Understanding Temporomandibular Dysfunction (TMD): How Physical Therapy Can Help

Maybe you’ve noticed coning or loafing in the middle of your abdomen with certain exercises or daily activities, like getting out of bed. You hop onto Instagram in search of answers to your questions on what to do and not do so that it doesn’t get worse. After all, you’re scared that your organs are going to push through the widening in your abdomen and cause herniations. You find an account by an influencer (possibly credentialed, or not…) who is selling their program to correct your diastasis recti and lose your mom pooch- sounds simple enough. They tell you to never do any exercises or activities that cause coning along your midline. You start the program you bought from them but notice your midline tenting/coning even with the most basic exercises, so you never progress to the next level of exercises because you don’t want to make things worse. You get down on yourself that you’ll never get back to your previous level of fitness because of your core problem. Due to frustration, you start working out less because you’re scared of doing it wrong and ruining your abdominal wall health. Exercise is no longer enjoyable because you are hyperfixated on if your abdominals are coning or not. Instead of bouncing back after kids, your self-image, mental health, and physical conditioning all take a dive. This story could sound a lot different, but unfortunately we frequently hear some version of it more than we would like. We recognize that misinformation is rampant in multiple spaces, including but not limited to personal trainers, social media influencers, coaches, physical therapists, and medical doctors. We acknowledge that it is incredibly difficult in this day of immediate access to a vast amount of information to find out what is actually true. After all, you are just trying to make the most informed decisions possible about your health. We are trying as rehab providers to increase our voices as educators on evidence based practice because it shouldn’t be this hard. The core is a canister that manages intraabdominal pressure. It is made up of your diaphragm, pelvic floor, transverse abdominus, obliques, latissimus dorsi, and multifidi muscles. As Orthopedic and Pelvic Health Doctors of Physical Therapy, our job is to teach you hands on how to recruit and coordinate these muscles to improve your abdominal wall resilience and load tolerance in a variety of movement planes. You deserve personalized, one-on-one care to retrain your core without the guess work of if you’re doing it right or not. The goal is to rebuild trust in your body so that you reach your specific goals, instead of forming a list of exercises that you should never do. The fear of movement leads to further deconditioning and musculoskeletal dysfunction. We want to help break that cycle with you. If you have questions, please don’t hesitate to reach out to our team- we would love to be a resource to you! 

Throughout pregnancy, the female body encounters a number of changes to allow room for the baby to grow. Some changes we may notice are that our hips start to tilt forward a little bit more, we have a more extension in our lumbar spine, the rib cage widens to allow room for organs to move up, and, with that, the abdominal wall stretches too. With the widening of the abdominal wall, we will also see the connective tissue, the linea alba, in the center of the abdominal muscles widen as well, which is termed diastasis recti abdominis. One fun fact about these changes is that all women during pregnancy have a diastasis recti abdominis, as it allows for adaptations and fetal growth with pregnancy (Gingerich & Prevett, 2023). With this particular change, you will hear a lot of talk and concern about pelvic floor weakness, abdominal weakness, and worsening of that widening with abdominal exercises that causes coning or doming of that tissue. However, all of these concerns are not necessarily true. During this blog, we are going to focus on how to return to exercise while addressing your diastasis rectus abdominus or DRA. Before we address some of the concerns with DRA, I think it’s important to recognize who this might occur in and factors contributing to it. While the pregnancy and postpartum population is the most common to experience this, it can also be seen in the very lean and muscular athletes, babies, and individuals with increased abdominal circumference (Gingerich & Prevett, 2023). There are many factors that can impact the extent of DRA, including genetics, type of delivery, time between and number of pregnancies prior and current activity level, as well as rehabilitation and strength return between pregnancies or before first pregnancy. Outside of pregnancy and postpartum and genetics, ability to manage intra-abdominal pressure and willingness to focus on form and quality of movement will also have an impact on an individual's DRA. So how does this impact our ability to exercising or return to our daily activities? With DRA, many people are aware that coning in the center of the abdomen can cause weakness of the abdominals muscles, particularly rectus abdominis, and pelvic floor weakness as well. This is thought to be because coning can worsen our DRA, result in poor management or activation of the core, and difficulty managing intra-abdominal pressure. These theories have led a lot of individuals astray from accessory core work that results in abdominal crunching or rotation of the abdomen to prevent weakness or abdominal/pelvic floor dysfunction. However, in a recent study by Gluppe et al., it has been found that there was no increase in prevalence of pelvic floor dysfunction or low back pain among postpartum individuals with DRA compared to those without (2021). It was noted, however, that abdominal weakness and pain were associated with diastasis recti abdominis (DRA) (Gluppe, et al. 2021). Along with this, Hills et al., found that individuals who worked on improving abdominal strength with sit ups and abdominal rotation consistently demonstrated improved strength through abdominal musculature and reduced pain (2018). While the inter-rectal abdominal distance may not have improved, working on rotation torque and lower sit ups actually was beneficial with improving the strength of our abdominal muscles regardless of coning (Hills et al., 2018). So, collectively the answer to the question above is with progressive loading and creating tension across the abdomen! Lastly, how do we go about this? If you are returning to exercise and are experiencing DRA, we need to focus on managing our intra-abdominal pressure by creating tension across the linea alba…this means we need to load it with exercise and really focus on muscle activation (Gingerich & Prevett, 2023). Ultimately, this means being intentional about our core activation whether we are squatting, picking up our baby, or lifting in the gym. And, before you go directly back to kipping and increasing your intensity, take the time to really work on the quality of form and consistency of practice so we can improve our efficiency with movements and reduce risk of injury.

Osteoporosis is a disease that weakens bones, makes the bones thin, and is often called a "silent disease" because it progresses without symptoms until a fracture occurs (NIH, 2022).Affecting millions worldwide—especially postmenopausal women and older adults—it weakens bones and increases the risk of breaks from minor falls or even simple activities like bending or coughing. While medication and dietary strategies are important in managing osteoporosis, one of the most effective and empowering approaches is strength training. Why Strength Training? Strength training, also known as resistance training or weightlifting, involves exercises that cause muscles to contract against external resistance. This can be done using free weights, resistance bands, weight machines, or even body weight. But here’s the critical part: strength training doesn’t just build muscle—it stimulates bone growth . When muscles pull on bones during resistance exercises, they trigger bone-forming cells called osteoblasts, helping to maintain or even increase bone density (Hong, 2018). Key Benefits of Strength Training for Osteoporosis Increases Bone Density Regular strength training can slow bone loss and may even build new bone in some people. This is particularly important in areas prone to osteoporotic fractures, like the spine, hips, and wrists. Improves Balance and Coordination By strengthening core and lower-body muscles, strength training reduces the risk of falls—the leading cause of fractures in older adults. Enhances Posture and Mobility Targeted exercises can combat the stooped posture and spinal compression often seen with advanced osteoporosis. Boosts Overall Health Strength training improves metabolism, insulin sensitivity, and mood, making it an all-around excellent tool for healthy aging. Getting Started Safely Before starting a strength training program, especially if you have osteoporosis or are at high risk, consult your healthcare provider or a physical therapist. They can help tailor a program to your needs and avoid movements that could be unsafe. Safe Practices Include: Start slow with light resistance and progress gradually. Focus on form, not weight—proper technique is key to preventing injury. As form gets better, slowly increase the weight Slowly work into high-impact movements, such as jumping Include balance exercises like standing on one foot to enhance fall prevention. Osteoporosis doesn’t have to mean frailty or fear. With a consistent, safe strength training routine, you can build resilience—not just in your bones and muscles, but in your confidence and quality of life as well! 

A Client Success Story!

Is Alcohol an Irritant for Pain? Often in sessions, I will discuss factors that can be an irritant to pain and what “low hanging fruit” we can work to improve upon to help reduce symptom irritation. This typically includes sleep habits, stress, volume/load management of exercise, overall daily movement, and diet. But is alcohol an irritant for pain and should you avoid it while coping with pain? The short answer is yes! Alcohol absolutely is an irritant and often worsens pain, especially for those coping with chronic pain. Alcohol can often increase inflammation due to how it is processed in the liver and GI tract, creating oxidative stress and cell damage inhibiting the repair of muscular tissue. It can also trigger the immune response and cause the release of pro-inflammatory cytokines, which can increase inflammation in the muscles and other tissues of the body. While rehabbing from an injury, some inflammation is expected and necessary for recovery, but the goal is to reduce exacerbation to inflammation of the tissues to allow them to heal Lastly, alcohol can also impact overall recovery by interfering with nutrient absorption, can create hormonal imbalances with growth factor hormones, and interfere with sleep. By interfering with these last three processes this prevents muscle and other tissues within the body from recovering and rebuilding from trauma/damage or general use, and can often increase lactic acid. Collectively, with the increased inflammation, this can enhance muscle soreness, slow recovery rates, and can mimic the pain that people are experiencing. In conclusion, while alcohol can be enjoyable when out with friends or at dinner (in moderation), it is best to at least reduce or abstain from alcohol consumption while recovering from an injury (or wanting to improve athletic performance). Overall, it can increase inflammation in the body, reduce your body’s ability to recover from the injury but also daily stressors by interfering with a wide variety of bodily processes, and enhance the overall pain that one may experience. Simon, L., Jolley, S. E., & Molina, P. E. (2017). Alcoholic Myopathy: Pathophysiologic Mechanisms and Clinical Implications. Alcohol research : current reviews , 38 (2), 207–217. Steiner, J. L., Gordon, B. S., & Lang, C. H. (2015). Moderate alcohol consumption does not impair overload-induced muscle hypertrophy and protein synthesis. Physiological reports , 3 (3), e12333. https://doi.org/10.14814/phy2.12333

What happened to RICE and what do we recommend now? The acronym RICE has been used for decades to guide management of acute musculoskeletal injuries. Although Dr. Gabe Mirkin coined the concept of Rest, Ice, Compression and Elevation in 1978, he changed his position in 2015 as new research demonstrated that “rest and ice can actually delay recovery.” When a muscle, tendon, or a ligament are injured, the body responds with a 3 step process of inflammation, followed by repair and lastly, remodeling. Inflammation has a bad reputation, but without an inflammatory response, there is no healing. Part of the inflammatory response is vasodilation, which allows increased blood flow to the site of injury to usher in immune supporting cells such as neutrophils and macrophages. Macrophages release a hormone called insulin-like growth factor (IGF-1) that helps with muscle regeneration. Ice causes vasoconstriction and therefore limits the body’s inflammatory response, leading to delay of steps 2-3 for full recovery. The lymphatic system is responsible for removing waste carried in lymphatic fluid from the site of injury up towards the heart to join the circulatory system to then be removed from the body via the urinary or gastrointestinal systems. Since the lymphatic vessels are passive structures with a one one direction of flow, contraction of muscles around the capillaries is vital for creating a pump effect to move the lymph through the system. Prolonged rest and inactivity reduces this muscle pump action, contributing to delayed clearing of waste at the site of injury, which can lead to increased swelling and incomplete healing of the tissues. Inactivity also leads to muscle atrophy, increases risk of reinjury, and reduces revascularization of the injured tissues. Clinical research does not have high level evidence supporting the usage of compression and elevation in a recovery process, but also has not found significant harm. Therefore, these two treatments are included in the updated, very long acronym PEACE & LOVE . P rotect: modify aggravating activities for 1-3 days after injury E levate: support limb in position above the heart A void antiinflammatory modalities: avoid antiinflammatory medications and ice C ompress: taping, wraps/bandages for swelling control E ducate: education from a therapist on load management and early activity to optimize recovery timeline and full healing with reduced risk reinjury, fear of movement and unnecessary medical interventions. After the first few days after injury: L oad: muscles, tendons, and ligaments rebuild in response to graded exposure to load. Early movement encourages this remodeling needed for daily, recreational and sport activities O ptimism: better outcomes and prognoses are correlated with positive outlook on recovery V ascularization: pain free aerobic exercise improves blood flow to injured tissues and helps manage pain without medications E xercise: improve proprioception, increase mobility, restore strength, and reduce risk of reinjury As with any injury, there is always nuance and exceptions that would be best answered for your specific situation by your rehabilitative medicine team. As Doctors of Physical Therapy practicing in an out of network model, our team at Evolve Physical Therapy is perfectly positioned to screen or evaluate your injury with reduced barriers to entry (no doctor’s referral needed, quick availability, and no limitations from insurance). Feel free to call or text our team at (919) 948-0880 for evidence based guidance to optimize your recovery! Dr. Rebecca Acevedo, PT, DPT Evolve Physical Therapy

Exercising While Pregnant: What You Need to Know Pregnancy is a transformative time in a woman's life, and staying active during this period can bring significant physical and emotional benefits. While every pregnancy is unique, the consensus among healthcare professionals is that moderate exercise is both safe and beneficial for expectant mothers! These guidelines have changed drastically over the years from recommending bed rest, to light exercise, and now encouraging women to continue to stay active throughout their pregnancy. Currently don’t exercise? That’s okay! Pregnancy can be an ideal time to start adopting a routine to help improve your health during pregnancy and postpartum. Why Exercise During Pregnancy? Staying active can help you: Reduce backaches, constipation, bloating, and swelling Boost your mood and energy levels (reduce risk of postpartum depression) Improve sleep quality Promote muscular strength and endurance Lower your risk of gestational diabetes and pre-eclampsia Enhance your ability to cope with labor and potentially shorten its duration Speed up postpartum recovery General Guidelines During Pregnancy The American College of Obstetricians and Gynecologists (ACOG) recommends that people engage in strength training and cardiovascular exercise before, during, and after pregnancy (2020). For a non-complicated pregnancy, some of the guidelines include: At least 150 minutes of moderate-intensity aerobic activity per week that is spread out over the week, such as 30 minutes a day for five days Women who engaged in vigorous-intensity aerobic activity before pregnancy can continue these activities during pregnancy and the postpartum period Strength training 2-3 times a week with following appropriate modifications as you progress through pregnancy Exercises to Avoid To protect yourself and your baby, avoid: Activities with a high risk of falling Contact sports Hot yoga or exercising in hot, humid conditions Warning Signs to Stop Exercising As you progress through your pregnancy, exercise modifications will start to occur. This is typically more common in the second and third trimester. But how do you know when to modify or stop exercising? While these are more significant signs and tend to signal for further medical care, some symptoms to look out for include: Vaginal bleeding Dizziness or feeling faint Chest pain Headache Shortness of breath before exercise Muscle weakness Calf pain or swelling Preterm labor signs or decreased fetal movement In conclusion, exercise during pregnancy offers many benefits for both mother and baby. This includes improving maternal health during pregnancy, improved sleep quality, and reduced risk of diabetes and preeclampsia. The key is to stay active in ways that are safe and appropriate for your trimester and personal health. Always work with your healthcare provider to create a plan that suits your individual needs.  References Physical activity and exercise during pregnancy and the postpartum period . ACOG. (2020). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/04/physical-activity-and-exercise-during-pregnancy-and-the-postpartum-period Current guidelines . Current Guidelines | odphp.health.gov. (2018). https://health.gov/paguidelines/second-edition/ Global Recommendations on physical activity for health.WHO. (2010). http://www.who.int/dietphysicalactivity/publications/9789241599979/en

Let’s Talk About Dry Needling Have you been talking to someone about your chronic pain and they mention dry needling? We are here to answer all your dry needling questions! Don’t worry, it’s not as scary as it sounds. In fact, for many, it’s a game-changer in pain relief and mobility. What Is Dry Needling, Anyway? Dry needling is a modern therapeutic technique used by licensed physical therapists and other trained healthcare professionals. One of the biggest questions we get is, how is it different than acupuncture? Acupuncture is rooted in Traditional Chinese Medicine, dry needling is based on Western anatomy and science. It involves inserting ultra-thin, sterile needles into myofascial trigger points —aka “knots” in your muscles, to help reduce pain, improve movement, and restore function. How It Works The theory is simple: When a needle hits a tight or irritable muscle band, it causes a twitch response, which helps the muscle release, improves blood flow, and promotes healing. The needle itself is “dry,” meaning no medication is injected. Patients have Post session: - Decreased Pain - Improved mobility - Improved function - Increased healing Does It Hurt? Most people describe it as a quick cramp or twitch, while others just experience a dull ache or mild soreness afterward (like post-workout stiffness). Who’s It For? Dry needling may help if you suffer from: Chronic muscle tightness Sports injuries Sciatica or low back pain Neck tension or whiplash Shoulder or knee pain Plantar fasciitis Headaches  Final Thoughts: Should You Try It? If traditional methods like massage, stretching, or medications haven’t quite done the trick, dry needling might be the missing piece in your recovery puzzle.

When most people think about preparing for birth, their minds jump to packing a hospital bag, picking out onesies, or maybe writing a birth plan. And while those are important, there's one powerful piece of prep that often flies under the radar: physical therapy—specifically, pelvic floor physical therapy. Yes, birth is natural. But natural doesn’t mean easy. It’s one of the most physically demanding events a body can go through, and just like you’d train for a marathon, preparing your body for labor and recovery can make a huge difference in how you feel during and after birth. What Is Birth Prep Physical Therapy? Birth prep physical therapy is about optimizing the body for labor, delivery, and postpartum recovery. It typically involves working with a pelvic floor physical therapist who focuses on: Pelvic floor awareness and relaxation Core strength and trunk stability Hip and spine mobility Breath work and pushing techniques Postural alignment Labor positions It’s not about doing Kegels on repeat (actually, in some cases, Kegels might not be what you need at all). It’s about balance—learning to relax and engage the right muscles when you need them most. Why It Matters Labor is like a full-body workout meets endurance event. Physical therapy can help you: Prepare for different labor positions that optimize pelvic space Minimize pain or discomfort during pregnancy, especially in the hips, back, and pelvis Improve pelvic floor mobility, which can aid in pushing and reduce tearing risk Recover more smoothly postpartum, especially if you’ve had a C-section or perineal trauma  Bonus: Postpartum Care Here’s the truth no one talks about enough: birth recovery doesn’t have to start or stop at your 6-week checkup. Physical therapy can support your healing journey sooner (up to 2 weeks postpartum), and can start months (or years!) postpartum, and can help with: Scar tissue mobilization (from tears or C-sections) Core and pelvic floor rehab Returning to exercise safely Managing pain with sex or daily movement Bowel and bladder dysfunction Final Thoughts Birth prep is more than buying the right swaddle. It’s about feeling connected to your body, understanding how it works, and feeling confident heading into labor. Physical therapy is a powerful, evidence-based tool that every birthing person deserves access to. If you’re pregnant, consider adding a pelvic floor PT to your birth team. It might just be the best-kept secret in birth prep and in your postpartum recovery.