Podcasts about mechanical diagnosis therapy

Mike interviews Physical Therapist Sarah Haag about Urinary Incontinence. 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 in Physical Therapy and a 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's Website: https://entropy.physio/ Sarah's Book: Understanding and Treating Incontinence: https://amzn.to/3D8pnsQ ~~~~Time Stamps~~~~ 0:00 Intro Song 0:08 Sarah Haag Introduction 0:44 Sarah's Background 2:16 Sarah's Website Information 2:42 Treating Patients Online & In-Person 3:04 What Causes Urinary Incontinence 6:19 Other Causes of Urinary Incontinence 7:55 How Urinary Incontinence is Diagnosed 9:52 Different Types of Urinary Incontinence 13:45 How to Tell Which Type of Urinary Incontinence You Have 14:47 Treatment Options for Urinary Incontinence 18:56 How to do a Kegel 24:55 Urinary Incontinence Women Vs Men 27:03 Urinary Incontinence Can Happen at Any Age 30:10 How to Manage Urinary Incontinence 35:23 Excessive Liquid Consumption 37:17 Can Urinary Incontinence Be Cured or Just Managed --- Support this podcast: https://anchor.fm/bobandbrad/support

In this episode, Founder of Enhanced Recovery After Delivery™, Dr. Rebeca Segraves, Co-Founder of Entropy Physiotherapy, Dr. Sarah Haag, Owner and Founder of Reform Physical Therapy, Dr. Abby Bales, and Co-Owner of Entropy Physiotherapy, Dr. Sandy Hilton, talk about the consequences of overturning Roe v. Wade. Today, they talk about the importance of taking proactive measure in communities, and the legal and ethical obligations of healthcare practitioners. How do physical therapists get the trust of communities who already don't trust healthcare? Hear about red-flagged multipurpose drugs, advocating for young people's education, providing physical therapy care during and after delivery, and get everyone's words of encouragement for healthcare providers and patients, all on today's episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “Our insurance-based system is not ready to handle the far-reaching consequences of forced birth at a young age and botched abortions.” “We do need to know abortive procedures so that we can recognize when someone has been through an unsafe situation.” “We really need to take into consideration the ramifications of what this will do.” “This is not good healthcare and we need to do more.” “We're going to have to know our rules, our laws, and what we're willing to do and go through so that we can provide the care that we know our patients deserve.” “We're looking at the criminalization of healthcare. That is not healthcare.” “We know who this criminalization of healthcare is going to affect the most. It's going to affect poor, marginalized people of color.” “We can no longer choose to stay in our lane.” “We need to have a public health physio on the labour and delivery, and on maternity floors.” “We don't get to have an opinion on the right or wrongness of this. We have a problem ahead of us that is happening already as we speak.” “We need to create more innovators in our field, and education is the way to do that.” “This is frustrating and new, and we're not going to abandon you. We're going to figure it out and be there to help.” “Our clinics are still safe. We are still treating you based on what you are dealing with, and we will not be dictated by anybody else.” “If you need help, there is help.” “If we believe in the autonomy of an individual to know all of the information before making a decision, then we still believe in the autonomy of an individual to know all of the information that is best for their body.” “This affects everyone. We're dedicated to advocating for you.”   More about Dr. Rebeca Segraves Rebeca Segraves, PT, DPT, WCS  is a physical therapist and Board-Certified Women's Health Clinical Specialist who has served individuals and families within the hospital and home during pregnancy and immediately postpartum. She has extensive experience with optimizing function during long-term hospitalizations for high-risk pregnancy and following perinatal loss and pregnancy termination. In the hospital and home health settings, she has worked with maternal care teams to maximize early recovery after delivery, including Caesarean section, birth-related injuries, and following obstetric critical care interventions. She is the founder of Enhanced Recovery After Delivery™, an obstetrics clinical pathway that maximizes mental and physical function during pregnancy and immediately postpartum with hospital and in-home occupational and physical therapy before and after birth. Her vision is that every person will have access to an obstetric rehab therapist during pregnancy and within the first 6 weeks after birth, perinatal loss, and pregnancy termination regardless of their location or ability to pay.   More About Dr. Sarah Haag Dr. Sarah Haag, PT, DPT, MS graduated from Marquette University in 2002 with a Master of Physical Therapy. She went on to complete Doctor of Physical Therapy and Master of Science in Women's Health from Rosalind Franklin University in 2008. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health, becoming a Board-Certified Women's Health Clinical Specialist in 2009 and Certification in Mechanical Diagnosis Therapy from the McKenzie Institute in 2010. Sarah joined the faculty of Rosalind Franklin in 2019. In her roles at Rosalind Franklin, she is the physical therapy faculty liaison for the Interprofessional Community Clinic and teaching in the College of Health Professions. Sarah cofounded Entropy Physiotherapy and Wellness with Dr. Sandy Hilton, in Chicago, Illinois in 2013. Entropy was designed to be a clinic where people would come for help, but not feel like ‘patients' when addressing persistent health issues.   More About Dr. Abby Bales Dr. Abby Bales, PT, DPT, CSCS is the owner and founder of Reform Physical Therapy in New York City, a practice specializing in women's health and orthopedic physical therapy. Dr. Bales received her doctorate in physical therapy from New York University and has advanced training through the renowned Herman and Wallace Pelvic Rehabilitation Institute, Grey Institute, Barral Institute, and Postural Restoration Institute, among others. She also holds her Certified Strength and Conditioning Specialist certification from the NSCA and guest lectures in the physical therapy departments at both NYU and Columbia University, as well as at conferences around the country. Dr. Bales has a special interest in and works with adult and adolescent athletes with a history of RED-S (formerly known as the Female Athlete Triad) and hypothalamic amenorrhea. A lifelong athlete, marathon runner, and fitness professional, Dr. Bales is passionate about educating athletes, coaches, and physical therapists about the lifespan of the female athlete. Her extensive knowledge of and collaboration with endocrinologists, sports medicine specialists, pediatricians, and Ob/gyns has brought professional athletes, dancers, and weekend warriors alike to seek out her expertise. With an undergraduate degree in both pre-med and musical theatre, a background in sports and dance, 20 years of Pilates experience and training, Dr. Bales has lent her extensive knowledge as a consultant to the top fitness studios in New York City and is a founding advisor and consultant for The Mirror and the Olympya app. She built Reform Physical Therapy to support female athletes of all ages and stages in their lives. Dr. Bales is a mom of two and lives with her husband and family in New York.   More About Dr. Sandy Hilton Sandra (Sandy) Hilton graduated with a Master of Science in Physical Therapy from Pacific University in 1988. She received her Doctor of Physical Therapy degree from Des Moines University in 2013. Sandy has contributed to multiple book chapters, papers, and co-authored “Why Pelvic Pain Hurts”. She is an international instructor and speaker on treating pelvic pain for professionals and for public education. Sandy is a regular contributor on health-related podcasts and is co-host of the Pain Science and Sensibility Podcast with Cory Blickenstaff. Sandy was the Director of Programming for the Section on Women's Health of the American Physical Therapy Association from 2012 - 2017. She is now on the board of the Abdominal and Pelvic Pain special interest group, a part of the International Association for the Study of Pain.   Suggested Keywords Healthy, Wealthy, Smart, Roe v Wade, Abortion, Trauma, Sexual Trauma, Pregnancy, Advocacy, Pelvic Health, Healthcare, Education, Treatment, Empowerment,   To learn more, follow our guests at: Website:          https://enhancedrecoverywellness.com                         https://enhancedrecoveryafterdelivery.com                         https://www.entropy.physio                         https://reformptnyc.com Instagram:       @sandyhiltonpt                         @reformptnyc                         @enhancedrecoveryandwellness Twitter:            @RebecaSegraves                         @SandyHiltonPT                         @Abby_NYC                         @SarahHaagPT LinkedIn:         Sandy Hilton                         Sarah Haag                         Abby Bales                         Rebeca Segraves   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  00:07 Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness and entrepreneurship. We give you cutting edge information you need to live your best life healthy, wealthy and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now, here's your host, Dr. Karen Litzy. Hey everybody,   00:36 welcome back to the podcast. I am your host, Karen Litzy. And on today's episode, I am very fortunate to have for pretty remarkable physical therapists who also happen to be pelvic health specialists. On to discuss the recent Supreme Court ruling in the dobs case that overturned the landmark ruling of Roe vs. Wade. How will this reversal of Roe v Wade affect the patients that we may see on a regular basis in all facets, facets of the physical therapy world. So to help have this discussion, I am very excited to welcome onto the podcast, Dr. Rebecca Seagraves and Dr. Abby bales and to welcome back to the podcast Dr. Sandy Hilton, and Dr. Sarah Hague. So regardless of where you fall on this decision, it is important that the physical therapy world be prepared to care for these patients. So I want to thank all four of these remarkable physical therapists for coming on to the podcast. Once the podcast starts, they will talk a little bit more about themselves, and then we will get right into our discussion. So thank you everyone for tuning in. And thanks to Abby, Rebecca, Sandy, and Sarah.   02:03 I, my name is Rebecca Seagraves, I'm a private practice pelvic health therapist who provides hospital based and home based pelvic health services and I teach occupational and physical therapists to provide their services earlier in the hospital so that women don't have to suffer.   02:20 Perfect Sarah, go ahead.   02:22 I am Sarah Haig. And I'm a physical therapist at entropy physiotherapy in Chicago, and I'm also assistant professor and at a university where I do get to teach a variety of health care providers.   02:35 Perfect, Abby, go ahead. My name is Abby bales. I'm a physical therapist, I specialize in pelvic health for the pregnant and postpartum athlete. I have my practice in New York City called perform physical therapy, and I do in home visits and I have a small clinic location.   02:54 Perfect and Sandy. Go ahead.   02:56 Sandy Hilton. I'm a pelvic health physical therapist. I'm currently in Chicago with Sara entropy. And I'm in Chicago and online. Because we can see people for consultations wherever they are, and we may be needing to do more of that.   03:13 So the first question I have for all of you lovely ladies, is how will the recent Supreme Court ruling in the dobs case, which was overturning Roe v. Wade? How is that going to affect people who give birth that we see in our clinics in the hospital setting in an outpatient setting in a home setting? So let's start with Sara, go ahead. I'll start with you. And then we'll just kind of go around. And and and also feel free to chime in and you know, the conversation as you see fit? Got?   03:58 That's such a big question. And I get to go first. So the question was how, how is this decision going to affect people who give birth? And I would say it just it affects everyone in in kind of different ways. Because I would say what this will undoubtedly do is result in us seeing people who didn't want to give birth. And and I think, you know, the effects of that are going to be far reaching and that we I think maybe we in this little group can have an idea of, of the vastness of this decision, but I think that even we will be surprised at what happens. I think that how it will affect people who give birth. Gosh, I'm kind of speechless because there's so many different ways. But when we're looking at that person in front of us with whatever they need to do For whatever they need assistance with after giving birth, we're going to have to just amplify exponentially our consideration for where they are and how they felt going into the birth, how they got pregnant in the first place. And, and kind of how they see themselves going forward. We talk about treating women in the fourth trimester. And it's, I mean, I'm in that fourth trimester, myself, and I can tell you that it would be harder to ask for help. And I'm really fortunate that I, that I have that I do have support, and that I do have the ability to seek help. I have a million great friends that I can reach out to for help, but I'm just how the how it's gonna affect the women, I'll say, I'm scared, but it's not about me. I'm very concerned for other women who won't be able to access the care that they that they need.   06:05 Yeah, Sandy, go ahead. What do you think? How do you feel this decision will affect people who can give birth, especially as they come to see physical therapist, whether that be during pregnancy? As Sarah just said, the fourth trimester, or perhaps after a procedure, or abortion that maybe didn't go? Well? Because it wasn't safe?   06:30 Yeah, so I work a lot with pain. One of my concerns is, but what is the future gonna hold for some people who did not want to be pregnant not added some sort of convenience or concern for finances, both of which, you know, your spot in life determines whether or not you have the the ability to raise another person at that moment. So there are individual decisions that people should make, in my opinion, but also, there's the if something happens to you, that you did not give permission to happen. And then you are dealing with the consequences. In this instance, pregnancy, and you happen to have back pain or have hip pain, or have a chronic condition, or a pelvic pain history, where you didn't not want to be pregnant. How's that going to affect the pain and the dysfunction that you're, you are already happening? And will it sensitize people to worse outcomes and recovery afterwards, because this is a, you know, there's a perceived injustice scale, I want to pull that back out. I hadn't been using it very often in the clinic just didn't seem to change the course of care. But I think that when I'm working with the people pre post, during pregnancy, I think I'm going to pull my perceived injustice scale back out and see if that might be a nice way to find out. If I need to hook someone up to a counselor, a financial counselor, psychologist, sexual therapist, anyone who might be able to support this person, we already don't have good support systems for pregnancy. I just am astounded at how much what a bad choice it is to add more need to a system that isn't currently handling the demand. I know we're gonna need to get creative because these people will need help. But I am a little awestruck at the possible quantum s we're gonna walk into   08:51 an abbey you had mentioned before we started recording about you know, some of the folks that you see that may have a history of different kinds of trauma, and how that may affect their abilities are to kind of wrap their head around being pregnant and then being forced to give birth because now they don't have any alternative. So how do you feel like that's going to play out in the physical therapy world, if they even get to physical therapy if they even get to a pelvic health therapist?   09:34 Yeah, that's, that's one of the things that I was I was thinking about as everyone was chiming in was, we really are just at the precipice in our niche of our profession, where people who give birth are seeking or even hearing about pelvic health and postpartum care, pregnancy care there. Just barely hearing about it. And my I have, you know, a concern, a very deep concern that these people will go into hiding if they have had an abortion in the past, because are we obligated to report that, and what is the statute of limitations on that, and the shame that they might feel for having had an abortion, or having had give birth and didn't want to, and the trauma that my patients who have, for the most part, not everyone who have wanted pregnancies that either the birth is traumatic, the pregnancy is traumatic, they get to a successful delivery, or they have a loss during the pregnancy, the trauma that they are experiencing, and for the most part, I'm seeing adults, and I cannot comprehend children, because it's this gonna be a lot of children who are forced to give birth, or who are having unsafe abortions, and the trauma that they're going to experience, and how, how much it takes for a person who has sexual trauma or birth trauma to get to my clinic, how these young people how these people who feel that shame, I don't know how they're going to get to me, or any of us, except for a real team based approach with pediatricians, with hospitals, with OB GYN, with your gynecologist with people who might see them first before us. I just don't know how they get to us to be able to treat and help treat that trauma. And like Sandy said, that pelvic pain that might be a result of the trauma if if it's unwanted sexual intercourse, I just don't know how we get to them. And that is something that we struggle with now, with, for the most part, wanted pregnancies. And I don't know how we get there. And I don't think we're prepared as a profession. for that. I think the advocacy for getting ourselves into pediatricians offices into into family medicine offices, is going to be so crucial in getting to these patients. But there aren't enough of us. We are not prepared. And our insurance based system is not ready to handle the far reaching consequences of forced birth at a young age and botched abortions. It is not ready to handle that.   12:52 Rebecca, go ahead. I'm curious to hear your thoughts around this because of your work in acute care systems.   13:00 Absolutely. I believe that I'm beyond the argument of whether this is right, or whether this is wrong. I think that as a profession, we're going to have to quickly change to a mindset of can we be prepared enough to handle what Abby was saying the amount of trauma, the amount of mental health I think, comes to mind when when someone's autonomy is taken away from them in any regard. I was very vocal as to how dangerous it was to force, you know, mandates on people even last year. And now here we are, we're at a point in our profession where we have to now separate our own personal beliefs and be committed to the oath of doing no further harm because this will result in harm, having treated individuals after an unplanned cesarean section or a cesarean hysterectomy, because of severe blood loss. They had no choice in those procedures. And they had no choice in the kind of recovery or rehabilitation they would get. I had to fight an advocate for our services, physical and occupational therapy services to be offered to individuals. So when you're looking someone in the eye who has lost autonomy over their body as last choice has gone through trauma that changes you it changes me really as a profession, even on this a professional or even on this issue. I'm now pivoting as quickly as I can't decide, do I have the skills that's going to be needed to address maybe hemorrhage events from an unsafe abortion that's performed? Maybe the mental health of having to try All across state lines so that you can find a provider that will treat you maybe the, you know, the shame around, you know, even finding Well, you know, is there a safe space for me to be treated for my pelvic health trauma from you know, maybe needing to carry this pregnancy longer than then I would have wanted to, there's, there's so much around this that we really have to start looking at with a clinical eye with a very empathetic or sympathetic eye as pelvic health therapists because of the fact that there's so few of us. And because now we're in a scenario where there will be more people who will be needing services but not knowing who to turn to. So my my biggest hope from this conversation, and many more that we'll have is that there's some how going to be a way to designate ourselves as a safe space for anyone, no matter what choice they've made for their body, period, I'm really done with being on one end of the spectrum with this, I'm a professional that doesn't have that opportunity to just, you know, be extreme on this, I advocate for the person and for their choice over their body period.   16:17 I think we need to, and it's just beautifully, beautifully said, the the getting getting some small systemic procedures in place in the communities we live in, is most likely the first step is reach out to the pediatricians and the chiropractors and the massage therapists and the trainers and the school athletic trainers and whoever you find that can have a connection with people and let them know on an individual basis. So like how do you tell people hey, I'm a trustworthy clinic to come to is not usually by writing it on your website. But if you can make connections in your community and be a trusted provider, that's going to go further, I suspect. I'm assuming there's going to be a fair bit of mistrust. And we have to earn it once it's lost. We've got to earn it back. So yeah, I like the proactiveness of that.   17:22 I, I totally agree on something you said Sandy sparked something that I would love for a health care lawyer to start weighing in on is we want, I am a safe space. I think every patient I have ever met who sees me cries. And I hold I hold that part of what I do. Very close to me, it's it's an honor to be someone that my patients open up to. And I know all of you on this call feel the same way because we we are that place that they they I love hearing birth stories. I love it. Even it just gives me an insight into that person into that experience. I feel like I'm there with them. And I understand better what they have gone through. But what happens when the legal system is going to come for us? Or them through us? What happens to that? How do we continue to be a safe space where they can share their sexual trauma, their birth trauma, their birth history, their pregnancy history, their menstruation, history, their sexual history? All of those really, really intimate things? How do we continue to be that for our patients?   18:56 I think we've had to do this I've had to do this previously, for in some very, in situations of incest in for the most part, we need a trigger warning on this. But, you know, there you have an individual that is a minor, or, or for some reason not independent that is being abused in what is supposed to be their safe space. And then that person, the abuser can be like, Oh, look, I'm helping you get better. And they're actually not safe. So there's some things and if the person you're treating is a minor, that adult has access to their records. And so I've worked in places not I don't know how to do with an EMR but I've worked in places where we have our chart that we write down the official record and sticky notes, which are the things that will not get put in the official record. But we need to have written down so people know it. And we've had to do that in situations where the patient wasn't safe. We all knew the patient wasn't safe. was being worked on to get them safe, but they were not yet safe. And you had to make sure there was nothing in their records that was going to make them more unsafe. I don't know how to do it as an EMR, if someone has a clever way to do that, that'd be great. Or we go back to EMR plus paper charts.   20:18 Even to to add to your point, Abby, if we're looking now at possible, you know, jurisdiction, you know, lead legal their jurisdiction or subpoena of documentation, you know, after having intervened for someone who may have had to make a choice that their state did not condone? Yeah, no, I, I'm completely, you know, on guard against that now, and that those are things that I'm thinking about now and thinking about, well, what would my profession do? Would we back, you know, you know, efforts on Capitol Hill to advocate for, you know, someone who, who has lost their, their autonomy, or lost their ability to, to at least have a safer procedure, and we've had to intervene in that way. You know, I think about that now, and I, that makes me fearful that this is such a hot topic issue that, you know, we might not as an organization want to choose size, but we as professionals on the ground as pelvic health therapists, I don't think that we have that luxury and turning someone away. And so So yeah, I think more conversations like this need to be had so that we can form a unified front of at least, you know, pelvic health specialists that can really help with the the after effects of this.   21:38 And I think a big barrier to that legal aspect of it is, you know, what is our legal responsibility. And what happens, if we don't do XYZ is because a lot of the laws and a lot of these states, some of these trigger laws and other laws being that are being passed, the rules seem to be a bit murky. They're not clear. And so I agree, I think the APTA or the section on pelvic health needs to come out with clear guidelines as to what we as healthcare professionals, can and should do. But here's the other thing that I don't understand and maybe someone else can. What about HIPAA? Isn't that a thing? Where did the HIPAA laws come in to protect the privacy between the provider and the patient? And I don't know the answer that I'm not a lawyer, but we have protection through hip isn't that the point of a HIPAA HIPAA laws? I don't know what   22:44 you would think so. But unfortunately, one of the justices who shall not be named has decided that abortion does not fall under HIPAA, because it involves the life of another being in so I can only state what has been stated or restate. But yes, the those are the very things that I'm afraid we're up against as professionals.   23:12 Yeah, I think they're going to try to make us mandatory reporters. for it. I think they're gonna try to make all healthcare we are mandatory. For some things, the thing that's good for some things. Yeah, the   23:24 thing that bothers me about that is the where I'm in Illinois right now, Illinois is a designated, look, we're not, we're not going to infringe on people's right to health care. Just great. But some of the laws and I've lost track, I was trying to keep track of how many have are voting on or have already voted on laws that would have civil penalties, penalties of providers from other states, regardless of the Practice Act of that provider, to be able to have a civil lawsuit against that provider. So that's fun. And then we go back to what ABBY You had mentioned before we started recording about medicine, that that is considered an abort efficient, I have a really hard time with that word. But that is also used for other conditions that we see in our clinics for pain for function and things like that. And then where's our role?   24:33 Right, so does someone want to talk about these more specific on what those medications are and what they're for? So that people listening are like, Okay, well, what medications, you know, so do you want to kind of go into maybe what those medications are, what they're for and how they tie back into our profession. Because, you know, a lot of people will say, well, this isn't our lane. So we're trying to do these podcasts. so people understand it's very much within our lane.   25:03 Well, I yeah, it's just from a pharmacology standpoint, the one of the probably most popular well known drugs that's used for abortion is under the generic name of Cytotec misoprostol, and that's a drug that's not only only used for abortion, but if individual suffers a miscarriage is used to help with retained placenta and making sure that the uterus clears. What other people don't know is is also used for induction. So the same drug is used for three or four different purposes. It's also used for postpartum hemorrhage. So measle Postel, or Cytotec is a drug as pelvic health therapists we should be very familiar with. And we should be familiar with it. Not only you know, for, you know, this this topic, but it's also been a drug that's been linked with the uterus going into hyperstimulation. So actually putting someone at risk for bleeding too heavily. And all of this has a lot of implications on someone's mental health, who's suffered a miscarriage who's gone through an abortion that maybe was not safely performed, which I have had very close experience with someone who's been given misoprostol Cytotec, it didn't take well, she continued bleeding through the weekend, because she lived in a state where emergency physicians could opt out of knowing a board of medications. So as professionals, we do need to know, a board of procedures so that we can recognize when someone has been through an unsafe situation it is, it is our oath as metal as medical professionals to know those things, not to necessarily have a stance on those things that will prevent us from providing high quality and safe care.   26:52 Another one of the medications is methotrexate, and it's used to treat inflammatory bowel disease. And as public health specialists, we'd see people who have IBD, Crohn's and Colitis, who have had surgery who are in flareups who are being treated like that treated with that medication. And it is again used in in abortions. And when you're on that medication, you have to take pregnancy tests in order to still be able to get your prescription for that medication. And as a person who I myself have inflammatory bowel disease and have been on that medication before, I can tell you that you don't go on those medications lightly. It is you are counseled when you are of an age where you could possibly get pregnant, and taking those medications. And it's very serious to take them. And you also have to get to a certain stage of very serious disease in order to take that it's not the first line of defense. So if we start removing medications, or they start to be red flagged on EMRs, or org charts, and we become mandatory reporters for seeing that medication, God forbid, on someone's you know, they're when they're telling us what type of medications they're taking, that there would be an inquiry into that for for any reason is just it's it's horrifying. I mean, it's, we treat these patients and they trust us, and we want them to trust us. But as we get farther and farther down this rabbit hole of, of going after providers, pharmacists, people who help give them information to go to a different state, I just it is. Like I said before, the breadth and the depth of this decision, reverberates everywhere. And if if PTS think that they are in orthopedic clinics, that they are somehow immune from it, you're absolutely not. And for those clinics who have taken on or encourage one of their one of their therapists to take on women's health because it's now a buzz issue. It's really cool. You are now going to see that in your clinic. And you know, like Rebecca was saying before, you know any number of us who have really strong and long term relationships with patients who are pregnant who are in postpartum I have intervened and sent patients to the hospital on the phone with them because they have remnants of conception and they have a fever and someone's blowing them off and not letting them into the IDI and sending them home. And we we are seeing those patients, they have an ectopic they're, they're bleeding, is it normal, they're calling me they're not calling their OB they can't get their OB on the phone. They're texting me and saying what should I do? And they have that trust with me and what happens when they don't? And they're bleeding and they're not asking someone that question and they don't know where to go for help. And so I know I took this in a different direction and we talked about pharmacology, but I just thing that I have those patients whose lives I have saved by sending them to the emergency department, because they are sick, they have an infection, they are bleeding, they have an ectopic, it is not normal. And I don't know what happens when they no longer have that trust with us not not because we're not trustworthy, but because they're scared.   30:26 The heavy silence of all of us going   30:31 you know, it's, it's not wrong. And I think the like, it just keeps going through my head. It's just like, so what do we do? I mean, Karen, you mentioned like, it'd be great if somebody came out with a list of, of guidance for us. And I just, that just won't happen. Because there's different laws in different states, different practice acts in different states. And no one, you know, like you even if you talk to a lawyer, they're going to say, this would be the interpretation. But also, as of yet, there's no like case law, to give us any sort of any sort of guidance. So that was a lot of words to say, it's really hard. I can tell you in Illinois, like two or three weeks ago, I'd be like, like, I'm happy, I feel like Illinois is a pretty safe space. We have, we have elections for our governor this year. And I have never been so worried, so motivated to vote. And so motivated to to really make sure to talk to people about it's not just like this, this category or this category, it's like we really need to take into consideration the ramifications of what this will do, I think there was a lot of this probably won't affect me a whole lot. But I think I'm guessing I think a lot of us on this call maybe I think all of us on all of us on this call, have lived our lives with Roe v. Wade. And, as all of this is coming up, and just thinking about how it impacts so many people, and how our healthcare system is already doing not a good job of taking care of so many people, the fact that we would do this with no, no scientific, back ground, no support scientifically. Like I pulled up the ACOG statement, and, and they condemn this devastating decision. And I really, I was like, it gave me gave me goosebumps. And this was referred to in our art Association's statement. And it makes me sad that we didn't condemn it. Hope that's not too political. But I'm really sad that we didn't take a stronger stance to say, this is not good health care. And we need to do more. Again, and that's like, again, so many words, to say we're gonna have to make up our own minds, we're gonna have to know, our rules, our laws and what we're willing to do, and go through, so that we can provide the care that we know our patients deserve. And that's going to be really hard. Because, you know, if I talk to someone, and if I call Rebecca in Washington State, she's going to have something different than if I talk to Abby in New York. And you know, that so it'll be, it'll be really hard even to find that support. That support there's going to be so much support, I think, from this community, but that knowledge and that, that confidence, we have to pull together so we have to pull together with all the other providers, but also we're gonna have to sit down and figure this out to   33:59 the clarity. So it's, I think a practical step forward would be each state to get get, like, every state, come up with a thing. So pelvic health therapists in that state come up with what seems to work for them get a lovely healthcare lawyer to to work with them with it. And then we could have a clearinghouse of sorts of all of the state statements. I don't know that that needs to go through a particular organization. I I know that they're in the field of physical therapy, two thirds of PTS aren't members. And we need this information to be out there for every single person so that they know   34:44 that we'll have to be grassroots there's I don't think that there's going to be widespread Association support from anywhere. But that being said, I think it's a great idea.   34:58 What are we going to do about it? Hang on issues that are too divisive, you're absolutely right, individual entities are going to have to take this on and just put those resources out to therapists who need them need the legal support, need the need to know how and how to circumvent issues in their states. And, you know, like I said before, even how to just provide that emotional support, there's going to be needed for their, their, their patients, so, and that's okay, if the organizations that were part of are not willing to take a heavy stance, you know, even like last year, if you're not willing to take a heavy stance, on an issue where someone feels their autonomy, and their choice is being threatened, then it's okay, well, we'll take it from here. But, you know, that's, that's really where these grassroots efforts come from and abound, because there are a group of individuals who are willing to say, No, this is wrong. And I'm going to do something about this so that our future generations don't have to suffer.   36:02 Yeah, and I think, you know, we're really looking at the criminalization of health care.   36:09 That is not healthcare.   36:12 And we also know who this criminalization of healthcare is going to affect the most. And it's going to affect poor, marginalized people of color, it is not going to affect the wealthy white folks in any state, they'll be fine. So how do we, as physical therapist, deal with that? How do we, how do we get the trust of those communities who already don't trust health care, so now they're going to stay away even more, we already have the highest mortality, maternal mortality rates in the developed world, I can only imagine that will get worse because people, as we've all heard today are going to be afraid to seek health care. So where do we go from here as health care providers? I,   37:10 Karen, you're speaking something that's very near and dear to my heart, I act as if you had to take this on, I am very adamant that we can no longer choose to stay in our lane, we do not have that luxury. And I as a black female, you know, physical therapist, I don't have the luxury to ignore that because of the color of my skin, and not my doctor's degree, not my board certification and women's health, you know, not my faculty position, I when I walk into a hospital, and I either choose to give birth or have a procedure, I will be judged by none other than the color of my skin. That is what the data is telling me is that I am three times likely to have a very severe outcome. If I were to have a pregnancy that did not go as planned or or don't choose a procedure, you know, that affects the rest of my function in my health. And so given the data on this, you're absolutely right there, there is going to be very specific populations that are going to receive the most blowback from this. And as a pelvic health therapist, I had to go into the hospital to find them, because I knew that people of color and of marginalized backgrounds, were not going to find me in my clinic. And we're not going to pay necessarily private pay services to receive that care. But I needed to go where they were most likely to be and that was the hospital setting or in their home. And so, again, as a field of a very dispersed and you know, not very many of us at all, we're going to have to pivot into these areas that we were not necessarily comfortable in being if we're going to address the populations that are going to be most affected by the decisions our lawmakers are making for our bodies.   39:11 You know, there's something that I think about, often when I hear this type of conversation come up in, in sexual health and in in whenever I am speaking with one of my patients and talking about their menstruation history, and, and them not knowing how their body works from such a young age is I just wonder if we should be offering programs for young people like very young pre ministration you know, people with uteruses and their parents, and grandparents and online, online like little anonymous. Yep. nonnamous   39:51 for it's just   39:52 Yes. Yes, it's it's just, you know, Andrew Huberman talks a lot about having data Back to free content that scientific, that's factual. And I think about that a lot. And I think, to my mind, where I go with this, because I do think about the lifespan of a person, is that creating something that someone can access anonymously at any age, and then maybe creating something where it's offered at a school? You know, it's it's ministration health. And it doesn't have to be under the guise of, you know, this happened with Roe v. Wade, but this it could be menstruation, health, what is a person who menstruating what can you expect? What you know, and going through the lifespan with them, but offering them? You know, I think I think about this with my own children, as our pediatrician always asks the question of the visit, who is allowed to see under your clothes who is allowed to touch you? And it's like, you and my, I have a five year old. So it's Mom, when when when I go number two, a mom or dad when I go number two? And that's it. And you know, I think about that, and I think about how we can educate young people on a variety of things within this topic, and kind of include other stuff, too, that's normal, not normal, depending on their age. Absolutely, there   41:22 was what I was excited about in pelvic health. Before this was people like Frank to physician and his PhD students and postdocs are working on a series of research about how if we identify young girls that are starting their period, and having painful periods, treat them and educate them, then that they will not go on to have as much pelvic pain conditions and issues in the future. So we look at the early childhood events kind of thing, but also period pain. And How exciting would it be if we could get education to young girls about just how their bodies work. And to know that just because you all your aunties have horrible periods doesn't mean that you're stuck with this, just like maybe they just didn't know, let's help you out and constipation information and those basic health self care for preventative problems. So I was super excited about all that. And now it's like, oh, now we have to do it. Because in that we can do little pieces of information. So people have knowledge about their body, that's going to be a little bit of armor for them, that they're going to need and free and available in short, and you know, slide it past all the YouTube sensors. This is this is doable, but it's gonna take time money doing, but we can do it. Well, it sounds like, ladies,   42:52 we've got a lot of work to do. One other thing I wanted to touch upon. And we've said this a couple of times, but I think it's worth repeating again and again and again. And that's that expanding out to other providers. So it's expanding out, as Rebecca said, expanding out to our colleagues in acute care, meaning you can see someone right after a procedure right after birth right after a C section. And, and sadly, as we were saying, I think we they may start seeing more women, I'm not even set children under the age of 18. In these positions of force birth on a skeletally immature body. So the only place to reach these children would be maybe in that acute care setting. How what does the profession need to do in order to make that happen? And not not shy away from it, but give them the information that they need. Moving forward?   44:07 I was just gonna say that I've given birth in the hospital twice. Not at any time was I offered a physical therapist, or did a physical therapist come by and I am in New York City. I gave birth in New York City, planned Solarians because of my illnesses. And nobody came by I did get lactation nurses, any manner of people who were seeing me I was on their service. But that has been something that we needed anyway. We mean to have a pelvic health physio on the labor and delivery and on the maternity floors, who is coming by educating as to what they can start with what they can expect. When can they have an exam if they want to have one? Who is a trusted provider for them to have one. And we need to get the hospitals to expand acute care, physical therapy to labor and delivery and, and the maternity floors. As a routine, it's not something you should have to call for, it should be routine clearance for discharge the same way you have to watch the shaking baby video to get discharged.   45:27 I'm happy older than all of you. I don't have it either. But taking baby video is not something that even existed back in the day. But that makes sense. I mean, I once upon a time was a burn therapist, and I was on call at a regional Trauma Center. And you know, it's like you're needed your, your pager goes off, because that's how long ago it was. And you just came in, did your thing, went back home went back to bed. There is no reason other than lack of will, that PTS couldn't be doing that right now.   46:03 I'm now of the opinion where it's unethical to not offer physical or occupational therapy within 24 to 48 hours of someone who had no idea who did not have a planned delivery the way they expected it who has now and a massively long road to recovery. After a major abdominal surgery, I'm now of the opinion that is unethical for our medical systems to not offer that those rehabilitative services. And I've treated individuals who had a cesarean section but suffered a stillbirth. So the very thought of not providing services to someone who has any kind of procedure that's affecting, you know, their their their not only their pelvic health, but their mental function. That to me is now given the you know, these these, this recent decision on overturning Roe v Wade, is now now we're never, you know, either we're going to now pivot again as pelvic health therapists and start training our acute care colleagues, as we did with our orthopedic colleagues, as we've done with, you know, our neurology colleagues, whatever we've had to do as pelvic health therapists to bring attention to half of the population, you know, who are undergoing procedures, and they're not being informed on how to recover, we will have to start educating and kind of really grow beyond just the clinics and beyond what we can do in our community or community. But we are going to have to start educating our other colleagues in these other settings, we don't have a choice, we know too much, but we can't be everywhere. And not all of us can be in the hospital setting, we're going to have to train the individuals who are used to seeing anything that walks through the door and tell them get over to the obstetric unit. Okay, there's someone there waiting for you.   48:06 Yeah, I totally agree. I mean, when I think back I remember as a student working in acute care and how we had someone who's dedicated to the ICU, we had someone dedicated to the medical floor, we had somebody who was dedicated to the ortho floor, and most of the time they had their OCS, their, their, the one for for, for ICU care, the one for NeuroCare, or they have a specialty. And I think it is just remnants of the bygone era of it's natural, your body will heal kind of BS from the past. It's just remnants of that and it's just, we don't need the APTA to give us permission to do this, this is internal, this is I'm going into a hospital, and I'm presenting you with a program. And here is what this what you can build this visit for here's the ICD 10 code for this visit here is here is here are two people who are going to give you know, one seminar to all of your PT OTs, to you know, so that you are aware of what the possible complications and when to refer out and that kind of thing. And then here are two therapists who are acute care therapists who are going to also float to the maternity floor one of them every day, so that we can hit the we can get to these patients at that point, and that is just that's just people who present a program who have an idea, who get it in front of the board that that it is not permission from anybody else to do it. And, you know, it really it fires me up to to create a world in which you know, when you know people who are the heads of departments and chairs and you know on the boards of directors You know, being in big, big cities or small cities, when you know those people, you know, you can, your passion can fire them up. And if you can fire people up, and you can advocate for your patients and you can in that can spread, you can make that happen. And this is, you know, I feel radicalized by this, I mean, I'm burning my bra all over the place with this kind of thing. And I just feel like, if we can, if we can get to young people, and if we can get to day zero, of delivery, day one, post delivery, or post trauma, then then maybe we can make a dent, maybe we can, maybe we can try, maybe we can really make a go of this for these people. Because, like I keep feeling and saying I, we are not prepared for the volume.   50:54 If individuals are going to be forced to carry a pregnancy, that they may not want to turn because it's affecting their health, we're going to have to be prepared for this. Again, this is not an option really, for us as pelvic health therapists, because we know what's down the road, we've seen mothers who have or you know, or individuals who have suffered strokes or preeclampsia or seizures, or, you know, honestly, long term health issues because of what pregnancies have done to their body. And now if they want the choice to say, you know, I'm not ready, they don't have it anymore. So we really don't have a choice. We have to start expanding our services into these other settings, making our neurologic clinical specialists in the hospital, see people before they have a stroke before they have a seizure actually provide services that can help someone monitor their own signs and symptoms after they've had now a procedure or given birth or even had, you know, a stillbirth, unfortunately, because the doctor had to decide, well, yes, now we will perform the abortion because you know, your health is like on the cliff, I mean, we're going to be seeing these and we just have to prepare. And if it's not our organizations that are laying the foundations, we will, we'll take it from here,   52:15 we need to reach out across so many barriers, like athletic trainers, they're gonna see the young girls, they're gonna see their track stars that is not reds, it's pregnancy. And it could be a very short lived traumatic pregnancy, in girls that are just not develop. They're developed enough to get pregnant, they're not developed enough to carry a healthy baby to term. Kind of just makes me like. But Rebecca is right as we don't get to have an opinion on the right or wrongness of this, we have a problem ahead of us now, that that is happening already, as we speak, that people are going to need help. I love that we have more technology than my grandma did when she was fighting this battle. And we have YouTube and we have podcasts and we have ways to get information out. But we need to use every single one of them in our sports colleague or athletic trainer colleagues. They need to know the signs. Because they may be the ones that see it first.   53:21 Yeah. And Sarah as being the most recent new mother here. What kind of care did you get when you were in the hospital?   53:36 I was sitting here thinking about that. And I mean, I will say that the care I had while I was there, that I had an uncomplicated delivery in spite of a very large baby. And I was fortunate enough to leave the hospital without needing additional help. But I wasn't offered physio. Nobody really they're just really curious to make sure you're paying enough. And that's about it if you're the mom and my six week visit was actually telehealth and that was the last time I had contact with a health care professional regarding my own health so it is minimal even if you're a very fortunate white woman in a large metropolitan area and but I'm working now further north and with a pro bono clinic clinic and in an area where we do a lot of work with communities of color and I'm I'm like I honestly don't even know the hospitals up here yet. But I'm gonna I have so many post it notes of things that are gonna start happening and start inquiring because Rebecca like we need to get into the hospitals like if if I can Do that. And honestly, up until now, like my world and entropy was, and pre this decision was it, there's so many people out there who need help with pelvic issues in general, like we can do this forever. And we set our clinic up so that people who weren't doing well in the traditional health care system could find us and afford us. At least some people could, I realized that it wasn't in companies, encompassing everybody who could possibly need help, but we were doing trying to figure out another way. And so again, like, like, again, the offer of assistance I got was minimal. But also I didn't need much. And I was in a position where also, I knew I could, I could ask for it if I wanted it. And I could probably get it if I needed it. And I'm just thinking about, again, some of the communities I'm interacting with now, in some of my other roles and responsibilities, and I cannot wait to take a look and see, how can we get in there? How can we be on that floor? How can we? What What can we make, make happen like, because it needs to happen, these are these, this is the place where I'm scared to start seeing the stats,   56:21 wouldn't it be amazing if you can get the student clinic part of that somehow somehow and get, you know, young beyond that bias, but younger, most younger but but like the physicians the the in training the PTs and training the PAs the you know, and get like Rebecca had said, let's get let's get the team up to speed here, because there aren't enough pelvic health therapists already. And they're heavens, we need, we need to get everybody caught up.   56:58 And there's so much I was telling you that being around student health care, providing your future health care providers is really energizing and also really interesting. I mean, the ideas that come up with in the in the connections they make and and the proposals they make are just amazing. But two things that I've noticed that I think probably we run into in the real world, real world, outside school world as well, is one. The that's being able to have enough people and enough support to keep it sustainable. So you have this idea, you have the proposal, you made the proposal, how are we going to keep it going and finding the funding or the energy or the volunteers to keep it going. Things ebb and flow, you get a great proposal, you're like yes. And then I literally today was like, I wonder what's up with that one, because it was an idea for a clinic to help was basically for trans people to our tree transitioning and might not have the support that they need. And also I was reached, they come up here for women's health clinic. And I'm going to reach out to them now. Because this again, this decision changes that because it is a pro bono clinic that they would like to set this up in and before it was going to be much more more wellness. And now it could turn out to be essential health care. So that's one thing. But then the other thing is still the education, that in school, we're not taught about what everyone else can do. And I think again, figuring out a way to make sure that future physicians really know what physical therapists have to offer, especially in this space. Most people know that if their their shoulder, their rotator cuff repair, they should send them to pt. But really, we need to get in with OB GYN news, we need to get in with the pediatricians. And I don't want to say unfortunately, but in this regard, unfortunately, we're going to have to really make sure that they know what we're doing. And again, I'm already kind of trying to think like how can we make this just part of how we do health care.   59:20 So I think I'm following in your footsteps by going into education and by by being a part of our doctor of physical therapy programs. You know, I especially chose the program in Washington state not because you know, of just the the the opportunity to teach doctors or incoming doctors but it was also an opportunity to teach doctors of osteopathic medicine and occupational therapy therapists. It was you know, very intimate program and opportunity to make pelvic health or women's health or reproductive health apart of cardiopulmonary content, a part of neurology content, a part of our foundations a part of musculoskeletal and not a special elective course that we get two days of training on, I had the opportunity to literally insert our care, our specialized and unique care and every aspect of the curriculum, as it should be, because we are dealing with, you know, more or less issues that every therapist generalists or specialists should be equipped to handle. So in the wake of Roe v Wade, to me, this is an opportunity unlike any other for pelvic health therapists to really get into these educational spaces where incoming doctors are, you know, MDS or PA programs, or NP programs are our therapy practices, and start where students are most riled up and having those ideas so that they can go out and become each one of us, you know, go into hospitals and say no, to obstetric units being ignored, go into hospitals and give and services to physicians. You know, we need to create more innovators in our field and education is the way to do that.   1:01:12 I just wrote down check Indiana and Ohio, and then I wrote border clinics, because Because Illinois is a it's like a not a prohibition state. Having so many flashbacks, because Illinois, is, is currently dedicated to maintaining health care access for everyone. We have cities that are on the border. And I was thought of that when you were talking, Sarah, because you're up next to Wisconsin now. But we have we have the southern part of the state and the western part of the state. And those those border towns are going to have a higher influx than I will see in Chicago, maybe. But I would anticipate that they would,   1:01:56 you know, and again, this is where laws are murky. Every state is different. It's I mean, it's a shitshow. For lack of better way of putting it I don't think there's any other way to put it at this point. Because that's kind of what what we're dealing with because no one's prepared, period. So as we wrap things up, I'll go around to each of you. And just kind of what do you want the listeners to take away? Go ahead, Sandy,   1:02:33 this is this is frustrating and new, and we're not going to abandon you. We're gonna figure it out and be there to help.   1:02:41 I would say that our clinics are still safe, it is still a safe place for you to open up and tell us what you wouldn't tell anybody else. It's still safe with us. And we still have you as an entire person with all of your history. We are still treating you based on what you are dealing with and not. We will not be dictated by anybody else. Our care won't be mandated or dictated by anybody. Sarah, go ahead.   1:03:22 What I would say is I would echo your safe. If you need help, there is help. And I'm sorry, that that this just made it harder than it already was. And I would say to healthcare providers, please let remember, let us remember why we're doing what we're doing. And, you know, we do need to stand up, we do need to continue to provide the best care for our patients. Because to be honest, I've been thinking like, I think it's a legal question. It's a professional question. But ultimately, if we can't give the best care possible, I'm not sure I should do this.   1:04:01 Ahead, Rebecca,   1:04:02 for our health care providers, in the wake of Roe v. Wade, being overturned, wherever we are, you know, as an organization or on our stance, if we believed in the autonomy of an individual to know all of the information before making a decision, then we still believe in the autonomy of an individual to know all of the information that is best for their body. And that is the oath that's the that's the that's the promise that we've made as professionals to people that we're serving, and to the people that we're serving to those who are there listening to this. You have safe spaces with providers that you trust and we're going to continue to educate one another, our field and also you we're going to put together resources that really bring During this education to your families so that you don't have to feel like you're in the dark and you're alone. This is not something that is per individual or per person. This affects everyone. And we're dedicated to advocating for you.   1:05:18 Perfect, and on that we will wrap things up. Thank you ladies so much for a really candid and robust discussion. I feel like there are lots to do. I think we've got some, some great ideas here. And perhaps with some help and some grassroots movements, we can turn them into a reality. So thank you to Rebecca to Sarah to Abby and to Sandy, for taking the time out of your schedules because I know we're all busy to talk about this very important topic. So thank you all so so much, and everyone thanks so much for listening, have a great couple of days and stay healthy, wealthy and smart.   1:06:03 Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy smart.com And don't forget to follow us on social media    

Bob interviews Sarah Haag on Urinary Incontinence. Sarah Haag is a physical therapist and co-owner of Entropy Physiotherapy & Wellness in Chicago, Illinois. Her area of interest is in treating the spine and pelvis, with a specialization in women's and men's health. In 2008, Sarah received her Doctorate of Physical Therapy and Master of Science degree in Women's Health from Rosalind Franklin University and was awarded a board certification as a Women's Health Clinical Specialist in 2009. Sarah has completed a Certification in Mechanical Diagnosis Therapy from the McKenzie Institute and is a Registered Yoga Teacher. She is passionate about learning more about the human body in order to provide efficient and compassionate care as she helps patients return to optimal functioning. Sarah Haag's Website: https://entropy.physio/ Sarah's Twitter: @SarahHaggPT Find A Therapist Website: https://aptaapps.apta.org//APTAPTDirectory/FindAPTDirectory.aspx Interested in learning more about the products mentioned in today's video: 1) Understanding and Treating Incontinence Book: https://amzn.to/3vutyda

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!

How to rapidly reverse your lower back pain (or avoid it) without surgery! Dr. Ron Donelson is a board-certified orthopedic surgeon who specialized in non-operative spine care for 20 years, first in private practice and then at the Institute for Spine Care at the State University of New York in Syracuse. He was granted the Diploma in Mechanical Diagnosis & Therapy and attained a Master of Science degree at Dartmouth Medical School’s Center for Evaluative Clinical Sciences. He is the Founder and President of SelfCare First, a consulting, publishing, and low back pain disease management company. His numerous research publications have focused on the assessment, classification, and non-operative treatment of neck and low back pain. He has written two books: the widely acclaimed “Rapidly Reversible Low Back Pain” and the recently published “Solving the Mystery”, written for individuals struggling with back or neck pain. The #1 Personal Leadership Podcast For Tales & Tactics To Thrive! Watch Adam's "Awaken Your Alpha" TEDx Talk here: www.bit.ly/TEDxALW This quest takes us across the globe to interview the world's most successful minds and share our own insights along the way. As we continue to learn and implement the “Hacks” to life, we share the best through the podcasts and in the Facebook community "Awaken Your Alpha Network" Search & Join us in the pursuit of high performance. The podcast also has a bestselling book! TALES & TACTICS TO THRIVE www.AYAlpha.com/book Get all the resources from each shows spotlighted guest, get your support and your questions answered. Connect across social media @AwakenYourAlpha @AdamLewisWalker to join the conversation.

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag on the show to discuss pelvic health for the non-pelvic health PT.  Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health.  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.   In this episode, we discuss: -Intake questionnaires to screen the pelvic floor for patients with low back pain -Pelvic health red flags -How to address pelvic floor health with a conservative population -Assessing the pelvic floor muscles without doing an internal exam -And so much more!   Resources: Oswestry Low Back Pain Disability Questionnaire: http://www.rehab.msu.edu/_files/_docs/oswestry_low_back_disability.pdf Sarah Haag Twitter Entropy Physio Website Home Health Section Urinary Incontinence Toolkit   For more information on Sarah: 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: Karen Litzy:                   00:01                Sarah, I was going to say doctor Sarah, hey, it just feels weird because we've known each other forever. But Sarah, thank you so much for coming on the podcast to talk about pelvic health for the non-pelvic health PT. So there are a lot of physical therapists who I think are interested in pelvic health, but maybe they don't want to like dive in literally and figuratively. So what we're going to do today is talk about how we as physical therapists can treat people with pelvic conditions, with pelvic issues without necessarily doing internal work. What are the functions of the pelvis, really important for bowel and bladder health, right? Sarah Haag:                  00:49                I mean, it is very important for survival, sex, very important for quality of life and propagation of the species. So these are all things that matter. But also when people come in with low back pain, when people come in with hip pain, I always find it very interesting that people say, but I don't do the pelvis. You know, the pelvic floor is only a musculoskeletal structure. We're not trained in most programs to palpate or to touch. It's just skeletal muscle. That's all we're assessing for really as pelvic floor PT’s. So I just think it's interesting. It's like a blurry void when you're looking at a body diagram.  Oh, there's your knee. So it's really important I think to understand what's there and you don't have to go there, but you have to know what's there and know that some people need help there and help them find the help. Karen Litzy:                   01:34                So if someone, let's take this person that has low back pain because that's a diagnosis that we can all agree that we see on a regular basis. So what are a couple of questions you can ask during your initial evaluation? Sarah Haag:                                          So the subjective part of the initial evaluation that perhaps a lot of people are missing or that can take in that pelvic area. There's a couple of ways that you can kind of like cheat your way in where you don't even have to think about what to ask to begin with. If you have a red flag questionnaire, there is a bowel and bladder question on there. So, it’s really interesting because people will sometimes circle yes on those and then never discuss it. Like, wait a second, we asked the question, they said yes, it's a thing. Sarah Haag:                  02:22                So there's your in, it was like, I noticed you, you marked yes on the bowel and bladder changes. Can you tell me a little bit more about that? Most of the time it is not truly a red flag. Most of the time it is not a sign they need to be referred to a physician.  Most of the time it's like no one's ever asked me that. Yeah. Stuff is different. There's your in. And then also if you use the classic Oswestry. So it was modified I think in 2001 or 2002 to take off a sex questionnaire. The second question of the questionnaire and it was revalidated and all of those things, but if you use the original, it's pretty awesome because now they're like, Huh, nobody's asked me about sex. And then you'd be like, ah, I see that this is an issue. Sarah Haag:                  03:06                One of my favorite Twitter stories is I get a direct message from someone asking me about a patient who was having pain with intercourse and I was like, thanks for reaching out. Absolutely. Can you tell me more about when they're having trouble and where it hurts? Would you like to know where it hurt their knees in one particular position? And I said, fantastic. You can help with that. So, so it's not always, it might be a sex problem, but it's not necessarily that problem. So we have to not be shy about asking those. Low back pain is the most expensive health care problem we have in terms of multibillion dollar, probably millions and millions worldwide. And so of course addressing back pain, we're still working on the best way to do that. Sarah Haag:                  03:52                But there’s a high prevalence of urinary incontinence and people who have low back pain. So if you're seeing people who have low back pain and after, if anyone else went to the pregnancy talk this morning, after vaginal deliveries, the prevalence of incontinence goes ways up, goes way up. So if you're seeing someone with back pain, if someone has had babies, all you can eat what you can do. So we were like, well I see this in your history cause that's pertinent history for back pain. Correct. And then it's like, Hey, I noticed this, any issues with this? And here's the reason I'm asking because you can't just go, do you pee your pants? Because people like, do I smell like what happened? Like, so if you're just like, you know, there is a really high prevalence and the nerves in your back go to your pelvis and all of these things. Sarah Haag:                  04:32                So I'd be really curious to know are you having any issues in this area? Cause there's help if you are. And then kind of go from there. Karen Litzy:                                           And I want to backtrack for just a second. When you were talking about red flags and said some are truly red flags and some aren't. So just so that we're all on the same page, what would be those truly red flags? Sarah Haag:                                          Truly in the pelvic world or in the entire rest of your body world is any unintentional weight loss or weight gain, 10 or 15 pounds over a short period of time. Also like fever, like temperature issues, loss of appetite when you have those other constitutional symptoms that go along with it. So just having some quirkiness with your bowel and bladder, it's really no reason to panic. But if you have also a fever and also a recent traumatic event, no, no, we want to just make sure everything's okay. Sarah Haag:                  05:26                And the cool thing is that if you go to the doctor, it's like you don't have a UTI. Everything else is looking fine. Awesome. Then I can help with that. But the red flags, there's been a couple of great papers that have come out where it's like, it's not like if you have pain at night, freak out. No, no. If you have pain at night but also a sudden bowel and bladder change and also, okay, now we need to check in for it. But don't panic if it’s the only one. Karen Litzy:                                           And now let's say you're using these questionnaires and someone puts on bowel, bladder or someone circles sex as something that they're having difficulty with. And I love this question because this was something that was brought up last year at CSM. So there was a physical therapist there who said, well, I live in the south and these are not easy questions to ask because people are more conservative or they don't want to talk openly about their bowel and bladder issues or about sex with their partners. Karen Litzy:                   06:28                And so what do you say to those people? Those therapists that, are dealing with a population that's maybe much more conservative and they're not sure how to approach those subject matters. Sarah Haag:                                          I always say just always with kindness and with a good intention and with a good explanation. So you can't not do it because it's awkward for you. You should be asking for a medical reason, right? So quality of life is in our wheelhouse, right? Like we're doing all sorts of quality of life questionnaires. Pee in your pants is a huge detriment for your quality of life in many cases, not being able to have sex can impact your relationship with your partner, your feelings of ability to even have a partner, having babies. All of these things that end up being huge stresses, which is gonna make a lot of other things not as good either. Sarah Haag:                  07:28                Just start simple if you're asking questions. So if someone comes in with like straight forward knee pain, I'm like, how sex, no, that's not how, that's not where we go with that. But if someone's coming in with low back or pelvic issues, the way I usually approach it is to bring it up anatomically. So this is the anatomy. This is what we're doing. These are where the muscles go. Most people don't think about them. And when they're, if they're having issues like incontinence or have had babies, those pelvic floor muscles are muscles. Like everything else. We're going to work in PT. So I'm going to ask you some questions and I try to do it in a spot where you have some privacy. I know some PT places you're like in the middle of a gym. Sarah Haag:                  08:06                If you can find a quiet corner, do everything you can to put them at ease. But just to be like this is why I'm asking. And if you can see that resistance be like all right, like it's not necessarily the number one priority for this treatment anyway, but if those things happen to be issues there is help, it can get better and you just let me know if you have any questions. Cause not everybody wants to talk about it and it's not my job to convince you to deal with it. It's my job to help you if you want help. Karen Litzy:                                           And if you're a physical therapist that isn't specializing in pelvic health, it's a little bit different. Cause if you're specializing in pelvic health and people are going to you because you specialize in pelvic health it’s way easier, you know, these questions are going to come up.  But for those of us who don't specialize in pelvic health, then those questions can be a little bit more sensitive. So I just want you to make that distinction there for people. Sarah Haag:                  08:48                Yeah. And also if you're going to ask if you're going to take that step and be like, all right, I'm going to ask about the incontinence. I mean cause sometimes you're in situations where it is an obvious issue. Other times it's like, well, based on their history they're actually at risk for it. Then you can talk prevention, which has always been kind of fun. But just if they give you some information, especially if you got up the guts to ask them, then please, please do something with it. Don't just be like, oh yeah, so great incontinence noted in the chart. I'll put it on the diagnosis list, like how the plan and there are some things you can do without doing a pelvic floor exam that can make amazing changes. Karen Litzy:                   09:49                How can you evaluate pelvic floor muscles without having to go internally? I think that's a question everybody wants to know. Sarah Haag:                                          Great question. I'll be honest, some people don't want you to touch him there like full stop. And so I will actually give people, I would say it's kind of like a choose your own adventure. So we can actually, we can all check our own pelvic floor muscles right here. And I would basically talk you through it. You would tell me what you felt. I keep an eye on everything else to see what else you were doing. But it would be very honest that my assessment is going to be, I believe you, it seems you're doing it correctly. Right? But I have to believe you, but you can actually palpate externally. As a clinician you can actually do it and you can do it in sidelying. Sarah Haag:                  10:33                You can do it in hooklying and some people will do it in prone. I'm not a super big fan cause I can't see their faces. And also it can be kind of a vulnerable position. Basically if you just palpate, if you find the ischial tuberosity, you know about where the anal sphincters are. Okay. There's normal human variation. So I always say move slow and make sure you're asking for feedback. But you know, mid line is where the sphincters are going to be. We're not going midline. So you just kind of find that ischial tuberosity and palpate your way around to the medial part of it. And that's where the pelvic floor attaches. So then you can kind of talk them through, like I'd like you to squeeze and there's a bunch of different cues. Sarah Haag:                  11:22                One of the most common cues, especially for the back end, is to like squeeze. Like you don't want to pass gas and that's awesome. But if you're a main problem with urinary incontinence, that's the back side, back side, not the front side. So how do we get it up there? So another cue that has been found to be very helpful, it's only been studied in men, but it is, shorten your penis. But what's interesting is ladies, I know we don't have them, right? Imagine that feeling, right? So like just imagine like pulling in, right? It totally changed where hopefully if this is a class, it would have asked where did you feel it? But like it, it changes it from the back and biases it towards the front of it. So find a cue that gets them to go, oh my God, I felt something. Sarah Haag:                  12:07                You're like, awesome. So if you're doing a Kegel and like this happens, you're probably not doing it right. If that's happening, you're probably not doing right. But if like I'm Kegeling now and then I let go, you shouldn't have seen me get taller or tensor or breathe funny. It should be very sneaky. So as you're palpating on the medial side of the ischial tuberosities your feeling for those muscles to contract. So it's kind of like a gentle bulge and you can totally feel this on yourself here if you're comfy or somewhere else. But when you feel it, it's almost like when you're feeling like if you have your biceps slightly bent and you kind of like contract and you feel at tensioning and like a little bit of a bulge, that's what you're feeling for. Sarah Haag:                  12:51                Okay but it can always be tricky cause I use the word bulge. Some people will have people push down. So we should also be able to like relax your pelvic floor and push down, like having a bowel movement. That shouldn't happen when you're trying to contract. So like when I say bulge, you should feel like a gathering of the muscle. That's what you're feeling. If you feel your fingers get pushed down in a way they're doing the opposite of a contraction. So there they're relaxing.  It would kind of depend on what they were doing and the cues you were giving. So it could just be like, I'm pushing down like doing a Valsalva. But it is basically a lengthening into the pelvic floor. I don't know if it's always a relaxation, so to speak. Karen Litzy:                   13:33                It's kind of lengthening. And what is the difference between that Valsalva or lengthening and that small bulge? Like why is that significant? Sarah Haag:                                          When you feel it, you'll know it's significant because if they're pushing down in a way that's not a contraction. So if you're going for strengthening or more closure to hold things in, yeah, you want that kind of like tensioning and bulge. But if you're actually the problems, constipation, I can't get things out, you want them to be able to relax and link them. Karen Litzy:                                           Got It. Okay. All right. So now we know how we can kind of feel our pelvic floor muscles without having to do an internal exam. So once you figure out, and kind of what you said sort of leads right into the next question is if you have someone that's coming in with incontinence and you are looking for that sort of tightening or gathering up of the muscle, which I think that's a nice cue for people to understand because bulge can sometimes be a little confusing for people, but I liked the cue you're feeling the gathering of that musculature. Karen Litzy:                   14:45                Is that something that you are then going to add into a home exercise program or like once you find that the pelvic floor muscles working or it's not working, what next? What do you do? Sarah Haag:                                          Well, so I'll be honest. It's always I like him and people are brave enough and the patients were brave enough to be like, sure you can have a feel like let's figure this muscle thing out. I usually try it in a normal active kid in a normal setting. So not a public one. No pelvic settings are normal too. But in like just a normal like say outpatient therapy, be it or orthopedics or neuro, I would actually have them ask more questions about incontinence before even checking the pelvic floor muscles. Because the different types of incontinence are going to kind of tell you a little bit more about what you should do. Sarah Haag:                  15:35                So some people have incontinence when they tried to go from sit to stand or when they cough or when they go running. So I want to know a little bit more about when is it happening because if it's only ever when you're putting your key in the front door or when you're running into the bathroom, that's more urgent continence. Would pelvic floor muscle exercises help? Maybe, but also probably looking at their overall bladder health, which is where a voiding log would come in very handy. And actually a shout out to the home health section and they have an incontinence urinary incontinence toolkit. It's free for members for sure, but I think it might be free for everyone. Sarah Haag:                  16:15                So it's a pdf that actually talks you through the different types of incontinence because the most common form of incontinence urge incontinence, which is you're an urge incontinence is proceeded by a strong urge to go. So this is one of those things where, so there's a bathroom at the end of the hall. So if you're like, I'm totally fine, but then your eyes wander, you're like, oh, I could go and I didn't have to go. And then I would get up to go and I got to the bathroom and all of a sudden it's like, oh, where did that come from? Like all of a sudden it felt like your kidneys did a big dump, but they don't, that's not how kidneys work. Sarah Haag:                  16:59                It's just how it feels to you. So what that really is, is your detrusor muscle kind of going, I'm so excited. I imagine a puppy, like have you ever like gone to let a puppy out the door? Like, so they're like, hey, I want to go out and you get up and you make a move for that door. And they're like so excited. Your bladder is like that sometimes. So that's more of a behavioral thing because what would you do with the puppy who's now like, wait, every time I do this, she lets me out. Pretty soon you're letting that puppy out every 10 minutes because yeah, because that's what the puppy trains you to do. So that's kind of more of a behavioral thing. And so that's proceeded by a strong urge. So it's not just when you're going to the bathroom, but if you get a strong, unexpected urge and leak, and that's usually a lot of people also experience some urgency and frequency. Karen Litzy:                                           So if you feel like you're not getting to the bathroom in time, what would be a really logical plan to that? Sarah Haag:                  17:52                You'd go more often, you're like, Ooh, maybe I need to not wait so long. But the thing is that then you're training yourself to go more often, your bladder is perfectly capable of holding more that kind of sensitivity and those signals you're interpreting or like, ah, no, I should go now. And then pretty soon you're that person who can't make it through a movie. You're that person who can't make it past a bathroom without needing to go. And you're the person that no one wants to go on a road trip with because you're stopping every like hour on the hour and every rest stop. But now is that because your brain is interpreting this as such? I know that there's a physical manifestation obviously, but is that like have you trained your brain and to feel that way to interpret that as such? I would say yes because most of the time, even if it wasn't intentional, like it's kind of like a slippery slope. It's like I almost didn't make it that one time. I'm going to plan ahead. And then what starts to happen, especially if you're like, all right, Sarah Haag:                  18:54                your bladder is filling up. You kind of feel like you need to go and you go to the bathroom and it came out and it's like, all right, so that was nice and normal. But then imagine that time where you're like, hold on, I almost didn't make it, but you were stretched this much. You're going to start going when the bladder stretches this much. And then pretty soon if you let it so you're like, Ooh, now I'm going down here. Now I need to go sooner. And this is one way you can tell this is happening. And it can happen sometimes without ending up with a diagnosis of urgency, frequency or incontinence. But where you get to the bathroom and you feel like you've got a goal, but then nothing happened. Goals, like it's the smallest tinkle and you're like, I thought it wasn't gonna make it, but that's ah, that's all that's in there. And so that was like big urge little output. That's kind of a mismatch. And that'll happen sometimes. Sarah Haag:                  19:48                But like if you're paying less than that, that's not much more than your poster board then a nice healthy post void residual. So you don't have to empty at that point if you're bladder’s saying, empty me now. And that's all that's in there. Yeah. So it's kind of like you're the sensitivity of your bladder has turned way up. Just like how we would compare that to the pain. So the sensitivity is turned way up so that it takes less of a stimulus in the bladder itself to trigger that feeling of you have to go, even though the bladder is barely full. Sarah Haag:                                          And there's actually some interesting conversations with urgency and frequency in that feeling of extreme urge, can that be considered a pain? And so it's kind of interesting conversation because there is normal, there is a normal sensitivity of normal urge, but when that urge becomes pathological, yeah. Sarah Haag:                  20:47                Too bothersome. Does that crossover into it? Distressing emotional experience? I would think so. Like can you imagine if you're like on a train or something like that and you have to really, really, you have, you're having that urge. I mean, that's very distressing dressing. That's very distressing. That's like you're suffering. So if you have someone like that what do we have them do? So they keep a diary, which you can get on the home health section and we'll have a link to that in the show notes. You basically ask them to keep track of things for a couple of days. I tend to keep it simple with what are you drinking and when and when, when are you going to the bathroom? If people are willing to measure, that's the best, but not many people are willing to measure. Sarah Haag:                  21:37                So what I try to have them do is to kind of come up with their own plan. And I tell them this is not an exact science because you're not measuring, but that's okay because if you have a strong urge, which is kind of a lot, but you have like a little tinkle, that's kind of a mismatch. If that only happens after your third Mimosa, okay, that might actually be like a normal bladder thing. Do you know what I mean? So we kind of look at things that they're bringing in that may or may not be irritating to them. We look at are they getting enough fluid and bladder loves, loves water. But the first thing most people cut out if they're having urgency, frequency or incontinence is water is they cut out their water. It'll almost always backfires. Sarah Haag:                  22:19                So don't do that anyone watching. It also makes you constipated, which you can increase your urgency and frequency. So, so yeah, so surprise. Everything needs to work well to work well. Okay. But yeah, so you kind of look at that and I just look for patterns and then I have people try to change one thing at a time. If all you're drinking his coffee all day, but actually you have good data, good parts of your day and bad parts of the day. Is it the coffee? Because if you're drinking coffee all day, you're probably not going to be very nice to me if I say, how about you stopped drinking coffee? Um, emotional response up. So you just kind of look at it. It's like, Oh, when does this happen? What do we need to change? And it can really help you narrow down. Is it really urge incontinence? Is it actually just frequency and they're not leaking like they thought they were or you know, is this primarily a stress incontinence issue? Karen Litzy:                                           Well, so it sounds to me like there's not a lot of hands on work there. Sarah Haag:                                          No, no, it's more behavioral. Susan:                          23:27                Do you ever use pelvic tilting to get the posterior versus anterior pelvic floor? Sarah Haag:                                          So that's a neat work with from Paul Hodges Group. So however you're sitting, most of us are Slouchy, just do a pelvic floor contraction, however your brain tells you to do that, do it and just feel where you feel it. But then if you get yourself in a situation where you like get more of that Lumbar Lordosis, and so like you stick your tail out, you get more lumber lordosis and then you do the exact same thing. So you're not changing your cue. For most people it's cuts to the front. And it's kind of neat because one of the things, one of my pet peeves is when we were talking about earlier is my pelvic floor therapist get tunnel vision and are just doing pelvic floor exercises, but not reintegrating it into how they're, they're using their body. Sarah Haag:                  24:18                So if you have a runner who's a chronic but Tucker and she's leaking out of the front, obviously, how would it feel if you like got those glutes back a little bit? Because you can't run and Kegel at the same time. You can't, you can try. It's not going to go well. And certainly not for like a 5K and let alone not a marathon. So changing how that is biased because most of us don't think about the pelvic floor until you have a problem, right? But they've been working, right? They've been doing their thing. You're using them when you walk up those stairs you're using them when you're getting up off the floor. So they do something, the key goal is like your bicep curl. You want a stronger bicep, you're going to do some curls, you want a stronger pelvic floor, you're going to have to do some pelvic floor exercises. Sarah Haag:                  25:07                But that's not your management plan. You kind of want to, someone said it yesterday, kind of like the core muscles are there like automatic, like when you get ready to do something you don't think, okay transversus were good. Like it just all happens and you want to kind of get the pelvic floor back into that system and make sure it's strong enough and coordinated enough to do its part. So you don't think about it. Dave:                            25:37                So along those lines then, would you say that if somebody is more lordotic, they're more likely to engage the anterior floor and then flat back more of the posterior floor? Sarah Haag:                  25:47                That tends to be what they're finding on like EMG studies and what I will see clinically with people if they do a ginormous buttock. It’s really interesting if you're like, how's your breathing when you do that and, and how good is your squat, let's say when you do that. And it's like, Eh, it is what it is. I'm like, okay, so what if we do kind of take it into where some people, especially if they've been told by other practitioners to like watch your Lordosis, it's kind of huge. Which isn't really a thing. But you know, they kind of, they're kind of like going in there, they're like, I'm so scared but it kind of feels good and then you have them do that movement or try that exercise. Usually they're like, that was way easier than I thought it was going to be. Sarah Haag:                  26:30                But again, if it's not working, then we try something else cause everyone's anatomy is different. Sometimes if they have a lumbar issue, getting into the ideal position for their pelvic floor, may or may not be easy for them, at least at first. But I think you need to play around with how it feels and how it's functioning as opposed to, I mean, I've been guilty of it in my career of like, ah, you need more or less of what you're doing with your spine and were just different. So it's where it works best is where it should be. Jamie:                          27:03                So for a lot of the outpatient conditions and orthopedic setting, there's still an emphasis on giving some kind of qualitative documentation to the muscle contraction, whether it's a manual muscle test or something like that for payment purposes. So what are some strategies or tips for clinicians to be able to take that palpation externally and then relate that into their strengthening documentation? Sarah Haag:                  27:29                So if you're just checking externally, like just palpating outside, it's like a plus minus like, Yup, I felt it. Uh, they couldn't find it. So kind of plus minus, cause you can't give it more than that. We also have to remember, so when I write about pelvic floor strength in my documentation, I have a number I can put and you can grade it. You have to do that internally, which is why if you're like, ah, we need to know more, refer him to a friend or go to the training. But I usually give a lot more information. So like, all right, so they, you know, they had like a three out of four, three out of five squeeze. The relaxation was not very coordinated and kind of slow, but then their subsequent contractions were five out of five. Sarah Haag:                  28:09                All right. Do you know what I mean? We have to, because of payment and insurance and all of those things, we have to write something down. So what I do is I write down what I find and I'm happy to talk about it. So if you want to deny it, I can talk vagina all day with you. And I have, and their questions usually get shorter and shorter. Um, because really they're asking for information that isn't necessarily the most helpful. So if you're checking an externally plus minus, but also I've had people who five out of five but still incontinent, Sarah Haag:                  28:41                So then they're like, well they're not weak but you put down, you're going to do strengthening. I'm like, well yeah, because it's more of a strengthening, not just a strengthening with a functional goal attached to that, if that makes sense. So sometimes it's more words, but don't be shy about one. Well, first of all, please be honest, be as accurate as you can be, but also don't be shy about doing the best care and be willing to stand up for it. If it gets denied. It's not cause you gave crappy care likely. I mean, do you know what I mean? I'm like, I dunno how long you practice, hopefully. Good. But if you get denied, it's not necessarily key because you gave bad care or even did a bad note. It's because they decided they weren't going to pay based on something. Hopefully logical that you can talk about. You can always appeal. So don't let payments scare you away from giving the best care. Sarah Haag:                  29:36                Sorry. Another soapbox of mine.  So that was urge incontinence. Stress Incontinence. Karen Litzy:                                           So let's talk about that because I think that gets the more airtime, so to speak. So that's when you see the crossfitters are the weightlifters or there's a great gymnast pitcher yesterday going backwards where you there backwards over the pommel horse, not the pommel horse. It's the worse just a horse. A spurt. Like it was, yeah. And you're just like, that could be photo shopped, but also it probably isn't. Yeah. Or like we've all seen like the crossfit videos where women are peeing and then everyone high fives them because they worked so hard that they peed, which, you know, not normal. We know that that's been addressed by a lot of a pelvic health physical therapists. Karen Litzy:                   30:32                So I would like to know first I think we just gave the definition of stress incontinence, but I'll have you give the definition quickly. But then I'd like to go back to something that the question that Dave had asked about the positioning and how that works within weightlifting or within, you know, waited or loaded movements. But go ahead and give the definition of stress incontinence first. Sarah Haag:                                          So stress incontinence is basically when there's an increase in intrabdominal pressure that is greater than the closure of pressure of the urethra. And you have some sphincters as well as the pelvic floor helping keep all of that closed. But if you increase the pressure enough on the insides, and that's why you hear, and again, it's primarily women, but also a lot of men after prostate surgery, they cough and you get a spurt or you know, you jump and you feel it come out. Sarah Haag:                  31:21                Those are usually because the closer pressure has gone down or the intra abdominal pressure has gone up. Karen Litzy:                                           Okay, great. So now what does that look like? For the average physical therapist who's not a pelvic health therapist. And let's say they are seeing someone for hip pain and you ask them, are you ever incontinent? Or if they are, you know, heavy lifters are, they are adding load and they say, oh yeah, but that's normal. Or they have low back pain and they say, yeah, but that's normal. Everybody does it at my crossfit box or whatever at my gym. So how do you then, if you're not you, you are someone who's not a pelvic health therapist, how do you address that? Sarah Haag:                                          Well, first of all, what all of us should know while incontinence is super common, it is not normal. Sarah Haag:                  32:16                Not ever being dry is normal. So we need to get away from this idea that like, well, everyone's doing it. It's like does that make you want to do it? Like I feel like, no, I feel like no is the answer. So first of all, just, and sometimes they don't know that. Like, I know that in some like young girl gymnastic teams, like the color of their leotards are chosen to like, not show the pee because they're incontinent that young. Yeah. And I see a lot of women as adults sometimes before they've had babies sometimes after, right? So like what's the, what came first? But they've had lifelong issues with what's essentially public flourish. She's with incontinence, sometimes pain with intercourse, all of those things. Competitive gymnasts, competitive cheerleaders. Dancers tend to be probably the biggest, runners or another group. Sarah Haag:                  33:12                There's been some studies, there's one study and I cannot recall it. I mean, it's probably like 15 years old now. We're 100% of this division one female track team reported urinary symptoms. 100%. Like every girl. So common. Heck yeah. Normal. So many girls. Yeah. So the biggest thing if you're not a pelvic floor therapist is to check out their function. So if they can identify when they're having issues, it's when I get to this particular weight or it's when I get to mile 17. Okay. And I usually throw in, like if I ran 17 miles, I'm not really sure what my body would do. Like I dunno, but it still shouldn't leak. But if you can find out where that breakdown in the coordination in the endurance and the strength and whatever it is happens and look at what's happening there. Sarah Haag:                  34:04                Because if you can run 17 miles or you can lift 200 pounds without leaking, but then you do, you're not, you're not weak. Right? Like if you can do all of that, something's happening there to make this happen. Cause if you can lift 200 pounds in that league, something's working, it's just not still working when you try to live 210. Okay. So let, let's look at what's changing or number of repetitions. Right? That’s what you're looking at. Sarah Haag:                  34:52                So if you collapse your chest and which I would probably do after running 17 miles and I'm like this. And now what happens when I collapse what happens to my bottom half when I collapsed my shoulders? Well my butt just tucked. Cause I'm just trying to get through now. The funny thing is the breathing is also harder. So while I'm doing this as kind of a mechanism to keep going, it's harder to breathe because nothing's working diaphragm to have a full excursion, right? Yeah. So, so I like to look at if you're running fine for 17 miles, I want to see you at mile 16. I want to see what's changing over that mile. I want to see what you looked through my team. And can you, when you start to get to that point, can you make an effort to change something? Sarah Haag:                  35:32                Do you notice a change in your breathing when you're lifting 210 instead of 200 and kind of look at it from that way cause you're not going to kegel why you do that. What do you mean? Oh well say to like precontract and prime and all these things and, and that's fine, but it's like if we go back to the running, you're not kegeling and all that time your pelvic floor after like 30 seconds is like, dude, you don't want me to get that tired. Like it's going to be like, we're going to stop that now. So yeah. So the way I would approach that, if you're not me, yes and not going to do a vaginal exam, is you look at their performance. So if they said, I have knee pain when I do this, when I go from 200 to 210, they're my squat. Sarah Haag:                  36:13                How they do, they're looking at the mechanics. You would look at what's happening, what is different? Cause you know, the joint can do it, you know, the muscles can do it. What's changing. And you would address that. So it’s really no different if they can tell when they're leaking, you're just looking what can, what are the things that can change it? Usually the tail lift and looking at their breathing or two really easy ways to go about it. Karen Litzy:                                           Okay. All right. That's great. And, and, and that goes with that. Does that also work with, let's say instead of you're not a runner weightlifter, but you’re like a new mom or something like that and you're okay, but then by the end of the day after you've been maybe lifting the baby or you know, doing whatever you're doing it, it doesn't necessarily have to be sport related is what I'm saying. Sarah Haag:                  37:06                I think about like function, but definitely, I mean, you asked about, but no, just everyday if getting out of a chair makes you leak, that's, but then it's basically a squat. So you are, you're looking at the activity that they're having difficulty with and making small changes got in most cases. Karen Litzy:                                           So I think the biggest takeaway here for me is that not everything is solved by doing a kegel. Sarah Haag:                                          I think a lot of non pelvic health PT’s may have that, that misconception that if someone has incontinence, well Kegel time. Right? And that's all you gotta do. That's what most people do. If they go to the doctor and they mentioned it's like, ah, you know, that's pretty normal. It's not, it's common. And then they'll be like, do some kegels and, and a lot of women and men don't know how to do them. Sarah Haag:                  37:53                So then they're just, I'm squeezing stuff and it didn't work. And it's like, Oh, before we get too far, can we check and see how you're doing them? And I think that's kind of a beautiful segway. So let's say you have your new mom or you have your athlete or whatever and you are, you've tried some stuff, right? Cause none of this is life or death, right? I mean it's fine to try some things. So already not doing anything about it. So trying to change up a couple of things is perfectly within your purview, especially again, you're seeing them for hip or low back. It all, it's all together. You're good. But if it's not changing, if it's not getting better, if when you ask them, you know, can you contract your pelvic floor, what do you feel? They're like, I got no idea. Sarah Haag:                  38:33                And they're like, but please also don't touch me there. Or are you touching there and you're like, yeah, I don't feel anything either. And I've used all my cards but I don't know what to do. That's when you refer. Because just like any other things, somebody coming to see you as a physical therapist, you're going to do some things. And if those things are not working or they're getting worse, you're going to try something different. Or call the doctor or refer to a friend. Right? So if you change some things and you're like, I'm amazing, they're all better. Awesome. Do they need to go to pelvic floor therapy? I'd say no if their incontinence resolves or their pain resolves. But sometimes with especially we see it a lot more in I would say the more active athletic population is a pelvic floor that's more like this. Sarah Haag:                  39:19                So it's like tight and there's a hundred people call it hypertonic or high tone or short pelvic floor and all these things and basically in my brain, the way I categorize it is like you should be able to contract your pelvic floor and you should be able to let it go. And we can all get better at that. But if you're like, I'm here, how good is my contraction going to be? Because I'm not showing you my pelvic floor. Like it's not going to, it's going to taste like it's going to not move very much. But if you get them to relax more or they're like, oh, I didn't know that was there, that's better. Then you all of a sudden you have a good contraction. Karen Litzy:                                           How do they relax? Do you just say relax? Sarah Haag:                  40:01                Before somebody tells him to relax, the worst thing to do is be like, can you just relax? So I try to have them feel the difference between contracting and not contracting. Because what will happen and people use what the traps all the time is like. So like, ah, so much tension. All right. Again, telling you to relax your shoulders. Things I didn't think of that. But if you squeeze and let go like as a little bit of like, Oh, I feel that, oh, oh there's some more space there. So I start with that. Okay. The pelvic floor. But again, if they're like, I just don't know, that's something that is so easy to feel with a vaginal or rectal exam. So that's where it's like, ah, you're having some trouble. I would recommend, would you see my friend for one visit have this exam, they're checking out your muscles and just see if he can feel that relaxation and then come up with like cueing or a plan that works for them. Sarah Haag:                  40:54                Cause it's not just about like slacking everything out. It's really feeling that that relaxation, that lengthening of the muscles there and being intentional about it. You don't want to lie there would hope like maybe it'll let go at some point. Audience member:                               So you talked about kegeling and what about dosage or prescription and quality versus quantity and how you prescribe that to your patient. Sarah Haag:                                          There is no hard and fast rule as to like how many, how much. So that's where, again, I would have them do some and see how the coordination goes. Cause if they're otherwise neurologically intact and they're kind of getting it, how many do they need to do? Sarah Haag:                  41:57                I would say it's not unreasonable to go kind of basic strength and conditioning principles of, you know, like I know eight to 12 reps three times a day. That's an okay starting point. And actually, I don't know if you know this, so I'm writing a book on incontinence and the PT people have it, but it's the editor just asked me, she's like, well, since we don't have like a hard and fast number, do we, should we put that in there? And I said, I think we do. So that's a good starting point. Not everyone would be able to do that right off the bat, but also some people be able to do that and they're not getting better. So it's kind of like let's start here and see what happens. And then you can kind of titrate it up and down. If I do an exam on somebody and they can't contract for 10 seconds, they can only contract for five, I'm not going to have them contract for 10 seconds at home. I would probably honestly in that case, have them go, I need you to make sure you can feel the good contraction. So you actually also asked about quantity and quality. I want quality, because all of us can do 100 crappy ones. I'm not sure how much it would help. So really looking to be like, okay, so I feel that contraction and I'm breathing Sarah Haag:                  43:10                and I usually actually have stopped counting seconds. I've had people go by breath, so if you, let's do it. We're going to squeeze our pelvic floors and you're just going to keep squeezing as you breathe in and breathe out normally. Nothing, nothing fancy. And then keep squeezing while you breathe in and breathe out and let go. And what I hope you felt was a squeeze to start with maintaining the squeeze. Some people will feel kind of like a little, a little wave as they breathe, which is not unusual. But then when you stop the breathing and you let go, you should feel that let go. So if you didn't feel that, let go. I usually say that's one of two things without feeling right. I can't tell without feeling is that you got tired and you lost it or you forgot to let go. Sarah Haag:                  43:51                So that's okay. Have a wiggle reset and try again. Because if you're not feeling the contraction, what are you doing? Like you might as well take a walk because then you'll actually be using your pelvic floor. I like going with the breath because a lot of people like to hold their breath when they're like, they'll do like they'll just suck at it and it, you'll feel a lift, but it's just a vacuum. It's not really your muscles doing their thing. So by doing the breathing, if you breathe in and out twice nice and slow, it's 10 seconds. You don't have to count. So if I have you do four of those, you just have to like count on fingers, two breaths come and arrest for two breaths. So much easier to keep track of. And then people actually do them. Cause if I could tell them to do ten second holds, one, two, three, four, five, six, nine, done. And that's not really helpful either. So like the too slow breaths. Now you're breathing and don't have to count and you're going to stay honest. Audience member:       44:57                So trying to bring this into the neuro world for someone who's post stroke and has stress incontinence or they've had neural damage of some sort and have stress incontinence, Are there any PNF techniques where you can incorporate the pelvic floor to help with that? Sarah Haag:                                          I haven't had PNF stuff since college. And I'm old. So what I would say is, is if I'm recalling that they go through movement patterns and as you're doing those things, there are things will be happening on the pelvic floor. It seems to make sense. What specifically, I don't know, but if you're kind of working more with that tone in general, I've only had a couple of patients come see me like post CVA and feeling their pelvic floors is amazing because while it makes perfect sense that one side might be like hypertonic are nonfunctioning until you feel it. Sarah Haag:                  45:49                It's like, wow, that's so cool. Like once I totally normal springy, they can contract and relax the other side just like they're, they're hemiparetic arm. It's cool. With stuff like CVA or neurological involvement, you really want to make sure you're on board with the physicians and you know that bladder function is still intact because depending on where the stroke is and what exactly happened or where the spinal cord injury is, you don't want to mess around with screwing up the bladder or the kidneys. So if they're not going to the bathroom or they're only leaking during transfers, that could be stress incontinence or it could be overflow incontinence because their bladder is so distended with the effort. So that's something you would really want to make sure you talk with their nurse or their attending physician and make sure, so how are things working? Sarah Haag:                  46:38                Because the other thing we need to remember is a lot of things we're still working on people who have had neurological insults, right? So once you're like, okay, bladder is relaxing as it fills, contracting, as it empties, it's emptied fine. We're not worried about this being overflow incontinence. I would actually start to incorporate stuff like blow before you go. Where you're managing it the same way you would for someone not having a stroke, but half of that, the beam continent and actually going to the bathroom it seems, I can make it sound very simple, but I have a slide and of course that I teach where it has all the like the tracks up to the brain and all the tracks who, the spinal cord to the bladder. But we got the sphincters, we got the detrusor, all of this stuff just happens. Sarah Haag:                  47:25                And when I click the slide from this beautiful simple picture, it's just font about this big, explaining all of the complex things that are happening so far as we know. So again, as long as they're, bladder is functioning on that basic level where it knows when to empty and it can empty, I would treat him like a anyone else and not assume that it's just because of a high tone pelvic floor on that one side. That's the issue. But if you get that person and you do your PNF, please tell me what happens. And if it changes their incontinence, I would really like to know. Karen Litzy:                                           And when you're looking at the bladder function, that is something the physician is doing through an ultrasound, is that how that works? How did they do that? Sarah Haag:                                          They can do it through an ultrasound so that that they are, they can look mostly at like post void residual. Sarah Haag:                  48:12                But then also there's a test called neuro dynamics. And this is a test that involves, a catheter and there you're a threat. And then a probe and another orifice down there to help measure for intra abdominal pressure. And it's kind of a neat test. If someone wanted to do it on me for free, I would probably do it. But they're also looking at an EMG the whole time. So they start to fill up your bladder was sailing so you know how much is in there and you're awake for this test because they go tell us when you, when you feel the first urge to go and they mark where that is. And so you can see how much fluid is in there. And I'm like, tell us when you get like the, I should go to the bathroom now urge. And they mark that and then they're like, okay, tell us when you can't take it anymore. Sarah Haag:                  49:00                And they mark that. So then they know how much your bladder can truly hold. But also looking at what's your detrusor doing, which is the smooth muscle around your bladder, what's happening to your pelvic floor, where is the weakness? And usually when they're full, sometimes they'll have people cough to see if anything leaks or if any sphincters happen or sphincters what they're up to. But it's, it's involved. But there's a lot of good information. And interesting side note is that if you do so, that's really I think really helpful for like a neurologic population just to make sure. I did have one patient I was lucky enough to work with a PT who became a physiatrist who specialized in neurogenic bowel and bladder and she let me come down to watch  urodynamics of one of my patients who was really against cathing. Sarah Haag:                  49:46                He didn't want to cath. So she came down, she brought him down to the urodynamics and as it and cause he's like, I am voiding 400 to 600 milliliters every time I have a bowel movement. And like that's pretty good. I mean like most are four to 600 CCS and turns out it was only under very high pressure. He was already getting reflects into his kidneys and after he voided four to 600 CC's, he still had four to 600 left, which is too much. So even though he was having some output, that was the test that really made it clear to him like, oh, it's coming out, but it's not healthy. Like I need to cath. Jamie:                          50:41                What are some of the considerations that you might go through in your thought process when you're dealing with a male versus a female pelvic pain or incontinence issue? Sarah Haag:                  50:53                That's a lot. I could talk for days on that. Well I'm not sure. When you're talking about considerations. We need to take into consideration our patient preference and what they're comfortable with. We can tell when our patients are uncomfortable or we should be able to but then kind of try to work out, they might not want to talk to me about this, but who can I get that they would, cause a lot of people would assume that men aren't really comfortable talking to females. But a lot of the men who come to see me, just want help, and we've had several male students come through and you know, they run into like women not wanting a male therapist to do it. Sarah Haag:                  51:36                It's just finding that, right? Just like any other body part, finding the right person to help. But then if we go to, you know, bringing up those subjects, I don't know that in my brain it's so, so different. Male to female, you're going to take into consideration their history for sure. I feel happy saying that because now with we have kind of like a gender spectrum, right? We have people who, who have transitioned in varying degrees and we have people who haven't transitioned but totally identify with the gender. They weren't assigned at birth and all of these things. So basically I take it functional. So can you just walk me through the issues you're having, your questions, concerns when it's a problem, if anything makes it better, does anything in particular make it worse? And then we problem solve from there? Sarah Haag:                  52:26                So I guess I didn't really have a good, a good answer, man. Male to female. Their situations are usually different, but it's kind of different across one gender or the other. Anyway. Is that kind of answer it? Yeah. Great question. Karen Litzy:                                           Well, thank you so much. Thank you. I think we covered a lot and I thank you guys for being here and I hope that you guys got a lot out of this and can kind of take this back to your patients now. So last question that I ask everyone and it's so knowing where you are now in your life and your career, what advice would you give to yourself as a new Grad? Sarah Haag:                                          Ask more questions. To be honest on, I came out of school pretty much like, like the teachers know best and what I learned is right. Sarah Haag:                  53:16                And then when you get into the real world, I ended up thinking I was not very good at my job for awhile because like you would do what you were taught to do but it wouldn't work. And then, you know, some things happen and I got older and more comfortable and when you start asking questions you realize there isn't one answer. So if you start asking those questions, you're part of, you're part of the solution. By kind of pushing those boundaries and not like, I wish I would've just asked more questions sooner. I'd be so much smarter than I am now. Karen Litzy:                                           Where can people find you on social media if they want to get in touch with you? Sarah Haag:                                          Sarah Haig, PT on Twitter, you can find me on my website, www.entropy.physio and um, I mean Facebook, Sarah Hague. Sarah Haag:                  54:07                I don't know what my picture looks like right now, but I'm friends with Karen, so if it says I'm friends with Karen, that's probably me. Karen Litzy:                                           Awesome. And just so that everyone knows a lot of this stuff that Sarah spoke about, we will have links to it. We'll have links to the home health section. We'll have links to the testing, the urogenic testing. Is that neurodynamic testing? You could just send me a link or something about it. So we'll have it all in the show notes. Thanks everyone for watching the live. We appreciate it and everybody, thanks for listening. Have a great couple of days. 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 iTunes!  

F. Scott Feil sits down with Sandy Hilton, Sarah Haag, & Karen Litzy while they are all at CSM 2018 in New Orleans to talk about international conferences. They talk about the benefits of going to international conferences, how to navigate international conferences, how to navigate which conference is best for you to attend, differences between conferences in the U.S and conferences outside of the U.S, the guests pitch their favorite conferences, and much more!   Join Karen and others at the Women in PT Summit!! The Early Bird rate expires on August 1st so be sure to grab a ticket at the discounted rate! Women in PT Summit: http://womeninpt.com/   Karen Litzy's Website: https://karenlitzy.com/  The Healthy, Wealthy & Smart Podcast Website: http://podcast.healthywealthysmart.com/  The Healthy, Wealthy & Smart Podcast on Itunes: https://itunes.apple.com/us/podcast/healthy-wealthy-smart/id532717264?mt=2  Karen's Interview on Therapy Insiders on "Why Aren't There More Women Leaders?" : https://itunes.apple.com/us/podcast/why-arent-there-more-women-leaders-special-episode/id609009250?i=1000384711690&mt=2  Karen's Facebook Page: https://www.facebook.com/karen.litzy  Karen's Twitter Page: https://twitter.com/karenlitzyNYC  Karen's Instagram Page: https://www.instagram.com/karenlitzy/  Entropy Physio Website: http://entropy-physio.com/  Pain Science & Sensibility Podcast: https://itunes.apple.com/us/podcast/pain-science-and-sensibility/id1003630972?mt=2  San Diego Pain Summit Website: https://www.sandiegopainsummit.com/  Sandy's Facebook Page: https://www.facebook.com/sandy.hilton.73  Sarah's Facebook Page: https://www.facebook.com/sarah.haag.129  Sandy's Twitter Page: https://twitter.com/SandyHiltonPT  Sarah's Twitter Page: https://twitter.com/SarahHaagPT  Sandy's Instagram Page: https://www.instagram.com/sandyhiltonpt/  Sarah's Instagram Page: https://www.instagram.com/ssarahjopt/  The PT Hustle Website: https://www.thepthustle.com/  Schedule with Kyle Rice : www.passtheptboards.com    HET L.I.T.E Tool: www.pteducator.com/het  Biographies: Sandy Hilton graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches  Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy's clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women.  Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.    Sarah Haag 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.  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.  Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes.  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.   Karen Litzy started her physical therapy career in an inpatient hospital in Scranton, Pa. Moving to New York a few years later she had the opportunity to work for the New York public school system, Broadway musicals and orthopedic outpatient clinics. While the work was rewarding, she always felt like she could do more to serve her clients.  As she was searching for ways to provide a more comprehensive approach to practicing physical therapy she became overwhelmed with requests from clients to be seen in their home or office. This was an opportunity to provide not just convenience, but a different kind of practice. By adopting a “concierge” model, she could dedicate a full hour of one-on-one treatment to each and every client. Now she had ample time to evaluate, treat and re-evaluate. The concierge model allowed me the time to provide vital client education. Her clients would now benefit from a comprehensive home education program.  As part of her commitment to her clients and her career, She is constantly engaging in continuing education. She has been lucky enough to learn directly from some of the best in the profession. She has received certificates from Dr. David Butler, Dr. Lorimer Moseley, Dr. Adriaan Louw, Dr. Paul Hodges, The Institute of Physical Art, The American Physical Therapy Association, Hospital for Special Surgery, and many more. She graduated from Misericordia University with her masters degree in Physical Therapy in 1997 and then graduated from the same university in 2014 with a Doctorate of Physical Therapy.  She is the host of the podcast, Healthy, Wealthy, and Smart. The podcast provides up to date clinical information combined with business strategies from the best and brightest thought leaders in physical therapy, wellness and entrepreneurship. The show promotes the profession and provides a channel to get the most accurate information out there for both practicing physical therapists and everyday people.  She is a proud member of the American Physical Therapy Association (APTA), the Orthopedic Section of the APTA, the Section on Women's health, the Home Health Section and the Private Practice Section of the APTA. She is also an official spokesperson for the APTA as a member of their media corps.  Physical therapy is an ever evolving practice and for her, a personal journey. That's why she's committed to staying at the forefront of the industry. Through continuing education and her practice, she works to enrich myself so she can impart to others the true value of physical therapy. Her mission is to show people how physical therapy can improve their lives. This is what drives her to help her clients attain their own goals and for herself to build upon the work of those who have helped lead the way

F. Scott Feil interviews Sandy Hilton & Sarah Haag (Founders of Entropy Physio in Chicago, IL) while live at CSM 2018 in New Orleans with Brandon joining via computer. Sandy & Sarah discuss their development and path to where they are now, the most common conditions they see related to female and male pelvic health, most effective education tactics for teaching patients with pelvic health conditions, advice for the newer clinician looking to develop more into pelvic health, and much more! Entropy Physio Website: http://entropy-physio.com/  Pain Science & Sensibility Podcast: https://itunes.apple.com/us/podcast/pain-science-and-sensibility/id1003630972?mt=2  "Why Pelvic Pain Hurts" book: https://www.amazon.com/Pelvic-Pain-Hurts-Adriaan-Louw/dp/0985718684/ref=sr_1_1?ie=UTF8&qid=1529551059&sr=8-1&keywords=why+pelvic+pain+hurts  International Pelvic Pain Society: https://www.pelvicpain.org/  International Continence Society: https://www.ics.org/  APTA Clinical Practice Guidelines: http://www.apta.org/EvidenceResearch/EBPTools/CPGs/  Sandy's Facebook Page: https://www.facebook.com/sandy.hilton.73  Sarah's Facebook Page: https://www.facebook.com/sarah.haag.129  Sandy's Twitter Page: https://twitter.com/SandyHiltonPT  Sarah's Twitter Page: https://twitter.com/SarahHaagPT  Sandy's Instagram Page: https://www.instagram.com/sandyhiltonpt/  Sarah's Instagram Page: https://www.instagram.com/ssarahjopt/  HET L.I.T.E Tool: www.pteducator.com/het  Biographies: Sandy Hilton graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches  Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy's clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women.  Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.    Sarah Haag 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.  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.  Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes.  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.

LIVE from the Combined Sections Meeting in New Orleans, Louisiana, it is my pleasure to welcome Dr. Sarah Haag, Dr. Sandy Hilton and Dr. Jason Falvey back for Part 4 all about sex. Check out Part 1, Part 2 and Part 3 and enjoy another installment!   In this episode, we discuss: -Biomechanical considerations for different sex positions -How to support your partner following child birth -Why sexual dysfunction may be an important predictor of future cardiovascular problems -Sexual health for the LGBTQI+ population -And so much more!   Pelvic health interventions follow the same treatment principles as any other orthopedic conditions. Sandy stresses, “Strength and conditioning principles really do apply to pelvic health it’s just the movement is a centimeter, it’s very small but the scale is proportionally the same so if you’re having problems with loading and frequency and dosage of your program, just adapt it. You don’t have to stop.” Sarah reaffirms this and recommends that patients, “Do what you do and should you run into issues, again graded exposure and practice I think is the best answer.”   When treating sexual dysfunction, it’s important to consider what could be affecting patients beyond purely biomechanical ailments. For example Sarah explains that, “When someone does become ill, if you’re not typically the caregiver and now there’s that role shift, that’s a psychosocial issue.” Jason stresses the importance this can play with older adults as, “It’s a very hard transition for people to transition from caregiver to lover.”   All physical therapists should be able to break past the stigma surrounding pelvic health issues, even if it is not their specialty. It’s important to inform patients that help exists as Sarah has found that, “When it comes to sexual dysfunction and bowel and bladder dysfunction, a lot of people don’t know what’s normal and even when people aren’t happy with the function which is really the key that they need to get help, they don’t know that there is help.”   For more information on the guests: SARAH HAAG PT, DPT, MS, WCS CERT. MDT, RYT: 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. Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes.   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.   SANDY HILTON PT, DPT, MS: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic.   JASON FALVEY PT, DPT, GCS, CEEAA: Jason is a board certified geriatric physical therapist with a strong interest in improving outcomes for both frail older adults and older adults with hospital-associated deconditioning. He has current funding from the Foundation for Physical Therapy (PODS 1 Award, 2015) and the Academy of Geriatric Physical Therapy to support his participation in ongoing research the use of a novel Progressive High Intensity Therapy (PHIT) training program on medically complex older adults after acute hospitalization. He also has funding from both the American Physical Therapy Association Health Policy and Administration Section and the Home Health Section to evaluate how physical therapists can reduce avoidable hospital readmissions. Lastly, Jason is collaborating with local long-term care providers to determine how physical functioning can be assessed and best managed to reduce rates of falls, ER visits, and hospitalization.   Resources discussed on this show: Jason Falvey Twitter Sarah Haag Twitter Sandy Hilton Twitter Uchenna Ossai Twitter Meryl Alappattu Twitter Rena McDaniel Twitter A THERAPY TOOLKIT FOR TREATMENT OF URINARY INCONTINENCE   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 iTunes!   Have a great week and stay Healthy Wealthy and Smart!   Xo Karen    

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag, Dr. Sandy Hilton and Dr. Jason Falvey for another installment all about sex. The was recorded live at CSM and we covered a wide range of topics including 50 Shades of Grey. Two of the four of us read the books…guess which two! Make sure to catch up on Part 1 and Part 2 and enjoy the show! In this episode, we discuss: -What’s normal female anatomy? -Graded exposure for women’s sexual health -Can interventions for sex be researched? -Sex education for people with low back pain -What you should and shouldn’t be inserting into the vagina -And so much more!   For a lot of people in today’s society, there is almost no body part which escapes insecurity. Sandy believes the variety of human forms should be celebrated and genitalia is no different. Sandy reminds us that, “The normal human variability is as variable as noses.”   Patients may question whether they should continue sexual activity that is accompanied by chronic pain. Both Sandy and Sarah emphatically agree, “sex should never be painful,” adding, “if it doesn’t feel good, don’t do it.”   Many chronic pelvic pain patients may have adverse experiences with sex. Sarah finds that a graded exposure treatment plan which is sensitive to psychological associations and fears will lead to better outcomes. Sarah finds, “It’s really important to have something that the person doesn’t feel the need to protect against.”   For more information on the panel: SARAH HAAG PT, DPT, MS, WCS CERT. MDT, RYT: 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 past 8 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. Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes. 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.   SANDY HILTON PT, DPT, MS: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy has teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is also pursuing opportunities for collaboration in research into the clinical treatment of pelvic pain conditions. Sandy brings science and common sense together beautifully to help people learn to help themselves.   JASON FALVEY PT, DPT, GCS, CEEAA: Jason is a board certified geriatric physical therapist with a strong interest in improving outcomes for both frail older adults and older adults with hospital-associated deconditioning. He has current funding from the Foundation for Physical Therapy (PODS 1 Award, 2015) and the Academy of Geriatric Physical Therapy to support his participation in ongoing research the use of a novel Progressive High Intensity Therapy (PHIT) training program on medically complex older adults after acute hospitalization. He also has funding from both the American Physical Therapy Association Health Policy and Administration Section and the Home Health Section to evaluate how physical therapists can reduce avoidable hospital readmissions. Lastly, Jason is collaborating with local long-term care providers to determine how physical functioning can be assessed and best managed to reduce rates of falls, ER visits, and hospitalization.   Resources discussed on this show: Jason Falvey Twitter Sarah Haag Twitter Sandy Hilton Twitter Pain Catastrophizing Scale Orebro Scale   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 iTunes!   Have a great week and stay Healthy Wealthy and Smart!   Xo Karen   P.S. Do you want to be a stand out podcast guest? Make sure to grab the tools from the FREE eBook on the home page! Check out my blog post on the Top 10 Podcast Episodes of 2016!  

Thanks for tuning in to the Healthy Wealthy and Smart Podcast! Coming to you from Chicago, Drs. Sarah Haag, Sandy Hilton, and Jason Falvey join me for Part 2 on our discussion all about sex! You can check out Part 1 from CSM in Anaheim, California here in case you missed out!   In this episode, we discuss: -Broaching the subject of sex with your patients -Recalibrating sex after surgery and childbirth -Rising rates of sexually transmitted diseases in the older adult population -How a bladder diary can help those with persistent UTI -And much, much more!   Sex has multiple health benefits outside what is commonly perceived and can be utilized as exercise. “There is so much that sex is good for cardiovascularly, musculoskeletally. It’s just awesome for so many reasons mentally. When we talk about population health and things that keep people moving and happy—that’s a good one.”   Sex is an important activity of daily living and can be a tool for clinicians to implement into their home exercise program. “Pleasurable movement is one of the things that help you get back to normal movement. So if you can make this make sense and feel good, it’s probably going to be one of the first and well motivated things you’re going to do in an exercise program.”   After patients have undergone surgery, surgical restrictions are not you’re only guiding tool for sex. “Always let pain be your guide, if it hurts, don’t do it. Sex is never supposed to hurt—it’s supposed to be amazing.”   We tend to forget about the vital functions our pelvic organs perform every day. “Peeing and pooping and sex, they are all very basic bodily functions and we can start to forget about it. If I ask any of you how often you peed today, you would have to think really hard and I betcha 10 bucks you’d be wrong with whatever you guessed. You can go pee mindlessly.” Today's guests: Sandy Hilton PT, DPT, MS: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy has teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy’s clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is also pursuing opportunities for collaboration in research into the clinical treatment of pelvic pain conditions. Sandy brings science and common sense together beautifully to help people learn to help themselves.   Sarah Haag PT, DPT, MS, WCS Cert. MDT, RYT: 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 past 8 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. Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah plans to integrate yoga into her rehabilitation programs, as well as teach small, personalized classes. 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.   Jason Falvey PT, DPT, GCS: PhD Student Jason Falvey was awarded a Kendall Scholarship from the Foundation for Physical Therapy in 2014 and a Fellowship for Geriatric Research through the Academy of Geriatric Physical Therapy in 2015 to support his research examining the role of home physical therapy in enhancing function and reducing re-hospitalizations for medically complex older adults. He is also the primary investigator on a research grant from the American Physical Therapy Association, Section of Health Policy and Administration looking at the role of physical therapists in models of transitional care for older adults after acute hospitalization.   Resources discussed in this show: Oswestry Disability Index Finding a pelvic health PT Holly Herman     Make sure to give Jason Falvey , Sarah Haag , and Sandy Hilton a follow on twitter!   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!   Have a great week and as always stay Healthy Wealthy and Smart!   Xo Karen   P.S. Do you want to be a stand out podcast guest? Make sure to grab the tools from the FREE eBook on the home page! Check out my latest blog post on Managing Expectations: It Shouldn't be That Difficult!

On Win's Women of Wisdom today, Best-Selling Author, Win Kelly Charles welcomes Dr. Sarah 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 past 10 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.  Most recently, Sarah completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Instructor. Sarah is co-owner of Entropy Physiotherapy & Wellness in Chicago, IL with Dr. Sandy Hilton.  Entropy Physiotherapy has been created to provide physical therapy in a comfortable setting, using the best evidence available to help people overcome their pain and meet their goals.  Entropy has also committed to providing innovative continuing education courses for healthcare and fitness professionals from taught by experts from all over the world. Sarah is an active member of the American Physical Therapy Association, as well as a member of the Sections on Women’s Health, Orthopedics, and Private Practice.  Sarah currently serves as the Director of Financial Development for the Section on Women’s Health. 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. To learn more about Sarah visit http://www.entropy-physio.com/. To learn more about your host visit https://wincharles.wix.com/win-charles. To learn more about the show visit http://winswomenofwisdom.weebly.com. To be on the show please fill out the intake at http://bit.ly/1MLJSLG. Be sure to FOLLOW this program https://itunes.apple.com/us/podcast/wins-women-of-wisdom/id1060801905