On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Helene Darmanin, PT, DPT, CSCS to the program to talk about physical therapy during and after pregnancy. Dr. Helene Darmanin is an orthopedic and pelvic health physical therapist with over a decade of experience facilitating healthy, empowering movement for her clients as a PT, and fitness and pilates instructor. Inspired by her own motherhood and ardent feminism, she specializes in preparing and healing pregnant and postpartum mamas.

In this episode, we discuss:

- Helene's experience with miscarriage, pregnancy, birth, postpartum

- Body positivity in pregnancy and postpartum and how it can optimize outcomes

- American College of Obstetrics and Gynecology guidelines for exercise while pregnant

- Reasons to go to PT when pregnant 

- Reasons to go to PT postpartum 

- And much more! 

Resources: 

When & Why To See A Pelvic Floor Physical Therapist

10 Ways to Love your Body

Helene's website

Helene's Instagram

Helene's LinkedIn

Helene's Facebook 

Danford Works 

A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. 

More Information about Dr. Darmanin: 

I am an orthopedic and pelvic health physical therapist who specializes in preparing and healing new and expectant mothers. I am currently seeing clients virtually through Danford Works, and am also the creator of Quarantoned, body-positive HIIT at home.

I practice guilt-free PT—physical therapy which fits easily into your day and improves your quality of movement and life. Research has shown that exercise and patient education are the two most effective interventions for positive long-term outcomes, and these can both be offered successfully virtually.

I have over a decade of experience facilitating healthy, strong movement in my clients' everyday lives. I have a Doctorate of Physical Therapy from New York University, and a Bachelors in Exercise Science from Smith College, and am a Certified Strength and Conditioning Specialist, and a Kane School-certified pilates mat instructor. I give workshops and webinars about fitness, pelvic health, and being guilt-free in your pursuit of wellness; I am published in peer-reviewed journals, blogs, and have presented at national conferences. Most importantly, I am a proud mama to my one year old son, and my calico cat.

Read the Full Transcript below:

Speaker 1 (00:01):

Hey, Helene, welcome to the podcast. I am thrilled to have you on welcome.

Speaker 2 (00:06):

Thanks so much, Karen. I'm so grateful to be here.

Speaker 1 (00:09):

And so today we're going to be talking about pelvic health or women's health after pregnancy, during pregnancy, which, you know, a lot of longtime listeners of this show will know that I've had a lot of episodes on this, but I'm particularly excited about this one, Helene, because you're going to, I think, bravely share a little bit about your story about your birthing experience and, and your experience with your body and how it changes and continues to change even after. So I'm just going to throw it to you and just kind of let you tell your side of the story. Thanks.

Speaker 2 (00:48):

Yeah, I know that in my, I have a my son is about to be one on Monday in just six days. So I know that in my time, since I gave birth or while I was pregnant hearing other women's stories always helped me to not, not feel alone, even though I knew what to expect because I specialized in pregnancy and postpartum long before I got pregnant. So I am really excited to share some of my story. The biggest, the biggest thing that, that happened when we first started trying to get pregnant was when we were trying to conceive and we got that positive pregnancy test. We were so excited. But then, and I remember, cause it was Thanksgiving. And all my family was so, so, so excited cause we shared right away. Cause I figured no matter what happened, I wanted to have the support of my loved ones.

Speaker 2 (01:43):

A few days after Thanksgiving, I started to have some bleeding and I started to have some cramping and it, it was before I had even gone for my first prenatal visit with my OB. And when I showed up for my first prenatal visit, she said, congratulations. I said, I'm pretty sure I'm having a miscarriage right now. And, and sure enough I did miscarry at about seven weeks which is early enough that some people don't even call it a miscarriage. It can be called a chemical pregnancy. My OB was incredible. And she said to me, they say, when it's this early, that you shouldn't be comforted because it was probably a chromosomal abnormality. And you know, it, it just naturally aborted itself. She said, but that didn't help me when I had two miscarriages. So I, I feel you that meant the world to me.

Speaker 2 (02:36):

Cause it was, it was it was a hard thing because we wanted the pregnancy so badly. And then actually I had a lot of trouble with continuing to bleed. And then I ended up needing an emergency DNC because I had a blood clot that was actually blocking the full shedding of the uterus. So that was, you know, in the midst of all the, the sadness, it was also scary and confusing. But I was really fortunate. I had some great practitioners and made it through, made it through. Okay. And then actually we were really lucky because we were able to conceive then the first month that we were allowed to start trying again, I had to get my normal period back, which took about six weeks and then we were able to start trying again. So I feel really fortunate that we were able to do that. And that time I texted my OB right away, I actually used progesterone depositories, which are really uncomfortable. They're like frozen popsicles of progesterone that you have to insert vaginally every night. There's really mixed evidence about them. There's nothing very conclusive, but my OB was like, it'll make you feel like you're doing something at bare minimum. You'll get that great placebo effect.

Speaker 1 (03:50):

And w what does it, what is the reasoning around using that?

Speaker 2 (03:55):

So there's some thought that the fetus won't implant, if the progesterone levels are too low, so you're causing a local increase in progesterone to help facilitate the fetus implanting. Got it.

Speaker 1 (04:06):

Got it. Okay. So sadly, you had a miscarriage, which, you know, for a lot of people listening to this, now, if you follow social media, we were talking about this before Chrissy Tiegen and John legend were very, very open about their miscarriage, which, which happened. I don't know how many months along she was, but enough. And that the comments were, Oh my gosh, I'm so glad you're, you're talking about this. No one talks about this. Women are so ashamed of it. Couples can be ashamed of it. Did you go through any of those feelings or was it like, okay, this happened full steam ahead. Let's keep trying, you know what I mean? I think you've got like both ends of the spectrum. Yeah,

Speaker 2 (04:51):

Yeah, yeah. I think I was somewhere middle of the road. I think I feel very fortunate that I'm was my awesome support network and my great care that I had from my OB and my acupuncturist to who I saw who helped me recover that I, I didn't feel guilty. I didn't feel like some I've I've heard people talk about feeling like their bodies had failed. But I did feel a lot of sadness. I didn't necessarily share right away, except for, with my very close circle. But I've certainly never kept it a secret. I've never felt like it was a shameful secret. And I I've always wanted to share it in case it does help someone else who has that experience, because as it turns out, the more I talked about it, the more women who I talked to said, Oh, yeah, that happened to me. Oh, that happened to me. Yeah. In fact, a lot of, a lot of my friends were like, I feel like over 30, the first one is like a trial run. And like, you kind of, a lot of women, their pregnancy was that chemical pregnancy or miscarriage.

Speaker 1 (06:01):

Yeah. So all of a sudden you're not quite so alone. Yes. Oh my goodness. Yeah. So, so now let's talk. So you get pregnant. So let's talk about your pregnancy, the birth postpartum, because all of this, part of your story, we're going to be tying into things that the listeners can do if they're in any of those phases.

Speaker 2 (06:24):

Yep, absolutely. So I was really lucky during the first trimester. I didn't have too much morning sickness, some slight nausea that usually eating a croissant helped. Unfortunately it was always a croissant. Well,

Speaker 1 (06:36):

Lucky you. Yeah. And

Speaker 2 (06:39):

But I was exhausted a hundred percent of the time. My first trimester, like I have always been super energetic. I've been a fitness instructor, like for my whole adult life. And I just wanted to sleep where I was standing all the time. So exercising was really difficult, which was hard for me because it's such a part of my life. And I would like put on an episode of Outlander and get on a stationary bike and be like, as long as your legs are moving, it counts. It's exercise, you know, was like no resistance on the bike. And that would be, I would get to my 30 minutes and counted as a win. So that, that was the first trimester. Second trimester is, was pretty awesome. That's kind of where it's at. Cause you're starting to show, which is fun. And then and energy levels come back up, but you're not like a whale yet, which is great.

Speaker 2 (07:32):

Well, by the end of the second trimester, when I was starting to get kind of big, then I started to have a very typical pregnancy symptoms of back pain. Interestingly my back pain was the worst kind of at that transition between the second and third trimesters. And then by the end of the third trimester kind of disappeared. My body kind of figured out how to be that size. I felt like I also had extreme swelling in my hands and feet. So I was wearing compression socks wearing wrist splints at night while I was having a lot of risk banks. I was actively working as a physical therapist on my feet and manually treating patients. So that was, that was hard to handle. I tried a cortisone shot, actually. I tried PT, of course. And then I tried a cortisone shot and none of that really helped. I had pretty bad carpal tunnel until I gave birth. And, and it would just like my hands and feet looked like little sausages, which was really pretty funny. And, and by the end of the third trimester, I was again, really tired, but I managed to work until I was 38 and a half weeks pregnant. On my feet demonstrating exercises, even though I gained well over the recommended amount and I gained 47 pounds, which interestingly was exactly what my mother gained with both her pregnancies

Speaker 1 (08:51):

Beard. And so what is the recommended? Isn't it like 20 to 35 or six 25

Speaker 2 (08:56):

To 35 is the midline though. The most recent American college of obstetrics and gynecology recommendation is anywhere from 11 to 40. So there's a little more acknowledgement that now there's a broader range that can be considered normal. Got it.

Speaker 1 (09:09):

Okay. Great. And so I think it's also, it's also good to note that what you were feeling back, pain, swelling, these are all, like you said, these are pretty typical, right? It's not outside the realm of, of normal to have these symptoms when you're pregnant. Right. Okay. So then you go in, you give birth. Yup. Yup. So,

Speaker 2 (09:30):

So I I had one day of false labor, which was very frustrating. I wanted that kid out by 39 weeks. I was like, Nope, done out. And then a week later I went into real labor. I had a doula, I was just ready to have my vaginal unmedicated birth. That's what I always wanted. I got to the hospital and luckily I was six centimeters dilated, which is when they consider active labor is starting. So they were able to keep me at the hospital, but Oh my goodness, was I tired? I started having contractions on a Friday, late morning, went into the hospital by about 3:00 AM, Saturday morning. I had gotten maybe three hours of sleep. My duals recommended that I sleep more and I was, and of course that's what I recommend to all my clients. And I was like, no, no, no, I don't need to sleep. I'm going to keep walking cause that'll help my labor progress. So I walked around my block 1 million times. And so by the time I got to the hospital, I was so tired. That's mostly what I remember is just being exhausted. And I had, you know, I advise on changing positions during labor and, and how to best facilitate things. And my doula was like, let's get on hands and knees. And I was like, Nope,

Speaker 3 (10:45):

Not moving. I am not moving.

Speaker 2 (10:49):

And then actually did have some complications during labor where my son had a cord wrapped around his shoulder. So every time I would push the cord would become compressed and his heart rate would drop. But my actually it wasn't my OB. I went in just after she got off call that night at midnight. And I got into the hospital at 3:00 AM. And let the OB who delivered me was sent Hastick. She was really, really fantastic and knew that I was really committed to having an unmedicated vaginal birth. So there was never a moment where she was not where she was considering anything else. She just kept kept me charging. And I ended up giving birth in exactly the position I didn't want to, which is lithotomy position. So on my back with my niece, Fred and doing directed bowel salvia breathing, which I also didn't want to do.

Speaker 2 (11:39):

Cause both of those things increase the likelihood of vaginal tearing. But it was the only way that we were going to get that kid safely out with his heart rate dropping. And, and we did, as she was, she was able to cut his before he was fully out and were able to get him delivered vaginally on medicated and safely. So that was, that was quite an experience. And it was really funny actually, my husband was like, yeah, like that's how you do it. You, you unmedicated. And he like, we're all these sissies who need, who need epidurals. And my doula was like, no, no, no, no, no, no. You don't understand. 90% of women in New York city get epidurals. Like your wife is nuts. So I was like, yeah, you don't get to judge. That's not an experience you'll ever have.

Speaker 4 (12:29):

Exactly. yeah. So it was, it was,

Speaker 2 (12:35):

It was a roller coaster and then I still didn't sleep because I was so excited about having my son. And so that was really like a crazy up and down day then that Saturday when he was born that morning. Yeah.

Speaker 1 (12:51):

Wow. That's dramatic. That's a lot of, that's a lot of drama for, for one birth. But it's, it's also, I mean, I can, I can imagine the relief of having him born safely and there you are, you're in the hospital, you take your baby home, you know, you're, you've been teaching other women on how to work with their postpartum bodies for a long time, but now let's talk about you get home and, you know, a couple of weeks go by and you have the, we all talk about the dad bod, but you know, there's like you have like the mummy tummy or the mom bod. So how do you, what advice do you have for people to kind of stay body positive during this whole period, whether it be during the pregnancy postpartum and, and what, what being body positive can do for you?

Speaker 2 (13:50):

Yeah. so I have always been an advocate of body positivity and this was the time in my life where I felt like it really paid off. In general, I think that body positivity creates this cycle of self-care where if you take care of yourself, then you feel good about yourself. And if you feel good about yourself, then you're more likely to take good care of yourself. And it becomes a very positive spiral. So I've often used that with my clients and and it was definitely my turn to use it for myself. I was a ballet dancer, so I definitely have had an awareness of body image for most of my life. When I was pregnant, I, I kept, I felt like when I was pregnant, it wasn't as hard to have positive body image because everyone was just telling you how beautiful you are and you're glowing.

Speaker 2 (14:43):

And it's so exciting and the thrill so you get a lot of positive reinforcement from outside, but I feel like a lot of that ends after you give birth. In fact, just, I was, we were just talking about the New York times in her words newsletter today was a mom who was talking about her experiences postpartum and saying that a lot of times, even if you had a complicated birth that you were in a lot of pain, people say, Oh, well, at least the baby's healthy and they completely brushed aside the mother and her experience and her symptoms. And I'm very much of the thought that, yes, it's wonderful, the baby safe and healthy, but in order to be a good parent and effective caregiver, you need to put on your own oxygen mask first. So starting to take good care of yourself and feeling good about yourself is going to make you a better parent in my opinion.

Speaker 2 (15:40):

Plus it's just it, regardless of your status as a parent, it's important for especially women because we're often ignored in this regard to feel good about ourselves. So in terms of staying body positive after I gave birth, I actually strangely I found it very helpful to spend some time like with my body and kind of noticing the changes. So I took a little longer in the shower where I w I would kind of be grateful to different parts of my body while I was showering, like, wow, thanks to my stomach that was able to stretch and hold my son, like thank you to my breasts that are able to produce breast milk and nourish my son. We did have a lot of struggles with breastfeeding. So I was very grateful when we got it down, Pat. And you know, I've got rid of a lot of clothing because anything that was squeezing me or making me feel uncomfortable you know, instead of trying to squeeze back into my old clothes where every time I would shift or move, I would feel like the pinching of my old jeans or you know, like the bra cutting into my sides.

Speaker 2 (16:52):

I got rid of all of that, unless I really thought it was realistic that in which case I put it aside and I didn't even look at it. I lived in leggings and nursing tops for at least three months because it was comfortable. So I wasn't constantly reminded that I was a different shape that I wasn't it wasn't my old body. And I, and then I started moving pretty early in my recovery. I was discharged with the hospital with the very old school instructions of you know, wait six to eight weeks before you start exercising. And then about three weeks I was losing my mind and I was like, Hey, wait a minute. I can give medical advice too. And I can exercise under my own medical supervision. So I I started exercising. I started really gently. And, but there's even, there's at least one study.

Speaker 2 (17:46):

I believe there are a couple studies that have shown that even one bout of exercise increase, improves your body image. So getting moving and feeling like I was in control of my body and really starting to feel what it was capable of for myself, not just feeling what it was capable of in terms of giving birth to a human, which was also incredible. But, but starting that again, feel like, Oh, look, I can lift this weight. I can do this movement. And, and all the positive feelings that come from exercise definitely also helped.

Speaker 1 (18:21):

Yeah. And, and kind of again, taking agency over your, over your body. And I really love the, you know, giving yourself a little extra love in the shower. I think that's great advice for anyone, if you had birth, if you gave birth or not, you know, sometimes just getting older things change, you know, and being able to acknowledge that things change and that's okay. And you're still, you know, in love with everything that you have. I love that. That's great advice. So now you talked about exercising. You sort of went back about three weeks after, but let's talk about exercising while pregnant. So there can college of obstetrics and gynecology. They put out guidelines on exercise. So do you want to kind of fill us in on maybe what those guidelines are so that if there are women out there listening that are pregnant at the moment, they can have a better idea of what they can and can't do.

Speaker 2 (19:20):

Absolutely. I'm really excited about them actually, because there are new ones this year that are much more forward thinking in their recommendations. So there has been a lot of fear-mongering about exercising while you're pregnant in the past. And this year, the recommendations are that virtually everyone can exercise while they're pregnant, whether you exercise before you were pregnant or not. They do recommend that everyone obtain a medical clearance first with a, with a thorough exam to talk about any possible medical complications that could arise from exercising. But you know, there used to be the wisdom used to be that if you didn't exercise before you couldn't start, while you were pregnant and they have completely changed that and they, even to the point where if you are an athlete or someone who regularly exercise at high intensity, they say that you can continue to do that through the third trimester safely.

Speaker 2 (20:20):

And they recommend exercise because it actually decreases the incidence of diabetes, of gestational diabetes and other blood pressure complications while pregnant like three clamps SIA. It decreases the likelihood of pre of giving birth preterm and decreases actually the incidents of low birth weight, interestingly, and it also decreases recovery time postpartum. So it improves postpartum outcomes kind of sets you up for success, especially during time where you might not have time or might not be able to exercise yet right after giving birth. And it actually increases the likelihood of having a vaginal birth. So if that's something you desire, exercise can help you get there. And it decreases the likelihood of postpartum depressive disorders. So those endorphins that you get while you're exercising kind of carry through to the postpartum period. Well, that's a lot of positives for exercising while pregnant. Are there any sort of big no-nos and on that,

Speaker 1 (21:18):

No, we're going to take a quick break to hear from our sponsor and be right back. This episode is brought to you by net health, helping you maintain strong relationships with your patients. The redox patient portal provides secure line of communication between you and your patients conduct virtual visits and have follow-up conversations with your patients via secure messaging. When it's convenient for you, patients have 24 seven secure on-demand access to their therapy, health information without phone calls and voice messages, video conferencing for telehealth, secure messaging, shared documents and photos and view health information, and appointments to learn more, contact them@redocatnethealth.com.

Speaker 2 (22:05):

A lot of it's on an individual basis and getting assessed by a PT who specializes is a great idea to see if you're able to still engage your transversus abdominis and see what positions might be best for you. If they do continue to recommend that you don't stay supine on your back for longer than two to three minutes, past 20 weeks of pregnancy, because you can become hypotensive because of the weight of the fetus on your on your blood supply. And they also recommend that you, they also really emphasize staying well hydrated. And if you're doing anything vigorous for more than 45 minutes to really make sure you have adequate calorie intake before maybe during and after to avoid hypoglycemia, which is not uncommon in pregnancy with my clients, I still recommend avoiding isometric exercises. So planks are awesome.

Speaker 2 (23:01):

Just make them dynamic somehow to help the body regulate the blood pressure, because it's just a lot of demand if you're holding a position and you're holding that tone in the muscles and you're trying to support a fetus it, it helps a little bit to keep those muscle pumps helping the blood pressure regulate. Besides that it's, it's on a very individual basis. It's what you're familiar with. It's how your pregnancy has been progressing. So it's really a good idea to talk to somebody. Okay. And speaking about talking to somebody, everybody who listens knows I'm a physical therapist, you're a physical therapist. So let's talk about reasons why women should go to a physical therapist when they're pregnant. I mean, it doesn't have to mean you, it doesn't mean you have to go every week of your entire pregnancy, but talk about why

Speaker 1 (23:47):

Every woman should be seeing a physical therapist when they are pregnant. Yes. Period.

Speaker 2 (23:53):

I love that. Yes, they should. So in the same guidelines this year, Aycock says that back pain has an incidence of about 60% in pregnancy, but that's extremely under-reported because most women just consider it a normal part of being pregnant. So I think back pain in pregnancy is pretty much universal. So that's one great reason to go to PT because it can help alleviate that back pain. And I did see a physical therapist myself when I was pregnant to help with the back pain. Also if you're having experienced experiencing things like sciatica wrist pain, which I had one kind of wrist pain while I was pregnant, different kind of risk pain after I gave birth, partly just because of the increase in fluid in the body. But then also changing joint mechanics because your ligaments are looser. If you have pelvic pain or pubic synthesis dysfunction, which you would know, cause your doctor would tell you, or you'd have a lot of fat in the front of your pelvis or even sprained ankles have a higher incidence in women who are pregnant. Because again, if those joint changes but also

Speaker 1 (24:57):

If you are having the perfect

Speaker 2 (25:00):

And see, which would be amazing and you have no pain whatsoever, you're that miracle person you can still help prepare for giving birth. There are PTs who specialize in helping with things like breathing, breathing techniques, preparing your pelvic floor muscles, and it might be a simple consultation. One time, two time to get some advice on, on what you can do to help yourself prepare. And also if you have any history of injuries or any current pain, then also PTs can help advise on what positions might be good for you and they can help coordinate with your OB or your midwife, whoever your burning professional is.

Speaker 1 (25:36):

Absolutely. And now all great reasons. Now let's talk about after you give birth the fourth trimester, right? So Aycock has came out with these guidelines about the fourth trimester. So first, can you tell us what the fourth trimester is for those who are not aware and then how, what is the physical therapist's role in the postpartum period?

Speaker 2 (25:57):

Absolutely. So fourth trimester kind of a tongue in cheek, a way of describing a three months after giving birth. Because the idea is that you're still, your body is still changing and your baby is also still changing a lot. There's some thought that when we were primates, our babies would have just dated for longer and come out further along, but our heads became too large and that's why babies started to be born earlier and earlier. So that's part of the reason that human babies are so vulnerable when they're born, as opposed to other species, like, you know, drafts who like pop out and run away from their mothers. And meanwhile, our kids can't, can't see, or

Speaker 1 (26:40):

Little blobs on my back. They're adorable blabs, but yeah,

Speaker 2 (26:44):

They, they can't do anything. So and one thing I hear a lot about the fourth trimester is women trying to get their bodies back which I need to bounce back quickly. I think it's just so depressing because, because you're not going back, why would we ever want to go backwards in your life? So why not take your body forwards with you? I love that. And, and you know what I, I will say just personally, like I, I gained, like I said, 47 pounds while I was pregnant. I have since lost all 47 pounds. I am still breastfeeding though. So we'll see what happens, but I am shaped totally differently than I was. And it's, it's not a good thing or a bad thing, at least to me, like it's just different. My body is totally different now. And that's, that's okay.

Speaker 2 (27:38):

You know, I, I'm really excited about what it can do. I love being a mom, so that's really important, but anyway, and physical therapy in the world of physical therapies. So again, it's a lot of similar reasons, usually back pain, but that can be again from a, it can be from how you gave birth. It can be from if you're, especially if you're still breastfeeding, you still have a lot of those quote unquote pregnancy hormones that cause the ligaments to be a little bit more flexible. Plus if you're breastfeeding the way that you're holding your child also if you're even just picking the kid up and down and getting on and off the floor and changing diapers, which can like, by the time they can turn over, sometimes it's like a circus you know, that that can cause back pain, wrist pain.

Speaker 2 (28:30):

And then of course you have your pelvic recovery, which I, for the first week, I, I don't think I was thinking about myself very much, but every once in a while I would realize that I felt like my vagina was on fire and sitting was horrible. It was the worst thing ever. I remember going, we were taking my son to his pediatrician, visit his first pediatrician visit. And I was sitting in the car like sideways on one butt cheek to try to avoid putting my perinatal area on the seat because it was so uncomfortable. So that, you know, that's normal for the first week, unfortunately even if you've had a Syrian birth that can you still have that huge change in, in your pelvis after it, no longer has this weight on it. And you have all these hormones released, so it could still be very uncomfortable and tender in your perinatal area.

Speaker 2 (29:25):

But yeah, that, that brings me to another point. Scars are big thing that should be treated. You would treat a scar from any other surgery or massive injury. So I don't know why it's not routine to refer for scar therapy after if you've had any vaginal tearing with giving birth or if you've had a cesarean birth those scars that can really cause a change in function. They're not as elastic as the tissue around them. And that excessive tissue that's there can disrupt the function and cause a lot of discomfort. So I had grade two vaginal tearing because of my birth experience. And I, I saw a PT myself to have my scar tissue manually worked on and work on some release techniques from my pelvic floor, which was super tense because it was trying to hold everything together during that postpartum phase. So I'm not, and that also for me, I had pain with penetrative sex after, you know, you go to the opiate and they're like, yup, healed, done. Yeah. You know, go back to doing whatever you want. And I was, I was terrified of resuming sexual intercourse and I'm very grateful for my PT who helped me figure out how to comfortably and safely get back to, to having sex. Yeah.

Speaker 1 (30:52):

You know, all these things, like you said, like so many women are experiencing these things and I think it's so important to just vocalize that and put that out into the universe so that women could be like, Oh, wait a second. Oh, I can go to a PT and they can help with that. Or I can go to PT and they can help with incontinence afterwards, or they can help, you know, like you said, have sex with my husband or my partner afterwards. I mean, wow, this is revolutionary for a lot of women, you know, to know that this resource exists. And you just have to find that physical therapist, preferably one who is trained in pelvic health and who understands understands the pelvis in a more intimate way. And, and that doesn't necessarily mean that they're, your therapist has to be a woman. There are also men who specialize in pelvic health as well. So I want to give a shout out to all of our colleagues doing that around the country as well.

Speaker 2 (31:50):

Yeah. Oh, go ahead. Sorry. I was just gonna say you know, also there are PTs who have been trained in helping support breastfeeding in terms of what positions to use treating clog ducks, or even just education on you know, effective techniques. There's also pelvic organ prolapse and incontinence, as you mentioned, which can happen regardless of if you've had a child or not. And that can also be treated with physical therapy. Again, some incontinence after giving birth is actually normal for up to a month or two, but if you're still leaking after that, then you should definitely seek help. And again, even, even like you said, it was pregnancy like why every pregnant woman should get PT. Everyone should get some advice, professional advice on how to safely return to movement, whatever movement you want to do, whether it's, you know a yoga class or a couple of group fitness classes or going back to playing a sport. And that's, that's something where we that's something we specialize in is movement. Yeah.

Speaker 1 (32:51):

And, and in many countries it's, everyone goes to standard care. It's a standard of care, you know, and, and hopefully now that these are part of the guidelines by a cog, that that is something that will become a standard of care. You know, I interviewed dr. Camila Phillips, who is an OB GYN at Lenox Hill and she recommends all of her patients to see a PT and I love it. And that was awesome. Brilliant. But I don't know. She might be in the minority. I'm not sure I think she is, but, you know, experience. Yeah. But I just, I just love that she is so forward-thinking, and, and for women to know that you have all of these resources, it's so empowering to kind of help you back, get back to not get back to, but help you move forward. I love that. I almost say get back to, well, get back to doing what you like to do. Yeah, yeah, exactly. Get back to doing what you like to do and whether that be any kind of movement or running or, or a high intensity sports, you know, just because you have a child doesn't mean that, that you can't return to the things you were doing before. And I think that's where the PT comes in.

Speaker 2 (34:03):

Absolutely. And with the help of my PT and like my own expertise at like five months, I was back to boxing and high intensity interval training. And I will tell you though, the first time I tried to do a jump after giving birth, I mean, I don't, I don't remember how long postpartum I was, maybe three or four months. I was like, Oh my God, I am an elephant. Like, I just felt like I had no pep, no spring whatsoever. I felt like every time I landed, I was like sod. It took a good few months for me to feel like I had my, my spring back, my like pep in my step.

Speaker 1 (34:36):

Yeah. Yeah. And, and again, you know, this is, I think this is all great for people to hear. Like we don't, I think women don't give birth and then, you know, go back to like walking the Victoria secret runway show like Heidi Clume, you know, like it's, that's not normal. No, do that like four weeks after you give birth, not normal. Like that is an exceptional human being there who has very good genetics, I'm assuming. And also it's her job.

Speaker 2 (35:04):

Yes. And a lot of expensive support

Speaker 1 (35:07):

And a lot of expensive support that us average Joe's just do not have. Nope. Don't have it. All right. So Helene, what would you like to leave the listeners with, if you could leave them with, you know, your, your top tip or your takeaways from this? From our discussion here,

Speaker 2 (35:27):

That's a tough one because there's so many good tidbits in there. Yeah, I think my top tip is, is just to love, love where you are. I would love your body, where it is, love it for what it's done, love it for what it can do right now. And, and get some help if you need help loving it. If you need help you know, getting it to do what you wanted to do, there is so much help available. It's just a matter of finding it, which shouldn't be as difficult as it is, but it is there. Yeah.

Speaker 1 (36:01):

Fabulous. And now last question that I ask everyone, given where you are now in your life and in your career, what advice would you give yourself as a new grad fresh out of physical therapy?

Speaker 2 (36:15):

Cool. Well, I would say trust your intuition. My program was very into evidence-based physical therapy, which is awesome and everything should be grounded in evidence, but never forget that clinical expertise in clinical experiences, also a level of evidence.

Speaker 1 (36:36):

And I've heard that many times from people on the show.

Speaker 2 (36:40):

Sure. You have that. I've heard it. I've heard it on your show too.

Speaker 1 (36:43):

Yeah. Many times. Well now, where can people find you? Where can people get in touch with you if they have questions or they want to know what you're up to.

Speaker 2 (36:50):

Ah, great question. I'm on Instagram at Halloween B underscore PT. That's the best place to find me I'm currently practicing at Danford works. And so you can find me there or I would love to hear from anybody via email, it's HD the pt@gmail.com. Perfect.

Speaker 1 (37:10):

And we will have all of those links in the show notes for this episode at podcast at healthy, wealthy, smart.com. So if you didn't have a pen on you, you didn't write it all down. Don't worry. One click will take you to everything Helene. And I will say she also on her Instagram account, really great exercises, advice, and support. So if you're looking for for that, then definitely follow her on Instagram because you give a lot of great XYZ and support, especially for women throughout an after pregnancy. So definitely give her a follow on Instagram. So Helene, thank you so much for coming on. This was wonderful. And thank you for sharing your story because I know it's not easy. Thanks, Tara and everyone else. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.

Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Haag to talk about exercise and urinary incontinence. This interview was part of the JOSPT Asks interview series. Sarah is the co-owner of Entropy Physiotherapy and Wellness in Chicago. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.

In this episode, we discuss:

• The prevalence of urinary incontinence
• Is urinary incontinence normal
• Pelvic floor exercises
• Pelvic floor exam for the non-pelvic health PT
• Sports specific pelvic health dysfunction
• And much more

Resources: 

Entropy Physiotherapy and Wellness

JOSPT Facebook Page

JOSPT Journal Page 

More Information about Dr. Haag: 

Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Teacher.

Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

Read the full transcript below: 

Read the Full Transcript below: 

Speaker 1 (00:06:25):

So, and hopefully it doesn't want to lose what we're doing here. We'll see. Okay. Going live now. Okay. Welcome everyone to JLS. PT asks hello and welcome to the listeners. This is Joe SPT asks the weekly chat where you, the audience get your questions answered. My name is Claire Arden. I'm the editor in chief of Joe SPT. And it's really great to be chatting with you this week, before we get to our guest. I'd like to say a big thanks for the terrific feedback that we've had since launching [inaudible] a week ago. We really appreciate your feedback. So please let us know if there's a guest that you'd like to hear from, or if you have some ideas for the show today, we're in for a very special treat because not only are we joined by dr. Sarah hake from entropy physio, but guest hosting [inaudible] asks today is dr. Karen Litzy who you might know from the healthy, wealthy and smart podcast. Dr. Lexi is also a new Yorker. And I think I can speak for many of us when I say that New York has been front of mind recently with the coronavirus pandemic. And I'd like to extend our very best wishes to everyone in New York where we're thinking of you. So I'm going to throw to Karen now. We're, I'm really looking forward to chat today on pelvic floor incontinence and exercise over to you, Karen.

Speaker 1 (00:08:25):

Hi everyone, Claire. Thank you so much. I really appreciate your giving me the opportunity to be part of J O S P T asks live stream. So I'm very excited about this and I'm also very excited to talk with dr. Sarah Hagar. Sarah is an educator, a clinician, and an author. She is also co-owner of entropy wellness and our physiotherapy and wellness in Chicago, Illinois, and is also a good

Speaker 2 (00:08:56):

Friend of mine. So it's really a an honor for me to be on here. So Sarah, welcome. Thank you so much. I was really excited that all this came together so beautifully. Yes. And, and again like Claire had mentioned, we're all experiencing some pretty unprecedented times at the moment. And the hope of these J O S P T asks live streams is to continue to create that sense of community among all of us, even though we can't be with each other in person, but we can at least do this virtually. And as Claire said, last week, we want to acknowledge our frontline healthcare workers and colleagues across the world for their dedication and care to those in need. And again, like Claire said before, a special shout out to my New York city colleagues, we are they are really working like no other.

Speaker 2 (00:09:52):

And I also want to acknowledge not just our healthcare colleagues and workers, but the scientists, the grocery store workers, the truck drivers the pharmacist, police, firefighter paramedics, they're all working at full capacity to keep the wheels turning around the world. So I just want to acknowledge them as well and thank them for all of their hard work during this time. Okay. So, like Claire said today, we're going to be talking about the pelvic floor, which is something Sarah loves to talk about because what I also, I also failed to mention is she is a certified pelvic health practitioner. So through the American physical therapy association. So she is perfectly positioned to take us through. And as a lot of, you know, we had, you had the opportunity to go onto Slido to ask questions. You can still do that. Even throughout this talk, just use the code pelvic that's P E L V I C, and ask some questions.

Speaker 2 (00:10:57):

So we do have a lot of questions. I don't know if we're going to get to all of them. So if we don't then certainly post them in the Facebook chat and maybe Sarah can find those questions in the chat below. And we'll try and get to those questions after the recording has finished. All right, Sarah. So like I said, lots of questions and the way the questions were, were written out, kind of corresponds quite well with maybe how you would see a patient in the clinic. So let's start with the patient comes into your clinic. They sit down in front of you. Let's talk about the words we would use in that initial evaluation. So I'll throw it over to you. Okay. So being a pelvic health therapist, obviously most people when they're coming to females, Things that happen in the pelvis, I like to acknowledge it, that there's a lot of things happening in the past. So I have

Speaker 1 (00:11:54):

Them tell me kind of what are the things that have been bothering them or what are the things that have been happening that indicate something might be going on? Like if something's hurting, if they're experiencing incontinence, any bowel issues, any sexual dysfunction. And, and I kind of go from there. So if the talk that's the title of the talk today includes incontinence. Continence is a super common issue that let's see in general might pop in. And if you would bother to ask there's actually, I think it's like one out of two people over 60 are experiencing incontinence of some kind. The answer is going to be yes, some, so you can start asking more questions. But starting out with what, what is bothering them is really what I like to start with. Then the next thing we need to know is after we vet that issue or that priority list of things that are bothering them in the pelvis, and it's not uncommon actually to have.

Speaker 1 (00:13:00):

So let's say they start with a discussion of incontinence. I still actually ask about sexual function, any pain issues, any bowel issues, just based on the innervation of the various, the anatomical arrangement of everything. It's not uncommon to have more than one issue, but those other issues might not be bothersome enough to mention. So it's kind of nice to get that full picture. Then the next thing we really want art. So there are times I've met women who come in and they're like, Oh yeah, you know, I have incontinence. And you're like, okay. So when did it start now? Like 25 years ago. Okay. Do you remember what happened then? Typically it was a baby, but sometimes these women will notice that their incontinence didn't happen to like four or five years after the baby. Hmm. So that's information, that's very help if they say my baby that was born six weeks ago, our interventions and expectations are going to be very different than someone who's been having incontinence for 25 years.

Speaker 1 (00:14:05):

So again, knowing how it started and when it happens, when the issues are happening, I just kind of let them, it's like a free text box on a form. Like just, they can tell me so much more excuse me. And when we are talking about things, we, I do talk anatomy. So when it comes to incontinence, I talk about the bladder and the detrusor, the smooth muscle around the bladder, the basically the hose that takes the urine from the bladder to the outside world. I do talk about the vagina and the vulva and the difference between the two. And then actually we do talk about like the anus and the anal sphincters and how all of that is is all there together and supported by the pelvic floor.

Speaker 1 (00:14:54):

Cause that's in physical therapy, it's going to be something with that pelvic floor or something. Drought, does it need to be more, more pelvic floor focused or does it need to be behaviorally focused, which is the case sometimes, or is it that kind of finding that perfect Venn diagram of both for those issues that the person's having? And let's say you're in a part of the world. One of the questions was what if you're I think this question came from Asia and they said, what if you're in part of the world where you have to be a little bit, maybe more sensitive around even the words that you use. I know we had gotten a question a couple of years ago about a woman in the Southern part of the United States that was from very conservative area. And do we even use these words with these patients?

Speaker 1 (00:15:48):

So what is your response to that? My response is that as healthcare providers, we are responsible, I think for educating people and using appropriate words and making sure people understand the anatomy like where things are and what they're supposed to be doing. However, definitely when I'm having this conversation with someone I want them to feel at ease. So like I will use the Ana vagina anus, anal sphincters Volvo, not, it's not a vagina, it's a Volvo it's on the outside. But then if they use different terms to refer to the anatomy, we're discussing, I'm happy to code, switch over to what they're most comfortable with because they need to be comfortable. But I think as, as again, healthcare practitioners, if we're not comfortable with the area, we're not going to make them feel very comfortable about discussing those issues. Right.

Speaker 1 (00:16:43):

And that makes a lot of sense. Thank you for that. So now let's say you, the person kind of told you what's going on and let's, let's talk about when you're taking the history for women with incontinence, especially after pregnancy, are there key questions you like to ask? Yes. So my, my gals that I'm seeing, especially when they're relatively relatively early in the postpartum period, are the things I'm interested in is did they experience this incontinence during their pregnancy? And did they have issues before pregnancy? And then also if this is not their first, tell me about the first birth or the, or the first two birth. So the first three birth to really get an idea of is this a new issue or is this kind of an ongoing marked by so kind of getting a bigger picture of it.

Speaker 1 (00:17:49):

And then also that most recent birth we want to know, was it vaginal? Was it C-section with vaginal birth? If there's instrumentation use, so if they needed to use forceps or a vacuum that increases the likelihood that the pelvic floor went over, went under a bit of trauma and possibly that resulted in a larger lab. And even if there isn't muscles, it's understandable that things might work well, if it's really small and if it's still healing you know, different, different things like that. So understanding the, kind of like the recent birth story, as well as their bladder story going back. So you've met first baby or before that first baby so that we know where, where we're starting from. And the, the reason why I do that is because again, if it's a longterm issue, we have to acknowledge the most recent event and also understand there was something else happening that, that we need to kind of look at.

Speaker 1 (00:18:58):

So would I expect it all to magically go away? No, I wouldn't. There's probably something else we need to figure out, but if it's like, Nope, this onset happened birth of my baby three months ago, it's been happening since then three months is, seems like forever and is also no time whatsoever. It took 10 months to make the baby. So it's you know, if you tear your hamstring, we're expecting you to start feeling better in three months, but you're probably not back to your peak performance. So where are we in that? And sometimes time will cure things. Things will continue to heal, but also that would be a time like how good are things working? Is there something else going on that maybe we could facilitate or have them reach continence a bit sooner. Okay, great. And do you also ask questions around if there was any trauma to the area?

Speaker 1 (00:19:56):

So if this birth was for example, the product of, of a rape or of some other type of trauma, is that a question that you ask or do you, is that something that you hope they bring up? It's, that's honestly for me and my practice, something, I try to leave all of the doors wide open for them to, to share that in my experience you know, I've worked places where it is on it's on the questionnaire that they fill out from the front desk and they'll circle no to, to any sort of trauma in the past.

Speaker 1 (00:20:34):

Yeah. They just, they don't want to circle yes. On that form. So and also I kind of treat everybody like they might have something in their past, right. So very nonjudgmental, very safe place, always making them as comfortable in a safe as possible. And I will say that there's anything I can do to make you feel more comfortable and more safe. We can do that. And if you don't feel safe and comfortable, we're not doing this w we're going to do something else. Cause you're right. That it's always one of those lingering things. And the statistics on abuse and, and rape are horrifying to the point where, again, in my practice, I kind of assume that everybody has the possibility of having something in their past. Okay, great. Thank you. And now another question that's shifting gears. Another question that came up that I think is definitely worthy of an answer is what outcome measures or tools might you use with with your incontinence patients? So with incontinence, honestly, my favorite is like an oldie buddy, but a goodie, like just, it's an IC, it's the international continents questionnaire where it's, I think it's five or six questions. Just simple. Like how often does this happen? When does it happen?

Speaker 1 (00:21:58):

There's a couple of other outcome measures that do cover, like your bladder is not empty. Are you having feelings of pressure in your lower abdomen? It gets into some bowel and more genital function. Can you repeat that? Cause it kind of froze up for a second. So could you repeat the name of that outcome tool as it relates to the bladder and output? Oh, sorry. I see. IQ is one and then, but like I see IQ vs which renal symptoms, right? So there are, there's a lot of different forms out there. Another one that will gather up information about a whole bunch of things in the pelvis is the pelvic floor distress bins questions about bowel function, bladder function, sexual function discomfort from pressure or pain. So that can give you a bigger picture. I'll be honest. Sometimes my, the people in my clinic they're coming in, and even though I will ask the questions about those things, when they get the, the questionnaire with all of these things that they're like, this doesn't apply to me. I'm like, well, that's great that it doesn't apply to you, but they don't love filling, filling it out. So sometimes what I will go with is actually just the pale.

Speaker 1 (00:23:24):

Can you say that again? Please help me. Oh yeah. Oh, so sorry. The patient's specific functional scale where, where the patient says, this is what I want to have happen. And we kind of figured out where they are talk about what would need to happen to get them there, but it's them telling what better. Right. Cause I've had people actually score perfect on some of these outcome measures, but they're still in my office. So it's like, Oh, I'm so patient specific is one of my one of my kind of go tos. And then there's actually a couple of, most of these pelvic questionnaires finding one that you like is really helpful because, because there's so many and they really all or discomfort. So if you have a really good ability to take a really good history, some of the questions on that outcome measure end up being a bit redundant.

Speaker 1 (00:24:26):

So I like, and you know the questions on there, make sure people are filling them out. You look at them before you ask them all the questions that they just filled out on the form for you. Yes. Good. Very good advice. So then the patient doesn't feel like they're just being piled on with question after question and cause that can make people feel uncomfortable when maybe they're already a little uncomfortable coming to see someone for, for whatever their problem or dysfunction is. So that's a really good point. And now here's a question that came up a couple of times, you know, we're talking about incontinence, we're talking about women, we're talking about pregnancy. What about men? So is this pelvic floor dysfunction? Is this incontinence a women only problem? Or can it be an everybody problem? So it very much can be an everybody problem. Incontinence in particular for men, the rates for that are much lower. And typically the men are either much older or they are they've undergone frustrate removal for prostate cancer.

Speaker 1 (00:25:33):

Fleur plays a role in getting them to be dry or at least dryer. And then it's like the pelvic floor is not working right. That can result in pain. It can result in constipation. It can result in sexual dysfunction. It can result in bladder issues. So it's, so yes, men can have all of those things. In fact, last night we had a great talk in our mentorship group at entropy about hard flacid syndrome. So this is a syndrome with men where everything is normal when they go get, get tested, no no infections, no cancers, no tumors, no trauma that they can recall. And, but the penis is not able to become functional and direct. And with a lot of these men, we're finding that it's more of a pelvic floor dysfunction issue, or at least they respond to pelvic floor interventions.

Speaker 1 (00:26:30):

So having a pelvic floor that does what it's supposed to, which is contract and relax and help you do the things you want to do. If, if we can help people make sure that they're doing that can resolve a lot of issues and because men have pelvic floors, they can sometimes have pelvic floor dysfunction. Okay, great. Yeah. That was a very popular question. Is this a woman only thing? So thank you for clearing up that mystery for everyone. Okay. So in going through your evaluation, you've, you've asked all your questions, you're getting ready for your objective exam. What do you do if you're a clinician who does not do internal work, is there a way to test these pelvic floor muscles and to do things without having to do internal work? My answer for that question is yes, there are things that you can do because even though I do do internal exams, I have people who come to see me who are like, no, we're not doing that.

Speaker 1 (00:27:31):

So, so where can we start? And so the first one is pants on and me not even touching you pelvic floor, I wouldn't really call it an assessment or self report. So even just sitting here, if you, if you were to call me up and and this actually goes into, I think another question that was on Slido about pelvic floor cues. So there is actually then it seems more research on how to get a mail to contract this pelvic floor then actually females. But I would ask you like like this is one that my friend Julie, we would use. So like if you're sitting there and you just sit up nice and tall, if you pretend you're trying to pick up a Ruby with your PA with your vagina is not on the outside, but imagine like there's just a Ruby on the chair and you'd like to pick it up with no hands, breathe in and breathe out and let it go. So then I would go, did you feel anything and you should have felt something happen or not. So if, if you did it, would you mind telling me what you built? You're asking me, Oh my goodness. Oh yes. I did feel something. So I did feel like I could pick the Ruby up and hold it and drop it.

Speaker 1 (00:29:04):

Excellent. And that's, and that, that drop is key. Excellent. So what I would say is this is like like a plus, like a, I can't confirm or deny you that you did it correctly, but I like, I would have watched you hold your, like she holding my breath. Is she getting taller? Cause she's using her glutes. Did she just do a crunch? When she tried to do this, I can see external things happening that would indicate you're might be working too hard or you might be doing something completely wrong. So then we'll get into, I mean, you said, yes. I felt like I pick up the Ruby, but if it's like, Hmm, I felt stuffed, but I'm not really sure we would use our words because they've already said no to hands to figure that out. But again, I can't confirm it. People are they're okay with that.

Speaker 1 (00:29:48):

And I'm like, and if what we're doing based on the information you gave me, isn't changing, we might go to step two. If you can send in step two is actually something, any orthopedic therapist honestly, should not feel too crazy doing. So if anyone has ever palpated the origin of the hamstring, so where is the origin of the hamstring facial tuberosity? If you go just medial to that along the inside part get, don't go square in the middle. That's where everyone gets a little nervous and a little tense, but if you just Pell paid around that issue, tuberosity it's pretty awesome. If you have a, a friend or a colleague who's willing to let this happen is you ask them to do a poll of our different cues with that in a little bit. You say that again, ask them to do what to contract the pelvic floor.

Speaker 1 (00:30:44):

Okay. And again, figuring out the right words so that they know what you're talking about. We can talk about that in a minute, but if they do a pelvic floor contraction, you're going to feel kind of like the bulging tension build, right there may be pushing your fingers. You should feel it kind of gather under your fingers. It shouldn't like push your fingers away, but then you can be like, well, you could test their hamstring and see that you're not on the hamstring and you can have them squeeze your glutes and you can kind of feel the differences. The pelvic floor is just there at the bottom of the pelvis. So you can palpate externally, even through BlueJeans is a bit of a challenge, but if they're in you know, like their workout shorts for yoga pants, it's actually very, very simple. And, and honestly, as long as you explained to them what you're doing and what you're checking for, it's no different than palpating the issue of tuberosity for any other reason.

Speaker 1 (00:31:36):

And with that, I tell them that I can, it's more like a plus minus, so I can tell that you contracted and that you let go. That's all I can tell. So I can't tell you how strong you are, how good your relaxation Wells, how long you could hold it for any of those things. And then I tell them with an internal exam, we would get a lot of information we could, we can test left to, right? We can, I could give you more of like a muscle grade. So like that zero to five scale be use for other muscles. We can use that for the pelvic floor. I can get a much better sense of your relaxation and see how was that going and I can even offer some assistance. So so we have two really good options for no touching.

Speaker 1 (00:32:19):

And then just as long as we understand the information we might gain from an internal exam, we can, we can, the information we gathered from the first two ways, isn't sufficient to make a change for them. And then as let's say, the non pelvic health therapist, which there might be several who are gonna watch this, when do we say, you know, something? I think it's time that we refer you to a pelvic health therapist, because I do think given what you've said to me and you know, maybe we did step one and two here of your exams. I think that you need a little bit more. So when do, when is that decision made to reach the point of, they have a bother that I don't know how to address so we can actually go to like the pelvic organ prolapse. So pelvic organ prolapse is, is when the support for either the bladder, the uterus, or even the rectum starts to be less supportive and things can kind of start to fall into the vaginal wall and can give a feeling of like pressure in with activity the sensation can get.

Speaker 1 (00:33:39):

So then we have two options, which is more support from below with perhaps a stronger meatier pelvic floor by like working it out to hypertrophy. So like if, if I had someone who had that feeling when they were running and we tried a couple are lifting weights, let's go lifting weights. No, like I feel it once I get to like a 200 pound deadlift. Okay, well, let's see how you're lifting when you're doing 150 and let's take a look at what you're doing at 200 in fresh with your mechanics or what's happening. And if there's something that is in your wheelhouse where you're like, well, can you try this breath? Or can you try it this way and see if that feeling goes away? I'm good with that. And if the, that the person who's having issue is good with that. Awesome. But if you're trying stuff or the incontinence is not changing, send them to a pelvic floor therapist, because what we love to do is we can check it out.

Speaker 1 (00:34:41):

We're going to check it out. We're going to give some suggestions. And then my, the end of every one of those visits that I get from my, from my orthopedic or sports colleagues is I'm like, excellent. So you're going to work on this, keep doing what you're doing. Cause another really common thing is like, is I don't really believe that they can make a lot of these things worse doing the things that they're doing. And by that, I mean, they can become more simple MADEC, but in many cases you're not actually making the situation worse. So if the symptoms seem to be not getting better or even getting worse, doing the things they're doing, they go come back to the pelvic floor therapist. And then that pelvic floor therapist also has a responsibility that the things I'm asking them to do, isn't helping them get there.

Speaker 1 (00:35:29):

You can try something a little more intense, still not helping. Then that's when I actually would refer for females, especially with like pelvic pressure. So Euro gynecologist for an assessment in that regard. Yeah. So I think I heard a couple of really important things there. And that's one, if you are the sports therapist or the orthopedic physiotherapist, and you have someone that needs pelvic health support, you can refer them to the pelvic health therapist and you can continue seeing them doing the things you're doing. So just because they're having incontinence or they're having some pressure, let's say it's a pelvis, pelvic organ prolapse. It doesn't mean stop doing everything you're doing.

Speaker 3 (00:36:12):

Okay.

Speaker 1 (00:36:15):

Correct. Okay. Yeah. It may mean modify what you're doing. Stop some of what you're doing, listen to the pelvic floor therapist. And I'm also seeing, well now we're, aren't we this great cause we're creating great team around this, around this person to help support them in their goals. So one doesn't negate the other. Absolutely correct. And I, and I think too often even, even within the PT world is people start to get kind of territorial. But it's not about what each one of us is doing. It's that person. Right. so telling them to stop doing something, especially if it's something they love it seems like a bad start. It's like, okay, let's take a look at this. Tell me what you are doing. Tell me what you want to be doing. Tell me what's happening when you do that. And let's see if we can change it.

Speaker 1 (00:37:02):

Cause like I said, like the, the other, that being something they're going to make worse and worse and worse is if symptoms get worse and worse and worse, but they're not causing damage, they're not causing, I mean, what they're doing and say leaking a bit. Got it. And now I'm going to take a slight detour here because you had mentioned pelvic organ prolapse. You had mentioned, there comes a time when, if that pressure is not relieving, you've tried a lot of different things. You would refer them to a urogynecologist now several years ago. They're so you're, you're a gynecologist. One of their treatments might be surgery. So there was pelvic mesh sweats. It's hard to say pelvic mesh surgery that years ago made some people better and made some people far, far worse with, with some very serious ramifications. So can you talk about that pelvic mesh mesh surgery and where we are now?

Speaker 1 (00:38:04):

Oh, the last bit cut out a little bit. So the pelvic mess, mess surgery and, and Oh, the most important part and kind of where we are now versus maybe where we were, let's say a decade ago or so. Awesome. Yeah. So, so the pelvic mesh situation certainly here, I think it's not a universal problem. I think it's a United States problem is if you're at home during the day, like most of us are now you will see law commercials, lawyers looking for your business to discuss the mesh situation on what's happening is there was there were, it was mesh erosion and the resulting fact that that was a lot of pain because they couldn't just take it all out. And it was several women suffered and are still sad.

Speaker 3 (00:38:55):

Mmm.

Speaker 1 (00:38:55):

But that was from a particular type of surgery with a particular type of surgical kit, which thankfully has, was removed completely from the market and isn't being used anymore and mesh surgeries, I would say at least for the last five to 10 years, haven't haven't been using that and mesh surgeries are being done with great success in resolving symptoms. So I think it's important that if a woman isn't responding

Speaker 3 (00:39:27):

Yeah.

Speaker 1 (00:39:30):

Well changing their breath or making a pelvic floor or changing how they're doing things is to have that discussion with the Euro gynecologist because they do have nonsurgical options for super mild prolapse. There are some even like over the counter options you can buy like poise has one where it's just a little bit of support that helps you. Actually not leak because if you're having too much movement of the urethra, it can cause stress or it can be contributing to stress incontinence. But so there's some over the counter things or there's something called a pessary, which I think about it. Like I'm like a tent pole, but it's not a pole. It's a circle don't worry or a square or a donut. There's so many different shapes, but it's basically something you put in the vagina and that you can take out of the vagina that just kind of holds everything back up where it belongs, so it can work better.

Speaker 1 (00:40:21):

And that it's not awesome. But there are also people who are like due to hand dexterity, or just due to a general discomfort with the idea of putting things in their vagina and living them there that they're like, no, I'd rather just have this be fixed. So, so there are, it's not just surgery is not your only option. There are lots of options and it just depends on where you want to go. But with the surgery, if that's what's being recommended for a woman, I really do. Some women aren't worried at all. They've heard about the mash, but they're sure it won't happen to them, but there are when we're still avoiding surgery, even with significant syndromes, because they're worried about the mesh situation. And I would still encourage those women to at least discuss us, to see if that surgeon can, can educate them and give them enough confidence before they move forward with the surgery.

Speaker 1 (00:41:18):

Because the worst thing I think is when I had one patient actually put it off for years. Not, not just because of the mesh because of a lot of issues, but the first time the doctor recommended it, she had a grade four prolapse. Like that means when things come all the way out. And she it was so bad. Like she couldn't use the pastory okay, so she needed it, but she avoided it until she was ready and had the answers that made her feel confident in that having the surgery was the right thing to do. So it might take some time and the doctor, the surgeon really should, and most of them that I've met are more than happy to make sure that the patient has all the information they need and understand the risk factors, the potential benefits before they move forward.

Speaker 2 (00:42:03):

Excellent. Thank you so much for that indulging that slight detour. Okay. Let's get into intervention. So there are lots of questions on Slido about it, about different kinds of interventions. And so let's start with lot of, lot of questions about transverse abdominis activation. So there is one question here from Shan. Tall said studies in patients with specific low back pain do not recommend adding transverse abdominis activation because of protective muscle spasm. What about urinary incontinence in combination? What do you do? So there is a lot on transfer subdominant as you saw in Slido. So I'll throw it over to you and, and you can give us all your share your knowledge.

Speaker 1 (00:42:55):

Okay, well, let's all do this together. So I don't know how many people are watching, but if we just sit up nice and tall and I'm going to give a different cue for the pelvic floor. So what I want you to squeeze, like you don't want to urinate, like you want to stop the stream of urine. Okay. So as we're pulling that in anything else other than the underneath contract, what did you feel Karen?

Speaker 2 (00:43:24):

Well, I did feel my TA contract. I felt that lower abdominal muscle wall started to pull in.

Speaker 1 (00:43:32):

Yes. So, so the, the way I explain it is that the pelvic floor and the trans versus are the best is to friends. And this makes sense when you think about when you remember the fact that the pelvic floor, isn't just there regarding like bowel bladder and sexual function. It's one of our posture muscles. So if we're totally like, like slacked out and our abs are off and all of that, our pelvic floor is pretty turned off as well. And then if I get a little bit taller and like, so I'm not really clenching anything. Right. But this is like stuff working like it should, my pelvic floor is a little more on, but not, I'm not acting. It's just but then I could like, right, if I'm gonna, if I'm expecting to hit, or if I'm going to push into something, I can tend to set up more and handle more force into the system.

Speaker 1 (00:44:21):

So I like to think about it in those in those three ways, because the pelvic floor, isn't just hanging out, down there and complete isolation it's, it's part of a system. And so in my personal, like emotional approach to interventions is I don't want them to be too complicated. So if I can get someone to contract their pelvic floor, continue to breathe and let go of that pelvic floor, then we start thinking about what else are you feeling? Cause I don't know that there's any evidence that says if I just work my transverses all the time, my pelvic floor will automatically come along for the ride. So a great quote. I heard Karrie both speak once at a combined sections meeting and she goes, your biceps turn on. When you take a walk, it's not a good bicep exercise. So just the fact we're getting activity in the pelvic floor when we're working other muscles, what's supposed to work. And also if you want to strengthen that muscle, you're going to need to work out that muscle.

Speaker 1 (00:45:26):

And that makes a lot of sense and something that people had a lot of questions around where we're kind of queuing for these different exercises. And I really love the can. You've made it several times comparisons to other muscles in the body. So can you talk about maybe what kind of queuing you might use to have someone on? I can't believe I'm going to say this turn on and I use that in quotes because that's what you see in, in a lot of like mainstream publications for, for layman. So it might be something that our patients may see when they come in. So how do you cue that? To, to turn on the pelvic floor? So honestly I will usually start with floor and I do if I'm able to do a public floor exam, that's usually, again, a lot more information for me, but I'm like, okay, so do that now.

Speaker 1 (00:46:27):

And I watched them do it or I feel them do it and I'd be like, Oh, okay. What did you, what did you feel move? And I start there. And then I always say it's a little bit, like I get dropped into a country and I'm not sure what language people are speaking. So sometimes excuse me, one of the first cues that I learned was like, so squeeze, like you don't want to pass gas. Okay. So everybody let's try that. So sitting squeeze, like you don't care and you got taller. So I think you did some glutes.

Speaker 1 (00:47:00):

It's like, OK. So like lift, lift your anal sphincter up and in, but activating mostly the back part. So if you're having fecal issues, maybe that's a good place to start, but most people are having issues a little further front. So then we moved to the, can you pick a upper with your, with your Lavia? I had a, I learned the best things for my patients. One woman said it's like, I'm shutting the church doors. So if you imagine the Lavia being churched doors, we're going to close them up. And that, that gives a slightly different feeling. Them then squeezing the anal sphincter. Now, if you get up to squeeze, like you don't want to like pee your pants, like you want to stop the stream of urine. That will activate more in the front of the pelvis. Look, men who are like if it gets stopped the flow of urine, I wouldn't be here.

Speaker 1 (00:47:57):

So what else do you get? What's really cool is in the male literature. So this is a study done by Paul Hodges is he found that what activated the anterior part and the urinary sphincter, this rioted urinary speaker, sphincter the most for men. What a penis or pull your penis in to your body now for women. So when I was at a chorus and it's like, so let's, let's think of like other cues and other words, but even if, so, I don't have a penis this fall that probably don't have a penis. Even if you don't have a penis, I want you to do that in your brain, shorten the penis and pull it in.

Speaker 1 (00:48:42):

And did you feel anything happen? Cause we do have things that are now analogous to the male penis, if you are are a female. So I'll sometimes use that. Like I know it sounds stupid, but pretend to draw on your penis and it works and it does feel more anterior for a lot of people. So I'll kind of just, I'll kind of see what's, like I said, sometimes it's like the 42nd way of doing it that I've asked them to do where they're like, Oh, that, and you're like yeah. So then also just another, it's a little bit of like a little bit of a tangent, but so as you're sitting, so if you're, if you're sitting I want you to pick the cue that speaks most to your pelvic floor, and I want you to slouch really, really slouch, and actually to give yourself that cue and just pay attention to what you're feeling. So when you squeeze, give yourself that cue, breathe in and breath out and then let go, we should have felt a contraction, a little hole and a let go. Now, the reason why I say breathe in and breathe out is if you breathe in and out, that's about five seconds and also you were breathing. Cause another thing people love to do when they're trying to contract their pelvic floors, just basically suck it in.

Speaker 1 (00:50:10):

And so that's, that's not great, but we want to feel the contraction and we want to feel it, let go. And that's super important. I think that was another question on the Slido is that yes. For any muscle we're working, you should be able to contract it and let it go. There's not a muscle in our body where I just keep it contracted. It's going to do much. It might look great. Eventually, but like I couldn't get my coat on, like getting a drink of water would be a little weird. It's not very functional muscles have to relax so that they can contract. So that's a big, yes, it's just as important that the contraction pelvic floor that cue and we felt where it happened, not tall, like, like you're sitting out at a restaurant and you just saw someone looking at you and you're like, Oh, what are they looking at? And then you're going to do the exact same cue and you're gonna breathe in and breathe out and let it go.

Speaker 1 (00:51:07):

And then did it feel different than menu or slouch that it did it change position? I feel like Karen's Miami. It feels different. Now what I want you to do is if you can, depending on how you're sitting really give me like an anterior pelvic tilt, really happy puppy and then do the exact same thing and then let it go. And so again, some more EMG work from, from Paul Hodges is that when you're in a posterior pelvic tilt, you tend to activate the posterior portion more, which is fine. And if you're not having problems in the front, if you're having problems activating and maintaining continence in the front, actually increasing that lordosis can favor the front a bit. So this is, that's really awesome when people can feel that difference. Because I want you to think about, if you start to leak on your fourth mile of a half marathon, there's no way, no matter how awesome you are, but you're going to be able to squeeze your pelvic floor for the rest of that race.

Speaker 1 (00:52:15):

Like there's just, there's no way. But sometimes if, because remember your pelvic floor is still doing its thing while you're running is if you're like, well, hold on, when you're at your fourth mile, are you starting to get tired or hopefully not if it's a half marathon, but you know, like is something changing and how you're using your body. And can you, when you get to that point, remember to stay tall or lift your tail a little bit, or is there a cue or something they can change that will help them favor the front instead of going about four steps with the contracted pelvic floor and then losing it anyway. So there's, there's a lot of different ways you can actually make that your intervention for the issue you're having and then let's just get it functional. Perfect. And since you brought up running a question that's been, got, gotten a couple of likes on Slido is how would you approach return to running after pregnancy?

Speaker 1 (00:53:15):

Do you have any tips on criteria for progress, timeframe and a recreational runner versus a full time athlete? Because I would think the majority of physiotherapists around the world are seeing the recreational runner versus the professional or full time athlete. So first, how would you approach return to running any tips for progress? So that's going to be after pregnancy, sorry. After pregnancy. Yeah. So this is where I was really excited. So just last year I'm going to say her name wrong, but Tom goom Gran Donnely and Emma Brockwell published returned to running postnatal guidelines for health professionals managing this population. And the reason why I was super excited is because even though it was just published last year, it's the first one. There was definitely a lot of emotion and feelings about, about women getting back into sport after having a baby, but to be perfectly Frank, there's very few actual solid guidelines for recreational or others.

Speaker 1 (00:54:30):

So I have not personally had a child, but I will tell you of all the women I've seen over the years, basically doctors are like, it's been six weeks ease back into it, see how it goes. I'm not really even mentioning if you have a problem come back so we can figure it out. It's just kind of like good luck with that. And as a result, what happens is a lot of women don't get back into exercise or they get back into exercise and and kind of freak themselves out because stuff feels different. So to get back to the question of what do I do, actually this this guide from Tom and team really, really helpful. I think, and, and it's just basically it's it does have a series of exercises that I've actually started to use with my postpartum moms to go like, look, if you can do these things without feeling heaviness, you're good.

Speaker 1 (00:55:30):

You're good to start easing back into your running program, but get up, get walking because I'm going to post Sandy Hilton and like, you can't rest this better, like just waiting, isn't going to make it all go away. But it can also be deceiving because again, with polo, you don't feel that heaviness and you don't leak. And so I'm just going to stay right here where everything is fine. So that's obviously not a good option longterm option for a lot of reasons. So, so what do I do? I do look at the patient's goals, their previous running history, and if they're having any options I recently had a patient who she was runner exercise or sr after baby number two for a bit, some feeling of happiness that got completely better, baby number three came along. So I saw her a bit while she was pregnant because she got, I think two thirds of the way through pregnancy before she started to feel that heaviness. Again, she was still running,

Speaker 1 (00:56:38):

Tried to see if we could change that feeling while she was running. And she could until about the, when did she start? I think she didn't stop running to her 35th week, which is pretty impressive. But then she wanted to do a half marathon. I think it was just three months postpartum. Right. So this is like going from having baby to running 13. You think that a lot of people would probably feel that was too soon, too much too fast, but she was able to do it completely symptom-free. So as she was training and she was really fast, she was timing it so that she could get back in time to breastfeed. Like I was like, Oh my gosh, like I, that would disqualify me. Like, there's no way I could run fast enough to make that happen. But she was able to, to work it out where she could perform at her level without symptoms. And I was really happy that I was able to support her in that she did all the hard work. For general people recreational, where you a runner before, or is this completely new and are you having any symptoms and is there any thing you're worried about? Again, a lot of women are worried about giving.

Speaker 1 (00:57:53):

It's actually really hard to perhaps to give yourself one baby babies are a great way to do it. But that's like the risk factors I look up for something else a couple of years ago, I haven't looked recently, but like you really have any prolonged lifting. So not like your CrossFit three days a week, but like your, your physical labor for eight, eight hours, 10 hours a day every day could eventually do it also having babies. So like once you get to every baby increases your risk of pelvic organ prolapse, which makes good sense. And that, and that is what it is. So kind of looking at what are their risk factors, are there any, and letting them know that if they feel it more, it doesn't mean they made it worse. They just made it more symptomatic. Got it. Great.

Speaker 1 (00:58:40):

All right. So we have time for maybe one or two more questions, and then I'm going to throw back to Claire. Cause we're coming up onto an hour here, maybe time for one more it's so w what am I going to ask? I think I'm going to go with the gymnasts I work with all believe it's normal to leak a little urine during training or competition. And this is something we talk about a lot. It might be common, but is it normal? You already gave me the answer. What is it, Karen? No, no, no. And so, yeah, so the, the short answer for that is no. Or I agree with the question where it is very, very, very common, and it is still, I would say, not to leak urine. Unfortunately, so there's any researchers out there who want to get together.

Speaker 1 (00:59:26):

Let me know. We haven't, we have information on athletes and incontinence, but mostly it's prevalent that it happens a lot and gymnastics and dancing and volleyball. There's, there's even some swimmers who have it, right? So there's, there's incontinence across the spectrum, which basically tells me, yep. People have incontinence. Some of the some of the sports are more likely to have urgent continents. A lot of them though, we're looking at stress incontinence, however, for none of the athletes, have, we really had a great study that says, this is what we're finding. We're thinking, this is the cause of this incontinence. And we certainly haven't gotten to the point where it's like, and this is what we should be doing for these women in particular. So I'm, I'm pretty curious as to what we would have to do as, as a profession, as, as a team with researchers to figure out what do we need to look at in these athletes, especially the female athletes, because most of these are also they've never had babies, right? So a lot of these athletes are the liberos. And so we can't, we can't blame them. There's something with how things are working. That seemed to be the situation it's not necessarily trauma or anything like that. So what do we need to look at? What do we think is happening? Can we measure it and assess it? And then can we get an intervention?

Speaker 1 (01:00:56):

My brain, obviously, something isn't working as well as it could. So could something like that improve their performance, even I don't, I don't know. I'd like to think so. Yeah. That would be distinct study. Yeah. But we ultimately don't know. So if anyone has any ideas for studies or doing studies, let me know, because I can't wait to read them. But I think maybe the first step is to let coaches and parents and young gymnast know very common. Don't be ashamed. Don't let it stop you from doing what you want to do. But also don't just ignore it. Maybe we can figure this out.

Speaker 2 (01:01:30):

All right. One more question with a short answer, if you can. So, and I'm going to ask this question because I feel like the person who posted this I think posted this in earnest. So that's why I'm asking, this is the last question. So a female patient age, 20 years still bedwetting from her childhood, otherwise she is normal, no incontinence. So other than this, just while sleeping, she tends to urinate any thoughts on this or any place you can direct this.

Speaker 1 (01:02:04):

Yeah. So I did, I was like, Oh, great question. And I did actually do a little research for this specific question. There's a lot of reasons why nocturnal enuresis, which is what bedwetting is called in the literature happens. And I think it's really important. So I don't know what kind of tests or studies this person has had done or what other issues they may be having. So things like sleep apnea is is something that could be related if there's any medications, any sort of diuretics, any kind of sleeping medications. Again, the fact it's kind of carried on since childhood, I, I would really wonder about how, how is the bladder functioning? The fact that it's working fine throughout the day makes me wonder what's changing at night. And I did find a study where it talked about when they look compared adolescents or adults who were bedwetting to people who weren't, they did have like detrusor overactivity. So like basically like an overactive bladder that they could see on the testing. So I would, I would really encourage this person to find a urologist that they trust if they haven't already and really to maybe investigate some of those other, other factors that could be contributing so that they can get some better sleep and not have that problem anymore.

Speaker 2 (01:03:28):

Excellent. Excellent. Oh, okay. Claire says we can go for one more question. So I'm going to listen to the boss here.

Speaker 1 (01:03:36):

And, Oh boy, are you ready? Because this is a question that did kind of get a lot of thumbs up. Okay. So we spoke about

Speaker 2 (01:03:44):

Briefly before we started.

Speaker 1 (01:03:47):

So let's see treatment of nonspecific, pelvic girdle pain, not related to pregnancy, which strategy with no susceptive pain mechanisms and which strategy with non nociceptive pain mechanisms would you incorporate with this patient? Okay. So I would say in the clinic, it's, it can be pretty hard. Like, I don't know how I would distinguish being nociceptive and non nociceptive or what even like non nociceptive might be if we're talking more central issues or stuff like that. I don't, I don't know. But honestly I would just look at, so in Kathleen's Luca has a great book about looking at the different types of pain or the different categories of pain and the most effective medications for it. Right. So we're really good in pharmacology. Like if you had this inflammatory process and, and inflammatory and anti-inflammatory should help, if you're having neuropathic pain, you want a drug that addresses that when we get into like physical therapy interventions, what's really cool is exercise is in all the categories.

Speaker 1 (01:04:59):

And it's one of the things we have the best evidence for. So regardless of pelvic girdle pain in pregnancy or not pregnancy, and regardless of how it may have been labeled by somebody else is I would, I would mostly want to know when did the pain start? Is there anything that makes it better? Anything that makes it worse and see if I could find a movement or change something for that person. Or that made me sound like I was going to do a whole lot of work. If I could find something for that person to change for themselves to have that hurt less and have the I tend, I would tend to keep it simple, mostly cause in the clinic again, we could do a lot of special tests that might say, Oh, Nope, they definitely hurt there, but it's still, if we're looking at what's going to be an effective intervention, that that patient is going to tell me what that is.

Speaker 1 (01:05:54):

Sorry. It would help a fire mute myself. So looks like we have time for one more. And I, I really, Claire was not clarity did not pop up yet. So we've got time for one more and then we're going to work. We're wrapping it up. I promise stroke patients, dementia patient. We just got the no go. Yes, no, it's a super short answer if you want Claire super short answer. Okay. So stroke dementia patients with urinary incontinence, any useful ideas for the rehab program? Yes, but not get an idea of their bladder habits, their bowel habits, their fluid intake. Because a lot of that's going to end up being outside caregiver help with the, with the stroke, it's much different. It depends on the severity and where it is and all of that. But for people with dementia is if you just get that, like if you can prompt them or take them to the toilet, a lot of the times that will take care of the incontinence.

Speaker 1 (01:06:48):

It's not a matter of like Cagle exercises. It's more management. All right, Sarah, thank you so much. I'm going to throw it back over to Claire to wrap things up. Thank you both for a wonderful and insightful discussion. Sarah and Karen. So many practical tips and pointers for the clinician, especially I was loving learning about all of the things that I could take to the clinic. So I hope our audience find those practical tips really helpful as always the link to this live chat will stay up on our Facebook page and we'll share it across our other social media channels. Don't forget. You can also follow us on Twitter. We're at Dow SPT. You can also follow us here on Facebook. Please share this chat with your friends, with family colleagues, anyone who you think might find it helpful. And if you like JSP T asks, please be sure to tell people about it at that what we're doing so they can find this here, please join us.

Speaker 1 (01:07:46):

Next week when we host our special guest professor Laurie from the university of Southern California, Larry is going to be answering questions on managing shoulder pain. We'll be here, live on Wednesday next week. So Wednesday, April the eighth at 9:00 AM Pacific. So that's noon. If you're on the East coast of the U S it's 5:00 PM. If you're in the UK and at 6:00 PM, if you're in Europe, before we sign off for the evening, there's also really important campaign that I'd like to draw your attention to. And it's one that we at Joe SPT supporting and it's get us PPE. So we're supporting this organization in their quest to buy as much a, to buy much needed personal protective equipment for frontline health workers who are helping us all in the fight against the coronavirus pandemic. So if you'd like to support, get us PPE, please visit their website, www dot, get us ppe.org, G E T U S P p.org as always. Thanks so much for joining us on this stale SPT asks live chat, and we'll speak to you next week. Bye.

Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Haag to talk about exercise and urinary incontinence. This interview was part of the JOSPT Asks interview series. Sarah is the co-owner of Entropy Physiotherapy and Wellness in Chicago. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.

In this episode, we discuss:

• The prevalence of urinary incontinence
• Is urinary incontinence normal
• Pelvic floor exercises
• Pelvic floor exam for the non-pelvic health PT
• Sports specific pelvic health dysfunction
• And much more

Resources: 

Entropy Physiotherapy and Wellness

JOSPT Facebook Page

JOSPT Journal Page 

More Information about Dr. Haag: 

Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Teacher.

Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

Read the full transcript below: 

Read the Full Transcript below: 

Speaker 1 (00:06:25):

So, and hopefully it doesn't want to lose what we're doing here. We'll see. Okay. Going live now. Okay. Welcome everyone to JLS. PT asks hello and welcome to the listeners. This is Joe SPT asks the weekly chat where you, the audience get your questions answered. My name is Claire Arden. I'm the editor in chief of Joe SPT. And it's really great to be chatting with you this week, before we get to our guest. I'd like to say a big thanks for the terrific feedback that we've had since launching [inaudible] a week ago. We really appreciate your feedback. So please let us know if there's a guest that you'd like to hear from, or if you have some ideas for the show today, we're in for a very special treat because not only are we joined by dr. Sarah hake from entropy physio, but guest hosting [inaudible] asks today is dr. Karen Litzy who you might know from the healthy, wealthy and smart podcast. Dr. Lexi is also a new Yorker. And I think I can speak for many of us when I say that New York has been front of mind recently with the coronavirus pandemic. And I'd like to extend our very best wishes to everyone in New York where we're thinking of you. So I'm going to throw to Karen now. We're, I'm really looking forward to chat today on pelvic floor incontinence and exercise over to you, Karen.

Speaker 1 (00:08:25):

Hi everyone, Claire. Thank you so much. I really appreciate your giving me the opportunity to be part of J O S P T asks live stream. So I'm very excited about this and I'm also very excited to talk with dr. Sarah Hagar. Sarah is an educator, a clinician, and an author. She is also co-owner of entropy wellness and our physiotherapy and wellness in Chicago, Illinois, and is also a good

Speaker 2 (00:08:56):

Friend of mine. So it's really a an honor for me to be on here. So Sarah, welcome. Thank you so much. I was really excited that all this came together so beautifully. Yes. And, and again like Claire had mentioned, we're all experiencing some pretty unprecedented times at the moment. And the hope of these J O S P T asks live streams is to continue to create that sense of community among all of us, even though we can't be with each other in person, but we can at least do this virtually. And as Claire said, last week, we want to acknowledge our frontline healthcare workers and colleagues across the world for their dedication and care to those in need. And again, like Claire said before, a special shout out to my New York city colleagues, we are they are really working like no other.

Speaker 2 (00:09:52):

And I also want to acknowledge not just our healthcare colleagues and workers, but the scientists, the grocery store workers, the truck drivers the pharmacist, police, firefighter paramedics, they're all working at full capacity to keep the wheels turning around the world. So I just want to acknowledge them as well and thank them for all of their hard work during this time. Okay. So, like Claire said today, we're going to be talking about the pelvic floor, which is something Sarah loves to talk about because what I also, I also failed to mention is she is a certified pelvic health practitioner. So through the American physical therapy association. So she is perfectly positioned to take us through. And as a lot of, you know, we had, you had the opportunity to go onto Slido to ask questions. You can still do that. Even throughout this talk, just use the code pelvic that's P E L V I C, and ask some questions.

Speaker 2 (00:10:57):

So we do have a lot of questions. I don't know if we're going to get to all of them. So if we don't then certainly post them in the Facebook chat and maybe Sarah can find those questions in the chat below. And we'll try and get to those questions after the recording has finished. All right, Sarah. So like I said, lots of questions and the way the questions were, were written out, kind of corresponds quite well with maybe how you would see a patient in the clinic. So let's start with the patient comes into your clinic. They sit down in front of you. Let's talk about the words we would use in that initial evaluation. So I'll throw it over to you. Okay. So being a pelvic health therapist, obviously most people when they're coming to females, Things that happen in the pelvis, I like to acknowledge it, that there's a lot of things happening in the past. So I have

Speaker 1 (00:11:54):

Them tell me kind of what are the things that have been bothering them or what are the things that have been happening that indicate something might be going on? Like if something's hurting, if they're experiencing incontinence, any bowel issues, any sexual dysfunction. And, and I kind of go from there. So if the talk that's the title of the talk today includes incontinence. Continence is a super common issue that let's see in general might pop in. And if you would bother to ask there's actually, I think it's like one out of two people over 60 are experiencing incontinence of some kind. The answer is going to be yes, some, so you can start asking more questions. But starting out with what, what is bothering them is really what I like to start with. Then the next thing we need to know is after we vet that issue or that priority list of things that are bothering them in the pelvis, and it's not uncommon actually to have.

Speaker 1 (00:13:00):

So let's say they start with a discussion of incontinence. I still actually ask about sexual function, any pain issues, any bowel issues, just based on the innervation of the various, the anatomical arrangement of everything. It's not uncommon to have more than one issue, but those other issues might not be bothersome enough to mention. So it's kind of nice to get that full picture. Then the next thing we really want art. So there are times I've met women who come in and they're like, Oh yeah, you know, I have incontinence. And you're like, okay. So when did it start now? Like 25 years ago. Okay. Do you remember what happened then? Typically it was a baby, but sometimes these women will notice that their incontinence didn't happen to like four or five years after the baby. Hmm. So that's information, that's very help if they say my baby that was born six weeks ago, our interventions and expectations are going to be very different than someone who's been having incontinence for 25 years.

Speaker 1 (00:14:05):

So again, knowing how it started and when it happens, when the issues are happening, I just kind of let them, it's like a free text box on a form. Like just, they can tell me so much more excuse me. And when we are talking about things, we, I do talk anatomy. So when it comes to incontinence, I talk about the bladder and the detrusor, the smooth muscle around the bladder, the basically the hose that takes the urine from the bladder to the outside world. I do talk about the vagina and the vulva and the difference between the two. And then actually we do talk about like the anus and the anal sphincters and how all of that is is all there together and supported by the pelvic floor.

Speaker 1 (00:14:54):

Cause that's in physical therapy, it's going to be something with that pelvic floor or something. Drought, does it need to be more, more pelvic floor focused or does it need to be behaviorally focused, which is the case sometimes, or is it that kind of finding that perfect Venn diagram of both for those issues that the person's having? And let's say you're in a part of the world. One of the questions was what if you're I think this question came from Asia and they said, what if you're in part of the world where you have to be a little bit, maybe more sensitive around even the words that you use. I know we had gotten a question a couple of years ago about a woman in the Southern part of the United States that was from very conservative area. And do we even use these words with these patients?

Speaker 1 (00:15:48):

So what is your response to that? My response is that as healthcare providers, we are responsible, I think for educating people and using appropriate words and making sure people understand the anatomy like where things are and what they're supposed to be doing. However, definitely when I'm having this conversation with someone I want them to feel at ease. So like I will use the Ana vagina anus, anal sphincters Volvo, not, it's not a vagina, it's a Volvo it's on the outside. But then if they use different terms to refer to the anatomy, we're discussing, I'm happy to code, switch over to what they're most comfortable with because they need to be comfortable. But I think as, as again, healthcare practitioners, if we're not comfortable with the area, we're not going to make them feel very comfortable about discussing those issues. Right.

Speaker 1 (00:16:43):

And that makes a lot of sense. Thank you for that. So now let's say you, the person kind of told you what's going on and let's, let's talk about when you're taking the history for women with incontinence, especially after pregnancy, are there key questions you like to ask? Yes. So my, my gals that I'm seeing, especially when they're relatively relatively early in the postpartum period, are the things I'm interested in is did they experience this incontinence during their pregnancy? And did they have issues before pregnancy? And then also if this is not their first, tell me about the first birth or the, or the first two birth. So the first three birth to really get an idea of is this a new issue or is this kind of an ongoing marked by so kind of getting a bigger picture of it.

Speaker 1 (00:17:49):

And then also that most recent birth we want to know, was it vaginal? Was it C-section with vaginal birth? If there's instrumentation use, so if they needed to use forceps or a vacuum that increases the likelihood that the pelvic floor went over, went under a bit of trauma and possibly that resulted in a larger lab. And even if there isn't muscles, it's understandable that things might work well, if it's really small and if it's still healing you know, different, different things like that. So understanding the, kind of like the recent birth story, as well as their bladder story going back. So you've met first baby or before that first baby so that we know where, where we're starting from. And the, the reason why I do that is because again, if it's a longterm issue, we have to acknowledge the most recent event and also understand there was something else happening that, that we need to kind of look at.

Speaker 1 (00:18:58):

So would I expect it all to magically go away? No, I wouldn't. There's probably something else we need to figure out, but if it's like, Nope, this onset happened birth of my baby three months ago, it's been happening since then three months is, seems like forever and is also no time whatsoever. It took 10 months to make the baby. So it's you know, if you tear your hamstring, we're expecting you to start feeling better in three months, but you're probably not back to your peak performance. So where are we in that? And sometimes time will cure things. Things will continue to heal, but also that would be a time like how good are things working? Is there something else going on that maybe we could facilitate or have them reach continence a bit sooner. Okay, great. And do you also ask questions around if there was any trauma to the area?

Speaker 1 (00:19:56):

So if this birth was for example, the product of, of a rape or of some other type of trauma, is that a question that you ask or do you, is that something that you hope they bring up? It's, that's honestly for me and my practice, something, I try to leave all of the doors wide open for them to, to share that in my experience you know, I've worked places where it is on it's on the questionnaire that they fill out from the front desk and they'll circle no to, to any sort of trauma in the past.

Speaker 1 (00:20:34):

Yeah. They just, they don't want to circle yes. On that form. So and also I kind of treat everybody like they might have something in their past, right. So very nonjudgmental, very safe place, always making them as comfortable in a safe as possible. And I will say that there's anything I can do to make you feel more comfortable and more safe. We can do that. And if you don't feel safe and comfortable, we're not doing this w we're going to do something else. Cause you're right. That it's always one of those lingering things. And the statistics on abuse and, and rape are horrifying to the point where, again, in my practice, I kind of assume that everybody has the possibility of having something in their past. Okay, great. Thank you. And now another question that's shifting gears. Another question that came up that I think is definitely worthy of an answer is what outcome measures or tools might you use with with your incontinence patients? So with incontinence, honestly, my favorite is like an oldie buddy, but a goodie, like just, it's an IC, it's the international continents questionnaire where it's, I think it's five or six questions. Just simple. Like how often does this happen? When does it happen?

Speaker 1 (00:21:58):

There's a couple of other outcome measures that do cover, like your bladder is not empty. Are you having feelings of pressure in your lower abdomen? It gets into some bowel and more genital function. Can you repeat that? Cause it kind of froze up for a second. So could you repeat the name of that outcome tool as it relates to the bladder and output? Oh, sorry. I see. IQ is one and then, but like I see IQ vs which renal symptoms, right? So there are, there's a lot of different forms out there. Another one that will gather up information about a whole bunch of things in the pelvis is the pelvic floor distress bins questions about bowel function, bladder function, sexual function discomfort from pressure or pain. So that can give you a bigger picture. I'll be honest. Sometimes my, the people in my clinic they're coming in, and even though I will ask the questions about those things, when they get the, the questionnaire with all of these things that they're like, this doesn't apply to me. I'm like, well, that's great that it doesn't apply to you, but they don't love filling, filling it out. So sometimes what I will go with is actually just the pale.

Speaker 1 (00:23:24):

Can you say that again? Please help me. Oh yeah. Oh, so sorry. The patient's specific functional scale where, where the patient says, this is what I want to have happen. And we kind of figured out where they are talk about what would need to happen to get them there, but it's them telling what better. Right. Cause I've had people actually score perfect on some of these outcome measures, but they're still in my office. So it's like, Oh, I'm so patient specific is one of my one of my kind of go tos. And then there's actually a couple of, most of these pelvic questionnaires finding one that you like is really helpful because, because there's so many and they really all or discomfort. So if you have a really good ability to take a really good history, some of the questions on that outcome measure end up being a bit redundant.

Speaker 1 (00:24:26):

So I like, and you know the questions on there, make sure people are filling them out. You look at them before you ask them all the questions that they just filled out on the form for you. Yes. Good. Very good advice. So then the patient doesn't feel like they're just being piled on with question after question and cause that can make people feel uncomfortable when maybe they're already a little uncomfortable coming to see someone for, for whatever their problem or dysfunction is. So that's a really good point. And now here's a question that came up a couple of times, you know, we're talking about incontinence, we're talking about women, we're talking about pregnancy. What about men? So is this pelvic floor dysfunction? Is this incontinence a women only problem? Or can it be an everybody problem? So it very much can be an everybody problem. Incontinence in particular for men, the rates for that are much lower. And typically the men are either much older or they are they've undergone frustrate removal for prostate cancer.

Speaker 1 (00:25:33):

Fleur plays a role in getting them to be dry or at least dryer. And then it's like the pelvic floor is not working right. That can result in pain. It can result in constipation. It can result in sexual dysfunction. It can result in bladder issues. So it's, so yes, men can have all of those things. In fact, last night we had a great talk in our mentorship group at entropy about hard flacid syndrome. So this is a syndrome with men where everything is normal when they go get, get tested, no no infections, no cancers, no tumors, no trauma that they can recall. And, but the penis is not able to become functional and direct. And with a lot of these men, we're finding that it's more of a pelvic floor dysfunction issue, or at least they respond to pelvic floor interventions.

Speaker 1 (00:26:30):

So having a pelvic floor that does what it's supposed to, which is contract and relax and help you do the things you want to do. If, if we can help people make sure that they're doing that can resolve a lot of issues and because men have pelvic floors, they can sometimes have pelvic floor dysfunction. Okay, great. Yeah. That was a very popular question. Is this a woman only thing? So thank you for clearing up that mystery for everyone. Okay. So in going through your evaluation, you've, you've asked all your questions, you're getting ready for your objective exam. What do you do if you're a clinician who does not do internal work, is there a way to test these pelvic floor muscles and to do things without having to do internal work? My answer for that question is yes, there are things that you can do because even though I do do internal exams, I have people who come to see me who are like, no, we're not doing that.

Speaker 1 (00:27:31):

So, so where can we start? And so the first one is pants on and me not even touching you pelvic floor, I wouldn't really call it an assessment or self report. So even just sitting here, if you, if you were to call me up and and this actually goes into, I think another question that was on Slido about pelvic floor cues. So there is actually then it seems more research on how to get a mail to contract this pelvic floor then actually females. But I would ask you like like this is one that my friend Julie, we would use. So like if you're sitting there and you just sit up nice and tall, if you pretend you're trying to pick up a Ruby with your PA with your vagina is not on the outside, but imagine like there's just a Ruby on the chair and you'd like to pick it up with no hands, breathe in and breathe out and let it go. So then I would go, did you feel anything and you should have felt something happen or not. So if, if you did it, would you mind telling me what you built? You're asking me, Oh my goodness. Oh yes. I did feel something. So I did feel like I could pick the Ruby up and hold it and drop it.

Speaker 1 (00:29:04):

Excellent. And that's, and that, that drop is key. Excellent. So what I would say is this is like like a plus, like a, I can't confirm or deny you that you did it correctly, but I like, I would have watched you hold your, like she holding my breath. Is she getting taller? Cause she's using her glutes. Did she just do a crunch? When she tried to do this, I can see external things happening that would indicate you're might be working too hard or you might be doing something completely wrong. So then we'll get into, I mean, you said, yes. I felt like I pick up the Ruby, but if it's like, Hmm, I felt stuffed, but I'm not really sure we would use our words because they've already said no to hands to figure that out. But again, I can't confirm it. People are they're okay with that.

Speaker 1 (00:29:48):

And I'm like, and if what we're doing based on the information you gave me, isn't changing, we might go to step two. If you can send in step two is actually something, any orthopedic therapist honestly, should not feel too crazy doing. So if anyone has ever palpated the origin of the hamstring, so where is the origin of the hamstring facial tuberosity? If you go just medial to that along the inside part get, don't go square in the middle. That's where everyone gets a little nervous and a little tense, but if you just Pell paid around that issue, tuberosity it's pretty awesome. If you have a, a friend or a colleague who's willing to let this happen is you ask them to do a poll of our different cues with that in a little bit. You say that again, ask them to do what to contract the pelvic floor.

Speaker 1 (00:30:44):

Okay. And again, figuring out the right words so that they know what you're talking about. We can talk about that in a minute, but if they do a pelvic floor contraction, you're going to feel kind of like the bulging tension build, right there may be pushing your fingers. You should feel it kind of gather under your fingers. It shouldn't like push your fingers away, but then you can be like, well, you could test their hamstring and see that you're not on the hamstring and you can have them squeeze your glutes and you can kind of feel the differences. The pelvic floor is just there at the bottom of the pelvis. So you can palpate externally, even through BlueJeans is a bit of a challenge, but if they're in you know, like their workout shorts for yoga pants, it's actually very, very simple. And, and honestly, as long as you explained to them what you're doing and what you're checking for, it's no different than palpating the issue of tuberosity for any other reason.

Speaker 1 (00:31:36):

And with that, I tell them that I can, it's more like a plus minus, so I can tell that you contracted and that you let go. That's all I can tell. So I can't tell you how strong you are, how good your relaxation Wells, how long you could hold it for any of those things. And then I tell them with an internal exam, we would get a lot of information we could, we can test left to, right? We can, I could give you more of like a muscle grade. So like that zero to five scale be use for other muscles. We can use that for the pelvic floor. I can get a much better sense of your relaxation and see how was that going and I can even offer some assistance. So so we have two really good options for no touching.

Speaker 1 (00:32:19):

And then just as long as we understand the information we might gain from an internal exam, we can, we can, the information we gathered from the first two ways, isn't sufficient to make a change for them. And then as let's say, the non pelvic health therapist, which there might be several who are gonna watch this, when do we say, you know, something? I think it's time that we refer you to a pelvic health therapist, because I do think given what you've said to me and you know, maybe we did step one and two here of your exams. I think that you need a little bit more. So when do, when is that decision made to reach the point of, they have a bother that I don't know how to address so we can actually go to like the pelvic organ prolapse. So pelvic organ prolapse is, is when the support for either the bladder, the uterus, or even the rectum starts to be less supportive and things can kind of start to fall into the vaginal wall and can give a feeling of like pressure in with activity the sensation can get.

Speaker 1 (00:33:39):

So then we have two options, which is more support from below with perhaps a stronger meatier pelvic floor by like working it out to hypertrophy. So like if, if I had someone who had that feeling when they were running and we tried a couple are lifting weights, let's go lifting weights. No, like I feel it once I get to like a 200 pound deadlift. Okay, well, let's see how you're lifting when you're doing 150 and let's take a look at what you're doing at 200 in fresh with your mechanics or what's happening. And if there's something that is in your wheelhouse where you're like, well, can you try this breath? Or can you try it this way and see if that feeling goes away? I'm good with that. And if the, that the person who's having issue is good with that. Awesome. But if you're trying stuff or the incontinence is not changing, send them to a pelvic floor therapist, because what we love to do is we can check it out.

Speaker 1 (00:34:41):

We're going to check it out. We're going to give some suggestions. And then my, the end of every one of those visits that I get from my, from my orthopedic or sports colleagues is I'm like, excellent. So you're going to work on this, keep doing what you're doing. Cause another really common thing is like, is I don't really believe that they can make a lot of these things worse doing the things that they're doing. And by that, I mean, they can become more simple MADEC, but in many cases you're not actually making the situation worse. So if the symptoms seem to be not getting better or even getting worse, doing the things they're doing, they go come back to the pelvic floor therapist. And then that pelvic floor therapist also has a responsibility that the things I'm asking them to do, isn't helping them get there.

Speaker 1 (00:35:29):

You can try something a little more intense, still not helping. Then that's when I actually would refer for females, especially with like pelvic pressure. So Euro gynecologist for an assessment in that regard. Yeah. So I think I heard a couple of really important things there. And that's one, if you are the sports therapist or the orthopedic physiotherapist, and you have someone that needs pelvic health support, you can refer them to the pelvic health therapist and you can continue seeing them doing the things you're doing. So just because they're having incontinence or they're having some pressure, let's say it's a pelvis, pelvic organ prolapse. It doesn't mean stop doing everything you're doing.

Speaker 3 (00:36:12):

Okay.

Speaker 1 (00:36:15):

Correct. Okay. Yeah. It may mean modify what you're doing. Stop some of what you're doing, listen to the pelvic floor therapist. And I'm also seeing, well now we're, aren't we this great cause we're creating great team around this, around this person to help support them in their goals. So one doesn't negate the other. Absolutely correct. And I, and I think too often even, even within the PT world is people start to get kind of territorial. But it's not about what each one of us is doing. It's that person. Right. so telling them to stop doing something, especially if it's something they love it seems like a bad start. It's like, okay, let's take a look at this. Tell me what you are doing. Tell me what you want to be doing. Tell me what's happening when you do that. And let's see if we can change it.

Speaker 1 (00:37:02):

Cause like I said, like the, the other, that being something they're going to make worse and worse and worse is if symptoms get worse and worse and worse, but they're not causing damage, they're not causing, I mean, what they're doing and say leaking a bit. Got it. And now I'm going to take a slight detour here because you had mentioned pelvic organ prolapse. You had mentioned, there comes a time when, if that pressure is not relieving, you've tried a lot of different things. You would refer them to a urogynecologist now several years ago. They're so you're, you're a gynecologist. One of their treatments might be surgery. So there was pelvic mesh sweats. It's hard to say pelvic mesh surgery that years ago made some people better and made some people far, far worse with, with some very serious ramifications. So can you talk about that pelvic mesh mesh surgery and where we are now?

Speaker 1 (00:38:04):

Oh, the last bit cut out a little bit. So the pelvic mess, mess surgery and, and Oh, the most important part and kind of where we are now versus maybe where we were, let's say a decade ago or so. Awesome. Yeah. So, so the pelvic mesh situation certainly here, I think it's not a universal problem. I think it's a United States problem is if you're at home during the day, like most of us are now you will see law commercials, lawyers looking for your business to discuss the mesh situation on what's happening is there was there were, it was mesh erosion and the resulting fact that that was a lot of pain because they couldn't just take it all out. And it was several women suffered and are still sad.

Speaker 3 (00:38:55):

Mmm.

Speaker 1 (00:38:55):

But that was from a particular type of surgery with a particular type of surgical kit, which thankfully has, was removed completely from the market and isn't being used anymore and mesh surgeries, I would say at least for the last five to 10 years, haven't haven't been using that and mesh surgeries are being done with great success in resolving symptoms. So I think it's important that if a woman isn't responding

Speaker 3 (00:39:27):

Yeah.

Speaker 1 (00:39:30):

Well changing their breath or making a pelvic floor or changing how they're doing things is to have that discussion with the Euro gynecologist because they do have nonsurgical options for super mild prolapse. There are some even like over the counter options you can buy like poise has one where it's just a little bit of support that helps you. Actually not leak because if you're having too much movement of the urethra, it can cause stress or it can be contributing to stress incontinence. But so there's some over the counter things or there's something called a pessary, which I think about it. Like I'm like a tent pole, but it's not a pole. It's a circle don't worry or a square or a donut. There's so many different shapes, but it's basically something you put in the vagina and that you can take out of the vagina that just kind of holds everything back up where it belongs, so it can work better.

Speaker 1 (00:40:21):

And that it's not awesome. But there are also people who are like due to hand dexterity, or just due to a general discomfort with the idea of putting things in their vagina and living them there that they're like, no, I'd rather just have this be fixed. So, so there are, it's not just surgery is not your only option. There are lots of options and it just depends on where you want to go. But with the surgery, if that's what's being recommended for a woman, I really do. Some women aren't worried at all. They've heard about the mash, but they're sure it won't happen to them, but there are when we're still avoiding surgery, even with significant syndromes, because they're worried about the mesh situation. And I would still encourage those women to at least discuss us, to see if that surgeon can, can educate them and give them enough confidence before they move forward with the surgery.

Speaker 1 (00:41:18):

Because the worst thing I think is when I had one patient actually put it off for years. Not, not just because of the mesh because of a lot of issues, but the first time the doctor recommended it, she had a grade four prolapse. Like that means when things come all the way out. And she it was so bad. Like she couldn't use the pastory okay, so she needed it, but she avoided it until she was ready and had the answers that made her feel confident in that having the surgery was the right thing to do. So it might take some time and the doctor, the surgeon really should, and most of them that I've met are more than happy to make sure that the patient has all the information they need and understand the risk factors, the potential benefits before they move forward.

Speaker 2 (00:42:03):

Excellent. Thank you so much for that indulging that slight detour. Okay. Let's get into intervention. So there are lots of questions on Slido about it, about different kinds of interventions. And so let's start with lot of, lot of questions about transverse abdominis activation. So there is one question here from Shan. Tall said studies in patients with specific low back pain do not recommend adding transverse abdominis activation because of protective muscle spasm. What about urinary incontinence in combination? What do you do? So there is a lot on transfer subdominant as you saw in Slido. So I'll throw it over to you and, and you can give us all your share your knowledge.

Speaker 1 (00:42:55):

Okay, well, let's all do this together. So I don't know how many people are watching, but if we just sit up nice and tall and I'm going to give a different cue for the pelvic floor. So what I want you to squeeze, like you don't want to urinate, like you want to stop the stream of urine. Okay. So as we're pulling that in anything else other than the underneath contract, what did you feel Karen?

Speaker 2 (00:43:24):

Well, I did feel my TA contract. I felt that lower abdominal muscle wall started to pull in.

Speaker 1 (00:43:32):

Yes. So, so the, the way I explain it is that the pelvic floor and the trans versus are the best is to friends. And this makes sense when you think about when you remember the fact that the pelvic floor, isn't just there regarding like bowel bladder and sexual function. It's one of our posture muscles. So if we're totally like, like slacked out and our abs are off and all of that, our pelvic floor is pretty turned off as well. And then if I get a little bit taller and like, so I'm not really clenching anything. Right. But this is like stuff working like it should, my pelvic floor is a little more on, but not, I'm not acting. It's just but then I could like, right, if I'm gonna, if I'm expecting to hit, or if I'm going to push into something, I can tend to set up more and handle more force into the system.

Speaker 1 (00:44:21):

So I like to think about it in those in those three ways, because the pelvic floor, isn't just hanging out, down there and complete isolation it's, it's part of a system. And so in my personal, like emotional approach to interventions is I don't want them to be too complicated. So if I can get someone to contract their pelvic floor, continue to breathe and let go of that pelvic floor, then we start thinking about what else are you feeling? Cause I don't know that there's any evidence that says if I just work my transverses all the time, my pelvic floor will automatically come along for the ride. So a great quote. I heard Karrie both speak once at a combined sections meeting and she goes, your biceps turn on. When you take a walk, it's not a good bicep exercise. So just the fact we're getting activity in the pelvic floor when we're working other muscles, what's supposed to work. And also if you want to strengthen that muscle, you're going to need to work out that muscle.

Speaker 1 (00:45:26):

And that makes a lot of sense and something that people had a lot of questions around where we're kind of queuing for these different exercises. And I really love the can. You've made it several times comparisons to other muscles in the body. So can you talk about maybe what kind of queuing you might use to have someone on? I can't believe I'm going to say this turn on and I use that in quotes because that's what you see in, in a lot of like mainstream publications for, for layman. So it might be something that our patients may see when they come in. So how do you cue that? To, to turn on the pelvic floor? So honestly I will usually start with floor and I do if I'm able to do a public floor exam, that's usually, again, a lot more information for me, but I'm like, okay, so do that now.

Speaker 1 (00:46:27):

And I watched them do it or I feel them do it and I'd be like, Oh, okay. What did you, what did you feel move? And I start there. And then I always say it's a little bit, like I get dropped into a country and I'm not sure what language people are speaking. So sometimes excuse me, one of the first cues that I learned was like, so squeeze, like you don't want to pass gas. Okay. So everybody let's try that. So sitting squeeze, like you don't care and you got taller. So I think you did some glutes.

Speaker 1 (00:47:00):

It's like, OK. So like lift, lift your anal sphincter up and in, but activating mostly the back part. So if you're having fecal issues, maybe that's a good place to start, but most people are having issues a little further front. So then we moved to the, can you pick a upper with your, with your Lavia? I had a, I learned the best things for my patients. One woman said it's like, I'm shutting the church doors. So if you imagine the Lavia being churched doors, we're going to close them up. And that, that gives a slightly different feeling. Them then squeezing the anal sphincter. Now, if you get up to squeeze, like you don't want to like pee your pants, like you want to stop the stream of urine. That will activate more in the front of the pelvis. Look, men who are like if it gets stopped the flow of urine, I wouldn't be here.

Speaker 1 (00:47:57):

So what else do you get? What's really cool is in the male literature. So this is a study done by Paul Hodges is he found that what activated the anterior part and the urinary sphincter, this rioted urinary speaker, sphincter the most for men. What a penis or pull your penis in to your body now for women. So when I was at a chorus and it's like, so let's, let's think of like other cues and other words, but even if, so, I don't have a penis this fall that probably don't have a penis. Even if you don't have a penis, I want you to do that in your brain, shorten the penis and pull it in.

Speaker 1 (00:48:42):

And did you feel anything happen? Cause we do have things that are now analogous to the male penis, if you are are a female. So I'll sometimes use that. Like I know it sounds stupid, but pretend to draw on your penis and it works and it does feel more anterior for a lot of people. So I'll kind of just, I'll kind of see what's, like I said, sometimes it's like the 42nd way of doing it that I've asked them to do where they're like, Oh, that, and you're like yeah. So then also just another, it's a little bit of like a little bit of a tangent, but so as you're sitting, so if you're, if you're sitting I want you to pick the cue that speaks most to your pelvic floor, and I want you to slouch really, really slouch, and actually to give yourself that cue and just pay attention to what you're feeling. So when you squeeze, give yourself that cue, breathe in and breath out and then let go, we should have felt a contraction, a little hole and a let go. Now, the reason why I say breathe in and breathe out is if you breathe in and out, that's about five seconds and also you were breathing. Cause another thing people love to do when they're trying to contract their pelvic floors, just basically suck it in.

Speaker 1 (00:50:10):

And so that's, that's not great, but we want to feel the contraction and we want to feel it, let go. And that's super important. I think that was another question on the Slido is that yes. For any muscle we're working, you should be able to contract it and let it go. There's not a muscle in our body where I just keep it contracted. It's going to do much. It might look great. Eventually, but like I couldn't get my coat on, like getting a drink of water would be a little weird. It's not very functional muscles have to relax so that they can contract. So that's a big, yes, it's just as important that the contraction pelvic floor that cue and we felt where it happened, not tall, like, like you're sitting out at a restaurant and you just saw someone looking at you and you're like, Oh, what are they looking at? And then you're going to do the exact same cue and you're gonna breathe in and breathe out and let it go.

Speaker 1 (00:51:07):

And then did it feel different than menu or slouch that it did it change position? I feel like Karen's Miami. It feels different. Now what I want you to do is if you can, depending on how you're sitting really give me like an anterior pelvic tilt, really happy puppy and then do the exact same thing and then let it go. And so again, some more EMG work from, from Paul Hodges is that when you're in a posterior pelvic tilt, you tend to activate the posterior portion more, which is fine. And if you're not having problems in the front, if you're having problems activating and maintaining continence in the front, actually increasing that lordosis can favor the front a bit. So this is, that's really awesome when people can feel that difference. Because I want you to think about, if you start to leak on your fourth mile of a half marathon, there's no way, no matter how awesome you are, but you're going to be able to squeeze your pelvic floor for the rest of that race.

Speaker 1 (00:52:15):

Like there's just, there's no way. But sometimes if, because remember your pelvic floor is still doing its thing while you're running is if you're like, well, hold on, when you're at your fourth mile, are you starting to get tired or hopefully not if it's a half marathon, but you know, like is something changing and how you're using your body. And can you, when you get to that point, remember to stay tall or lift your tail a little bit, or is there a cue or something they can change that will help them favor the front instead of going about four steps with the contracted pelvic floor and then losing it anyway. So there's, there's a lot of different ways you can actually make that your intervention for the issue you're having and then let's just get it functional. Perfect. And since you brought up running a question that's been, got, gotten a couple of likes on Slido is how would you approach return to running after pregnancy?

Speaker 1 (00:53:15):

Do you have any tips on criteria for progress, timeframe and a recreational runner versus a full time athlete? Because I would think the majority of physiotherapists around the world are seeing the recreational runner versus the professional or full time athlete. So first, how would you approach return to running any tips for progress? So that's going to be after pregnancy, sorry. After pregnancy. Yeah. So this is where I was really excited. So just last year I'm going to say her name wrong, but Tom goom Gran Donnely and Emma Brockwell published returned to running postnatal guidelines for health professionals managing this population. And the reason why I was super excited is because even though it was just published last year, it's the first one. There was definitely a lot of emotion and feelings about, about women getting back into sport after having a baby, but to be perfectly Frank, there's very few actual solid guidelines for recreational or others.

Speaker 1 (00:54:30):

So I have not personally had a child, but I will tell you of all the women I've seen over the years, basically doctors are like, it's been six weeks ease back into it, see how it goes. I'm not really even mentioning if you have a problem come back so we can figure it out. It's just kind of like good luck with that. And as a result, what happens is a lot of women don't get back into exercise or they get back into exercise and and kind of freak themselves out because stuff feels different. So to get back to the question of what do I do, actually this this guide from Tom and team really, really helpful. I think, and, and it's just basically it's it does have a series of exercises that I've actually started to use with my postpartum moms to go like, look, if you can do these things without feeling heaviness, you're good.

Speaker 1 (00:55:30):

You're good to start easing back into your running program, but get up, get walking because I'm going to post Sandy Hilton and like, you can't rest this better, like just waiting, isn't going to make it all go away. But it can also be deceiving because again, with polo, you don't feel that heaviness and you don't leak. And so I'm just going to stay right here where everything is fine. So that's obviously not a good option longterm option for a lot of reasons. So, so what do I do? I do look at the patient's goals, their previous running history, and if they're having any options I recently had a patient who she was runner exercise or sr after baby number two for a bit, some feeling of happiness that got completely better, baby number three came along. So I saw her a bit while she was pregnant because she got, I think two thirds of the way through pregnancy before she started to feel that heaviness. Again, she was still running,

Speaker 1 (00:56:38):

Tried to see if we could change that feeling while she was running. And she could until about the, when did she start? I think she didn't stop running to her 35th week, which is pretty impressive. But then she wanted to do a half marathon. I think it was just three months postpartum. Right. So this is like going from having baby to running 13. You think that a lot of people would probably feel that was too soon, too much too fast, but she was able to do it completely symptom-free. So as she was training and she was really fast, she was timing it so that she could get back in time to breastfeed. Like I was like, Oh my gosh, like I, that would disqualify me. Like, there's no way I could run fast enough to make that happen. But she was able to, to work it out where she could perform at her level without symptoms. And I was really happy that I was able to support her in that she did all the hard work. For general people recreational, where you a runner before, or is this completely new and are you having any symptoms and is there any thing you're worried about? Again, a lot of women are worried about giving.

Speaker 1 (00:57:53):

It's actually really hard to perhaps to give yourself one baby babies are a great way to do it. But that's like the risk factors I look up for something else a couple of years ago, I haven't looked recently, but like you really have any prolonged lifting. So not like your CrossFit three days a week, but like your, your physical labor for eight, eight hours, 10 hours a day every day could eventually do it also having babies. So like once you get to every baby increases your risk of pelvic organ prolapse, which makes good sense. And that, and that is what it is. So kind of looking at what are their risk factors, are there any, and letting them know that if they feel it more, it doesn't mean they made it worse. They just made it more symptomatic. Got it. Great.

Speaker 1 (00:58:40):

All right. So we have time for maybe one or two more questions, and then I'm going to throw back to Claire. Cause we're coming up onto an hour here, maybe time for one more it's so w what am I going to ask? I think I'm going to go with the gymnasts I work with all believe it's normal to leak a little urine during training or competition. And this is something we talk about a lot. It might be common, but is it normal? You already gave me the answer. What is it, Karen? No, no, no. And so, yeah, so the, the short answer for that is no. Or I agree with the question where it is very, very, very common, and it is still, I would say, not to leak urine. Unfortunately, so there's any researchers out there who want to get together.

Speaker 1 (00:59:26):

Let me know. We haven't, we have information on athletes and incontinence, but mostly it's prevalent that it happens a lot and gymnastics and dancing and volleyball. There's, there's even some swimmers who have it, right? So there's, there's incontinence across the spectrum, which basically tells me, yep. People have incontinence. Some of the some of the sports are more likely to have urgent continents. A lot of them though, we're looking at stress incontinence, however, for none of the athletes, have, we really had a great study that says, this is what we're finding. We're thinking, this is the cause of this incontinence. And we certainly haven't gotten to the point where it's like, and this is what we should be doing for these women in particular. So I'm, I'm pretty curious as to what we would have to do as, as a profession, as, as a team with researchers to figure out what do we need to look at in these athletes, especially the female athletes, because most of these are also they've never had babies, right? So a lot of these athletes are the liberos. And so we can't, we can't blame them. There's something with how things are working. That seemed to be the situation it's not necessarily trauma or anything like that. So what do we need to look at? What do we think is happening? Can we measure it and assess it? And then can we get an intervention?

Speaker 1 (01:00:56):

My brain, obviously, something isn't working as well as it could. So could something like that improve their performance, even I don't, I don't know. I'd like to think so. Yeah. That would be distinct study. Yeah. But we ultimately don't know. So if anyone has any ideas for studies or doing studies, let me know, because I can't wait to read them. But I think maybe the first step is to let coaches and parents and young gymnast know very common. Don't be ashamed. Don't let it stop you from doing what you want to do. But also don't just ignore it. Maybe we can figure this out.

Speaker 2 (01:01:30):

All right. One more question with a short answer, if you can. So, and I'm going to ask this question because I feel like the person who posted this I think posted this in earnest. So that's why I'm asking, this is the last question. So a female patient age, 20 years still bedwetting from her childhood, otherwise she is normal, no incontinence. So other than this, just while sleeping, she tends to urinate any thoughts on this or any place you can direct this.

Speaker 1 (01:02:04):

Yeah. So I did, I was like, Oh, great question. And I did actually do a little research for this specific question. There's a lot of reasons why nocturnal enuresis, which is what bedwetting is called in the literature happens. And I think it's really important. So I don't know what kind of tests or studies this person has had done or what other issues they may be having. So things like sleep apnea is is something that could be related if there's any medications, any sort of diuretics, any kind of sleeping medications. Again, the fact it's kind of carried on since childhood, I, I would really wonder about how, how is the bladder functioning? The fact that it's working fine throughout the day makes me wonder what's changing at night. And I did find a study where it talked about when they look compared adolescents or adults who were bedwetting to people who weren't, they did have like detrusor overactivity. So like basically like an overactive bladder that they could see on the testing. So I would, I would really encourage this person to find a urologist that they trust if they haven't already and really to maybe investigate some of those other, other factors that could be contributing so that they can get some better sleep and not have that problem anymore.

Speaker 2 (01:03:28):

Excellent. Excellent. Oh, okay. Claire says we can go for one more question. So I'm going to listen to the boss here.

Speaker 1 (01:03:36):

And, Oh boy, are you ready? Because this is a question that did kind of get a lot of thumbs up. Okay. So we spoke about

Speaker 2 (01:03:44):

Briefly before we started.

Speaker 1 (01:03:47):

So let's see treatment of nonspecific, pelvic girdle pain, not related to pregnancy, which strategy with no susceptive pain mechanisms and which strategy with non nociceptive pain mechanisms would you incorporate with this patient? Okay. So I would say in the clinic, it's, it can be pretty hard. Like, I don't know how I would distinguish being nociceptive and non nociceptive or what even like non nociceptive might be if we're talking more central issues or stuff like that. I don't, I don't know. But honestly I would just look at, so in Kathleen's Luca has a great book about looking at the different types of pain or the different categories of pain and the most effective medications for it. Right. So we're really good in pharmacology. Like if you had this inflammatory process and, and inflammatory and anti-inflammatory should help, if you're having neuropathic pain, you want a drug that addresses that when we get into like physical therapy interventions, what's really cool is exercise is in all the categories.

Speaker 1 (01:04:59):

And it's one of the things we have the best evidence for. So regardless of pelvic girdle pain in pregnancy or not pregnancy, and regardless of how it may have been labeled by somebody else is I would, I would mostly want to know when did the pain start? Is there anything that makes it better? Anything that makes it worse and see if I could find a movement or change something for that person. Or that made me sound like I was going to do a whole lot of work. If I could find something for that person to change for themselves to have that hurt less and have the I tend, I would tend to keep it simple, mostly cause in the clinic again, we could do a lot of special tests that might say, Oh, Nope, they definitely hurt there, but it's still, if we're looking at what's going to be an effective intervention, that that patient is going to tell me what that is.

Speaker 1 (01:05:54):

Sorry. It would help a fire mute myself. So looks like we have time for one more. And I, I really, Claire was not clarity did not pop up yet. So we've got time for one more and then we're going to work. We're wrapping it up. I promise stroke patients, dementia patient. We just got the no go. Yes, no, it's a super short answer if you want Claire super short answer. Okay. So stroke dementia patients with urinary incontinence, any useful ideas for the rehab program? Yes, but not get an idea of their bladder habits, their bowel habits, their fluid intake. Because a lot of that's going to end up being outside caregiver help with the, with the stroke, it's much different. It depends on the severity and where it is and all of that. But for people with dementia is if you just get that, like if you can prompt them or take them to the toilet, a lot of the times that will take care of the incontinence.

Speaker 1 (01:06:48):

It's not a matter of like Cagle exercises. It's more management. All right, Sarah, thank you so much. I'm going to throw it back over to Claire to wrap things up. Thank you both for a wonderful and insightful discussion. Sarah and Karen. So many practical tips and pointers for the clinician, especially I was loving learning about all of the things that I could take to the clinic. So I hope our audience find those practical tips really helpful as always the link to this live chat will stay up on our Facebook page and we'll share it across our other social media channels. Don't forget. You can also follow us on Twitter. We're at Dow SPT. You can also follow us here on Facebook. Please share this chat with your friends, with family colleagues, anyone who you think might find it helpful. And if you like JSP T asks, please be sure to tell people about it at that what we're doing so they can find this here, please join us.

Speaker 1 (01:07:46):

Next week when we host our special guest professor Laurie from the university of Southern California, Larry is going to be answering questions on managing shoulder pain. We'll be here, live on Wednesday next week. So Wednesday, April the eighth at 9:00 AM Pacific. So that's noon. If you're on the East coast of the U S it's 5:00 PM. If you're in the UK and at 6:00 PM, if you're in Europe, before we sign off for the evening, there's also really important campaign that I'd like to draw your attention to. And it's one that we at Joe SPT supporting and it's get us PPE. So we're supporting this organization in their quest to buy as much a, to buy much needed personal protective equipment for frontline health workers who are helping us all in the fight against the coronavirus pandemic. So if you'd like to support, get us PPE, please visit their website, www dot, get us ppe.org, G E T U S P p.org as always. Thanks so much for joining us on this stale SPT asks live chat, and we'll speak to you next week. Bye.

Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Leigh Hurst on the show to discuss breast cancer awareness.  Leigh Hurst is a breast cancer survivor and the founder of the Feel Your Boobies® Foundation, which she started to educate young women (under 40) by reminding them to "feel their boobies" - a call to action that can save their life. Feel Your Boobies® is one of the largest followed breast cancer awareness foundations on Facebook and has inspired women all over the world to feel for lumps starting before they are formally screened for breast cancer. And, most importantly, it has directly resulted in countless women finding lumps early and giving them a better shot at living a full, meaningful life after their diagnosis. The Feel Your Boobies® Foundation has been featured in The New York Times, New York Daily News, and other national publications. At one point, Feel Your Boobies® was the largest cause on Facebook, with more than 1 million supporters.

In this episode, we discuss:

-Leigh’s experience advocating for her own breast cancer diagnosis

-The story behind the Feel Your Boobies Foundation

-Why women need to prioritize self-care

-The voices of breast cancer survivors in the book Say Something Big

-And so much more!

Resources

Leigh Hurst Website

Say Something Big Book

Say Something Big Facebook

Say Something Big Instagram

Feel Your Boobies Website

Feel Your Boobies Facebook

Feel Your Boobies Twitter

Feel Your Boobies Instagram   

A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. 

For more information Leigh:

LEIGH HURST is a breast cancer survivor and the founder of the Feel Your Boobies®

Foundation, which she started educate young women (under 40) by reminding them to

feel their boobies - a call to action that can save their life. Feel Your Boobies® is one of

the largest followed breast cancer awareness foundations on Facebook and has inspired

women all over the world to feel for lumps starting before they are formally screened for

breast cancer. And, most importantly, it has directly resulted in countless women finding

lumps early and giving them a better shot at living a full, meaningful life after their

diagnosis. The Feel Your Boobies® Foundation has been featured in The New York Times,

New York Daily News, and other national publications. At one point, Feel Your Boobies®

was the largest cause on Facebook, with more than 1 million supporters.

Hurst is also the author of the new book, Say Something Big: Feel Your Boobies, Find Your

Voice. Stories About Little Lumps Inspiring Big Change (Oct. 2020)

Beyond her work with Feel Your Boobies®, Leigh regularly speaks to audiences large and

small, sharing her own personal journey and inspiring others to “Say Something Big”

amidst life’s hurdles and hardships. She resides in Pennsylvania with her family.

Feel Your Boobies® uses innovation around media to reach women across the world with

their important message.

For more information, visit www.leighhurst.com or www.feelyourboobies.com, and connect

with Leigh on Instagram, Facebook, and LinkedIn.

Read the full transcript below:

Karen Litzy (00:01):

Hi, Leigh, welcome to the podcast. I'm happy to have you on.

Leigh Hurst (00:05):

Thanks for having me, happy to be here.

Karen Litzy (00:07):

Yeah. And now we're in the month of October. And for those of people who don't know October is breast cancer awareness month. And in the past, I've had shows about breast cancer during the month of October, but this is the first time I am speaking to a breast cancer survivor. So thank you so much for coming on and sharing your story because I know it's going to be so helpful for other women and men listening to this podcast. So before we kind of get into everything, I'm going to just throw it over to you so that you can just kind of tell your story how old you were when you were diagnosed. How did you find out? So I'll send it over to you.

Leigh Hurst (00:51):

Okay, cool. Thank you. So I was officially diagnosed when I was 33 that I had felt the lump for some time leading up to the actual diagnosis. So I think I was probably around 30 or 31 when I started to notice the lump. And I was living in New York city at the time and I was a marathon runner. So really health conscious, certainly educated about my health felt very kind of plugged into that kind of thing. And for a little while, I didn't really think much about it. I just thought it was, you know, something no big deal. I really small breasts. So I felt like when I'd go to the doctors, I'd let them sort of do their exam of my breasts and they would never notice it until I would point it out. So I would literally take their hand, put it on my boob and say, this kind of feels a little different to me.

Leigh Hurst (01:39):

I don't know if you notice it or not. It's like a ridge on the outer side of my left breast and then they would feel it and then they would say, I don't really think that's anything to worry about. I had no family history, so I wasn't exceptionally worried about it. Although, as I know now, that's not necessarily a primary risk factor. It is, but most women diagnosed don't have a family history. So I was pacified about that for a while. You know, that kind of went on for maybe a year or two. I eventually decided to sort of simplify my life and I moved out in New York city. I was in a really kind of super corporate job, traveled a lot for my work on a weekly basis. And I was just trying to find ways to sort of step out of that.

Leigh Hurst (02:20):

And so I moved back to central PA, which is where I live now. I'm kinda got set up on a house was back near my family and it came time for my annual exam. And I went again to the doctors and again, it wasn't noticed, but I mentioned it and it was the first time someone's like, Oh, she probably should just get a mammogram. It can't hurt to sort of just see if it's something or not. So that's how it started and ended up having the mammogram showed some areas of concern, took me right in and did an ultrasound and eventually at the biopsy a couple of weeks later and it did turn out to be cancer. So that was 2004. And you know, needless to say, I was very concerned because I knew I had had the lump for quite some time, so I wasn't sure what to expect, but it didn't turn out to be stage one, so early stage breast cancer.

Leigh Hurst (03:09):

And so, yeah, that's kinda how it started with, you know, finding out that I had a lump and went through treatment. I decided to have a lumpectomy, the lump was small stage one had no lymph node involvement. So that was good. And I did do chemotherapy because I was young. So they suggested that because of being premenopausal and being so young at the time, it was some preventative. So I did chemotherapy than I did seven weeks of daily radiation treatment to the lump site. And then I took five years of a pill called Tamoxifen, which is estrogen reducing medicine at the time they were still prescribing it for five years. I believe now the regimen is 10 years. But so the actual treatment itself was about six months start to finish. And then it was the five years of the Tamoxifen following that.

Karen Litzy (03:59):

And at the age of 33, you must have been kind of shocked. Right. Cause it's not something that we hear a lot of, you know, like even to get a mammogram, they don't suggest getting a mammogram until you're 40.

Leigh Hurst (04:15):

Correct. Yeah. And you know, it was, you know, looking back on it, I remember thinking, gosh, I never talked about breast cancer, never talked about it. I didn't know anybody who had had it. I'm not even really sure. I knew anybody who’s mother that had had it. So I was really taken aback by that when I was diagnosed and I was single at the time really hadn't thought about having a family quite yet. You know, I was living in the city, it was very common to still be kind of doing your thing. And so there are other issues that came up other than of course the life or death issue with breast cancer. There were the other possibilities of losing your fertility through chemo. Certainly that's a possibility certain decisions that you might be faced with can also, you know, if you decide to remove any of your female organs, ovaries, whatever, to minimize your risk, of course, those are big decisions when you haven't started a family yet.

Leigh Hurst (05:08):

And I wasn't really sure I was going up, but I didn't want that choice to be taken away from me. I didn't want it to be something that I couldn't do at a later date. So yeah, it was, it was shocking. And you know, out of that, I really started to like, think about why didn't I talk about this? Why didn't I think about this? And so that's kind of how the feel your boobies idea came about is that I just made some t-shirts for friends. Cause I would joke around during my treatment, I was actually still running and I didn't get sick. So I was really happy about that. And I just made sure that said, feel your boobies for fun. I'd always wanted to make t-shirts. I was kinda crafty kind of thing, you know, hobbies on the side.

Leigh Hurst (05:47):

And so my friend and I mocked up a tee shirt and I got a hundred made, put a website up, my background's in technology based learning. So I was kind of techie and I'm just send it around to my friends that had lived in the cities where I had moved after grad school. And I started selling shirts to people. I didn't know, very quickly, it just kind of went viral. I was getting checks in the mail from people. I had no idea who they were. And so, you know, that whole idea of, of using a message, like feel your boobies, which is lighthearted, but very pointed in terms of what it's trying to get you to do. Made me think about, you know, is this really creating behavior change? Is this creating a meaningful dialogue among a population of women like me that never really talked about it before? Or if they did, it was the third serious town and it was about their mother or it was in the context of a doctor's office. And so to that accidental t-shirt, that was just a hobby sort of evolved in time into something that took over my life quite honestly, and quickly I had to figure out what I was doing with it. So that's how the foundation itself came to be.

Karen Litzy (06:53):

Yeah. It's amazing. The things that happen to you that can just do a 180 and change your life. Right. So you could have had this diagnosis and then just went on and got a job and just went on your way. Right. But instead you were like, wait a second, like I'm young, I never talked about this. There's gotta be other people out there just like me. So how can I reach them?

Leigh Hurst (07:15):

Right, right. Sort of back fitting it. Right. Because I didn't create the tee shirt with that in mind, but I watched it happen. And that started to make sense to me with my background in behavior theory and that kind of thing. And so I kind of ran with it and, you know, we were able to support ourselves for quite some time just through t-shirt sales. So fortuitously, unlike other nonprofits that you know, have to submit for grants and you know, really the funding side of it is the tricky part. We were fortunate in those early days the t-shirt sales themselves allowed us to do a lot of creative things through social media before that was a standard way of spreading our message. And so we really tried to leverage the idea of media and the peer to peer sharing because what I saw when somebody would wear the tee shirts, like a happy hour or a cookout was I was watching like a 20 something talk to another 20 something or a guy even who might say your shirt says feel your boobies.

Leigh Hurst (08:16):

Can I feel your boobies? And then they would say, it's not about that. It's about breast cancer. Or you got to feel your boobs to see if you find a lump. And to me that was a productive conversation. It was somebody articulating something very simple, but in a playful and a more friendly and lighthearted way than trying to impart stats or other types of things that I think a lot of campaigns do, or certainly they have the aesthetic and the sensibility that feels like it's for an older woman. So you may relate to it because you're trying to just be proactive and educate yourself about health. But the messaging itself is not really created for you. It's not created for the younger population, the style of the images, the style of the graphics, and even the use of the channel that you use to spread it.

Leigh Hurst (09:01):

Right? So a tee shirts, just one way you can not, but you can do that in many other ways. You know, we flew aerial banners up and down the Jersey shore in the summertime on all the very populated beaches. And I'm thinking of these young women that are like dragging themselves out to the beach after going out Friday night. And they see a, you know aerial banner and they say, Oh my God, that says feel your boobies. And I'm like, that's wonderful. That's a great way to kind of intersect with them where they are in a way that they can relate to. And, you know, it's created testimonials from women that say, that's why they found their lumps. So very proud of the campaign. And eventually I went on and left my corporate career and ran the foundation full time. So it really wouldn't do that 180 for me, that you mentioned about changing your life. It was definitely that for me.

Karen Litzy (09:50):

Yeah. So we can definitely see how your life has changed after diagnosis, but what are the big lessons that you learned?

Leigh Hurst (10:00):

Well, you know, I definitely learned I'm type A, very much of an ambitious overachiever and, you know,

Karen Litzy (10:06):

Well, I mean, you were in New York city in a corporate job, we get it, that came across.

Leigh Hurst (10:12):

Right. And so you kind of like play these scripts out in your head. Like I really should slow down this. Isn't really how I want to spend my time. I'm really too busy. I wish I could make more time for X and part of my move home quite honestly, before breast cancer was in an effort to sort of really operationalize some of that stuff to sort of extract myself out of the environment that wasn't really fueling me anymore. It was draining me. And so, you know, earlier in my career, there's coast to coast flights on a Monday morning to get to a meeting on time. That was exciting. And as I got older, I'm kind of like, I don't really want to do that anymore. I don't care how much money I make. I don't want to be on a plane. I want to be involved in the place that I live.

Leigh Hurst (10:55):

And so my move was in part to get that going right, to really start to be outside more to, you know, I decided to go part time cause I kept my job in New York city. So I didn't need the amount of money I was making where I lived anymore. But I didn't truly step out like that until breast cancer came. And then I quite honestly, I got depressed at the end of my treatment, I got depressed and I took three months off work. I called it my be nice to me times. So I like got weekly massages. I went to get therapy because I felt like I needed to sort of sort through some things, you know, I felt like I should be getting back to normal, but nothing about my life felt normal. Everything had changed, you know, whether or not.

Leigh Hurst (11:39):

So I think during that time is when I started to realize what it meant to say no, that you can say no and not give a reason. And that having lots and lots of friends, which I had is great, but having a lot or having fewer really good friends became more important to me. People that I could really keep in touch with and have meaningful conversations. And my family quite honestly, too, was a big part of that. So I would say that that was the biggest thing slowing down. And I still struggle with that because that's not my genetic makeup. My genetic makeup is to, you know, attack a problem, and make a change and go through something like breast cancer, trying to get back to normal is tricky because you really can't change the future. You never know if it's going to come back.

Leigh Hurst (12:26):

That's just a fact with breast cancer. And so I think learning to live with the ambiguity of not knowing, you know, and accepting that, truly accepting that that kind of translates out into other parts of your life, where you can, if you really allow yourself to sit in that space, you can apply that to other uncomfortable things that come up, right. Things that happen with your job or relationships or other things that make you feel anxious. Like you want to make a change or you want a resolution immediately. I think I have a better sense of pause around that where I trust that in time things will sort themselves out and I will have a greater sense of peace around whatever it is. I'm stressing about things that came out of that period of time in my life. Yeah. That's so powerful. I don't do it well by the way, but I work at it all the time.

Karen Litzy (13:19):

Well, I mean, I think the fact that you were able to identify that as, Hey, listen, this is something that I know I need to work on. And of course we're all a work in progress. Nothing's perfect. But to just be able to recognize that and say, I need to make a change. Like this is too much, that's so powerful. And then to be able to kind of leave the city, move to central PA and say, I know I'm doing this for me. And that was even before the diagnosis. So you were already, you know, heading in that direction. And I also really appreciate that. You said at the end of treatment that you were depressed, that you were unsure, you know, because I think oftentimes when people see breast cancer survivors or they hear from, or just looking at a picture, let's say, right, it's a person smiling or it's I beat it, or, but you don't really get into the background of that.

Leigh Hurst (14:22):

I talk about the mental health side all the time, because I think it is something that's not discussed as much as it should be and not everybody gets depressed, but I do think everybody has down days. Of course, I mean, when you're struggling with something that's life or death and that happens at different times for different people. For me, I was fight or flight during the treatment. For me, it was like a project, right. I knew I had a plan and I had to do it. And the tricky part for me was when I entered into that gray space where I was kind of released from all of that care. And I had to make sense of my life on a day to day basis, be my own cheerleader, quiet those voices in my head that would raise all those scary thoughts and realize that this was going to be forever. You know, like you can't let this consume you. And you know, being brave enough to say I'm depressed. I wasn't brave enough to say that right away. You know, I went into therapy, very hesitantly feeling like, what do you have to be upset about? It was stage one, you got through it, shouldn't you be happy with it?

Karen Litzy (15:22):

That self-defeating language, right? There's someone worse off than you.

Leigh Hurst (15:27):

Right? So therefore you can't feel any sort of emotion around your own words is not true and very dangerous by the way. And so, you know, I really try to bring that up when I speak to women who are going through it or who have gone through it, who I sense might be struggling with a little bit of that, because there's so much, and it's different for everybody. If you might be balancing kids, I wasn't, but it might be balancing kids, little children and trying to mask what you're going through to keep them from being afraid. And so that you're hiding your own emotions for some period of time, or same thing goes for spouses that can have issues. So finding a place where you can be truly honest with your own feelings and dealing with that is I think really important because it delays your ability to heal. If you don't find your way.

Karen Litzy (16:18):

You have to say to yourself, okay, this is the situation and I need to live with this. What's the best way I can move forward. Right. We discussed that a lot with people who have like chronic pain. So the pain may never go away, but can you get to a point where you're still doing all the things you want to do, but in order to do that, you kind of have to accept it.

Leigh Hurst (16:48):

Yeah. And the way you choose to do that, whatever steps you take to make that possible in your life. The biggest thing for me was realizing that other people don't have to get it right. Like if I had a choice, things that make me able to have good days or days that I need to step out for a little bit, I don't have, I shouldn't have to worry, or I can't worry if that makes sense to somebody else, because the only thing I can do is reconcile within myself. What makes me the best version of me, the fullest version of me, for the people that need me. And the way I choose to do that is probably not going to be the same as the way someone else chooses to do that, or should it yeah. Nor should it be. Right. So looking for affirmation about those decisions outside of yourself is a real challenge. You know, if you're a pleaser or you're, you know, sometimes you just gotta bone up and do what you have to do, right. You always just satisfy your needs. But the times when you have choices to flake out on plan that you just don't feel up for, or push something that you thought you should do today to tomorrow those things are okay to do, and you don't need someone else to tell you they're okay.

Karen Litzy (18:01):

Right, right. It comes down to like giving yourself the permission and the grace and the ability to do what you need. Like you said, to do what you need to do in the moment at that time, that's going to be best for you. That's going to allow you to show up fully as the person you need to be.

Leigh Hurst (18:20):

Right. Yeah. That makes total sense. I thought it was a great way of putting it as like self care is not the same as selfish. So making those choices, you have to be, you know, polite, honest, a good person when you're doing all of those things, but taking care of yourself, the self care part of it is not being selfish. It's about being in touch with what makes you the good person that you are.

Karen Litzy (18:46):

Right. And I think also being able to communicate that to someone maybe it's your partner or your spouse or your children or work, I think the way you go about communicating, that makes all the difference, right. Because there's a difference between, listen, right now, maybe you might have felt, you know, I just need to be by myself for a couple of hours, you know, that's what's best for me, but if you don't communicate that properly or if you just flake out and go stout on people like that is not that that's how you, you create a lot of friction. Right. So what advice would you give to people if they do have to make these decisions to do what's best for them? What's the best kind of language? Cause I know you're very good at communication and all that other stuff.

Leigh Hurst (19:38):

So I have two small children. I had kids after breast cancer and I'm a single mom now. And I was since they were very little good friends with their father and all of that, but still, you know, being I'm 50 now, but I was 40 and 42 when I had them. And so, you know, the loss of independence around raising two children alone when you're used to like literally flying coast to coast, you know, rewind five years. And it was like, the world was at your feet. So I found myself becoming extremely protective of my space when they were not with me. And, you know, so I was very cautious about making plans. And I would just be honest about that if it was a weekend that I didn't have them and somebody invited me to go away for example, Oh, we're having a girl's weekend.

Leigh Hurst (20:24):

We're going to go to a winery. Do you want to come? And I would say, well, I might, I might want to come if you need a commitment though. I can't commit because a lot of times when the kids go away, I just like to have some quiet time to myself. I don't like to come back from a weekend and be tired. So I would, I mean, that's just being honest, you know, some things, those are, it's not as easy as something like that, but you know, I think with work where there's deadlines and it's a little trickier to push things off I've gotten better at prioritizing where I'll say it has not really in it today. I know I said I would have this by two o'clock is it possible I could have it tomorrow by maybe 10. So I'm not telling them all the inner workings of what's going on in my brain, but I'm floating the idea that I'd like to shift the priority around because I think it would work better for my mental state. You know, so those are just some ideas for how I do it.

Karen Litzy (21:20):

Yeah. That's great. That's great. Thanks for sharing that. And now what I'd also like to talk about is your book. So you're about to release, well, this will be out the first weekend of October. So the book should hopefully be out by then, right? They will be. Okay. Perfect. So say something big, feel your boobies, find your voice stories about little lumps, inspiring, big change. So first of all, congratulations, because writing a book is no joke. So tell us a little bit about why you wrote the book and what's in it.

Leigh Hurst (21:57):

So I wanted to write this book for quite some time. You know, I do a lot of speaking and people often say, Oh, your story is so inspiring about how you just created something and then you ran with it and you saved lives. And now you have this big foundation. And I do realize that that's inspirational, but I kind of tire of my own story over time. So every time I would sit down and try to write about it, I was like, Oh my gosh. But what I found inspirational enough to get me going this time. And it was really an honor of our 15th anniversary, which was last year. I was hoping to have it done by them, but that's the 15th anniversary of the foundation. And it was also my anniversary from breast cancer is the same as the foundations university.

Leigh Hurst (22:39):

So I started writing it back then and the way I got inspired to really get into it was as I started writing about my own story, I was things were coming to mind about these other women that I had met over time through my path, as you know, being very involved in the breast cancer community and quite honestly, their stories while different were very similar. So they were young when they were diagnosed, they found their own lump and they made some sort of change that was remarkable that they hadn't really pivoted from one path to another and really in an effort to give back. And so, as I started seeing that sort of common thread through some other women that I respected, I thought, well, what if I wove their stories into mine? And so, you know, our stories are different. So how I felt it, this part of the journey, you know, when I found the lump, the way I found it is different than the way one of the other women found it and how I felt during chemo is a lot different than the way some other people felt during chemo.

Leigh Hurst (23:38):

So if I can weave their stories in to mine, then it will relate to so many more people because can kind of say, Oh, I really relate to Leigh. When she was deciding if she wanted to have a mastectomy or lumpectomy, but I really, really related to Holly during chemo, cause I'm really struggling with it. And she struggled with it too. And so there's lots of tidbits of inspiration and advice that come out of all of these stories. And so after each chapter, I write a little piece that's called big lessons from little lumps. And it's basically trying to suss out the things that I felt were common through each of the women's stories at each stage of the breast cancer journey. And then of course at the end, you know, they've all sort of found their voice. They've started their own nonprofits, where they started a company to create underwear, lingerie line that's meant to make you feel sexy, even if you've had your breast removed.

Leigh Hurst (24:35):

And that was because that particular survivor did not feel sexy after she was diagnosed and had surgery and she was a designer. So she decided to do that. And so I just found great inspiration and listening to their stories and trying to weave them into mine. And, really at the end of the entire book, what I found were basically three ideas that I saw across all the women that I think can relate to anybody that's going through any sort of difficult time, not just breast cancer. And one of them was that I really noticed that each woman found a frame for their situation that really focused on the idea of looking forward into the future versus looking only backwards and only wishing they could redo it differently. Right? Like being sad about what had happened. They all had those emotions, but the way they ultimately framed things was with the idea of looking forward.

Leigh Hurst (25:31):

Then each of them also talked a lot about finding a passion, something that really, you know, gave them those goosebumps or that feeling you get in your stomach when you're doing something right. And that is what they chose to spend their time on. And they really made an effort to strip anything out of their life that got in the way of them being able to focus on that type of activity. And then the thing that we talked about earlier, but the third thing is that they all recognize that change is continuous, right? It's not like you flip a switch and say, I'm going to make this change, or I'm going to start fuel your movies. And all of a sudden I'm happy because I started a nonprofit and it does good things. I mean, it has all the same challenges that a normal job has.

Leigh Hurst (26:11):

So change is truly this continuous thing, but because of the passion and they're focused on the future, they were able to realize that, sure, there's going to be some bad days throughout this process, but nothing is going to get in the way of my path to create this change towards the way I really want to live my life. And I found that so powerful when I saw that kind of trend throughout each woman. And I really think a lot of people will benefit from watching how each of them kind of, you know, injected that into their own lives.

Karen Litzy (26:44):

And isn't it amazing how storytelling creates such great learning moments, right? I think that's the way to do it. People they remember the stories, they think it's digestible, they internalize it. Like you said, what someone may not relate to you, but they may relate to someone else in the book. And it's those stories that weave through that come up with these great themes that anyone can relate to. So I just always think that I'm such a huge fan of storytelling and storytelling makes things real and relatable.

Leigh Hurst (27:16):

And I think that's an important way. It's one of the things we try to do with the foundation too, is when we do provide messaging or things, we try to really make it relatable. And that we're telling a story about someone who is real, someone who was young when they were diagnosed. So when you say that looks like me, I can relate to that. I also think women who are brave enough to share their story and I, by no means think it's wrong to not share your story. I think you're a private person and that's how you heal, then that's what you should pay attention to. But for those who choose to, and they don't always realize they've chosen to one of the women in the books that she never talked about it. The first time she was diagnosed, she was 26 and she was embarrassed.

Leigh Hurst (27:56):

And then she unfortunately was rediagnosed nine years later with metastatic cancer at 45, which means it's terminal. And at that point she really became braver to start talking about it and she realized how much strength she got from sharing her story. And so I think when women put their stories out there they have no idea how many people they touch when they do it, because no one's gonna necessarily walk up to you and say, I really respect that. You said that, or I want you to know that that really made a change in my life that day, but it does. It does. And it goes beyond what you will ever actually know.

Karen Litzy (28:32):

Absolutely. Yeah. And I love that sort of women pushing other women forward and building them up and paying it forward. It's just such a lovely, a lovely lesson for anyone. But as we all know, you know, the power of women in groups is very powerful.

Leigh Hurst (28:52):

Unstoppable. Exactly.

Karen Litzy (28:54):

Exactly. That's better unstoppable. Yes, absolutely. And so before we kind of wrap things up, what I would love from you is what would you like the audience to sort of take away from maybe from your experience or from our talk today? Cause I know that you do and you also, I also want to point out that you also talked to a lot of young people, college students, things like that, right?

Leigh Hurst (29:18):

Yeah, I do. I do. Yeah. So one of the aspects of our campaign in the past has been what we call our college outreach program, which we provided free materials to college health centers nationally through sororities and women's centers and so forth. And that was in an effort to get our message out to the college campuses. And we've also started running a media campaign which we did last year called are you doing it was a minority outreach campaign focused on young African American women in low income areas. African American women have a higher, are diagnosed at an earlier age than white women. And once they're diagnosed, they have a higher mortality rate as well. And so it's a very important audience to target. And so we funded a campaign that leveraged billboards, bus shelters, bus wraps, as well as targeted digital outreach to that demographic of women specifically to spread the message and that incorporated five local survivors, real survivors who were diagnosed at a young age, we did a photo shoot, shot a video with them.

Leigh Hurst (30:22):

And we shared that through all the channels that I mentioned, but we got over 6.2 million impressions with that campaign. Amazing. Very amazing. So, yeah. So we reach out to that younger population, like you mentioned in a lot of different ways, but I mean, I think if you asked me what the one thing is, I want someone to take away is that, you know, it sounds cliche, but I really do believe that one voice matters. I feel like the ripple effect from one person's passion and when one person's devotion to an idea can really make a difference and they don't have to be big actions. The things that you choose to do, don't have to necessarily change the world, but you can start small. And the actions that you choose, the words that you choose and how you choose to navigate your life, I think affects other people. And this book really showed me that in the smallest of ways, people can have the biggest impact in their communities and in other people's lives. And that's, I think that's a really great lesson for anybody to take away.

Karen Litzy (31:24):

Absolutely. And now if people want to get in touch with you, where can they find you? Where can they find the book?

Leigh Hurst (31:31):

So the book will be available on Amazon. Starting October 1st, I believe. You can read more about the book leighhurst.com. You can follow the book on Facebook, which is, say something big as well and Instagram to say something big. So those are all the channels. And then of course, if you're interested in feel your boobies and the work that we do, the Facebook pages you know, at feelyourboobies on Facebook, Instagram, and Twitter, and our website is feelyourboobies.com.

Karen Litzy (32:08):

Awesome. And we'll get all of those links. So for everyone, if you don't have something to take it down, or you're not right in front of the computer, we'll have all of the links. You can go to podcast.healthywealthysmart.com. And we'll have a quick link to everything that Leigh mentioned today throughout the podcast. So not to worry, everything will be right there. So Leigh, thank you so much for sharing your story. I just know, like you said, even if one person hears this and they say, Oh, well maybe I will feel my boobies, mission accomplished. Well, thank you so much for sharing your story and coming on the podcast. I appreciate it. And everyone out there listening. Thank you so much. Have a great couple of days and stay healthy, wealthy and smart.

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