidelines, but it depends on an individual's goals with their exercise that determines the type/amount/frequency.

Is your goal to:

• lose weight?
• gain muscle mass?
• decrease stress?
• train for an event?
• prevent illness/injury?
• gain flexibility?

Ask yourself, why? What is your goal with exercise? If you don't have one, start brainstorming. It is extremely difficult to get very far without a destination in mind.

Excuse #2: I can't afford a gym membership.
Yes, many gym memberships are super, duper expensive. Especially with the influx of boutique-y type gyms, memberships can easily hit over $100/month with individual 1-hour classes at $15. But here are a few options for those on a budget.

• ClassPass. If you enjoy variety, and I mean everything under the sun, ClassPass may be a good opinion for you. Personal training, cycling, yoga, Pilates, you name it, ClassPass probably has it. It is a monthly membership fee of anywhere from $79-$129 (depending on where you live) which is still a good chunk of change, but if you are going to 3-4 classes per week, you are paying less than $10 per class. You sign up for a class before you get there, so you don't have to worry about there being a spot for you. A con (or a pro based on how you think of it) is that there is a fee if you sign up for a class but don't show up, or don't cancel ahead of time, which could be a con for those who have inconsistent schedules but a pro for those who need the extra motivation to go. Another con (kinda) is that you are only able to go to one gym three times within one month. So if you really like the Monday night Vinyasa Yoga at Yo-Yo-Yogie, you won't be able to go one week out of the month. I do this three is kind of silly, it makes it a little difficult to get into a routine. But it does make it so that you try out various places, different teaching/coaching styles, and new experiences.
• Meet up. The website meetup.com has a lot of different exercise classes, many for free or donation based. You simply go to the website, click "Find" a group, put in your zip code, and there is a search bar if you want to look up "Tai Chai" or whatever it is your heart desires, or there is a "fitness" and "health/wellbeing" page to help if you really don't have any specific interests.
• Various Apps/You Tube Videos. There are a bunch of FREE You Tube videos that have guided exercise routines whether is a quick interval training session or meditation. You only need yourself and probably some space in order to get a workout in. iTunes has an app called "Daily Workouts-FREE" that has videos as well as a listed exercise progression.

Excuse #3: I don't have the time.
I probably hear this one the most. Guess what, no one has the time. You have to make the time. This is your health that we are talking about, how do you not have time for that?

Excuse #4: I've never been an exerciser.
It's never to late to start something new! Maybe brainstorm why you have never been an exerciser. Is it because you never had an exercise goal to strive for, you've tried various types of exercise, but never for long enough to actually give it a shot? Have you been putting everybody else's health/wellbeing before yourself? Time for some self exploring. Everyone had to start somewhere. I was telling a patient the other day that my mom literally forces me to play sports as a kid. My first soccer game at 4 years old, she was standing by my side the entire time or else I refused to get on the field. My first golf tournament at 6 years old,  I didn't want to play. My mom basically dragged me onto the course while I had tears in my eyes. Some make think, "wow that's torture!" or "I would never force my kids", while my mom did and I'm so glad she did. I was a super shy kid, and not very self motivated. So she pushed me quite a bit. But that's how it is with all new things, including exercising, it's scary. I've wanted to quit different exercises classes various times because I didn't feel like I fit in. Me talking to myself in my head: "I'm the only one not wearing Lululemon in the yoga class therefore I must stick out like a sore thumb", or "um.. this is embarrassing, I didn't know you needed socks for Barre, now the teacher just came up to me and told me that I need to leave and go borrow some from the front desk because it's a health hazard without any", or "I cannot keep up with everyone else in this Pilates class, how the heck are they doing the exercises so fast with that much weight!?". My point is, everything is awkward at first, don't give up and just say that your not an exerciser. Do me a favor, try a class/exercise at least 4 times before making an opinion about it. Your future self will thank you for going out of your comfort zone and trying again.

Excuse #5: I already work out because my job involves labor, or I'm on my feet at work, etc.
I hear this one a lot too. When I ask, "do you have a current exercise regime?" and sometimes I'll get back "well no, but I'm exercising all day long at my work when I get up and down to the bathroom (I've literally heard this one), or "Yeah I'm lifting/stocking shelves at Trader Joe's". That's great that your job doesn't make you sit behind a desk all day like a lot of America, but exercise doesn't just have physical benefits, but psychological benefits as well. You rushing to and fro in the chaos of work, or walking 40 times to the fax machine down the hallway does not give you the same benefits as deep breathing in yoga and it doesn't increase your heart rate like cardio activities do. I'm going to emphasis this again, exercise is not just for our physical body, but we are understanding more than ever the benefits of exercise on the mind. And in my opinion, the mental benefits of exercise far outweigh the physical benefits.

Excuse #6: I just really don't enjoy exercising.
Is it that you don't enjoy it? Or is is that you just don't have the motivation? To be honest, this excuse sometimes I can understand. I can understand not wanting to get out of bed an hour earlier to go to that cycle class when my cozied up next to significant other in bed, and I'm warm under this comforter and it's freezing the second my skin touches the air.

Excuse #7: It hurts.
There are lots of reasons why exercise can hurt. Maybe you are performing the activities incorrectly or inefficiently, causing a repetitive type injury. Maybe you have an acute injury that is causing a motion to be painful. Your brain may be so oversensitive to movement that it is sending pain signals to the body, thus causing pain. Pervious injuries, stress, and fatigue are just a few reasons why the brain can be hypersensitive to movements such as exercise. GUYS, PLEASE GO SEE A PHYSICAL THERAPIST IF EXERCISE HURTS!!

Excuse #8: I just eat really healthy.
High-five. Now if you have the drive to eat really healthy, just imagine what would happen if you stopped making excuses to exercise.

So I already mentioned that I myself can be an excuse queen. In fact, it took me two years to finally get back into a solid weekly routine that includes strength training, cardio, flexibility and mindfulness type exercises. After moving to Portland, I pretty much had to start all over again. I had to find the motivation in the miserably cold weather to get up and outside. I was already fatigued from probably lack of vitamin D (no sun for 24 days in a row is rough people, especially for a California beach girl), and I didn't really know my way around town or even how to drive in the dark/cold in an unfamiliar place (see the excuse list just keep growing??) It wasn't until none other than my Uber driver on New Years Eve who really got me thinking about exercise in a different way. When he heard that my boyfriend and I had recently moved from California he said, "the only way you are going to survive this place is if you exercise every day. It is the only way that you will be able to get your body warm the next couple of months, and it's key for getting through the Winter into the Spring". I'm not sure why this reason out of every known benefit of exercise is what finally kicked me in my rear end, but it worked. I was back into a routine within the month and have been keeping with it. It was extremely rough the first few weeks. I was so tired at the end of everyday. I had to literally plan my days around when I could exercise, which was frustrating and annoying. I even had to skip out on plans with some friends, but I set a goal and it was important that I stick to it this time. Even though it's only been about 7 weeks with this new routine, I have more energy at the end of the day than I ever have before. I don't find myself feeling foggy during the day, and I don't just pick up a less health food option on my way home to save time when I have stuff to cook at home. I've had a couple of mornings where I have slept in, but I had the determination to make it up sometime during the week.

Some tips to getting back into the routine.

1. Pick a date. Mark it on the calendar, tell your friends.
2. Find a group. When you know others will call you out for not showing up, it's all the bit more motivating
3. Give yourself external rewards (only at first). The goal is that exercise itself will be the reward to exercising. But when you are first get back into it, exercise my not be all that motivating.
4. Make a realistic goal. The worst is when we set our expectations too high and we fail. Be nice to yourself and make a short term goal, something like "I will run for so many minutes per week", or "I will take yoga 2 times this week". Write this goal down, and put it somewhere that you can see it, so when you are feeling weak you can have the reminder. My gym actually has an app that you can write a goal and it tracks your progress for you. When you reach your goal it gives you a little congrats email, which is silly how satisfying it is. 
5. Get your support system involved. Get them on your team and hey! maybe they will even want to join you. When you are feeling weak, call one of your friends who can help motivate you. Let them know how important this is to you, and that their support is very important to you. Start up #deadlifts4datenight or #crunchbeforebrunch... yeah??? I like the sound of those.
6. Make it excuse-proof. Don't join a gym that is clear across town that has odd hours, or times that don't really work with your schedule. Find something close to work, or your house. Better yet, find something that you literally have to drive by on your commute. Preferably this gym will have showers so you can go before work since we all know that we are dead tired at the end of a work day. Keep an extra pair of sneakers and clothes in your car or at work. Sleep in your running pants and shirt with your shoes and socks right next to your bed- I do this all the time, one less step/excuse to have in the morning.
7. Keep it low and take it slow. Please don't jump off the couch straight into playing tennis four times a week. Too much, too fast, too soon can result in injury and we are right back to where we started from.

A cheviot to my exercise soap box- more doesn't always mean better. An extreme example would be this: Many people have seen the TV show The Biggest Loser where a dozen or so overweight/obese contestants compete to lose the highest percentage of weight in order to win a million dollars. At "the ranch" where the show takes place, they are exercising most hours of the day, and have a professional chef cooking for them. Most of them shed 100's of lbs., but sadly many do not keep the weight off once they get back home. Working out all day, having someone cook for you, and no external stress to worry about except for shedding the weight isn't "real life". So the contestants go back to their daily routines and find it is difficult to keep up exercising and eating the way they were before.

Keep exercise at a level that can be maintained and even enjoyable. This isn't temporary, it's a lifestyle.

Let's Talk About Sex, Baby!

Okay guys and gals, it's time that we talk. It's Valentine's Day on Sunday, and I thought it was a good time to discuss everyone's favorite topic, sex. Sex is great! It's a way to show love to your partner, a way to express yourself, and a way to make yourself and partner feel good. But what about those who can't stand sex? Not because they necessarily don't want to have sex, but because it is actually painful. Unfortunately, for those suffering in the bedroom, sex is often a hush-hush topic. We sometimes talk about it with our friends, if you are lucky maybe with your significant other. But it's really hard to admit that you aren't enjoying sex when you hear your friends bragging about how they just had the best orgasm ever. You start to think, what's wrong with me? Not to mention the pressure you feel to make your partner happy, so you have sex anyway, even though you can't stop thinking about when this pain will just be over, just finish already!

For those ladies suffering, you aren't alone.

It has been found that over one-third of females have pain during intercourse, which is probably under reported. It doesn't matter the age, whether you are 18-years-old in your first sexual relationship, 30 years old in a happy, healthy marriage, or post-menopausal, all women can be affected. The North American Menopause Society (NAMES) found between 17-45% of post-menopausal women say that they find sex to be painful. According to the same survey, only 25% of women seek treatment. This may be in part due to the fact that women aren't being asked by their healthcare providers if they are having trouble in the sack. According to the International Menopause Society, 70% of women reported that  their healthcare provider did not ask about sexual health.

Sex. Should. Not. Be. Painful.

Ladies, have you ever checked out your vagina? Chances are you haven't. Or even if you have, you have no idea what's what. Here is a QUICK anatomy lesson of the female pelvic floor:

Yeah, there is a lot going on down there. (and yes men, you also have a pelvic floor too)... Basically, the pelvic floor is like a muscular sling, a trampoline of muscles that run from the tailbone, to the pubic bone, and between the sits bones. It has "passageways" through it, three in women (vagina, urethra and anus) and two in men (anus and urethra).

It is made up three layers of muscles that help with:
1) sphincter control (so we don't poo/pee ourselves, and hold in gas)
2) support for the pelvic organs such as the bladder, urethra, and rectum
3) sexual function including ejaculation for men and arousal in women
4) It works with the abdominals and back muscles for stabilization of the spine.

Okay, I told you it was going to be quick. So, I'm going to continue discussing the third function listed above, specifically different pelvic pain disorders that can cause painful intercourse, aka dyspareunia.

Types of pelvic pain:

Vaginismus: I'm sure this is a term that you have never heard of before, however approximately 17% of females worldwide suffer from vaginismus. Generally this is when there is pain during penetration, whether it be during intercourse, with tampon use, or during a pelvic exam. This occurs when the vaginal muscles involuntarily  spasm, making it virtually impossible to penetrate. In other cases, penetration may occur, but is followed by periods of involuntary muscular tightness. It may feel like a burning and/or stinging with tightness on entry. Often times this leads to avoidance of sexual intercourse, because it hurts! The cause is unknown, however it often can follow childbirth, yeast/urinary infections, STDs, hysterectomy, cancer, surgery, rape, and menopause. Symptoms can come on at any point in a women's life, even after years of non-painful, enjoyable sex. If left untreated, symptoms can get worse since the experiences of sexual pain can increase in intensity and duration due to the anticipation that pain will occur. If we fear that we will feel pain, then we will involuntarily muscle guard due to fear/anxiety reality to pain, which perpetuate the cycle.

The good news is, you don't have to live with this and there is hope. Physical therapists can teach relaxation exercises to decrease muscular guarding, desensitization techniques to decrease reflexive pelvic floor activation, help to manually relax and stretch tight pelvic floor muscles, provide dilators to increase vaginal canal size, and treat additional musculoskeletal issues related to the core, pelvis, and back. For more information, check out: https://www.vaginismus.com/

Example of different dilator sizes.

Vestibulodynia: aka Vulvar Vestibulitis Syndrome, but the term 'itis' infers that there is an inflammatory process occuring, however with vestibulodynia, there is no active inflammation. Symptoms for each women can be look very different, however it is overall a hypersensitivity to light touch at the vestibule, or opening of the vagina. Some women explain the intense symptoms as being felt like "acid being poured on my skin" and "constant stabbing, knife-like pain".  The picture below outlines with red circles the areas most commonly affected. In the clinic, we perform what is called the Q-tip test in which we gently place a Q-tip at these areas to assess for hypersensitivity, or what we would call elevated pain levels.

Why hypersensitivity occurs isn't entirely known, but it may be due to an overgrowth of the nerves to this area. There may or may not be redness associated with vestibulodynia, however itching is not usually a symptom. This can also make tampon use, intercourse, or vaginal examination painful due to the hypersensitivity to touch. Lifestyle habits such as prolonged sitting and wearing of fitted pants can also increase the symptoms. Physical therapists can help to educate patients on safe hygiene for the vulva.  For more information, check out: http://www.vulvalpainsociety.org/vps/index.php/vulval-conditions/vestibulodynia


Vulvodynia: another type of vulvar pain similar to vestibulodynia, however symptoms are considered more general, and not specific to the vestibule. Symptoms are often constant, with intermittent periods of symptom relief. Pain may be found at the inner thigh, clitoris, labia, and/or vestibule. The picture below depicts there most commonly affected areas with the red circles.

Interstitial Cystitis: (IC) aka Painful Bladder Syndrome. This diagnosis includes pelvic pain, pressure and/or discomfort with urination or directly after urination, as well as urinary urgency (strong urge to go), and frequency (needing to go often). Ten percent of women with IC also suffer from ulcers, and a hardened bladder. This condition is very difficult to diagnosis, and is often misdiagnosed as urinary tract infections, treated with ongoing antibiotics. Usually it is diagnosed after additional treatments are utilized without success. Currently, there isn't really a gold standard test for IC since the current tests have low sensitivities. Obviously, this can lead to chronic, persistent pain since these individuals are often bounced around from one healthcare provider to another. For more information, check out : http://www.ichelp.org/


Additional causes of pelvic pain can also include endometriosis, pelvic organ prolapse (POP), low estrogen, scarring from surgeries/child birth, radiation treatments, and persistent muscular tension.


PHYSICAL THERAPY is a treatment option! Yes, physical therapists can help you improve your sex life.

This is what your physical therapy evaluation will include:
- History/systems review of symptoms, exercise habits, bowel/bladder habits, etc.
- Brief discussion about the anatomy & function of the pelvis/pelvic floor.
- Internal pelvic floor muscular exam through the vaginal canal to assess muscle symmetry, strength, "tone"/tension, and pain.
- External musculoskeletal exam of the hips/pelvis/core. Your PT should ask, but just in case make sure to tell your PT if you are currently or have a history of low back, hip, or abdominal pain, or if you have issues with constipation.
- You will be given homework at the end of the evaluation. Some homework may include -- mindfulness, posture, relaxation techniques, strengthening, and stretching.


If you are having pain with intercourse, tampon use, and/or gynecological exams, let your doctor know! Although it is common, it is not normal, and there is help out there.



Check out the International Pelvic Pain Society at: http://pelvicpain.org/home.aspx for more information and a healthcare provider near you.