Know Your Nodes, Part III

By Riva Preil

Background complete- you have made it through the anatomy, good job!  Time to discuss the PATHOPHYSIOLOGY.  Unfortunately, things don’t always run as smoothly and perfectly as we just described, and dysfunction of the lymphatic system can result in LYMPHEDEMA.  Lymphedema (LE) is swelling of the upper or lower extremities due to impairment in the lymphatic system.  It can also develop in the trunk, head, neck, or genitals.  It is a chronic disease and treatment involves lifetime management of the condition.

There are two types of lymphedema, primary and secondary.  Certain individuals are born with a congenital malformation of the lymphatic system, (ex. the vessels are too large or too small).  This is known as PRIMARY LYMPHEDEMA.

Furthermore, an initially healthy lymphatic system can develop problems through infection, obstruction, or damage.  This is known as SECONDARY LYMPHEDEMA.  Globally, the most common cause of lymphedema is filariasis, a parasitic disease that is caused by thread-like roundworms which occupy the lymphatic system, including the lymph nodes.  The worms enter the lymphatic system through blood feeding mosquitos and black flies in certain tropical countries.

In the United States, the most common cause of lymphedema is breast cancer-related surgeries that involve removal of affected axillary lymph nodes.  Removal of lymph nodes results in impairment in the lymphatic system, and it disrupts the normal return of fluid to the venous angles.  This can result in swelling of the involved upper extremity.  Similarly, lower extremity lymphedema can develop after removal of pelvic and or inguinal lymph nodes (ex. due to prostate or gynecological cancer surgeries).

Lymphedema can develop days, weeks, months, or even years after surgical node removal.  Therefore, individuals who have undergone these types of surgeries should be aware of their predisposition towards developing the disease. Any abnormal swelling or changes should be reported to one’s physician immediately, because the prognosis is better if the disease is detected and treated earlier.

Know Your Nodes, Part II

By Riva Preil

Approximately 10% of water that exits the capillaries and enters the interstitial space at the arterial end of the capillary does NOT return at the venous end due to pressure related factors (refer to Starling’s Equation for more details).  This “extra” water (referred to as the lymphatic load) enters the lymphatic system at lymphatic capillaries to the venous angles (the junction of the left subclavian vein and the internal jugular vein).  The lymphatic system meets the circulatory system at the venous angles, and it is where the extra water is returned to the circulatory system.

Furthermore, certain molecules, including fats from the digestive system and certain large proteins, are TOO LARGE to travel through the narrow diameters of the circulatory vessels.  Instead, they travel through the larger lymphatic vessels along with the water.

Now, moving on to the title of this blog…It would be impossible to explain the lymphatic system without mention of our ever so crucial LYMPH NODES.  Lymph nodes are small oval shaped organs that contain white blood cells, T cells, and B cells which are responsible for fighting infection and are a component of the immune system).  All lymph fluid travels through a series of lymph nodes, which are also responsible for filtering the lymphatic fluid.  There are approximately 600 lymph nodes in the average adult human body.

Know Your Nodes, Part I

By Riva Preil

Can you believe that Labor Day has come and gone?  Yes, dear readers, summer is officially over.  But boy, was it an amazing and memorable summer!

Believe it or not, when asked about the highlight of my summer, I unequivocally and enthusiastically respond that it was my lymphedema certification course.  (#PTnerd.  And darn proud of it too).  Fortunately, I had the wonderful opportunity to return to class this summer and learn some pretty incredible, stimulating, and practical material. Touro College, right here in New York City, hosted a course taught by The Academy of Lymphatics, one of the highly recognized training centers in the world of lymphedema.  The course was an intensive nine day class which was three classes condensed into one.  In addition, each participant was required to complete seven modules which included extensive textbook reading. Each module contained a written online examination which we were required to complete prior to attending the class. I found this approach extremely beneficial, because it allowed me to begin with a strong foundation.

The course itself was fascinating!  The instructor, Marina Maduro, and her assistant, Kirat Shah, are excellent educators who were clearly well versed in the material and who explained difficult concepts well. I would be one to know; let’s just say I am not shy when it comes to asking questions, and I challenged them on many a concept that they clarified and explained clearly.

You are probably wondering, okay Riva, so what did you ACTUALLY learn, in a nutshell, in this course?  Let’s start off by first discussing the lymphatic system itself.  I like to call the lymphatic system “the secondary circulatory system.”  It is an OPEN system without a central pump. The primary circulatory system, which consists of the heart, blood vessels (arteries, veins, and capillaries), are responsible for transporting fluids, nutrients, gases, and waste products throughout the body.  It is a CLOSED system with a pump (the heart)…

To learn more, stay tuned for my next post!

YOUR Voice, Your Choice

Dear Reader,

Thank you for following the Beyond Basics Blog. I hope that you enjoy READING the blog posts as much as I enjoy WRITING them!  I strive to talk about topics that interest you.  That being said, I cordially invite you to submit questions that you have regarding the pelvic floor and I encourage you to share ideas that YOU want to learn about.  Are there any burning topics that you wish I discussed in greater detail?  Do you have any questions in particular that I can help answer?  Have you heard about any innovative treatments or new research that spark your curiosity?

I would love to hear YOUR VOICE and know your interests.  Consider this an opportunity to “choose your own adventure”, so to speak, in the world wide web of blogs.  I am happy to hear your suggestions and aim to please, so don’t be shy!  It is my pleasure to respond and discuss matters that matter to you!



Did YOU Miss Last Week’s Blog Talk Radio Show?

By Riva Preil

In case you missed The Pelvic Messenger’s STIMulating Science with Dr. Kenneth Peters on Thursday, August 21…fear not! Lucky for you, the show was recorded and is accessible online here.

Dr. Peters discussed many important and fascinating topics. He opened by describing different bladder disorders (ex. painful bladder syndrome vs. Interstitial Cystitis/IC).  He explained MANY people who think that they have IC actually DO NOT have IC, and that only a small percentage of his patients actually have it.

Dr. Peters then proceeded to explain what neuromodulation is, and he explained how it can be used to help treat various bladder disorders. He explained the difference between sacral, pudendal, and tibial nerve stimulation. In addition, he described the minimally invasive surgical procedure involved with neuromodulation implantation, and he described what to expect during the recovery phase of the “bladder pacemaker” procedure.

Finally, Dr. Peters elaborated upon emerging research in the neuromodulation arena, including neuromodulation in treating pudendal neuropathy, multiple sclerosis, patients with spinal cord injuries, and pediatric patients.  He described additional areas of interest that require further research.

WHAT WAS THE MOST INTERESTING THING YOU LEARNED FROM THE SHOW? Please share your favorite aspect of the show on Facebook (under this blog posting) and ENTER OUR RAFFLE TO WIN A COMPLIMENTARY MASSAGE STICK!    

Get excited for our next show, on September 4 at 10 AM, when Dr. Sarah D. Fox will discuss her integrative treatment approach to target chronic pelvic pain.  Stay tuned for more details!   

Work Hard, Play Harder

By Riva Preil

In honor of the summer and all our hard work, Amy Stein generously treated the Beyond Basics Staff to a summer weekend of fun!  Last Sunday and Monday, our team met at the Allegria Hotel in Long Beach where we proceeded to bond, eat, and laugh…a LOT!

We participated in team building games that helped us improve our communication skills.  In addition, we played a “Guess Who” game, during which we all submitted three random and unexpected facts about ourselves, and then we tried guessing who submitted the clue.  For example, would you have guessed that Amy was the captain of her cheerleading team in high school?  Or that Yarissa is one of SEVEN children?  Or that Arianna wanted to be a pilot?  Yep, neither did I, and it was definitely a fun experience learning more about my co-workers.

Our group trip was a huge success, and we are especially grateful to Mary Hughes and Karen Medina for planning the details of our outing.

One of the most rewarding aspects of working at Beyond Basics is that I feel part of a TEAM.  I feel truly blessed to work alongside so many talented, accomplished, intelligent, and beautiful women. In the daily hustle and bustle of New York fast paced life, it is easy to forget how lucky I am!  That is why office outings such as this past weekend’s trip are so special.  They serve as important reminders to me to count my blessings and appreciate my unique work environment.  Not only are my co-workers excellent colleagues professionally speaking, but they are also my FRIENDS!  I enjoyed spending quality time with them this weekend, and look forward to many more future team building opportunities.

Take a look at some pictures below!



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Still Having Issues Getting that Flat Belly? Part III: Diastasis Recti Q&A

I’ve had some really great questions come my way since starting this blog series. I was not able to address all the questions within my past two entries, so I decided to dedicate one post to responding to questions and concerns of our readers. I hope this addition is helpful and informative. If you continue to have any questions or concerns, please email me at or visit our clinic website to schedule an appointment:



I just had my first baby 9 weeks ago and think I may have a Diastasis Recti. How can I check if I have one? 

            – D.M., FL

A small separation is normal for everyone. Although standardized norms are still yet to be determined, generally a 2 cm separation at and above the belly button and a 1 cm separation below the belly button is considered typical. Most people don’t have a caliper for an accurate measurement and using a ruler to measure on yourself can be tricky. An easy cheat is to use your fingers. Two finger widths above and at the belly button is average and 1 finger width below is average. It can be hard to feel the edges of the muscles when relaxed, so measuring first while lifting your head and bringing your ribcage towards the pelvis is often easier. You want to measure at three different locations along the linea alba: At the belly button, 3-4 inches above the belly button and 3-4 inches below the belly button. The separation is often different at each location and knowing where your separation is can help direct where you should be splinting your abdominals during the exercises.

Start by lying onto your back with both knees bent. Take one hand and place your fingers at your belly button aligned horizontally (see picture below). Press into the tissue with moderate pressure so that your fingertips are past the depth of the skin. Lift your head off the floor and slowly bring your ribcage towards your pelvis. When you feel your muscles start to pop into your fingers, stay in that position and take note of how many fingers fit within the gap. If you do not feel the muscles either move more into the crunch, press until the tissue with more pressure or increase the number of fingers (The separation may be wider). Lay your head back down and repeat at 3-4 inches above and below the belly button.

DRA Measurement



Is a diastasis recti the same thing as a hernia?

-          J.R., NY


Great question. A hernia and a diastasis recti are not the same thing. The lina alba consists of multiple fascial layers and while one layer may be overly stretch, the others may still be intact. With a diastasis recti, the rectus abdominis muscle separates from a widening of the linea alba, but the stretched and thinned linea alba still holds in all the abdominal contents. A hernia is when there is a hole in the abdominal wall and the abdominal contents are pressed outwards through the hole. The below picture is a great example of an infant with both a diastasis recti AND a hernia. You can see the separation of the muscle in the front (football shaped bulge) as well as a hernia (circular bulge above belly button) coming through the diastasis.

DRA with Hernia



I had surgery a while ago for ulcerative colitis. I had an incision from just above the belly button to about 3 inches below. I used to have good abs but I’m struggling to get them back especially towards to lower abs.  I can feel some separation in the middle of the muscles of my core and am wondering if that’s part of the problem. I was hoping you might have some advice. I’m desperate to get my flat tummy back. I don’t need a 6 pack but I do miss having a flat tum. Would really appreciate your thoughts. 

            – A.H., UK


Having any surgical incision along the linea alba definitely compromises the integrity of the closed canister and often leads to a diastasis recti. Studies have shown that almost 100% of women with laparoscopies (just a small hole) through the belly button or along the linea alba are left with a separation, so a longer incision line would almost definitely leave you with one. The separation could definitely be contributing to your difficulty with getting your flat tummy back. I would stay away from crunches right now, but start introducing some TA (Transversus Abdominis) exercises with abdominal splinting that I discussed in part 2 of this blog. Make sure you have support for all abdominal exercises you do – meaning a sheet wrapped around your abdomen or you can just grab the edges of the rectus abdominis and make sure they stay together with the exercises.

If the muscles are not coming together in 6-8 weeks, I would visit a women’s health physical therapist. Scar tissue is laid down anytime a surgeon cuts into the body, and especially with abdominal surgery, the scar tissue may be preventing the muscles from coming together in the front. The fiber orientation of scar tissue is disorganized and laid down in a random manner, meaning it can attach to anything around it – skin, muscle, bone, organs, etc. This can result in adhesions that inhibit normal gliding of the surrounding organs and normal contraction of abdominal/pelvic/hip musculature.  Without manual intervention to break up the scar tissue, it may be difficult for the muscles to return to a better resting position.



I had a cesarean section and am having difficulty engaging my abdominal muscles. I think I also may have a diastasis in my lower abdominals. Does having a cesarean section affect which exercises I should be doing and my recovery rate? Thank you so much!

-          E.K., CA


I am so glad you asked this question as there is a huge population of women who have had cesarean sections. Scar tissue is also an issue with this population and can restrict the abdominal muscles from gliding normally. The abdominal muscles and fascia are sewn back together following the operation and it takes 6-8 weeks for the muscles to heal – meaning you should not begin an abdominal exercise program for 6-8 weeks (you must receive clearance from your Obstetrician first). Scar tissue will be laid down along the entire depth of the incision line and will decreased tissue glide unless the issue is addressed. This may prolong or prevent correct muscle activation and can therefore affect proper closing of the diastasis recti. The exercises for women with cesarean sections are the same, but if you notice that your muscles are not coming back to midline within 6-8 weeks following the start of the exercises, then you may want to consider seeing a women’s health physical therapist.



I had twins 6 months ago and am still struggling with looking pregnant. I have a moderate separation above, at and below my belly button. I have being doing exercises for diastasis recti for a month now and I think my muscles are slowly coming back together. Should I be wearing an abdominal binder to help with the process? Also – I think my TA, the muscle on the inside of my hip bone, is starting to hurt from working it so hard. Is that normal? Thanks for your help!

            – R.M., NY


For a moderate to significant separation (> 6 cm separation at rest), an abdominal binder can definitely be useful. The binder helps with preventing further separation of the abdominal muscles during functional activities, such as lifting your child and pushing a stroller, by providing external passive splinting of the muscles. You should wear the binder during the day when you are doing physical activities and only if you are also doing abdominal exercises without the binder. If you rely on the binder, the muscles will become weak and your separation will not come back together. While wearing the binder, you don’t have to actively hold in your abdominals. The splint should bring the two ends of the muscles together so that when you need to engage your abdominals (lifting, pushing) they are in a good, safe position. The muscle just inside your hip bones are either your obliques or Transverses Abdominis – neither should be getting sore with the exercises. Make sure you are not constant holding in your abdominals throughout the day with the binder and that you are only lightly contracting the TA with the exercises (your buttocks and superficial abdominals should not be contracting).



What does “women’s health physical therapy” mean and how does it differ from regular physical therapy? If I have issues surrounding my pregnancy, can’t I just go into any physical therapy clinic?

            – C.W., FL


Great question! To be honest, “women’s health” is an outdated term since many of these clinics also treat men and children. The term is now shifting to “pelvic floor physical therapist.”  I specifically used the term women’s health because many general orthopedic PT clinics that don’t treat pelvic floor issues do treat pre- and post-partum women. If you are interested in physical therapy services, be sure to call the clinic and ask if there is anyone there who specializes in pre- or post-partum care.

I specifically work as a pelvic floor physical therapist treating varying orthopedic conditions, women’s health issues and bowel, bladder and sexual dysfunction in men and women. Typical diagnoses that I treat are painful sex, painful urination, urinary frequency, urinary urgency, urinary incontinence, interstitial cystitis, endometriosis, pre/post-partum, rectal pain, constipation, fecal incontinence, lower back/coccyx/pelvic/sacral pain and any post-op abdominal, back, hip, pelvic or bowel/bladder/vaginal surgery. Pelvic floor refers to the group of muscles that sling from your pubic bone in the front to your coccyx bone in the back. Since three different systems (Bowel, Bladder & Sexual) go through these muscles any pelvic mal-alignment, weakness, tightness or dysfunction in coordination can disturb any or all three systems. If you remember back to the analogy of the core as a closed canister, any dysfunction in these muscles can affect breathing, abdominal organ function, trunk stability and in turn the extremities that rely on the trunk for stability.

Again, if you continue to have any questions or concerns, please email me at or visit our clinic website to schedule an appointment:

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