Podcast appearances and mentions of sarah haag

Ep. 107 Live from MAX – Reflections on Equity in the Field This week Kevin shares some great news and our hosts think they are hay-larious before diving into the serious topic of changes in equity in our field. Our guests at the Midwest Arts Xpo discuss slow shifts in programming and the hierarchical structures that impede progress, and we dig deep into just a few of the challenges with contracting. Our guests this week are: Sarah Haag, Artist Wallace Thomas, Artist, Ball in the House Clare Longendyke, Pianist Karoline Myers, Director of Education, Des Moines Performing Arts Follow us on social media and let us know your thoughts and questions - https://linktr.ee/nobusinesslikepod Our theme song is composed by Vic Davi (@VicDaviMusic).

In this episode with Dr Sarah Haag, we discuss her Research Review of a recent article looking at the impact of a 12-week, home-based abdominal exercise program on inter-recti distance and other health indicators in women with diastasis recti abdominis (DRA) 6 to 12 months postpartum.We discuss the key takeaways of the paper, the impact of kinesiophobia in these patients and what we can clinically use with our patients in the clinic.

Check out the Daily 21's Program: https://osi-online.com/courses/the-daily-21s-for-vitality/ In this episode, Tim talks with Dr. Sarah Haag about men's pelvic health. Dr Haag is a treasure trove of wonderful information regarding the pelvic floor of men. If you are a guy with pelvic health issues, you can get help and you can heal! Listen to Sarah tell you how. To learn more from Dr. Sarah or to seek her services, click here: https://entropy.physio/sarah-haag To find a pelvic health specialist near you, click here: https://www.aptapelvichealth.org/ --- Support this podcast: https://podcasters.spotify.com/pod/show/original-strength/support

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    

On this episode I speak to Dr Sarah Haag about pelvic floor physiotherapy - from what we need to listen to when talking to our patients to when we should refer on for a specialist and beyond! Tune in to this episode as we explore an area of the body that has, for me, for all intents and purposes, been a bit of a black hole that, I admittedly say on the podcast - I'm glad I've worked previously with pelvic floor specialists in the same clinic as I would never have even recognised to refer on in the past! An area under-explored by our education (there's a lot to cover during the education - not hating) I hope this episode can, for you, help shine a light on the area where the sun don't shine!

Tune in to this musical HuttCast, more than you will ever expect.Ted Yoder Band is a progressive band led by the barefoot “Bela Fleck of the hammered dulcimer.” Ted's music rocketed around the world when his instrumental version of Everybody Wants to Rule the World went viral with over 100 million views. Ted leads from a heart in touch with human emotion and experience. When his whole family survived a car accident, it caused Ted to rethink everything. “My dad died in a car accident when he was 54. I had to ask myself, ‘If this were my last day on earth, am I satisfied with what I've done and how I've shown my children to live?'” And so he took the leap into a music career. Ted then won the title of National Hammered Dulcimer Champion. His breakout band has already opened for Jake Shimabukuro. At concerts Ted is joined by marimba, drums, percussion, fretless bass, and strings to create a sound like the love child of Dave Matthews Band and Emerson, Lake, & Palmer. The musical chemistry and stage banter between Ted, Sarah Haag (marimba), Doug Haag (drums and percussion), and Toby Hazlett (fretless bass and electric upright), puts the sheer joy of pursuing your dreams on display.SUPER FUEL ENERGY DRINK A BLAST OF PREMIUM NATURAL ENERGY! Dependable Heating & Cooling Dependable Heating & CoolingExcel Roofing Excel RoofingBuzzsprout - Let's get your podcast launched! Start for FREEDisclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.

Renowned women's health physiotherapist Sarah Haag joins us on the show for an in-depth discussion on Pilates and pregnancy, exercise, and continence issues. She shares her wisdom on what you should and shouldn't do — exercise-wise — with your prenatal and postpartum client. Pregnant people aren't delicate flowers. We want to empower clients in the perinatal period, be honest about their needs, and let you know how you can support them as an exercise professional. -------------------------------- Ways to Connect with Sarah Haag Web https://entropy.physio/sarah-haag (Entropy Physiotherapy & Wellness) Entropy Physio on https://www.instagram.com/entropy_physio/?hl=en (Instagram) and https://www.facebook.com/Entropy.Physio (facebook) -------------------------------- Ways to engage with us for FREE Join ourhttps://breathe-education.com/pilates_elephants-register/ ( free weekly Q&A)  Get our free ebook onhttps://breathe-education.com/posture/ ( Posture Myths in Pilates) Connect on Instagramhttps://www.instagram.com/breathe.education/ ( Breathe Education),https://www.instagram.com/the_raphaelbender/ ( Raphael Bender),https://www.instagram.com/cloebunterpilates/ ( Cloe Bunter) and Facebookhttps://www.facebook.com/BreatheEducation ( Breathe Education) -------------------------------- Masterclasses and online courses Do ahttps://breathe-education.com/masterclasses/ ( Masterclass) with us Read more about thehttps://breathe-education.com/diploma-of-clinical-pilates/ ( Diploma of Clinical Pilates) -------------------------------- Have Questions? https://breathe-education.com/coachingcall (Book a time to talk with our team)   *Links may not work on some platforms. You'll find all the info athttps://breathe-education.com/podcast/ ( https://breathe-education.com/podcast/) This podcast uses the following third-party services for analysis: AdBarker - https://adbarker.com/privacy

This topic was one suggested by Get Glutes member Nadege, and it's one many postpartum women will resonate with. Whether you've just had a baby or are years down the line and only learning about this now."I recently discovered that I may have abdominal separation, reason why no matter what, I'm not having a flat belly (when I do get great result with all other muscles). Also, most exercises i was doing to build the muscles, actually make it worse. I'm so frustrated as it is a lot of waste time and energy."What Nadege is describing is a process called Diastasis Recti Abdominis, which is the thinning of the "six-pack" abs to accommodate a growing fetus. It can happen for other reasons, too, but this is how most women experience it.It's often blamed for the "mummy tummy" or "belly pooch" appearance many women have, and even still it's blamed for things like pain, weakness, pelvic floor dysfunctions like incontinence, pelvic organ prolapse (POP), pelvic girdle pain (PGP), and even other orthopedic pain and "bad posture". But are these things true? Or if they are true, how much should we *actually* worry about them.With all that in mind, it's no wonder I see so many women afraid of making it worse and desperate to "fix it". Not only does the presence of a non-flat stomach bother us (so much pressure to have a flat tummy), but with all these "problems" looming over us, there's a lot of fear and confusion about making it worse.Imagine how that affects your body trust. To be afraid of moving certain ways because you've been told it's going to make it worse. Or believing that having diastasis is somehow bad and you NEED to fix it.I invited Women's/Pelvic Health Physical Therapist of Entropy Physiotherapy & Wellness, and Assistant Professor at Rosalind Franklin University of Chicago, Sarah Haag, PT, DPT on to talk about this contentious topic.You may have heard many things about Diastasis Recti - or ab separation - and you may be wondering how to fix the diastasis, but is diastasis bad? Is it a dysfunction waiting to happen? WHERE ELSE TO FIND ME, YOUR HOST:Join the Body Trust Movement: https://equippedwithstrength.comWorkout Membership: https://equippedwithstrength.com/enroll

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

Dr. Kimberly Durant (e-mail) of Leadbetter Rehab is interviewed by Becca Catlin regarding a presentation she gave at the 2020 Virtual AAOMPT Conference titled, “Bridging the Gap Between Pelvic Health and Orthopedic Physical Therapy.” Please note that the rehabilitation professions mentioned by Dr. Durant during the interview are Susan Clinton, Julie Wiebe, and Sarah Haag. This episode contains information that will be interesting for practitioners who want to learn more about how a non-pelvic certified orthopaedic physical therapist can begin to consider pelvic health during their clinical practice.Find out more about the American Academy of Orthopaedic Manual Physical Therapists at the following links:Academy website: www.aaompt.orgTwitter: @AAOMPTFacebook: https://www.facebook.com/aaompt/Instagram: https://www.instagram.com/officialaaompt/?hl=enPodcast e-mail: aaomptpodcast@gmail.comPodcast website: https://aaomptpodcast.simplecast.fm

Dr Sarah Haag brings her engaging brand of practical tips and her down-to-earth demeanor as she demystifies how to assess and treat the pelvic floor, whatever the clinical setting. No longer fear the pelvic floor—instead, head into the clinic this week confident in your skills.

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Haag to talk about exercise and urinary incontinence. This interview was part of the JOSPT Asks interview series. Sarah is the co-owner of Entropy Physiotherapy and Wellness in Chicago. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. In this episode, we discuss: The prevalence of urinary incontinence Is urinary incontinence normal Pelvic floor exercises Pelvic floor exam for the non-pelvic health PT Sports specific pelvic health dysfunction And much more Resources:  Entropy Physiotherapy and Wellness JOSPT Facebook Page JOSPT Journal Page  More Information about Dr. Haag:  Sarah graduated from Marquette University in 2002 with a Master’s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women’s and men’s health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women’s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women’s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women’s health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.  Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a  Registered Yoga Teacher. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. Read the full transcript below:  Read the Full Transcript below:  Speaker 1 (00:06:25): So, and hopefully it doesn't want to lose what we're doing here. We'll see. Okay. Going live now. Okay. Welcome everyone to JLS. PT asks hello and welcome to the listeners. This is Joe SPT asks the weekly chat where you, the audience get your questions answered. My name is Claire Arden. I'm the editor in chief of Joe SPT. And it's really great to be chatting with you this week, before we get to our guest. I'd like to say a big thanks for the terrific feedback that we've had since launching [inaudible] a week ago. We really appreciate your feedback. So please let us know if there's a guest that you'd like to hear from, or if you have some ideas for the show today, we're in for a very special treat because not only are we joined by dr. Sarah hake from entropy physio, but guest hosting [inaudible] asks today is dr. Karen Litzy who you might know from the healthy, wealthy and smart podcast. Dr. Lexi is also a new Yorker. And I think I can speak for many of us when I say that New York has been front of mind recently with the coronavirus pandemic. And I'd like to extend our very best wishes to everyone in New York where we're thinking of you. So I'm going to throw to Karen now. We're, I'm really looking forward to chat today on pelvic floor incontinence and exercise over to you, Karen. Speaker 1 (00:08:25): Hi everyone, Claire. Thank you so much. I really appreciate your giving me the opportunity to be part of J O S P T asks live stream. So I'm very excited about this and I'm also very excited to talk with dr. Sarah Hagar. Sarah is an educator, a clinician, and an author. She is also co-owner of entropy wellness and our physiotherapy and wellness in Chicago, Illinois, and is also a good Speaker 2 (00:08:56): Friend of mine. So it's really a an honor for me to be on here. So Sarah, welcome. Thank you so much. I was really excited that all this came together so beautifully. Yes. And, and again like Claire had mentioned, we're all experiencing some pretty unprecedented times at the moment. And the hope of these J O S P T asks live streams is to continue to create that sense of community among all of us, even though we can't be with each other in person, but we can at least do this virtually. And as Claire said, last week, we want to acknowledge our frontline healthcare workers and colleagues across the world for their dedication and care to those in need. And again, like Claire said before, a special shout out to my New York city colleagues, we are they are really working like no other. Speaker 2 (00:09:52): And I also want to acknowledge not just our healthcare colleagues and workers, but the scientists, the grocery store workers, the truck drivers the pharmacist, police, firefighter paramedics, they're all working at full capacity to keep the wheels turning around the world. So I just want to acknowledge them as well and thank them for all of their hard work during this time. Okay. So, like Claire said today, we're going to be talking about the pelvic floor, which is something Sarah loves to talk about because what I also, I also failed to mention is she is a certified pelvic health practitioner. So through the American physical therapy association. So she is perfectly positioned to take us through. And as a lot of, you know, we had, you had the opportunity to go onto Slido to ask questions. You can still do that. Even throughout this talk, just use the code pelvic that's P E L V I C, and ask some questions. Speaker 2 (00:10:57): So we do have a lot of questions. I don't know if we're going to get to all of them. So if we don't then certainly post them in the Facebook chat and maybe Sarah can find those questions in the chat below. And we'll try and get to those questions after the recording has finished. All right, Sarah. So like I said, lots of questions and the way the questions were, were written out, kind of corresponds quite well with maybe how you would see a patient in the clinic. So let's start with the patient comes into your clinic. They sit down in front of you. Let's talk about the words we would use in that initial evaluation. So I'll throw it over to you. Okay. So being a pelvic health therapist, obviously most people when they're coming to females, Things that happen in the pelvis, I like to acknowledge it, that there's a lot of things happening in the past. So I have Speaker 1 (00:11:54): Them tell me kind of what are the things that have been bothering them or what are the things that have been happening that indicate something might be going on? Like if something's hurting, if they're experiencing incontinence, any bowel issues, any sexual dysfunction. And, and I kind of go from there. So if the talk that's the title of the talk today includes incontinence. Continence is a super common issue that let's see in general might pop in. And if you would bother to ask there's actually, I think it's like one out of two people over 60 are experiencing incontinence of some kind. The answer is going to be yes, some, so you can start asking more questions. But starting out with what, what is bothering them is really what I like to start with. Then the next thing we need to know is after we vet that issue or that priority list of things that are bothering them in the pelvis, and it's not uncommon actually to have. Speaker 1 (00:13:00): So let's say they start with a discussion of incontinence. I still actually ask about sexual function, any pain issues, any bowel issues, just based on the innervation of the various, the anatomical arrangement of everything. It's not uncommon to have more than one issue, but those other issues might not be bothersome enough to mention. So it's kind of nice to get that full picture. Then the next thing we really want art. So there are times I've met women who come in and they're like, Oh yeah, you know, I have incontinence. And you're like, okay. So when did it start now? Like 25 years ago. Okay. Do you remember what happened then? Typically it was a baby, but sometimes these women will notice that their incontinence didn't happen to like four or five years after the baby. Hmm. So that's information, that's very help if they say my baby that was born six weeks ago, our interventions and expectations are going to be very different than someone who's been having incontinence for 25 years. Speaker 1 (00:14:05): So again, knowing how it started and when it happens, when the issues are happening, I just kind of let them, it's like a free text box on a form. Like just, they can tell me so much more excuse me. And when we are talking about things, we, I do talk anatomy. So when it comes to incontinence, I talk about the bladder and the detrusor, the smooth muscle around the bladder, the basically the hose that takes the urine from the bladder to the outside world. I do talk about the vagina and the vulva and the difference between the two. And then actually we do talk about like the anus and the anal sphincters and how all of that is is all there together and supported by the pelvic floor. Speaker 1 (00:14:54): Cause that's in physical therapy, it's going to be something with that pelvic floor or something. Drought, does it need to be more, more pelvic floor focused or does it need to be behaviorally focused, which is the case sometimes, or is it that kind of finding that perfect Venn diagram of both for those issues that the person's having? And let's say you're in a part of the world. One of the questions was what if you're I think this question came from Asia and they said, what if you're in part of the world where you have to be a little bit, maybe more sensitive around even the words that you use. I know we had gotten a question a couple of years ago about a woman in the Southern part of the United States that was from very conservative area. And do we even use these words with these patients? Speaker 1 (00:15:48): So what is your response to that? My response is that as healthcare providers, we are responsible, I think for educating people and using appropriate words and making sure people understand the anatomy like where things are and what they're supposed to be doing. However, definitely when I'm having this conversation with someone I want them to feel at ease. So like I will use the Ana vagina anus, anal sphincters Volvo, not, it's not a vagina, it's a Volvo it's on the outside. But then if they use different terms to refer to the anatomy, we're discussing, I'm happy to code, switch over to what they're most comfortable with because they need to be comfortable. But I think as, as again, healthcare practitioners, if we're not comfortable with the area, we're not going to make them feel very comfortable about discussing those issues. Right. Speaker 1 (00:16:43): And that makes a lot of sense. Thank you for that. So now let's say you, the person kind of told you what's going on and let's, let's talk about when you're taking the history for women with incontinence, especially after pregnancy, are there key questions you like to ask? Yes. So my, my gals that I'm seeing, especially when they're relatively relatively early in the postpartum period, are the things I'm interested in is did they experience this incontinence during their pregnancy? And did they have issues before pregnancy? And then also if this is not their first, tell me about the first birth or the, or the first two birth. So the first three birth to really get an idea of is this a new issue or is this kind of an ongoing marked by so kind of getting a bigger picture of it. Speaker 1 (00:17:49): And then also that most recent birth we want to know, was it vaginal? Was it C-section with vaginal birth? If there's instrumentation use, so if they needed to use forceps or a vacuum that increases the likelihood that the pelvic floor went over, went under a bit of trauma and possibly that resulted in a larger lab. And even if there isn't muscles, it's understandable that things might work well, if it's really small and if it's still healing you know, different, different things like that. So understanding the, kind of like the recent birth story, as well as their bladder story going back. So you've met first baby or before that first baby so that we know where, where we're starting from. And the, the reason why I do that is because again, if it's a longterm issue, we have to acknowledge the most recent event and also understand there was something else happening that, that we need to kind of look at. Speaker 1 (00:18:58): So would I expect it all to magically go away? No, I wouldn't. There's probably something else we need to figure out, but if it's like, Nope, this onset happened birth of my baby three months ago, it's been happening since then three months is, seems like forever and is also no time whatsoever. It took 10 months to make the baby. So it's you know, if you tear your hamstring, we're expecting you to start feeling better in three months, but you're probably not back to your peak performance. So where are we in that? And sometimes time will cure things. Things will continue to heal, but also that would be a time like how good are things working? Is there something else going on that maybe we could facilitate or have them reach continence a bit sooner. Okay, great. And do you also ask questions around if there was any trauma to the area? Speaker 1 (00:19:56): So if this birth was for example, the product of, of a rape or of some other type of trauma, is that a question that you ask or do you, is that something that you hope they bring up? It's, that's honestly for me and my practice, something, I try to leave all of the doors wide open for them to, to share that in my experience you know, I've worked places where it is on it's on the questionnaire that they fill out from the front desk and they'll circle no to, to any sort of trauma in the past. Speaker 1 (00:20:34): Yeah. They just, they don't want to circle yes. On that form. So and also I kind of treat everybody like they might have something in their past, right. So very nonjudgmental, very safe place, always making them as comfortable in a safe as possible. And I will say that there's anything I can do to make you feel more comfortable and more safe. We can do that. And if you don't feel safe and comfortable, we're not doing this w we're going to do something else. Cause you're right. That it's always one of those lingering things. And the statistics on abuse and, and rape are horrifying to the point where, again, in my practice, I kind of assume that everybody has the possibility of having something in their past. Okay, great. Thank you. And now another question that's shifting gears. Another question that came up that I think is definitely worthy of an answer is what outcome measures or tools might you use with with your incontinence patients? So with incontinence, honestly, my favorite is like an oldie buddy, but a goodie, like just, it's an IC, it's the international continents questionnaire where it's, I think it's five or six questions. Just simple. Like how often does this happen? When does it happen? Speaker 1 (00:21:58): There's a couple of other outcome measures that do cover, like your bladder is not empty. Are you having feelings of pressure in your lower abdomen? It gets into some bowel and more genital function. Can you repeat that? Cause it kind of froze up for a second. So could you repeat the name of that outcome tool as it relates to the bladder and output? Oh, sorry. I see. IQ is one and then, but like I see IQ vs which renal symptoms, right? So there are, there's a lot of different forms out there. Another one that will gather up information about a whole bunch of things in the pelvis is the pelvic floor distress bins questions about bowel function, bladder function, sexual function discomfort from pressure or pain. So that can give you a bigger picture. I'll be honest. Sometimes my, the people in my clinic they're coming in, and even though I will ask the questions about those things, when they get the, the questionnaire with all of these things that they're like, this doesn't apply to me. I'm like, well, that's great that it doesn't apply to you, but they don't love filling, filling it out. So sometimes what I will go with is actually just the pale. Speaker 1 (00:23:24): Can you say that again? Please help me. Oh yeah. Oh, so sorry. The patient's specific functional scale where, where the patient says, this is what I want to have happen. And we kind of figured out where they are talk about what would need to happen to get them there, but it's them telling what better. Right. Cause I've had people actually score perfect on some of these outcome measures, but they're still in my office. So it's like, Oh, I'm so patient specific is one of my one of my kind of go tos. And then there's actually a couple of, most of these pelvic questionnaires finding one that you like is really helpful because, because there's so many and they really all or discomfort. So if you have a really good ability to take a really good history, some of the questions on that outcome measure end up being a bit redundant. Speaker 1 (00:24:26): So I like, and you know the questions on there, make sure people are filling them out. You look at them before you ask them all the questions that they just filled out on the form for you. Yes. Good. Very good advice. So then the patient doesn't feel like they're just being piled on with question after question and cause that can make people feel uncomfortable when maybe they're already a little uncomfortable coming to see someone for, for whatever their problem or dysfunction is. So that's a really good point. And now here's a question that came up a couple of times, you know, we're talking about incontinence, we're talking about women, we're talking about pregnancy. What about men? So is this pelvic floor dysfunction? Is this incontinence a women only problem? Or can it be an everybody problem? So it very much can be an everybody problem. Incontinence in particular for men, the rates for that are much lower. And typically the men are either much older or they are they've undergone frustrate removal for prostate cancer. Speaker 1 (00:25:33): Fleur plays a role in getting them to be dry or at least dryer. And then it's like the pelvic floor is not working right. That can result in pain. It can result in constipation. It can result in sexual dysfunction. It can result in bladder issues. So it's, so yes, men can have all of those things. In fact, last night we had a great talk in our mentorship group at entropy about hard flacid syndrome. So this is a syndrome with men where everything is normal when they go get, get tested, no no infections, no cancers, no tumors, no trauma that they can recall. And, but the penis is not able to become functional and direct. And with a lot of these men, we're finding that it's more of a pelvic floor dysfunction issue, or at least they respond to pelvic floor interventions. Speaker 1 (00:26:30): So having a pelvic floor that does what it's supposed to, which is contract and relax and help you do the things you want to do. If, if we can help people make sure that they're doing that can resolve a lot of issues and because men have pelvic floors, they can sometimes have pelvic floor dysfunction. Okay, great. Yeah. That was a very popular question. Is this a woman only thing? So thank you for clearing up that mystery for everyone. Okay. So in going through your evaluation, you've, you've asked all your questions, you're getting ready for your objective exam. What do you do if you're a clinician who does not do internal work, is there a way to test these pelvic floor muscles and to do things without having to do internal work? My answer for that question is yes, there are things that you can do because even though I do do internal exams, I have people who come to see me who are like, no, we're not doing that. Speaker 1 (00:27:31): So, so where can we start? And so the first one is pants on and me not even touching you pelvic floor, I wouldn't really call it an assessment or self report. So even just sitting here, if you, if you were to call me up and and this actually goes into, I think another question that was on Slido about pelvic floor cues. So there is actually then it seems more research on how to get a mail to contract this pelvic floor then actually females. But I would ask you like like this is one that my friend Julie, we would use. So like if you're sitting there and you just sit up nice and tall, if you pretend you're trying to pick up a Ruby with your PA with your vagina is not on the outside, but imagine like there's just a Ruby on the chair and you'd like to pick it up with no hands, breathe in and breathe out and let it go. So then I would go, did you feel anything and you should have felt something happen or not. So if, if you did it, would you mind telling me what you built? You're asking me, Oh my goodness. Oh yes. I did feel something. So I did feel like I could pick the Ruby up and hold it and drop it. Speaker 1 (00:29:04): Excellent. And that's, and that, that drop is key. Excellent. So what I would say is this is like like a plus, like a, I can't confirm or deny you that you did it correctly, but I like, I would have watched you hold your, like she holding my breath. Is she getting taller? Cause she's using her glutes. Did she just do a crunch? When she tried to do this, I can see external things happening that would indicate you're might be working too hard or you might be doing something completely wrong. So then we'll get into, I mean, you said, yes. I felt like I pick up the Ruby, but if it's like, Hmm, I felt stuffed, but I'm not really sure we would use our words because they've already said no to hands to figure that out. But again, I can't confirm it. People are they're okay with that. Speaker 1 (00:29:48): And I'm like, and if what we're doing based on the information you gave me, isn't changing, we might go to step two. If you can send in step two is actually something, any orthopedic therapist honestly, should not feel too crazy doing. So if anyone has ever palpated the origin of the hamstring, so where is the origin of the hamstring facial tuberosity? If you go just medial to that along the inside part get, don't go square in the middle. That's where everyone gets a little nervous and a little tense, but if you just Pell paid around that issue, tuberosity it's pretty awesome. If you have a, a friend or a colleague who's willing to let this happen is you ask them to do a poll of our different cues with that in a little bit. You say that again, ask them to do what to contract the pelvic floor. Speaker 1 (00:30:44): Okay. And again, figuring out the right words so that they know what you're talking about. We can talk about that in a minute, but if they do a pelvic floor contraction, you're going to feel kind of like the bulging tension build, right there may be pushing your fingers. You should feel it kind of gather under your fingers. It shouldn't like push your fingers away, but then you can be like, well, you could test their hamstring and see that you're not on the hamstring and you can have them squeeze your glutes and you can kind of feel the differences. The pelvic floor is just there at the bottom of the pelvis. So you can palpate externally, even through BlueJeans is a bit of a challenge, but if they're in you know, like their workout shorts for yoga pants, it's actually very, very simple. And, and honestly, as long as you explained to them what you're doing and what you're checking for, it's no different than palpating the issue of tuberosity for any other reason. Speaker 1 (00:31:36): And with that, I tell them that I can, it's more like a plus minus, so I can tell that you contracted and that you let go. That's all I can tell. So I can't tell you how strong you are, how good your relaxation Wells, how long you could hold it for any of those things. And then I tell them with an internal exam, we would get a lot of information we could, we can test left to, right? We can, I could give you more of like a muscle grade. So like that zero to five scale be use for other muscles. We can use that for the pelvic floor. I can get a much better sense of your relaxation and see how was that going and I can even offer some assistance. So so we have two really good options for no touching. Speaker 1 (00:32:19): And then just as long as we understand the information we might gain from an internal exam, we can, we can, the information we gathered from the first two ways, isn't sufficient to make a change for them. And then as let's say, the non pelvic health therapist, which there might be several who are gonna watch this, when do we say, you know, something? I think it's time that we refer you to a pelvic health therapist, because I do think given what you've said to me and you know, maybe we did step one and two here of your exams. I think that you need a little bit more. So when do, when is that decision made to reach the point of, they have a bother that I don't know how to address so we can actually go to like the pelvic organ prolapse. So pelvic organ prolapse is, is when the support for either the bladder, the uterus, or even the rectum starts to be less supportive and things can kind of start to fall into the vaginal wall and can give a feeling of like pressure in with activity the sensation can get. Speaker 1 (00:33:39): So then we have two options, which is more support from below with perhaps a stronger meatier pelvic floor by like working it out to hypertrophy. So like if, if I had someone who had that feeling when they were running and we tried a couple are lifting weights, let's go lifting weights. No, like I feel it once I get to like a 200 pound deadlift. Okay, well, let's see how you're lifting when you're doing 150 and let's take a look at what you're doing at 200 in fresh with your mechanics or what's happening. And if there's something that is in your wheelhouse where you're like, well, can you try this breath? Or can you try it this way and see if that feeling goes away? I'm good with that. And if the, that the person who's having issue is good with that. Awesome. But if you're trying stuff or the incontinence is not changing, send them to a pelvic floor therapist, because what we love to do is we can check it out. Speaker 1 (00:34:41): We're going to check it out. We're going to give some suggestions. And then my, the end of every one of those visits that I get from my, from my orthopedic or sports colleagues is I'm like, excellent. So you're going to work on this, keep doing what you're doing. Cause another really common thing is like, is I don't really believe that they can make a lot of these things worse doing the things that they're doing. And by that, I mean, they can become more simple MADEC, but in many cases you're not actually making the situation worse. So if the symptoms seem to be not getting better or even getting worse, doing the things they're doing, they go come back to the pelvic floor therapist. And then that pelvic floor therapist also has a responsibility that the things I'm asking them to do, isn't helping them get there. Speaker 1 (00:35:29): You can try something a little more intense, still not helping. Then that's when I actually would refer for females, especially with like pelvic pressure. So Euro gynecologist for an assessment in that regard. Yeah. So I think I heard a couple of really important things there. And that's one, if you are the sports therapist or the orthopedic physiotherapist, and you have someone that needs pelvic health support, you can refer them to the pelvic health therapist and you can continue seeing them doing the things you're doing. So just because they're having incontinence or they're having some pressure, let's say it's a pelvis, pelvic organ prolapse. It doesn't mean stop doing everything you're doing. Speaker 3 (00:36:12): Okay. Speaker 1 (00:36:15): Correct. Okay. Yeah. It may mean modify what you're doing. Stop some of what you're doing, listen to the pelvic floor therapist. And I'm also seeing, well now we're, aren't we this great cause we're creating great team around this, around this person to help support them in their goals. So one doesn't negate the other. Absolutely correct. And I, and I think too often even, even within the PT world is people start to get kind of territorial. But it's not about what each one of us is doing. It's that person. Right. so telling them to stop doing something, especially if it's something they love it seems like a bad start. It's like, okay, let's take a look at this. Tell me what you are doing. Tell me what you want to be doing. Tell me what's happening when you do that. And let's see if we can change it. Speaker 1 (00:37:02): Cause like I said, like the, the other, that being something they're going to make worse and worse and worse is if symptoms get worse and worse and worse, but they're not causing damage, they're not causing, I mean, what they're doing and say leaking a bit. Got it. And now I'm going to take a slight detour here because you had mentioned pelvic organ prolapse. You had mentioned, there comes a time when, if that pressure is not relieving, you've tried a lot of different things. You would refer them to a urogynecologist now several years ago. They're so you're, you're a gynecologist. One of their treatments might be surgery. So there was pelvic mesh sweats. It's hard to say pelvic mesh surgery that years ago made some people better and made some people far, far worse with, with some very serious ramifications. So can you talk about that pelvic mesh mesh surgery and where we are now? Speaker 1 (00:38:04): Oh, the last bit cut out a little bit. So the pelvic mess, mess surgery and, and Oh, the most important part and kind of where we are now versus maybe where we were, let's say a decade ago or so. Awesome. Yeah. So, so the pelvic mesh situation certainly here, I think it's not a universal problem. I think it's a United States problem is if you're at home during the day, like most of us are now you will see law commercials, lawyers looking for your business to discuss the mesh situation on what's happening is there was there were, it was mesh erosion and the resulting fact that that was a lot of pain because they couldn't just take it all out. And it was several women suffered and are still sad. Speaker 3 (00:38:55): Mmm. Speaker 1 (00:38:55): But that was from a particular type of surgery with a particular type of surgical kit, which thankfully has, was removed completely from the market and isn't being used anymore and mesh surgeries, I would say at least for the last five to 10 years, haven't haven't been using that and mesh surgeries are being done with great success in resolving symptoms. So I think it's important that if a woman isn't responding Speaker 3 (00:39:27): Yeah. Speaker 1 (00:39:30): Well changing their breath or making a pelvic floor or changing how they're doing things is to have that discussion with the Euro gynecologist because they do have nonsurgical options for super mild prolapse. There are some even like over the counter options you can buy like poise has one where it's just a little bit of support that helps you. Actually not leak because if you're having too much movement of the urethra, it can cause stress or it can be contributing to stress incontinence. But so there's some over the counter things or there's something called a pessary, which I think about it. Like I'm like a tent pole, but it's not a pole. It's a circle don't worry or a square or a donut. There's so many different shapes, but it's basically something you put in the vagina and that you can take out of the vagina that just kind of holds everything back up where it belongs, so it can work better. Speaker 1 (00:40:21): And that it's not awesome. But there are also people who are like due to hand dexterity, or just due to a general discomfort with the idea of putting things in their vagina and living them there that they're like, no, I'd rather just have this be fixed. So, so there are, it's not just surgery is not your only option. There are lots of options and it just depends on where you want to go. But with the surgery, if that's what's being recommended for a woman, I really do. Some women aren't worried at all. They've heard about the mash, but they're sure it won't happen to them, but there are when we're still avoiding surgery, even with significant syndromes, because they're worried about the mesh situation. And I would still encourage those women to at least discuss us, to see if that surgeon can, can educate them and give them enough confidence before they move forward with the surgery. Speaker 1 (00:41:18): Because the worst thing I think is when I had one patient actually put it off for years. Not, not just because of the mesh because of a lot of issues, but the first time the doctor recommended it, she had a grade four prolapse. Like that means when things come all the way out. And she it was so bad. Like she couldn't use the pastory okay, so she needed it, but she avoided it until she was ready and had the answers that made her feel confident in that having the surgery was the right thing to do. So it might take some time and the doctor, the surgeon really should, and most of them that I've met are more than happy to make sure that the patient has all the information they need and understand the risk factors, the potential benefits before they move forward. Speaker 2 (00:42:03): Excellent. Thank you so much for that indulging that slight detour. Okay. Let's get into intervention. So there are lots of questions on Slido about it, about different kinds of interventions. And so let's start with lot of, lot of questions about transverse abdominis activation. So there is one question here from Shan. Tall said studies in patients with specific low back pain do not recommend adding transverse abdominis activation because of protective muscle spasm. What about urinary incontinence in combination? What do you do? So there is a lot on transfer subdominant as you saw in Slido. So I'll throw it over to you and, and you can give us all your share your knowledge. Speaker 1 (00:42:55): Okay, well, let's all do this together. So I don't know how many people are watching, but if we just sit up nice and tall and I'm going to give a different cue for the pelvic floor. So what I want you to squeeze, like you don't want to urinate, like you want to stop the stream of urine. Okay. So as we're pulling that in anything else other than the underneath contract, what did you feel Karen? Speaker 2 (00:43:24): Well, I did feel my TA contract. I felt that lower abdominal muscle wall started to pull in. Speaker 1 (00:43:32): Yes. So, so the, the way I explain it is that the pelvic floor and the trans versus are the best is to friends. And this makes sense when you think about when you remember the fact that the pelvic floor, isn't just there regarding like bowel bladder and sexual function. It's one of our posture muscles. So if we're totally like, like slacked out and our abs are off and all of that, our pelvic floor is pretty turned off as well. And then if I get a little bit taller and like, so I'm not really clenching anything. Right. But this is like stuff working like it should, my pelvic floor is a little more on, but not, I'm not acting. It's just but then I could like, right, if I'm gonna, if I'm expecting to hit, or if I'm going to push into something, I can tend to set up more and handle more force into the system. Speaker 1 (00:44:21): So I like to think about it in those in those three ways, because the pelvic floor, isn't just hanging out, down there and complete isolation it's, it's part of a system. And so in my personal, like emotional approach to interventions is I don't want them to be too complicated. So if I can get someone to contract their pelvic floor, continue to breathe and let go of that pelvic floor, then we start thinking about what else are you feeling? Cause I don't know that there's any evidence that says if I just work my transverses all the time, my pelvic floor will automatically come along for the ride. So a great quote. I heard Karrie both speak once at a combined sections meeting and she goes, your biceps turn on. When you take a walk, it's not a good bicep exercise. So just the fact we're getting activity in the pelvic floor when we're working other muscles, what's supposed to work. And also if you want to strengthen that muscle, you're going to need to work out that muscle. Speaker 1 (00:45:26): And that makes a lot of sense and something that people had a lot of questions around where we're kind of queuing for these different exercises. And I really love the can. You've made it several times comparisons to other muscles in the body. So can you talk about maybe what kind of queuing you might use to have someone on? I can't believe I'm going to say this turn on and I use that in quotes because that's what you see in, in a lot of like mainstream publications for, for layman. So it might be something that our patients may see when they come in. So how do you cue that? To, to turn on the pelvic floor? So honestly I will usually start with floor and I do if I'm able to do a public floor exam, that's usually, again, a lot more information for me, but I'm like, okay, so do that now. Speaker 1 (00:46:27): And I watched them do it or I feel them do it and I'd be like, Oh, okay. What did you, what did you feel move? And I start there. And then I always say it's a little bit, like I get dropped into a country and I'm not sure what language people are speaking. So sometimes excuse me, one of the first cues that I learned was like, so squeeze, like you don't want to pass gas. Okay. So everybody let's try that. So sitting squeeze, like you don't care and you got taller. So I think you did some glutes. Speaker 1 (00:47:00): It's like, OK. So like lift, lift your anal sphincter up and in, but activating mostly the back part. So if you're having fecal issues, maybe that's a good place to start, but most people are having issues a little further front. So then we moved to the, can you pick a upper with your, with your Lavia? I had a, I learned the best things for my patients. One woman said it's like, I'm shutting the church doors. So if you imagine the Lavia being churched doors, we're going to close them up. And that, that gives a slightly different feeling. Them then squeezing the anal sphincter. Now, if you get up to squeeze, like you don't want to like pee your pants, like you want to stop the stream of urine. That will activate more in the front of the pelvis. Look, men who are like if it gets stopped the flow of urine, I wouldn't be here. Speaker 1 (00:47:57): So what else do you get? What's really cool is in the male literature. So this is a study done by Paul Hodges is he found that what activated the anterior part and the urinary sphincter, this rioted urinary speaker, sphincter the most for men. What a penis or pull your penis in to your body now for women. So when I was at a chorus and it's like, so let's, let's think of like other cues and other words, but even if, so, I don't have a penis this fall that probably don't have a penis. Even if you don't have a penis, I want you to do that in your brain, shorten the penis and pull it in. Speaker 1 (00:48:42): And did you feel anything happen? Cause we do have things that are now analogous to the male penis, if you are are a female. So I'll sometimes use that. Like I know it sounds stupid, but pretend to draw on your penis and it works and it does feel more anterior for a lot of people. So I'll kind of just, I'll kind of see what's, like I said, sometimes it's like the 42nd way of doing it that I've asked them to do where they're like, Oh, that, and you're like yeah. So then also just another, it's a little bit of like a little bit of a tangent, but so as you're sitting, so if you're, if you're sitting I want you to pick the cue that speaks most to your pelvic floor, and I want you to slouch really, really slouch, and actually to give yourself that cue and just pay attention to what you're feeling. So when you squeeze, give yourself that cue, breathe in and breath out and then let go, we should have felt a contraction, a little hole and a let go. Now, the reason why I say breathe in and breathe out is if you breathe in and out, that's about five seconds and also you were breathing. Cause another thing people love to do when they're trying to contract their pelvic floors, just basically suck it in. Speaker 1 (00:50:10): And so that's, that's not great, but we want to feel the contraction and we want to feel it, let go. And that's super important. I think that was another question on the Slido is that yes. For any muscle we're working, you should be able to contract it and let it go. There's not a muscle in our body where I just keep it contracted. It's going to do much. It might look great. Eventually, but like I couldn't get my coat on, like getting a drink of water would be a little weird. It's not very functional muscles have to relax so that they can contract. So that's a big, yes, it's just as important that the contraction pelvic floor that cue and we felt where it happened, not tall, like, like you're sitting out at a restaurant and you just saw someone looking at you and you're like, Oh, what are they looking at? And then you're going to do the exact same cue and you're gonna breathe in and breathe out and let it go. Speaker 1 (00:51:07): And then did it feel different than menu or slouch that it did it change position? I feel like Karen's Miami. It feels different. Now what I want you to do is if you can, depending on how you're sitting really give me like an anterior pelvic tilt, really happy puppy and then do the exact same thing and then let it go. And so again, some more EMG work from, from Paul Hodges is that when you're in a posterior pelvic tilt, you tend to activate the posterior portion more, which is fine. And if you're not having problems in the front, if you're having problems activating and maintaining continence in the front, actually increasing that lordosis can favor the front a bit. So this is, that's really awesome when people can feel that difference. Because I want you to think about, if you start to leak on your fourth mile of a half marathon, there's no way, no matter how awesome you are, but you're going to be able to squeeze your pelvic floor for the rest of that race. Speaker 1 (00:52:15): Like there's just, there's no way. But sometimes if, because remember your pelvic floor is still doing its thing while you're running is if you're like, well, hold on, when you're at your fourth mile, are you starting to get tired or hopefully not if it's a half marathon, but you know, like is something changing and how you're using your body. And can you, when you get to that point, remember to stay tall or lift your tail a little bit, or is there a cue or something they can change that will help them favor the front instead of going about four steps with the contracted pelvic floor and then losing it anyway. So there's, there's a lot of different ways you can actually make that your intervention for the issue you're having and then let's just get it functional. Perfect. And since you brought up running a question that's been, got, gotten a couple of likes on Slido is how would you approach return to running after pregnancy? Speaker 1 (00:53:15): Do you have any tips on criteria for progress, timeframe and a recreational runner versus a full time athlete? Because I would think the majority of physiotherapists around the world are seeing the recreational runner versus the professional or full time athlete. So first, how would you approach return to running any tips for progress? So that's going to be after pregnancy, sorry. After pregnancy. Yeah. So this is where I was really excited. So just last year I'm going to say her name wrong, but Tom goom Gran Donnely and Emma Brockwell published returned to running postnatal guidelines for health professionals managing this population. And the reason why I was super excited is because even though it was just published last year, it's the first one. There was definitely a lot of emotion and feelings about, about women getting back into sport after having a baby, but to be perfectly Frank, there's very few actual solid guidelines for recreational or others. Speaker 1 (00:54:30): So I have not personally had a child, but I will tell you of all the women I've seen over the years, basically doctors are like, it's been six weeks ease back into it, see how it goes. I'm not really even mentioning if you have a problem come back so we can figure it out. It's just kind of like good luck with that. And as a result, what happens is a lot of women don't get back into exercise or they get back into exercise and and kind of freak themselves out because stuff feels different. So to get back to the question of what do I do, actually this this guide from Tom and team really, really helpful. I think, and, and it's just basically it's it does have a series of exercises that I've actually started to use with my postpartum moms to go like, look, if you can do these things without feeling heaviness, you're good. Speaker 1 (00:55:30): You're good to start easing back into your running program, but get up, get walking because I'm going to post Sandy Hilton and like, you can't rest this better, like just waiting, isn't going to make it all go away. But it can also be deceiving because again, with polo, you don't feel that heaviness and you don't leak. And so I'm just going to stay right here where everything is fine. So that's obviously not a good option longterm option for a lot of reasons. So, so what do I do? I do look at the patient's goals, their previous running history, and if they're having any options I recently had a patient who she was runner exercise or sr after baby number two for a bit, some feeling of happiness that got completely better, baby number three came along. So I saw her a bit while she was pregnant because she got, I think two thirds of the way through pregnancy before she started to feel that heaviness. Again, she was still running, Speaker 1 (00:56:38): Tried to see if we could change that feeling while she was running. And she could until about the, when did she start? I think she didn't stop running to her 35th week, which is pretty impressive. But then she wanted to do a half marathon. I think it was just three months postpartum. Right. So this is like going from having baby to running 13. You think that a lot of people would probably feel that was too soon, too much too fast, but she was able to do it completely symptom-free. So as she was training and she was really fast, she was timing it so that she could get back in time to breastfeed. Like I was like, Oh my gosh, like I, that would disqualify me. Like, there's no way I could run fast enough to make that happen. But she was able to, to work it out where she could perform at her level without symptoms. And I was really happy that I was able to support her in that she did all the hard work. For general people recreational, where you a runner before, or is this completely new and are you having any symptoms and is there any thing you're worried about? Again, a lot of women are worried about giving. Speaker 1 (00:57:53): It's actually really hard to perhaps to give yourself one baby babies are a great way to do it. But that's like the risk factors I look up for something else a couple of years ago, I haven't looked recently, but like you really have any prolonged lifting. So not like your CrossFit three days a week, but like your, your physical labor for eight, eight hours, 10 hours a day every day could eventually do it also having babies. So like once you get to every baby increases your risk of pelvic organ prolapse, which makes good sense. And that, and that is what it is. So kind of looking at what are their risk factors, are there any, and letting them know that if they feel it more, it doesn't mean they made it worse. They just made it more symptomatic. Got it. Great. Speaker 1 (00:58:40): All right. So we have time for maybe one or two more questions, and then I'm going to throw back to Claire. Cause we're coming up onto an hour here, maybe time for one more it's so w what am I going to ask? I think I'm going to go with the gymnasts I work with all believe it's normal to leak a little urine during training or competition. And this is something we talk about a lot. It might be common, but is it normal? You already gave me the answer. What is it, Karen? No, no, no. And so, yeah, so the, the short answer for that is no. Or I agree with the question where it is very, very, very common, and it is still, I would say, not to leak urine. Unfortunately, so there's any researchers out there who want to get together. Speaker 1 (00:59:26): Let me know. We haven't, we have information on athletes and incontinence, but mostly it's prevalent that it happens a lot and gymnastics and dancing and volleyball. There's, there's even some swimmers who have it, right? So there's, there's incontinence across the spectrum, which basically tells me, yep. People have incontinence. Some of the some of the sports are more likely to have urgent continents. A lot of them though, we're looking at stress incontinence, however, for none of the athletes, have, we really had a great study that says, this is what we're finding. We're thinking, this is the cause of this incontinence. And we certainly haven't gotten to the point where it's like, and this is what we should be doing for these women in particular. So I'm, I'm pretty curious as to what we would have to do as, as a profession, as, as a team with researchers to figure out what do we need to look at in these athletes, especially the female athletes, because most of these are also they've never had babies, right? So a lot of these athletes are the liberos. And so we can't, we can't blame them. There's something with how things are working. That seemed to be the situation it's not necessarily trauma or anything like that. So what do we need to look at? What do we think is happening? Can we measure it and assess it? And then can we get an intervention? Speaker 1 (01:00:56): My brain, obviously, something isn't working as well as it could. So could something like that improve their performance, even I don't, I don't know. I'd like to think so. Yeah. That would be distinct study. Yeah. But we ultimately don't know. So if anyone has any ideas for studies or doing studies, let me know, because I can't wait to read them. But I think maybe the first step is to let coaches and parents and young gymnast know very common. Don't be ashamed. Don't let it stop you from doing what you want to do. But also don't just ignore it. Maybe we can figure this out. Speaker 2 (01:01:30): All right. One more question with a short answer, if you can. So, and I'm going to ask this question because I feel like the person who posted this I think posted this in earnest. So that's why I'm asking, this is the last question. So a female patient age, 20 years still bedwetting from her childhood, otherwise she is normal, no incontinence. So other than this, just while sleeping, she tends to urinate any thoughts on this or any place you can direct this. Speaker 1 (01:02:04): Yeah. So I did, I was like, Oh, great question. And I did actually do a little research for this specific question. There's a lot of reasons why nocturnal enuresis, which is what bedwetting is called in the literature happens. And I think it's really important. So I don't know what kind of tests or studies this person has had done or what other issues they may be having. So things like sleep apnea is is something that could be related if there's any medications, any sort of diuretics, any kind of sleeping medications. Again, the fact it's kind of carried on since childhood, I, I would really wonder about how, how is the bladder functioning? The fact that it's working fine throughout the day makes me wonder what's changing at night. And I did find a study where it talked about when they look compared adolescents or adults who were bedwetting to people who weren't, they did have like detrusor overactivity. So like basically like an overactive bladder that they could see on the testing. So I would, I would really encourage this person to find a urologist that they trust if they haven't already and really to maybe investigate some of those other, other factors that could be contributing so that they can get some better sleep and not have that problem anymore. Speaker 2 (01:03:28): Excellent. Excellent. Oh, okay. Claire says we can go for one more question. So I'm going to listen to the boss here. Speaker 1 (01:03:36): And, Oh boy, are you ready? Because this is a question that did kind of get a lot of thumbs up. Okay. So we spoke about Speaker 2 (01:03:44): Briefly before we started. Speaker 1 (01:03:47): So let's see treatment of nonspecific, pelvic girdle pain, not related to pregnancy, which strategy with no susceptive pain mechanisms and which strategy with non nociceptive pain mechanisms would you incorporate with this patient? Okay. So I would say in the clinic, it's, it can be pretty hard. Like, I don't know how I would distinguish being nociceptive and non nociceptive or what even like non nociceptive might be if we're talking more central issues or stuff like that. I don't, I don't know. But honestly I would just look at, so in Kathleen's Luca has a great book about looking at the different types of pain or the different categories of pain and the most effective medications for it. Right. So we're really good in pharmacology. Like if you had this inflammatory process and, and inflammatory and anti-inflammatory should help, if you're having neuropathic pain, you want a drug that addresses that when we get into like physical therapy interventions, what's really cool is exercise is in all the categories. Speaker 1 (01:04:59): And it's one of the things we have the best evidence for. So regardless of pelvic girdle pain in pregnancy or not pregnancy, and regardless of how it may have been labeled by somebody else is I would, I would mostly want to know when did the pain start? Is there anything that makes it better? Anything that makes it worse and see if I could find a movement or change something for that person. Or that made me sound like I was going to do a whole lot of work. If I could find something for that person to change for themselves to have that hurt less and have the I tend, I would tend to keep it simple, mostly cause in the clinic again, we could do a lot of special tests that might say, Oh, Nope, they definitely hurt there, but it's still, if we're looking at what's going to be an effective intervention, that that patient is going to tell me what that is. Speaker 1 (01:05:54): Sorry. It would help a fire mute myself. So looks like we have time for one more. And I, I really, Claire was not clarity did not pop up yet. So we've got time for one more and then we're going to work. We're wrapping it up. I promise stroke patients, dementia patient. We just got the no go. Yes, no, it's a super short answer if you want Claire super short answer. Okay. So stroke dementia patients with urinary incontinence, any useful ideas for the rehab program? Yes, but not get an idea of their bladder habits, their bowel habits, their fluid intake. Because a lot of that's going to end up being outside caregiver help with the, with the stroke, it's much different. It depends on the severity and where it is and all of that. But for people with dementia is if you just get that, like if you can prompt them or take them to the toilet, a lot of the times that will take care of the incontinence. Speaker 1 (01:06:48): It's not a matter of like Cagle exercises. It's more management. All right, Sarah, thank you so much. I'm going to throw it back over to Claire to wrap things up. Thank you both for a wonderful and insightful discussion. Sarah and Karen. So many practical tips and pointers for the clinician, especially I was loving learning about all of the things that I could take to the clinic. So I hope our audience find those practical tips really helpful as always the link to this live chat will stay up on our Facebook page and we'll share it across our other social media channels. Don't forget. You can also follow us on Twitter. We're at Dow SPT. You can also follow us here on Facebook. Please share this chat with your friends, with family colleagues, anyone who you think might find it helpful. And if you like JSP T asks, please be sure to tell people about it at that what we're doing so they can find this here, please join us. Speaker 1 (01:07:46): Next week when we host our special guest professor Laurie from the university of Southern California, Larry is going to be answering questions on managing shoulder pain. We'll be here, live on Wednesday next week. So Wednesday, April the eighth at 9:00 AM Pacific. So that's noon. If you're on the East coast of the U S it's 5:00 PM. If you're in the UK and at 6:00 PM, if you're in Europe, before we sign off for the evening, there's also really important campaign that I'd like to draw your attention to. And it's one that we at Joe SPT supporting and it's get us PPE. So we're supporting this organization in their quest to buy as much a, to buy much needed personal protective equipment for frontline health workers who are helping us all in the fight against the coronavirus pandemic. So if you'd like to support, get us PPE, please visit their website, www dot, get us ppe.org, G E T U S P p.org as always. Thanks so much for joining us on this stale SPT asks live chat, and we'll speak to you next week. Bye. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Sandy Hilton, David Butler and Bronnie Thompson on the show to discuss persistent pain during COVID-19.  In this episode, we discuss: -Shifting current healthcare curriculum to better educate clinicians on persistent pain -Can passive modalities empower people to pursue more active treatment options? -How to create more SIMS during the COVID-19 pandemic -Can telehealth appointments adequately address persistent pain? -And so much more!   Resources: International Association for the Study of Pain Website Factfulness Book David Butler Twitter Sandy Hilton Twitter Bronnie Thompson Twitter   A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!                                                                      For more information Bronnie: I trained as an occupational therapist, and graduated in 1984. Since then I’ve continued study at postgraduate level and my papers have included business skills, ergonomics, mental health therapies, and psychology. I completed by Masters in Psychology in 1999, and started my PhD in 2007. I’ve now finished my thesis (yay!) and can call myself Dr, or as my kids call me, Dr Mum.   I have a passion to help people experiencing chronic health problems achieve their potential. I have worked in the field of chronic pain management, helping people develop ‘self management’ skills for 20 years. Many of the skills are directly applicable to people with other health conditions.   My way of working: collaboratively – all people have limitations and vulnerabilities – as well as strengths and potential. I use a cognitive and behavioural approach – therapy isn’t helpful unless there are visible changes! I don’t use this approach exclusively, because it is necessary to ‘borrow’ at times from other approaches, but I encourage ongoing evaluation of everything that is put forward as ‘therapy’. I’m especially drawn to what’s known as third wave CBT, things like mindfulness, ACT (Acceptance and Commitment Therapy) and occupation.   I’m also an educator. I take this role very seriously – it is as important to health care as research and clinical skill. I offer an active knowledge of the latest research, integrated with current clinical practice, and communicated to clinicians working directly with people experiencing chronic ill health. I’m a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences.   I also offer courses, training and supervision for therapists working with people experiencing chronic ill health.   For more information Sandy: 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.   For more information on David: Understanding and Explaining Pain are David’s passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI in the early 1990’s. David is an Adjunct Associate Professor at the University of South Australia and an honoured lifetime member of the Australian Physiotherapy Association.   Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley –  Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, Explain Pain Supercharged. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests.   Read the full transcript below: Karen Litzy (00:00:23): Hello everyone. And thank you for joining us today for this webinar. For those of you who are here live, you got to hear a little bit of pre-conversation which is great. And of course in that pre-conversation we were talking about all the things happening in the world today, specifically here in the United States with a lot of unrest and protests for very, very good reasons, in my opinion. And so we just want to acknowledge that and that we see it and that we are trying to learn, and we are doing our best to be allies to our fellow healthcare workers and citizens across the country and across the world for all of the other countries who have been showing solidarity. So I'm Karen Litzy, I'm going to be sort of moderating this panel of minds and I'm going to now go round and just have each of them say a little bit about themselves. So Sandy I’ll start with you.   Sandy Hilton: Okay. Hi, I'm Sandy Hilton. I'm a physiotherapist here in Chicago, Illinois with Sarah Haag. We have entropy physiotherapy and our clinic is predominantly working with pain. It's like a hundred percent of my case load is people in pain and about 80% of that is pelvic pain in particular. But I still see, you know, the rest of humans. David Butler (00:01:49): Hi, I'm David Butler from Adelaide Australia. I'm a physio, although I'm completely a professional and I believe everybody has the exact same role in treating pain. I'm trying to hire, but I can't retire. And then in world, our changing knowledge and our changing potential just keeps me, keeps me on track. So yeah, any sort of pain I'm happy to talk about. Bronnie Thompson (00:02:16): I’m Bronnie Thompson, I'm an occupational therapist by original training with some psychology thrown in, and I'm an educator and clinician as well, but a teeny tiny bit of research, but not much. And I'm a painiac and quite proud of it actually.   Karen Litzy: Excellent. So again, everyone, like I said, if you have questions as we go along, please feel free to put them in the Q and a part. And I will be looking at that as we're going through now, like I said, we've got some questions ahead of time, but before we get to some of the questions that some of the listeners and viewers have wanted to ask, I also want to just quickly acknowledge that we've got a bit of a mixed audience, so we've got healthcare practitioners and clinicians and we've also got people living with pain. Karen Litzy (00:03:11): And so as a clinician for me, it's a great opportunity. I think to address people in pain who maybe don't have the access or the ability to kind of get this information that's in their town or where they're living. So I am really, I'm really looking forward to this discussion, especially for those people that are watching that are living with persistent pain. So the first question I'm going to ask is and I'll ask this of all of you. If you were to give a piece of advice to a new professional or a healthcare professional that is sort of newly working with people with persistent pain, what would that piece of advice be? Sandy Hilton (00:04:11): I'm in Chicago. I'm just going to take it. I really like to stress, especially to students that, you know, we get this concept that the longer you've been in the field, the better you are at it. And, I think that maybe we make different mistakes, but everyone is learning this. And there's so much about pain that we're learning. And so if you're just starting in, I don't know that you might have an easier time because you have less bad habits to get rid of and can start with some of the better newer research and avoid some of the mistakes we made. Bronnie Thompson (00:04:50): So she's doing the popcorn approach. She looks at me. And so I think my advice would be, listen, listen very carefully to what people tell you and trust that they're telling you your experience. Don't try and read stuff into it, just listen and reflect, show that you're listening by reflecting what you've heard. So you can give that you've understood one another, because it's really easy to come out of school with all of this knowledge packed up and your brain thinking, Oh, I've got to do an info dump just like that. And it's not that great for the person, stop and listen. David Butler (00:05:37): They are lovely comments. I'd add. I would welcome anybody to the most new and exciting area of health. And there is a true pain revolution out there. And I would say to anybody, when you come in to just lift your expectation of outcome or what, might've been five or 10 years ago, because the clinical trials and our knowledge of the potential for humans to change is just increasing so dramatically. And I say, now we can say think treatment, not necessarily management because for many people recovery or some form of recovery is on the cards and what's leading the charge is the talking and the movement therapies. It's not the drug therapies for chronic pain. And, I just like to reflect as an older therapist now, patients who maybe 10, 15 years ago with maybe complex post pain surgery or Phantom limbs or complex regional pain syndrome would have thought, and I can't really help here. Now we welcome them through the door and you can get such pleasure, pleasure from treating these people no matter how long they've had the problem. Karen Litzy (00:06:48): Great. And, I would echo what Bronnie said is, you know, really listen and also believe, you know, they're giving you their experience. So try and take your bias out of it and believe what they're telling you and try not to talk them out of it because you see this quite a bit of, Oh, I have pain with this. And well, do you really have pain with that? Or is your pain really that much? And as the patient, it's very frustrating to have someone try and tell you what your pain is. So I'm looking at it from the person who has lived with the really chronic and at times debilitating neck pain is just listen, which is good. Believe them, and try not to talk people out of their experiences because it's very frustrating and it's very sort of dehumanizing for the patient, you know? Karen Litzy (00:07:54): And when I look back at when I first met David and went up to him at an APTA event and said, would you like to be on my podcast? And he said, yeah, sure, but I'm going to New York. I said, Oh, well, that's great. Cause that's where I live. And so then he met me at my, where I was working at the time and spent two hours with me. And I just, after that felt like, Whoa, like this is the first time that someone really listened and didn't interrupt and believed what I was saying and really set me on a path that just changed my life. Like, I don't know where I would be, had I not had that encounter with David. I think it was like 2011 or 2012. And so I always reflect on that and try and be that person, because I know what it felt like. Karen Litzy (00:08:45): And then when someone does come in and, and gives you their full attention and their time and their understanding, and then says, well, challenges your beliefs in a positive way, it was something for me that, you know, and I've talked about it many times that just completely changed my pain and my life. And so, you know, try and be that person is what I would say to people.   Bronnie Thompson: It's like, we've got to remember that people with pain and I live with fibromyalgia, those of you that don't know that's my reality, it's our experience and what it's like to live without pain. You know, what it feels like to know the things that sit at off things that settle it down and our relationship to it, to that pain and conditions. We come in with a whole lot of knowledge about other people and what we've seen. So we are experts and a whole lot of stuff, but what we're not experiencing as this person's life, their experience via what they're wanting from us even, what's important to them. And that's where when we meet and we can kind of share the hidden paradigms things that we don't know about each other, then we've got a chance to make a huge change and that as we know, I just feel so good about what I do. I just love it. I'm such a pain geek. Sandy Hilton (00:10:09): And I think the pain science or the science of pain really gives as a clinician, a lot of comfort to the listen to them, believe them, you don't have to prove it. You don't have to go. And like they say, I hurt here. You don't have to go poke it to reproduce the symptoms to believe it. And that's how I was taught of you have to reproduce the symptoms so that you can document that it's true. And it was like, that's a giant piece of unnecessary that we don't even have to do anymore, which really saves us a lot of time, not to mention establishing that trust and not being one more person. That's poked them in the sore spot. But, that's the thing that I was taught in school. Bronnie Thompson (00:10:58): So the question is, do you think that all chronic pain patients were not treated particularly when they were having the first or second episodes of their acute pain or are they in any way destined to become chronic pain patients? Well, my story is I hurt my back. I was what, 21, 22, doing a tango with the patient and a doorway patient was bigger than me. I landed on the floor on my back and I had all the best evidence based treatment at the time, maybe not, maybe not all the ultrasound, but you know, they didn't lie. They're really and relax a bit. Bronnie Thompson (00:11:48): But I didn't recover. I was then seeing the Auckland regional pain Center with amazing dr. Mike Butler, who is a rheumatologist and founded, and basically was one of the first in this initiations of bringing the international association for the study of pain to New Zealand, good friend of Patrick Wall knew her stuff very well. Gave me the book the challenge of pain to read. So essentially an explain pain paradigm back in the eighties, I know pain pretty well. My pain has not gone away. So there are some people who will not have a complete recovery of all of their pain, but because none of our treatments provide a hundred percent abolition of pain and actually I'm comfortable with it. I live with the pain and it gives me some stuff that some other people don't have access to. I know what it's like to have every bit of my body feeling really rotten. Bronnie Thompson (00:12:53): At the same time. I'm not limited by my pain. And I think sometimes we look at pain removal is that end goal. But I think our end goal is to help people live full, productive, satisfying, joyful and enriched lives. And some people will bring the pain along with them and many people won’t have to and that's amazing. Let's let the person make that decision about what is the most important outcome. But yeah, sometimes we can do all the right things, but if you have a spinal cord injury and you've got a smashed up spine, probability is that at the moment, our technology doesn't give us a solution. We can help, but we can't always take it all away.   Karen Litzy: David, what are your thoughts on that, that sort of movement from acute pain to chronic pain? You know, what are your feelings on that is, is like you said, are you destined to have it are I know, cause I get this question a lot from people like, well, you know, it started out with like an ankle sprain or it started out with a knee sprain and now it's turned into this. So did I do something wrong or was something not done? David Butler (00:14:12): I think you’re not destined to have it, but I think our treatment or therapies and the politics of treating acute pain probably gets in the way. And I also think if someone's hurt their back or any part of their body bad enough to see a health professional, the data is that 50 or 60 or 70% will have a recurrence in the following year. Now most health professionals think a recurrence is a reinjury, but if they really explored what happened, that reoccurance probably happened at a time when they would look at down and flat the immune system's a bit out of balance and they might've just done something simple, lifted up and picked something we would now from pain science, reconceptualize that as well, that's quite good. It's your body testing yourself out like a fire alarm with all the stuff you've been through in the past. It's no wonder your brain. Wouldn't want to play it again to check out how your systems are working, but that just simple piece of knowledge and usually should check to make sure nothing serious has gone on because you check and you can normally say, well, that should ease in a couple of days. That's an example of a little bit of knowledge dampening down. They don't have to go through the old acute process again of more, x-rays more tests, more power. David Butler (00:15:31): I think if that's correct, that observation was seen for many years, it could save governments Billions. Bronnie Thompson (00:15:37): Oh, absolutely. We've got a great thing. The language we use don't we, is it an injury or is it just a cranky body? David Butler (00:15:46): That whole linguistics? And for me and my treatment, you're now a physio by trade. I feel it says important to help someone change the story, to have a story, to take their experience out into society and let it go. That to me is as important as having healthy movement, although they obviously like go together. Sandy Hilton (00:16:07): I was gonna say that the saving of money for systems, for sure, but also the saving of time for people and the saving in our healthcare system. Every test you go do is going to cost you a lot of money. And, that time that it takes to get it in a time away from work and family and the concern of what the test results will be. If we can divert them wisely to not do that when it's not really indicated, that's just so good.   Bronnie Thompson: Yeah. And then I also for, you know, I've had a test now I'm going to wait for the results and now I'm going to wait for what are they going to do as a result of those results? And then, Oh, it's the same. And it just feels very demoralizing to people. And I think that's something we need to think about with make the decision about when and we to stop doing investigations often. That's the sense of the clinician worrying that something, are they going to sue me? It’s not a good way to practice.   Karen Litzy: Yeah. here's another, we'll do this from Louise. She says, picking up on something David had said earlier, how do we move towards being more, a professional? How do we move the pain industry toward this goal? Excellent question Louise. David Butler (00:17:51): There's a lot of answers to it, but a couple would be, I think you just got a quite badly out there would know sports trainers who could deliver an equally good management strategy to some physios, to some doctors, et cetera, right? This pain thing is across all spectrums, which is why the national pain society meetings are so good. And why everybody there is usually humbled and talks to all the other professionals because they realize the thing we're dealing with is quite hard. And we need all the help that that's a weekend get, but it ultimately comes back to provision of pain education throughout all the professions and that pain education should be similar amongst all the professions it's not happening yet. We've tried pushing it, but it's not out there. And it's incredible considering the cost of pain is to the world is higher than cancer and lung diseases together. Karen Litzy (00:18:51): Yeah. The burden of care is trillions of dollars across the world. And, you know, even in the United States, I think the burden of care of back pain is third behind heart disease, diabetes. And then it was like all cancers put together, which, you know, and then it was back pain. So, and, and even I was in Sri Lanka a couple of years ago and I did a talk on pain and I wanted to know what the burden of disease of back pain was in Sri Lanka. And it was number two. So it's not like this is unusual even across different, completely different cultural and socioeconomic countries. And, you know, David kind of what you said, picks up on a question that we got from Pete Moore. And he said, why isn't it mandatory that pain self management and coaching skills isn't taught in medical schools? Is it because there isn't expertise to teach it? Well, I mean, David's right here. He's semi retired. David Butler (00:19:58): Why isn’t that mandatory? That's a big, big question. I would say that the change is happening. Change is happening. I would say that at least half of the lectures or talks I give now are to medical professionals and out of my own profession or even more than half. So yeah, change is happening, but it's incredibly slow. It needs a bloody revolution, quite frankly. A complete reframing of the problem and awareness that this problem that we can do something about it and awareness that there's so much research about it let's just get out and do it now. Sandy Hilton (00:20:40): The international association for the study of pains curriculum and interdisciplinary curriculum would be a nice place to start. And I know some schools here in the States are using it in different disciplines to try and get at least a baseline.   Bronnie Thompson: The way we do it as the core for the post grad program, that I am the academic coordinator for it. Doesn't that sound like a tiny, tiny faculty. But anyway the other thing that we know is that looking at the number of hours of pain, education, Elizabeth, Shipton, who's just about completed. If she hasn't already completed her PhD, looking at medical education and the amount, the number of hours of pain, it's something like 20 over an entire education for six to six or more years. In fact, veterinarians get more time learning about pain then we do then doctors medical practitioners do, which suggests something kind of weird going on there. Bronnie Thompson (00:21:50): So I think that's one of the reasons that it's seen as a not a sexy thing to know about and pain is seen as a sign of, or a symptom of something else. So if we treat that something else in pain will just disappear, but people carry the meaning and interpretation in their understanding with them forever. We don't unlearn that stuff. So it makes it very difficult, I think for clinicians to know what to do. Because they're also thinking of pain is the sign of something else not is a problem in its own, right? Persistent pain is a really a problem in its own right. Karen Litzy (00:22:29): Yeah. And wouldn't it be nice if we were all on the same page or in the same book? I wouldn't even say the same chapter, but maybe in the same book, across different healthcare practitioners, whether that be the nurse, the nurse practitioner, the clinical nurse specialist, the physician, the psychologist, the therapist, physical therapist, it would be so nice if we were all at least in the same book, because then when your patient goes to all these people and they hear a million different things, it's really confusing. I think it's very, very difficult for them to get a good grasp on their pain. If they're told by one practitioner, Oh, see, on this MRI, it's that little part of your disc. And that's what it is. So we just have to take that disc out or put it back in or give a shot to this. Karen Litzy (00:23:25): And, and then you go to someone else and they say, well, you know, you've had this pain for a couple of years, so, you know, it may not be what's on your scan. And then the patient's like, who am I supposed to believe? What am I going to do? And, and you don't blame the patient for that. I mean, that's, you'd feel this that's the way I, you know, I had herniated discs and I say, you just get a couple of epidurals and the pain goes away and then it didn't. And I was like, Oh, okay, now there's so my head, I was thinking, well, now there's really something wrong.   Sandy Hilton: That's the problem. Because yeah, if you think it's the thing you did that helped you or didn't help you, then you lose that internal control. Karen Litzy (00:24:13): Yeah, yeah. Yeah. So I think, I think it's a great question and, and hopefully that's a big shift, but maybe it'll start to turn with the help of like the international association for the study of pain and some curriculum that can maybe be slowly entered or David can just go teach it virtually from different medical schools, just throwing it out. There is no pressure, no pressure. Okay. Speaking of modalities, we had a question. This is from someone with pain and it's what can be the appropriate regimen for usefulness of tens, for acute and chronic cervical and lumbar pain of nerve origin. So Bronnie, I know that you had said you had a little bit of input on this area, so why don't we start with you? And then we'll kind of go around the horn, if you will. Bronnie Thompson (00:25:24): I think of it in a similar way to any, any treatment, really, you need to try it and see whether it fits in your life. So if you are happy and tens feels good and you can carry it with you and you can tuck it in your pocket and you can do what you want to do. Why not just is, I would say the same about a drug. If you try a drug and it helps you and it feels good and you can cut the side effects, there's nothing wrong with it. Cause we're not the person living life. It's more to think about it in a population. How effective does this? And my experience with tens is that for some people it does help and it gives a bit of medium, like a couple of hours relief, but often it doesn't give long sustained relief and you have to carry this thing around. That's prone to breaking down and running out of batteries, right when you need it. So to me, it's agency, but then I put the person who's got the pain and the driving seat at all times to say, how would this fit in your life? Do you think you want to try this one out? It's noninvasive it's side effects. Some people don't like the experience and sometimes the sticky pads are a bit yuck on your skin, but you know, that's more bad. So yeah, that's my, my take on it. David Butler (00:26:44): I haven't used it for 40 years after the second world war. When you start to stop, when they, I was friendly with the guy who invented it and I'm thinking it'd be happy pet we'll would be happy to, with these comments that I agree with what Bonnie said. Absolutely. I would also say that, hi, wow, you have got something there which can change your pain by scrambling some of the impulses coming in. You can change it, let's add some other things which can change the impulses coming in or going out as well. So let's use that. Let's get you building something, maybe something repetitive or something contextual or something as well. So you you've shown change you're on the track. So I would use it as a big positive to push them on keep using it, but on the biggest things. Sandy Hilton (00:27:32): Yeah, the advantage is it's. So it's gotten so inexpensive. So for something that has minimal to no side effects and has the potential of helping them to move again, which I think is always the thing that we're aiming for. It's not very expensive. But now like several hundred dollars, right? You can order it online. Now you don't even need a prescription or approval or anything like that. Karen Litzy (00:27:59): Yeah. Yeah. That's true. And something that I think is also important is, you know, you'll have people say, Oh, those passive modalities, that's passive. You know, I had a conversation with Laura Rathbone Muirs. Is that how you say the last name? I think that's right. Laura. And we were talking about this sort of passive versus active therapies and, you know, her take on, it was more from that if they're doing these passive modalities, they're giving away their control. And, she said something that really struck and, kind of what the three of you have just reinforced is that no, they still have that locus of control. Cause they're making that conscious effort, that conscious choice to try this, even though it's a passive modality, they still made the choice to use it. Karen Litzy (00:29:03): And I think that coupled with what David said, Hey, this made a difference. Maybe there's some other things that can make a difference that I think that I don't think they're losing that locus of control, or I don't think that they're losing they're reliant on passivity, right.   Sandy Hilton: When they have their own unit and they're not coming into the clinic to have it put on you. And you lie there on the bed while you do it.   Bronnie Thompson: It's something that you have out in the world. It's not different to sticking a cold compress on your forehead when you're feeling a bit sick, you know, we did it. That's just another thing that we can do. So I see it as a really not a bad thing. And it is in the context, you know, if you can do stuff while you've got it on, then it's the hold up problem, as long as you like.   Karen Litzy: Great, great. Yeah. As long as you like it. Exactly. Yep. Okay. so we've got another question that we got ahead of time and then there's some questions in the queue. So one of the questions that we got ahead of time was how do we explain pain responses like McKenzie central sensitization phenomenon in modern pain science understanding. David Butler (00:30:35): I'd answer that broadly by saying that the definition that we've used and shared with the public in the clinical sense is that we humans hurt when our brains weigh the world. And judge consciously subconsciously that there's more danger out there than safety. We hurt equally. We don't hurt when there's more safety out there, then danger. So somebody who's in a clinic and is bending in any way and it eases pain. There will never be one reason for it. So it might just be, that might just be the clinic. It might be the receptionist. It might be all adding up. It might be the movement. They might've done one movement. And so, Oh, I can do that. And then all safety away, we go again, the next movement helps within that mix. There may be something structural. You've done to tissues in the back and elsewhere that might have eased the nociceptors that barrage up. But by answer will always be that when pain changes, it's multiple things are coming together, contributing to them. And they'll never never just be related to nociception. Sandy Hilton (00:31:49): I have to say this to say, I am not McKenzie certified. So this is my interpretation of that. I like the concept of you can do a movement. That's going to help you feel better. And we're going to teach you how to do that throughout the day. Maybe as a little buffer to give you more room, to challenge yourself a little more knowing that you'll have a recovery. And I just pick that part and use that.   Bronnie Thompson: I heard the story of how it all came about and it, and it's you know, it's an observation that sometimes movement in one direction bigger than another. And that's cool. It's like, you're all saying, let's make this little envelope a little bigger and play with those movements because we're beasts of movement. Bronnie Thompson (00:32:50): We just forget that sometimes we think we've got to do it one way. And you know, I can't tell my plumbers who crawl under houses. Look, you've got to carry things the way, you know, the proper safe handling thing. And I wasn't, I was the same safe handling advisors like me. But you know, there's so many ways that we can do movements and why can't we celebrate that? And the explanation, sometimes we come up with really interesting hypotheses that don't stand the test of time. And I suspect it might be some of the things that have happened with the McKenzie approach. It's same time. What McKenzie did that very few people were doing at the time was saying, you can do something for yourself that as we are the gold ones, that's what changed. David Butler (00:33:40): Bronnie, what's really helped us to start the shift away from poking the sore bit, come on, do it yourself. And, and I always give great credit to Robin McKenzie for that shift in life. Sandy Hilton (00:33:53): Yeah. And an expectation that it's going to get better. Right. David Butler (00:34:00): You think that’s showing something in the clinic that helps. Wow. Let's ride let's rock. Karen Litzy (00:34:07): Yeah. And oftentimes I think patients are surprised. Do you ever notice that Sandy, like, or David, or, you know, when you're working with patients, they're like, Oh, Oh, that does feel better. And they're just sort of taken aback by, Oh, wait a second. That does feel better and it's okay. I can do it. Yeah. And then you give them the permission to do so. And like you said, is it's certainly not one single thing that makes the change. But I think everything that you guys just said are probably the tip of the iceberg of all of the events surrounding that day, that time, that movement, that can make a change in that person. And I think that's really important to remember. That's what I sort of picked up from the three of you.   Bronnie Thompson: But the stories like that kind of convenient ways of, for us to think that we know what we're doing, but actually within what this person by what this person feels and how they experience it. And the context we provide us safety, security. And I'm going to look after you, that's, you know, changes, motivations about how important something is and how confident you are that you can do it. We can provide the rationale important part. The person ultimately drives that. So we can also provide that sense of safety and that I'm here. I'm going to hang around while you do this stuff. Let's play with it. Let's experiment. And if we can take that experiment, sort of notion of playing with different movements in, we've got a lot more opportunity for people in the real world to take that with them. We can't do that. Or forgive people are prescribed. You will do this movement. And this way perfectly I salute, but the old back schools, Oh, I know scary, And they did get people seeing the other people were moving. And that's a good thing that we can take from it. It's always good and not so good about every approach. Karen Litzy (00:35:11): Now I have a question for David and then out to the group, but you know, we've been talking about Sims and dims and safeties and dangers. And so for people who maybe have no idea what we're talking about, when we're talking about Sims and dims, can you give a quick overview of what the Sims and dims, what that is so that people understand that jargon that we're using? David Butler (00:36:40): Okay, it's a model we use. There's lots of other similar models out there. So basically based on neuro tag theory, the notion of a network that there's danger danger in me networks out there, and there's safety in me networks, rather simple, structured thinking here, and we've looked at these this has emerged due to the awareness, the pain science that we have a network in our brain. But me as an old therapist, when the brain mapping world came in and we realized, hang on pain, isn't just a little nest up there. There could be thousands of areas of the brain ignited indeed the whole body ignited in a pain experience. And one of the most liberating bits of information for me and my whole professional career, because what it meant was that many things influence a pain experience and a stress experience, move experience lab experience, and many things can be brought in to actually try and change it. David Butler (00:37:39): And all of a sudden means that everything matters. So this is where dims danger in me, safety sims in me, it was just a way to collect them. So an example of a dim with categorize them could be things you hear, see, smell, taste, and touch. So for one person, it could be the smell of something burning or looking at something or hearing something noise. The things you do could be a dim. It could be just doing nothing, but then there's Sims, gradually exercising, gradual exposure seems in things you hear, see, smell, taste, and touch could be going out. One of my most common exercises I now give somebody is to go down to our local market and find four different smells, four different things to taste, four different things to touch. And then they'll say, why should I do that? Because you can sculpt new safety pathways in your brain, which will flatten out some of them, some of the pathways they're linked to pain and it comes to of the things you say important. David Butler (00:38:37): You know, I can't, I'm stuffed, I'm finished. I got mom's knees. We try and change that language too. I can, I will. I've got new flight plans. I can see the future, the people you meet, the places you're with. So it's a way of categorizing all those things in life into either danger or safety, we try for therapy, we try and remove the dangerous. It is often via education. What does that mean? And we try and help them find safety and health professionals out there are good at finding danger, but we're not used to getting out there and finding those liberating safety things. And of course the DIMS SIMS thing. It's also closely linked in, we believe to immune balance. So the more dims you have, the more inflammatory broad immune system, the more sims you have, you move more towards the analgesics or the safety. And so it's the way to collect them. It's a way to collect as we try and unpack and unpack a patient's story listing to it within to unpack it and then to re-pack it again with them in a different way. Did that make sense? Karen Litzy (00:39:49): Absolutely. Yes. I think that made very good sense. And I believe you, there is a question on it, but I believe you answered it in that explanation. It says, have you had patients that cannot find Sims or it's difficult to identify and if so, how can you teach them what a SIM is? But I think you just answered that question in that explanation. David Butler (00:40:11): Once they get it. They're on their way. And we send people on SIM hunting homework. So for example, the same might be places you go, okay, if you can get out, just walk in the park or walk somewhere, then power up the SIM by feeling the grass, touching the box, spelling something. And we pair it up by letting them know that if you do that, your immune system gets such a healthy blast, that it can also help dampen down some of the pain response. Bronnie Thompson (00:40:39): And with regard to our current situation, sort of around the world COVID-19 and all the subsequent stuff. And also the situations in the U S at the moment, is it any wonder that lots of people are feeling quite sore because we’re eating this barrage of messages to us. And so I would argue that at the moment it might be worthwhile if you're a bit vulnerable to getting fired up with the stuff said, it's a good idea to ration, how much time you're spend looking at the stuff, not to remain ignorant, but to balance it with those other things that feel good, that make you feel treasured and loved and committed. And for me, it's often spending some time in my studio, walking the dog, going outside, doing something in nature. And there is some really good research showing that if you're out in the green world nature, that there is something that our body's really relish, kind of makes sense to me. Sandy Hilton (00:41:42): So taking that concept into what's going on right now, there's been a challenge clinically of the things that helped people balance that out, got taken away from them. Yeah. So it was a complicated it still is. It was a complicated thing where it wasn't your choice to stop going to the swimming pool because it made you happy and it gave you exercise and balance this out. Someone closed the pool and told you, you couldn't go. And so there's all different layers of loss in that and lost expectations and loss of empowerment and all of these things. So we have had to help people rediscover things that they could access that could be those positives. And that's been hard and really working my muscles of how to help people find joy or pleasure or happiness or safety in an unsafe environment to really get that on a micro level when you've lost the things that used to be there. And, it's been like a lot, but you can do it. It just takes concentration. David Butler (00:42:57): An important thing. That's so important. I think a question for therapists health professionals should be a sane question should be, you know, what's your worldview at the moment. And I would ask that, and it's usually not good, but I chat and have a chat. And actually I'd like to take people through some graphs that the world is not as bad as it really is. And if you look at I've been reading a book by Hans Rosling called factfulness. And really over time, our world is getting better. There's less childhood diseases, a whole range of things, getting better, bad, and bad things, getting better. This is a hiccup. This, for example, I had a musician recently and I had a graph I could show her that say that there's now 22,000 playable guitars to a million people in the world. But 12 years ago, there was only 5,000. All right, this is just one little thing. All right, cool. There's a lot of stats that show that our world is improving, you know, children dying, amount of science, a whole range of things. And this hiccup we have that I'm hopeful humanity can get, can get through, but just a little message I pass on is therapy. Bronnie Thompson (00:44:13): Even though we can't do stuff, we can't access places. What can't be taken away as our memory of being there. So it's really easy to take a moment to back a memory that feels good to say, actually, you can't take that one away from me. I might not be physically getting there, but I can remember it, feel those same feelings. And then being mindful.   Sandy Hilton: This is funny because if you look at Bronnie's background, that's one of the memories I've been using. When I lost the lakefront, I was like, okay, I'm just going to sit there and pretend that I'm not at that beach by that pier. So it's, it's fabulous. And even pictures or recordings of things that you've done before is like, okay, now there is still good stuff. I might not have it right here, but they're still good stuff. So that's really funny. As soon as I saw the picture, I'm like, yeah. And gratitude and just, yeah. Bronnie Thompson (00:45:05): The other thing as well, we've always got something that we can be grateful for all that. It might feel trite, you know, I'm living in winter, but I've got a roof over my head. I can have a damn fine cup of coffee and probably a nice craft. I'll at the end of the day, these are things that I can do and can have any way. So we can create the sense of safety insecurity inside ourselves without necessarily having to experience it. David Butler (00:45:38): Right. Just a quick comment. I would share that with patients who can't get out are saying the things you do when you're still can be as important as the things you do when you move. Right? So let's explore. If you can't do things, you can still really work you yourself with the things you do. And you're still calm. The introspection reading, thinking, contemplation memory enhancement, go through the photo album, et cetera. And I'd also like to always say to someone to link that in that is a very, very healthy thing to do to your neuro immune complex. Karen Litzy (00:46:13): And that sort of brings, I think we answered this question. This was from a woman who is living with chronic pain and at high risk with COVID-19. So how do we get past the fear of going out where people are crowding areas to get the exercise we need to maintain our fitness and muscle tone to reduce our pain. She said, even though I'm doing exercises and stretching, I've lost the ability to walk unaided on uneven grounds through weeks of lockdown. And the hydrotherapy pool is closed. She said, she knows, I need to get out and walk more, but shopping centers, which are the best place to find level floors are out. And a lot of places that she used to go are now very crowded because people are, don't have the access to gyms and things like that. Are health professionals able to suggest options when she lives in a hilly area with only a few but all uneven footpaths or sidewalks. And she has a small house. Sandy Hilton (00:47:18): That's the kind of thing that we've been doing since it's like, okay, let's problem solve this out. Because yeah, you have your carefully set way to get through this and then it's disrupted.   Bronnie Thompson: Yeah, boy, I like having lots of options for movement opportunities. So we don't think of my exercise, but we think of how can I have some movement today and bring that sense of, we are alike to be like, if I can imagine I'm walking along the beach while I'm standing and doing something and, you know, doing the dishes or watching TV or something that still can bring some of those same neuro tags it's same illusion, imaginary stuff activating in my brain. And that is a really, really important thing because we can't always the weather can be horrible, especially if you're in Christchurch and you can't go out for a walk. Bronnie Thompson (00:48:27): Yeah. But you know, we can think novelty is really good. So maybe this is a really neat opportunity to try some play. And I've been watching some of the stuff that our two chiropractor friends do with you put, let's put, at least try some obstacle courses and the house so that it's not we're not thinking of it as exercise. And I've got, do three sets of 10, please physios change that. Let's do something that feels like a bit of fun. There's some very cool inside activities that are supposed to be for kids. I haven't grown up yet. I'm still a baby. Sandy Hilton (00:49:16): Yeah. A lot of balance and things like that you inside that would help when you have your paths back outside. Yeah, yeah.   Karen Litzy: Yeah. Great. And then sticking with since we're talking about this time of COVID where some places are still in lockdown, some places are opening up. Bronnie and David are in an area of the world where they have very, very few cases, very, very few cases, Sandy and I are in a part of the world where we have a lot more than one. So what a lot of practitioners have had to do is we've had to move to tele-health. And so one of the questions David Pulter, I believe, as I hope I'm saying his name correctly is do we perceive that our ability to be empathetic and offer effective pain education is somehow diminished by a tele-health consult. So are we missing that? Not being in person.   Sandy Hilton: I have found it equally possible in person or telehealth cause you're still making that connection. We do miss stuff. We can't read the microexpressions in people as easily. So we as therapists have to work harder, but for the person on the other end, think about what the alternative is. Sandy Hilton (00:50:46): And it's been really cool for the people with pelvic pain, that every single time they've gone to a physio it's been painful. And on tele-health it's the first time she has been able to talk to someone about all of her bits and pieces without being afraid that it's going to hurt because there was no way to see somebody inside somebody's home.   Bronnie Thompson: You get to know something more about me. I've met more pets than ever thought. It was wonderful. This is a privilege that occupational therapists have had for a long time. And I'm so pleased that other other clinicians are getting that same opportunity, because we know so much more about a person when we can see the environment that they live with. That's just fantastic, but it's harder. David Butler (00:51:39): I find I've come back into clinical practice. I thought I was going to retire because I wanted to go, but also doing it. I was hopeless at first, but I'm really enjoying it. And I actually believe, I actually believe for the kind of therapies we're doing it's equal or better than face to face. Ideally, I think I'd like to have one face to face or maybe two but then to continue on with the tele health, particularly for people are in rural areas and it's almost no this kind of therapy was coming anyway, but the COVID has hastened it. So I found myself getting anecdotally here a much more emotional, closer, quicker link to patients by the screen. They were in a safe place. They're in their house. That's number one. They're not in a clinic you're there. And you can actually look at that face in the screen, as we're doing now, I'm looking at your faces, maybe one or two feet away, and I'm just keep looking at you. David Butler (00:52:46): And there's this connection, which is there. And there's also these other elements it brings in like, you start at 10 o'clock and you finish at 10:45. So there's open and closure, which isn't really there in some of the, in some of the clinics, the difficulty I'm having with it though is I was never in face-to-face practice a very good note taker. I used to make notes at the end. I was talking too much, but what you have to do here, my suggestion with face to face is you really need to plan and make your notes straight after. What did I tell that one on the screen, last clinical context, to sort of remind you of all the little juicy bits that we've got in the interaction. So it's really, for me, it's coming back to curriculum and mind you, I'm glad I'm not doing dry needling or just manipulating it with the talking therapy, but my suggestion is to have the habit curriculum. David Butler (00:53:44): So I've got my key target concepts. I know that I've addressed them in that particular session in the next session. I know I've gone back and I've done teach them the self reflection as well. Then to come back to see if I can get it all, or if I've translated my knowledge into something functional or some change. So I'm really, I'm really loving it. And I think there's something rather new and special with this, with this interaction. But maybe that's just me as a physio who sort of used to the more physical stuff. Maybe this is something more natural to the psychologist, its perhaps, but I'm with it. Bronnie Thompson (00:54:22): I’ve been doing the group stuff. And I found that has been, I've seen, I like it because they don't have to go and travel someplace. It does mean that we can offer it to people who otherwise can't get here. You know, they can't seek people, especially rural parts of New Zealand, low broadband is not that great in many parts as well. So it gets that it's an opportunity. I'd like to see the availability of it as an option. So we can use like we do with our therapies, we pick and choose the right approach or the right piece at the right time and the right place that doesn't have to be one or the other, like you said, you could see him a couple of times in person and then a couple tele-health and then maybe they come back again and then you do mix and match.   Karen Litzy: We have time for one more question here, maybe two. So David, this was one you might be able to answer it really quickly. As a practitioner, what is the utility of straight leg raise slump and prone knee bend test and the assessment of chronic back pain. Is it still relevant? David Butler (00:55:38): Oh gosh. Oh gosh. I'm going to dodge that question and would say it, it would depend on the client who comes in so I think those neurodynamic tests, which I still do. I think the main principle from them is you're testing movement. You're not testing a damaged tissue and anytime you're doing a physical examination, the deeper thing is the patient is testing you. You're not testing them. So what that patient, what that patient offers back in terms of movement or pain responses or whatever, depends on so many things. I might however, have a client and they are out there who do have maybe a specific stickiness or something or something catchy, whatever that may well, the scar around it might well be polarized by action, where I might spend a little bit more time taking a closer look at it. Now that might be relevant. Someone might have, for example, someone might come out of hospital and have had a needle next to the IV drip, next to their musculocutaneous or radial sensory nerve there where it's really worthwhile. Let's explore all the tissues here and see that that nerve can move or slide or glide. But in the second case, I'd made a clinical decision that we probably have issues out in the tissues, which are with a closer evaluation. That's a really broad answer. Karen Litzy (00:57:11): I think it's a tough question to answer because it, sorry, got a cat behind me. I felt my chair moving and I was like, what's going on? Just a large cat. So last question. So how to manage tele-health when the patients may be kind of embarrassed of their house or context or spaces or family it's very common in low socioeconomic patients. So they may not want to turn on their camera.   Sandy Hilton: Yeah. I've had that shaking well, and I've had people in their car or very clearly like I'm kind of angled cause there's a lot going on in my house and I don't have a green screen. So where it's like, and there's just a wall behind me and it's one of the reasons like I'll talk to him ahead of time of if I'm in the clinic, it's clearly the clinic, but I'll tell them I'm at my house. Sandy Hilton (00:58:12): Cause of COVID. So, you know, no judgment, you're going to see a wall and probably a cat and just kind of be up front in the beginning of this as a thing, I've had people that start with the phone on or turn it off or whatever, you just, you roll with it. But I have those conversations ahead of time, before we even do the call.   Bronnie Thompson: It's about creating a safe space for people. You know, if somebody feels, you know, was not having the video, it won't be that long before. I hope we've got some rapport and it feels better. I'm just, I'm doing a bit of a chuckle because the reason I've got my green screen behind me as my silversmith studio, which has an absolute shambles because it's a creative space. So I'm just disguising it because it's works. David Butler (00:59:07): There is something about delivering a story of some talking in the patient's room and there's cupboard doors open and you're looking in their cupboard at the same time. And you know, looking at that, then I just look at that thing. We’re safe here. Karen Litzy (00:59:26): Well, listen, this has been an hour. Thank you so much. I just want to ask one more question or not even a question, more like a statement from all of you that, what would you like the people who are listening and they're, like I said, there were clinicians, there were non-clinicians on here. And I think from the comments that we're seeing in the chat is very valuable and very helpful. So what do you want to leave people with?   Sandy Hilton: I'm gonna echo how I started. We're learning more every single week. I'd say, day but I'm not reading that often. So even if you've gone or you've treated someone and you couldn't quite figure out a way to help them, don't give up because there's more information and more understanding and more ways to get to this all the time. And I don't think you're stuck if you hurt. David Butler (01:00:26): I'd like to mirror those comments, explore the power of tele health, lift your expectations of outcome for those patients, people who are suffering and in pain, who are listening for those who are getting into pain treatment there's a science revolution and a real power in that revolution behind what you do. So just go for it. Bronnie Thompson (01:00:52): I think don't be hung up on with the pain changes or not, be hung up on does this person connect with me. We create trust. Am I listening? Can I be a witness? Can I be there for you? Because out of that will come this other stuff. There are some people whose pain doesn't get better. It doesn't go away. And that's a reality, but it doesn't mean that you have to be imprisoned or trapped by your pain. That means you develop a different relationship with your pain. And I think that's a lot of what we are doing is creating this chance to have some wiggle room, to begin to live life. That's what I'm looking for. Karen Litzy (01:01:53): Beautiful. Well, you guys thank you so much. And for everyone that is here listening, I just want to say thank you so much for giving up an hour of your time. I know that time is valuable, so I just want to thank you all and to Bronnie and to David and to Sandy. Thank you. Thank you. Thank you. And kind of on the fly. So I just want to thank you so much and to everyone. I guess the thing that I would leave people with is, if you're a clinician or if you are a patient, the best thing that you can do, if you are in pain is reach out to someone who might be able to help you, find a mentor, find a clinician, ask around Google, do whatever you can try and find someone who like Bronnie and David and Sandy I'll echo everything. You said that number one first and foremost, you connect with and that you feel safe with. You want them to be your super SIM, you know, like Sandy's my super SIM. Karen Litzy (01:02:48): So you want them to be your super SIM. And, if you can find that person, that clinician just know that that there can be help, you know, whether you're struggling as the clinician to understand your patients or your the patient struggling to find the clinician, I think help is out there. You just have to make sure that you be proactive and search for it. Cause usually they're not going to come knock on your door. So everybody thank you so much for showing up. Thank you, everyone who is on the call and to everyone who is watching this on the playback I hope you enjoyed it. If you have any questions, you can find us we're on social media and various websites and things like that. So we're not hard to find. 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

In this episode we break down: - What is Pelvic Health - Why you should be screening for it and how - What you can do to help those with pelvic health issues and much more! If you'd like to subscribe to PhysioNetwork Research Review, check out this link - https://physio-network.com/#a_aid=E3 If you'd like to subscribe to MASS Research review, check out this link - http://bit.ly/E3MASS 

In honor of the recent DPT and PTA graduates across the country we had some very special guests send us their ultimate message that they wanted to share with all PT/PTA graduates as they start their careers for a special commencement episode featuring: Ben Fung, Sandy Hilton, Sarah Haag, Zak Gabor, Stephanie Allen, Justin Moore, Greg Todd, Barbara Sanders, & Jeff Moore. Thanks to the Knowbodies podcast for creating this creative idea for an episode in the past!   The Knowbodies 2016 DPT Commencement Speech Episode            The PT Hustle Website Schedule an Appointment with Kyle Rice HET LITE Tool Anywhere Healthcare (code: HET)      

LIVE on the Sport Physiotherapy Canada Facebook Page, I welcome Greg Lehman on the show to preview his lecture for the Third World Congress of Sports Physical Therapy in Vancouver, Canada. Greg is a physiotherapist, chiropractor and strength and conditioning specialist treating musculoskeletal disorders within a biopsychosocial model.  He currently teaches two 2-day continuing education courses to health and fitness professionals throughout the world.  Reconciling Biomechanics with Pain Science and Running Resiliency have been taught more than 60 times in more than 40 locations worldwide. In this episode, we discuss: -Common misconceptions surrounding the source of pain -Do biomechanics matter? -Promoting movement optimism in your treatment framework -What Greg is looking forward to at the Third World Congress of Sports Physical Therapy -And so much more!   Resources: Greg Lehman Website Greg Lehman Twitter Third World Congress of Sports Physical Therapy David Butler Sensitive Nervous System Alex Hutchinson Endure                                                                      For more information on Greg: Prior to my clinical career I was fortunate enough to receive a Natural Sciences and Engineering Research Council MSc graduate scholarship that permitted me to be one of only two yearly students to train with Professor Stuart McGill in his Occupational Biomechanics Laboratory subsequently publishing more than 20 peer reviewed papers in the manual therapy and exercise biomechanics field. I was an assistant professor at the Canadian Memorial Chiropractic College teaching a graduate level course in Spine Biomechanics and Instrumentation as well conducting more than 20 research experiments while supervising more than 50 students. I have lectured on a number of topics on reconciling treatment biomechanics with pain science, running injuries, golf biomechanics, occupational low back injuries and therapeutic neuroscience. While I have a strong biomechanics background I was introduced to the field of neuroscience and the importance of psychosocial risk factors in pain and injury management almost two decades ago. I believe successful injury management and prevention can use simple techniques that still address the multifactorial and complex nature of musculoskeletal disorders. I am active on social media and consider the discussion and dissemination of knowledge an important component of responsible practice. Further in depth bio and history of my education, works and publications.   Read the full transcript below: Karen Litzy:                   00:00                Hey everybody, welcome to the live interview tonight with Doctor Greg Lehman. And we have a lot to cover tonight. So for everyone that is on watching, oh good. And we're on. Awesome. Just wanted to make sure, for everyone that's on watching and kind of throughout the interview, if you have any comments or you have any questions or you want to put Greg on the spot, feel free to do so. We can see your comments as they come up. Greg, if you can't see them, just know I'll kind of let you know. But one thing we do want to know is if you're watching, say hi and let us know where you're watching from. And that way when you start asking questions, at least I'll have a better, kind of know who you are a little bit. Now before we get to the meat of the interview, I just want to remind everyone that if you are watching this, this is not on my page and it's not on Greg's page, but instead we are on the Facebook page for the Third World Congress in Sports Physical Therapy and that is going to be taking place on October 4th and fifth in Vancouver, Canada. Karen Litzy:                   01:20                So hopefully we're going to be doing more of these throughout the year talking to a lot of the presenters and Greg is one of the presenters at the congress. So that's why he's here. Greg Lehman:               01:31                Not just me every time Karen Litzy:                   01:35                Although I have to say, I bet people would really enjoy that. Greg Lehman:               01:39                Yeah, I'll fill in for whatever speaker it is and I'll just learn their stuff and then pretend like I know Karen Litzy:                   01:46                Okay. So I'd like to see you fill in for Sarah Haag. Greg Lehman:               01:50                Done. I’ll shake my pelvis. Karen Litzy:                   01:53                Pelvic health and stuff like that. That would be amazing. I would actually wouldn't mind seeing that. Now before we get started, Greg, can you talk a little bit more about yourself, just kind of give the listeners, the viewers here a little bit more of a background on you so that they know where you're coming from, if they are in fact not familiar with you. Greg Lehman:               02:13                Okay. Well, leading into that, I'm a generalist. I'm not a specialist. I have a background in kinesiology and then a master's in spine biomechanics and I was really into spine biomechanics for a long time. But you know, I became not, sorry, I was going to say dissolutioned. That's a little too strong. I've always been skeptical, skeptical of everything that I've known, and that's probably why I got accepted to my master's in biomechanics because they liked the questions I asked. And then my research there was in mainly exercise, like EMG and manual therapy, what manual therapy does. And I was pretty lucky because I was with Stuart McGill and two chiros named Kim Ross and Dave Breznik, who I always have to mention. And I should give a big shout out to Stu because he took on Kim Ross Dave Breznik who were chiros at the time and they did like amazing research that challenged so much of what we know about, you know, spine manipulation. Greg Lehman:               03:19                And they also challenged me to think about what I thought about low back pain at the time. So my master's was really helpful for me because it challenged so much of what I thought. And so that's when I was first introduced to the bio psycho social, not actually first, cause I used to read John Sarno when I was like 19 years old. I was a bit of a nerd when I was a kid. But definitely the occupational biomechanics at Waterloo, even though they love biomechanics, even back then they knew that psychosocial factors were important for your pain and injury. And then I went to chiro school, actually I went to, that's like in quotes. I like was registered, but I didn't go to class, but I had a research program and they were awesome. They funded me to do more biomechanical research. Then I was in practice for a long time and then I went back to physio school and then I was in practice for a long time and didn't do a lot of research. And then I just started teaching with John Sarno who's running the conference with the running clinic and they were great. And at the same time I also started teaching my course which is about biomechanics and pain science. How do we like bring them together? And you've hosted me. Karen Litzy:                   04:38                I've taken that course. Yes. Greg Lehman:               04:41                For you is like an echo chamber. Just it was confirmation bias. Yeah, yeah, yeah. We know this shit, Greg. But thanks for confirming what I already know. And my course does that a lot, which I don't mind. So that's me. There you go. That was fun. Karen Litzy:                   04:56                Excellent. Very good. And, you know, just as a side note that I spoke to John Sarno a couple of years, like when I was in the middle of like all my neck pain, I reached out to him via email and he said, you need to call me. Greg Lehman:               05:11                Oh, interesting. Karen Litzy:                   05:12                So I called him and I spoke to him. I never saw him but I spoke to him and he was like, you're a young chickadee. I was like, what? And like crying and all this neck pain. I'm like, who is this guy? And he said, well, just get my book. Read it. If it doesn't work, come in and see me. Greg Lehman:               05:30                Yeah, that's funny. I had a patient, he was very famous, very rich, and he bought like a hundred of his books and gave them out to his friends. He thought it was amazing. Sarno was interesting because and this happens, this is the issue with biomechanics sometimes is he had physios working with him for a long time and then he realized that doing physical medicine conflicted with the message he was giving about where pain came from, meaning like predominantly emotional, I'm probably bastardizing my sense in a long time since I thought about them. And so, which is funny that he had the problem that I had for a long time and so many of us do where we think it's bio-psychosocial, but often our biomechanical ideas will conflict with their psychosocial. So we have to be careful in how we navigate all the multidimensional nature of pain. Karen Litzy:                   06:26                I think that's the important part is that it's multidimensional and that you can't have that pendulum swing too far in either direction. And you know, now that we're on the topic of pain, let's go in a little bit deeper, so what would you say are the biggest misconceptions or common misconceptions around pain and it's, I'll put this in quotes, sources, quote unquote sources. Greg Lehman:               06:53                Yeah. The biggest one. And I really like to focus on this because it helps me in practice, it's this idea that, and I like this cause it's how our practice is that we don't always need to fix people, right? And I kind of mean, I don't just mean that in the biomechanical way. And I would have meant that in the biomechanical way five years ago where I would have said, well, you don't have to fix that posture. You don't have to fix that strength or that weakness or we don't fix strength. We're gonna have to fix that weakness or tightness. And I believe that although I do think strength and weakness and range of motion can be relevant sometimes, but I also don't think we need to always fix catastrophizing and depression and anxiety and worry, and so that criticism goes both ways. Greg Lehman:               07:53                It started out for biomechanical with me, but I would also say psycho social and we see that in the literature where people recover and they still have these, you know, mediators of disability and pain. It could be high catastrophizing but they still do really well because maybe they built up their self efficacy and they got a little bit of control and they were able to do something and something to control their pain or do something that they loved or they had some sort of hope. And so that's the biggest one, that idea of like fixing and if you want to be more technical or mechanical, it's the same idea. Like I don't think you have to get rid of nociception. So like your tissue irritation stuff, you can have shit going on in the tissues, but it's how you kind of respond to that stuff. That’s exciting. Karen Litzy:                   08:45                Well why would want to get rid of nociception. Greg Lehman:               08:49                Yeah. Well I mean I don't, well I know what you mean. Like, we don't, you don't want to, cause when you sit down you want to get an ass ulcer. Right. You definitely want to move around. So, but that now we get into crazy stuff with that. Karen Litzy:                   09:03                Well do you mean the sensitivity around it? Greg Lehman:               09:05                Yeah, it'd be like you definitely don't want like a raging disc herniation that's pressing on a nerve root and you have chemical inflammation, things like that. It’s worthwhile getting rid of. But you know, other things, you know, you can have tendinosis and a muscle strain and it can definitely hurt. But it's the idea that sometimes maybe what our rehab does is helps us cope with those, with those things, right? That's at a peripheral level and more central level. You can have anxiety and worry and those might magnify your pain response, but you can also cope with them as well. And so I love that message because I think it's just positive. Like people think I'm so messed up, I got scoliosis, I'll never got pain. And I'm like, dude, like it might contribute. I don't think the research actually supports that. Perhaps. Perhaps it does, but you can have that and still be doing awesome. Karen Litzy:                   10:00                Right. So just cause you have chronic, let's say persistent pain or you've had pain for x amount of time, it doesn't mean that that should be the thing that defines what you do or defines whether you're happy or sad or anxious but that it's a part of your life that perhaps you can cope with or like in my case I had many years of chronic pain. Now I have pain every once in awhile. But there are times where it's more severe than I would like it to be. And there are times when I want to fix it or I need to fix it. And then there are other times where I feel like I can cope with it and it's not horrible. Karen Litzy:                   10:45                I think it's context dependent. So like I had pain last year, like pretty severe for like a week or so, and I knew that in another couple of days I had to get on a flight to go to Sri Lanka. And so I needed it. So what I did for myself was I decided to get medication to help bring those pain levels down and that's what I needed at the time. But I felt so guilty about it. I would like say is this the bio psycho social way? Is this the way I should be handling this? Greg Lehman:               11:20                I would think so. I’m going to mansplain you for a second. Cause I'm guessing that you knew that this was just a flare it was going to go away and that you've managed it before, but you're just giving yourself a break for a few days. Yeah. I don't think there's anything wrong with taking Tylenol for a few days. I've talked off topic, but it's how you do manual therapy, I don't do a lot of manual therapy, but I don't begrudge people that do. And it's, especially at an athlete level, I brought this up with some of the people who are going to be at the congress and I'm like, I find it ironic that all of us who teach a running course, none of us really teach manual therapy at our running courses and no one would ever say that manual therapy is a strongly evidence based, you know, modality for running injury. Greg Lehman:               12:16                It's not, we would all talk about load management and exercise and blah, blah, blah, blah, blah, all of these things. Yet when you're a physio or a chiro training like elite athletes and you're working with them the day before their competition, what are you doing? You're probably doing some manual therapy. And so I just found that ironic that we do that, that when we're traveling with the team, I don't travel with teams, but I do have athletes come to see me the day before an event or I've been working with them for months and here I am doing what people would call low value care. But I'm like, no, sometimes it's a bandaid, but sometimes bandaids help and that's the only solution. Well, the solution that works then. Karen Litzy:                   13:08                Well again, it's context dependent, right? So if, and I saw this conversation on Twitter about, you know, what are we doing race day and race day yeah you probably are doing some sort of manual therapy. Greg Lehman:               13:30                You’re treating that little niggle and this things tight and sore and you treat and people feel better. And if fatigue is psychobiological, which it is, then our intervention is probably psychobiological and it could certainly be more psycho based. Yeah. Karen Litzy:                   13:48                Right, right. It’s still real. And you know, in the context of athletes and being, this is the Third World Congress in Sports Physical Therapy. So there'll be a lot of, we can assume, I don't know, physios there that probably work with an athletic population. And so I think it's important to bring that up. All right. I digress. Greg Lehman:               14:14                I did, you were the professional. Karen Litzy:                   14:20                So one common misconception is that we don't have to fix everything and not just the biological part, but the psychosocial part as well. Is there any other, maybe one other common misconception around pain and its sources that you hear a lot or you see a lot? Greg Lehman:               14:40                I mean if I had to say anything, it's like it's the relationship between bio motor abilities, which would be like strength and flexibility and pain. I think that it’s over sold. You know, I don't think posture is relevant. I don't think strength or motor control is irrelevant. I just think it gets over done in that, that to me is that kinesio pathological model, which I have a big issue with, which would be like your knee goes into Valgus, you're going to pay for it later and you're going to get knee pain or hip pain. And, I'm like, well if your knee hurts and it goes into Valgus it's certainly a reasonable option to avoid that for a little bit. And then you might recover cause it's an avoidance strategy and build yourself back up and you'll do great. But I think what often happens is we then say, well, you went into valgus and it hurt, therefore valgus is inherently wrong and we need to make rules for everyone on how they should function. I hardly saw you when we were in Denver together, but I gave that whole, I forgot about that. We just saw each other, sorry, I was with Betty the whole time. I couldn't hang out with you guys. And so that I gave that example of limping, like when you sprain your ankle. Karen Litzy:                   16:06                That example was great. Greg Lehman:               16:08                Yeah. You sprained your ankle and it feels better to limp. That's totally reasonable. But no one would then conclude that we all should be limping. That that's the right way to move. When I see like people I really respect, like Shirley Sahrmann or Jill Cook who will, you know, say avoid hip abduction, right? It's so horrible on the tendon, on the outside of the hip or is so bad on the knee. And I'm like, yeah, it's reasonable for symptom modification but I don't want to make a general rule and that happens too much and then we're too quick to be like, well just cause someone got better with exercises that try to change those movement patterns. That doesn't mean that's why that treatment was successful. Often those rehab programs that try to change movement patterns are like amazingly comprehensive and excellent rehab programs. And then you have like awesome therapists like you know, Stuart McGill or Shirley Sahrmann who just like build in this graded self efficacy and pump them up and they tell them you can do whatever you like. Let's just change your movement patterns and start doing this stuff you love again, may have nothing to do with the movements. It's just like the person was like, wow, I'm awesome, you're awesome. Let's do it. Karen Litzy:                   17:26                I think you can’t sort of parcel out one part of that complete treatment program and say this is the thing that worked. This is why this worked. I mean, you can't do that. I think that's impossible. Greg Lehman:               17:37                No. And it's certainly the same with the people who I really love, like Peter O'Sullivan and that whole group when they help people, like I don't really agree. I'm such a jerk. I don't always agree with their mechanisms because when I see Pete treat, he's just so confident. It's like, you can do this, you can do this and bend over and do this and do this. And like, and I would never practice that way. I just couldn't pull it off. But I can imagine how much he helps people. That's actually why I really respect him. What he does really well. When he tests RCTs, he doesn't test himself. He trains people and other people do it. So, I actually shouldn't, I'm not knocking his research. I can't get to his style because he's so confident. It's absolutely really honorable what he does where he's like, I'm not going to be the dude that's in the RCT and train people and then we'll do the studies on them, which is just, that's nice science. Karen Litzy:                   18:34                Yeah, for sure. And all of those people you mentioned also have great reputations. People are referred to them when nothing else works. And so as the patient, you're like, well I know this person's the expert. Karen Litzy:                   18:49                Right. So I think in the patient mind they're thinking, if anyone can fix me, yeah, it's going to be this person. And I think that that also plays into it. Greg Lehman:               19:00                I just opened my own little clinic out of my house. We have like a little gym. It used to be a workshop and now it's a clinic gym and I have nothing on the walls. And I'm like, how can I placebo the hell out of this? So that's my answer. I like art. I want to put up like, no, I should put up like placebo shit. Like what was like going to make me look amazing? Karen Litzy:                   19:25                Yeah. Well you can put up like awards you've gotten put up your degrees. People will be like, look at how many degrees he has. Look at all of his qualifications. He must be amazing. Greg Lehman:               19:37                Yeah. Maybe, I don't know. Karen Litzy:                   19:41                You see that a lot in the US like when you walk into an office, the degrees and the licenses and certifications, right? Greg Lehman:               19:46                All that weekend certifications, all that nonsense. After I teach, I always tell everyone, like, whenever you want me to write on your certificate, I will write levels six fascial blaster done, master Fascia blaster. I don't care. It's all bullshit. Karen Litzy:                   20:03                Biomechanics. Does it matter? Greg Lehman:               20:07                Since the sport conference let's start. They definitely matter for performance. We got to listen to our coaches and the physios. But biomechanics and technique matter for performance. So if you want to tell someone to sit up straight, yeah, it's totally reasonable to do that if you're thinking how they're going to function 30 years from now. So that's great advice. And then, it's like a question of when they matter after that. And so I kind of Parse it into a few different areas of when they matter. The big one for me is like what's more important, is it's not how you move, it's that you're prepared to do what you're doing. So make the mechanics and the loads on the person matter. Greg Lehman:               20:59                But it's the movement preparation. So my pithy expression is preparation trumps quality, right? Something like that. And then the other way or the other area where they matter is this symptom modifications. So if it hurts to do something, like if you're a runner and your knees hurt and you heel strike and you have a long stride, it's totally reasonable to shorten your stride, maybe changed your foot strike, although that's debatable, but it could serve it is certainly is an option. And if it feels better, keep running like that. So the mechanics there help but it doesn't prove, you know, the thesis that there's a right way of running. It's just that you're running differently cause another run or you're going to be like stop forefoot striking and actually lengthen your stride. I've done that plenty of times. So you're just symptom modifying. Greg Lehman:               21:45                So mechanics help a ton for symptom modification. And then you know there's probably under high high loads, there's probably better ways for your tissue to tolerate strain. You know, like if you're landing and cutting you can go into valgus but you probably don't want to go into Valgus if your knee's not flexed. Right. So high loads where the tissue gets overloaded matters. And then after that with that principal there, it gets more difficult because you start thinking of the spine and you're like, okay, is there a better way for the spine to tolerate loads? And that's where we have been debating biomechanical principles here because certainly the bio does drive nociception sometimes. And so those are the big areas for me where biomechanics matters. Sorry I went over that fast. Karen Litzy:                   22:39                I think that makes perfect sense. And I mean, I don't know if you saw this since you are probably more into tumbling and gymnastics than I am.  I haven't seen this yet. But did you see yesterday a gymnast broke both of her legs or something. Greg Lehman:               23:01                I saw that by accident. I won't see it again. Karen Litzy:                   23:02                But I don't know what happened there. Greg Lehman:               23:07                I think it may have been in a double Arabian or a double front tack and she landed and then hyper extended. And what freaked me out a little, only saw it once and I'm not gonna see it again, is I don't think she landed with straight knees. They were like bent and then they went into extension like, which freaks me out because my daughter's learning front and I'm doing them with her front tuck step outs, and you kind of land on that one leg and it's straight ish. And I was worried of extending. Karen Litzy:                   23:46                Yeah. I mean I haven't seen the footage of that, so I was just wondering if that would be a time when biomechanics mattered or just an accident. Greg Lehman:               23:55                It certainly did. But here's the problem with all the biomechanics mattering stuff, is it the mechanics mattered and caused the injury. It's just whether you can prevent it. Yeah. It's like so many ACLs. Someone might cut 10,000 times with their knee in valgus. Well, that's proof of principle, that they're safe and then they do it one way that's slightly different and then they tear their ACL. But it doesn't mean that the way they were doing it before was unsafe because they could have had less valgus pattern before and then they could have done that too. Like, yeah, I don't know. It's difficult. Karen Litzy:                   24:34                Yeah, and I think when you're talking about injury prevention, I mean that's a whole other conversation. But I think that so many factors go into that as well. It's sleep, it's nutrition. It's what did you do the day before or was the beginning of the game, the end of the game? Are you fatigued? Are you not? I mean, so much can go into that. So yeah, you can cut 10,000 times and one time you have an injury. It doesn't mean that the way you did it was incorrect. It doesn't mean that the preparation leading up to it, it could have been that day. It could have been what you did the night before. I mean, so many factors and elements that go into something, some sort of accident or injury like that, which is why injury prevention programs are difficult. Greg Lehman:               25:25                Yeah. And, and we see them running, you know, like we've been saying the same thing for years. So you don't have training errors, which just means don't do too much too soon. And then you try to nail it down in the research and you say, well, what's too much and what's too soon? And then there's no real good research on that, right? Because there's so many different variables that influence that. So my joke tonight, we're arguing not we were talking on Twitter about this. I'm like, well, we can probably all agree when it's like just looks ridiculously like too much too soon. And that's the pornography test, right? Which is your old Supreme Court justice is either pornography or obscenity and they're like, I can't define pornography, but I know when I see it. And so when a movement pattern or a training load is pornographic than maybe you avoid it or depending on your personality. Karen Litzy:                   26:17                Right. Well, you mean it just gets a point where it's so obscene. Greg Lehman:               26:20                It's so obscene. You say, ah, that's probably some of them. But it has to be that and who knows? That's the worst part is there's probably people who can handle that obscenity. And I stopped this analogy because I dunno, they're built for it. They prepared to handle. Karen Litzy:                   26:41                All right. Let's talk about being a movement optimist. Yes. So for those of people watching and listening that aren't familiar with this, can you talk about it a little bit more and how this came about? Greg Lehman:               27:02                Well, I mean, I have already, I've already said all the good stuff I've run out of material. Karen Litzy:                   27:08                I can't, I can't even believe for a second. That's true. You're not like your greatest hits album. Greg Lehman:               27:18                I was in Denmark and they gave me this little bobble head that you've pressed the top of and the whole thing like bounces. And it's funny, I was in Scandinavia three or four years ago and they gave me the same thing. It's like this thing that I would get there, but it's called a hop to mist. I loved it. My kids have it anyways, so what it means is like we need to stop vilifying like certain movements. You know, like when you look at someone's skateboarding, their knees are going to cave in and it's amazing and it's a successful movement pattern. If you rock climb and you were just at a birthday party. Karen Litzy:                   28:01                I was  at a rock climbing birthday party yesterday for my 10 year old niece. Greg Lehman:               28:05                Well, I doubt they were doing it, but there's something called a drop knee, which is what I do on a climb is, is you can do it. I'm not doing it. You put your foot up behind you almost and drop your knee down into valgus and then stand up on that and you go into that. Karen Litzy:                   28:24                There are actually some more like real climbers there and they were doing that. There are a couple of people doing that move. Cause I remember my friend that I was with was like, oh my God, look at that person's knee. How is she doing that? Greg Lehman:               28:37                Yeah. And so Alex Honnold is a famous rock climber. They just won the Oscar for Free Solo Yosemite without a rope. But I have sometimes he's in another documentary about Yosemite. I've filmed it when he's in it because he sits like me. He's like super hunched forward with the super forward head posture. And here he is climbing, you know, these massive granite walls and that's a movement optimists, it says you can do all these weird funny things with your body and still be fantastic. You can be a paralympian where you're missing a limb than have induced, you know, assymmetry that you can have scoliosis and make it to the Olympics. You can have scoliosis and lift five times your body weight. And so that's the optimism. It's this revolt a bit against the kinesio pathological model, which to me is certainly has value. Greg Lehman:               29:39                It's certainly has treatment efficacy because I like the treatments that are associated with it, but the fundamental ideas behind it that there's like bad ways to move or better ways to move for injury and pain, that's what I would challenge. I'd be like, let's be more optimistic about how we move, you know, we don't have to always fix these things right now is go and anytime someone like me talks and says to people, all you can move this way, you always want to look for exceptions, right? When you're in practice, like, when should I, you know, disregard what I think, like when you know, when is how someone moves. Like when is that important? You know that and that'll help him be a better clinician. I think. I always challenge challenging whatever you think is true. It makes it difficult. Karen Litzy:                   30:40                Yeah. But I think having that as a clinician, having that sense of doubt is not a bad thing. Greg Lehman:               30:48                Yeah. I mean, I'm going to want to agree with you. Sorry. It was like, why am I listening to this guy? It's like, but then there's those clinicians that get people better by sheer force of personality. They have that utmost belief in what they do, even when they may be full of shit. And so that's how it was hard. Karen Litzy:                   31:16                I have a great example of that, I'm not going to go into it right now. Greg Lehman:               31:25                Now you also have to wake up in the morning and be happy with yourself, so. Karen Litzy:                   31:29                This'll be an easy one for you. What is the most common question you get asked by other physio therapists? If you could say whether it's maybe they private message you or at your courses or lectures. What is the most common question that other physios or healthcare providers ask you? Greg Lehman:               31:59                Oh, that's funny. I didn't read this one before, but a few things. But usually it's like what's the paper that you mentioned? And then I have to like come up with a name and I usually know it, but the bigger one is this is what I do with people. This is not what you talked about, but tell me why it's helping them. That's, what I get a lot, they want validation and then they want to like, you know, tell me their theories of things, but really tell me they want me to tell them why it's great. It's like what the mechanism is. Karen Litzy:                   32:47                That's why it's okay. Looking for just your confirmation. Greg Lehman:               32:54                Confirmation and then like, and then trying to like find out why it works. Like they want me to do the research behind it, I'm going to go. Okay. So what do you say? I mean it depends. Like I probably do like the motivational interviewing thing where I roll a bit with towards distance and I just probably, it's pretty bad, but I probably just read say are actually depends if I've met them before, I'll just talk about the general things that help pain and I'll say maybe it's working this way, but I don't, that's all I do if I think they're totally off base. I don't think I ever really say that. I don't know if I've ever done that. Karen Litzy:                   33:49                Now, and you kind of alluded to this in your answer there, but if you could recommend one must read book or article, what would it be? And if you want to say one book and one article, but just one. Greg Lehman:               34:06                Yeah. You know what I'd go old sounds funny saying old school, but I would read David Butler's the sensitive nervous system. So good. Yeah, it is. Cause it's not only good in like a pain, but if when you read that he's just throwing out little ideas all the time. Like it would be nice for me to reread and just pull out his anecdotes and like little things that he says to do because there's things that I do and I thought, oh, this is kind of neat. And I thought I'd discovered them myself. I thought I'd, you know, you know, found it myself and then I'm realizing here at, he said it 20 years ago or something like that. Yeah, yeah, yeah. That, and then like his former partner would been Louie Gifford and I've only read parts of his books, but I've read some of his other writings and I like his stuff too. But David Butler's the central nervous system, which is just, and it's what, 15 years old, but it's still plenty accurate. Karen Litzy:                   35:07                Yeah. Yeah. And for people who are listening or watching, I can plug that into the comment section, when this is done. All right, so let's move on to the conference. October 4th and fifth in Vancouver, the Third World Congress is sports physical therapy. So can you give us a little bit of a glimpse into what you're going to be talking about? Greg Lehman:               35:32                Not really. I am talking with Alex Hutchinson who's kind of a friend of mine here in Toronto, like the same kind of know those same people. Karen Litzy:                   35:46                You run in the same crowd. Greg Lehman:               35:53                Like, you know, like we rock climb together. We've been to some similar weddings. I've known Alex for awhile and I love his stuff and I always pump up his stuff in my courses. That's what's funny. And then when they put him with me, I was like, this is awesome. Because I always talk about the psychobiological model of fatigue, which is that fatigue is kind of a nice analog for pain. That it's not just purely physiology, that there's a psychology component to fatigue. And I'm like, Whoa, we should talk about this because look how this area of function relates to pain. But so we're talking together on like this massive nebulous talk topic of pain science and athletes. Karen Litzy:                   36:44                Yeah. Yeah. That's a heavy one. I listening to his book Endure right now. Greg Lehman:               36:48                Yeah. See I like the breath holding stuff in there. Karen Litzy:                   36:55                That's the chapter I'm on now, which I can't even fathom. Greg Lehman:               37:13                So go, go online and find David Blaine's breath holding stuff. He needs to have the breath holding record. He did. But he could also do like eight minutes without that. I used to hold my breath in church all the time to pass the time. But breath holdings interesting because if you just hold your breath right now, you might make it 30 seconds, but you can train yourself to make it for four minutes. And so within like a few days if not an hour. So it means your physiological reaction to try to breathe is way over cooked. And that often happens with persistent pain. We do this protective response. So I've been talking about breath holding for years and then Alex's book came out and I'm like perfect. Now I can refer people to that way better down. But so like finding analogs between weird things about pain and then interesting things about performance or breath holding is really nice. Greg Lehman:               38:04                So we've been talking, we were probably going to go rock climbing and then we're going to try to maybe come up with something that parallels each other. I will probably, I'm guessing talk about like how we, I like doing something really practical, like instead of saying this, which might have a negative connotation to some patients, like set them up to have some, you know, less than good expectations say this instead. So, you know, like the diet stuff, don't eat this, eat this. Well it would be the same idea with explaining common running injuries. Which we'll probably talk about, cause Alex’s a runner and I'm a slow runner. So mine will probably be something like that. Just met her way to phrase things. And because everyone always says to me like, okay, well what the hell do I do then if I don't tell them that they have SI joint pain cause it's out of place than what the hell do I say? No, no, not yet. Yeah, I think. And then that's really fun and it's a nice end. We'll have time to talk about it too because there'll be a lot of wisdom in the room and hopefully we'll maybe pull that out. Karen Litzy:                   39:22                Yeah, that sounds great. And I really appreciate those kinds of conversations because then I know that I can kind of take that and use that with my patient population on Monday. Or Tuesday, whatever day. But you know, the next day in clinic. Greg Lehman:               39:38                That's the idea. I don't want to hammer people with research. I know I won't do that. That's for sure. That's easy. I could do that. And it'll be entertaining by your life. Go. Well I got some more research, but it'll probably be more practical. Right. And we're real, more practical story. Karen Litzy:                   39:52                Nice. And I look forward to, you know, the two of you speaking together, I think we'll be entertaining and educational and I look forward to that kind of play that you guys will most likely have off of each other. I’m reading his book and you brought the bread holding, which is exactly where I am. And it reminded like in the breath holding chapter, you know, he said like the people who had like, who broke these records or who could really hold their breath the longest are the people who knew that someone was there to pull them up if they needed it. Yeah. And so when I think about that as it compares to pain, like especially persistent pain, I wonder if you knew like you had an out, would that pain still be as persistent? So that's what got me thinking listening to this chapter was like, hmm, if you knew your pain had a safety net, how would that change your view of your pain? Greg Lehman:               41:03                Oh, that's interesting. No, and I think what you're talking about has actually more ramifications for the negative aspects, right? Because most people think, oh, this will pass, but there's some that think that this won't pass. And Yeah. And that's why there is no optimism. And that's of building that where, there's no reason for them to think that it will change. And that's kind of what we have to do is build that model that there's a possibility for change. Karen Litzy:                   41:35                Yeah. And before we're going to wrap things up in a second, but Kate Pratt said, well, I find one of the greatest sources of misinformation to patients about pain and biomechanics is their MD/ortho. As PTs we hopefully consistently educate our patients. Do you think it's possible to educate MD’s or orthos regarding pain and how would you begin to approach such a scenario? So I think she means as the individual clinician with, you know, the referring physician or the physician who's seeing that patient. Greg Lehman:               42:11                Yeah. I mean in general, I think that's a problem across the board of all professions. How we change our colleagues, view the docs, like our colleagues. And I'm not really sure cause you would assume that has to happen at a school level, right at the training there and at a conference level. So it's really conferences in schools who are open to, you know, providing the different messages there. But I would say, and we've talked a lot about this is when you do have patients who have these beliefs from their doctors or other healthcare providers, which is super common, there are routes that you can, you know, still address those beliefs without throwing the doctor under the bus and that’s what you have to figure out. So often it's more like acknowledging yeah, that's, you know, you have hip pain because he has OA or something you can say that's part of it. Greg Lehman:               43:15                This is the my optimism approach. Yeah. The hip OA is part of your hip pain, but you can still do great even though you have those changes on the scan. And that often really helps, especially with when physios and like we're navigating referral sources. And it's so funny that you bring, I just got, I just like 10 minutes ago before we started, I got a referral from a sport MD who was in the course. I taught with JFS school. On running five years ago and said, are you seeing patients? And like it was so funny that she was in the course because you don't normally see MDs. Yeah. You know, taking courses with the PTs. Great to do that. And so that's how we have to change. You use it somehow get into that educational system. Karen Litzy:                   44:01                Yeah, I agree. And from a one on one. I think it's difficult. I mean Karen Litzy:                   44:11                What I've done once that worked with the referring physician was, you know, I said, hey, you know, we're doing this, this, this and this, but I found this article, do you want to take a look and let me know what you think? Cause I'm thinking of incorporating it. And it was like an, I don't know, I think it was an article, Moseley or Peter O'sullivan. And so I sent them that and then he was like, oh yeah, that's really interesting. Yeah, definitely start doing that. So that's a way you can kind of maybe start. Greg Lehman:               44:44                Yeah. O he or she just rolled with your resistance maybe. No, I totally agree. Yeah. I think we're good. Karen Litzy:                   45:00                It's so hard, but it's a way to be diplomatic. It's a way to say, you know, I don't know. Greg Lehman:               45:08                I really liked that you just sold a good treatment plan and then you gave them other research behind it. That's nice. Yeah. That's probably better than saying you're an idiot. Karen Litzy:                   45:20                Yeah. Well, yeah. But I mean I also find that like I had one doctor that came back to him and he's also a good friend of mine. He was like, that's really interesting. Like we need to talk more about it. Oh, that's cool. Which is awesome, you know? But he's also a friend began, you know, we played softball together. So it's like the different opinions. Karen Litzy:                   46:01                Chris Johnson said to say thanks for carving out the time you need to stop picking your eye. Always exercise diplomacy and avoid creating a disconnect. It doesn't accomplish anything. And that's in regards to Kate's question that we just tried to answer. Like I'm bringing a course to New York City and we're going to have like a free two hour preview of it and just invite doctors. Greg Lehman:               46:44                Wow. Karen Litzy:                   46:45                That's, you know, one way to do it if you want to get them involved in the educational process with Physios, which I think is great. Greg Lehman:               46:52                One of my best course ever in Toronto here was, we had three physiatrists that came and they were fantastic. That's awesome. Go into this stuff. It was a bit, some of it seemed a bit new, but they're open and like, and then the email to everyone after and they share their experiences. I love when you have multi disciplinary people at the course. There are some, I mean I'm not throwing MDs under the bus. They certainly, it's so hard. I have a friend who was an MD and he's like the best motivational interviewer. He was so good. Like he knew this thing is that as patients had to do, but you know, in Canada you only have eight minutes with them. Yeah. And there or whatever. Anyways, so I'm off topic. Karen Litzy:                   47:42                So let's wrap things up here. Are there any presentations you're looking forward to seeing at the conference? Greg Lehman:               47:48                Rob Whiteley. Yeah. I really like is like career and that the stuff he's done and what he's doing there, you know. I'm a socialist I like exercise for everybody and I like the name to change things. But I have trouble like arguing with exercise. It's amazing. It's jam packed like there, there's so many. So that's one of the reasons I wanted to go cause you know, I would have, it'd be nice to go to that conference as well. Karen Litzy:                   49:22                Well, I am looking forward to your talk with Alex. I will obviously finish his book within the next week, so that's very exciting. And I've already taken your class and read your free resource. So I feel like I'm like ready for it. Greg Lehman:               49:39                I'll bring something new. Karen Litzy:                   49:42                I'll come armed with lots of questions. All right. So before we hop off, where can people find you? Greg Lehman:               49:49                Just my website I guess, which is Greglehman.ca. Which I hardly do anything on and then Twitter, same thing. Twitter is my favorite. I like the discussions on Twitter, even cultivate them, trying to keep them polite and nice and you know. So Facebook, Nah, it's for the trolls. Karen Litzy:                   50:15                I think. Yeah, I guess it depends anyway. Again, a whole other conversation. Yes. Greg Lehman:               50:21                No, I'm doing a big thing on Facebook right now. I shouldn't say that. Greg Lehman:               50:29                Yeah. Cause we have like a podcast with me and Oh, I have a podcast, I guess. Never. It's, well it's Adam, it's Meakins podcast, but I'm the cohost so I guess is mine. I don't know. When do you get part of that? I've done three with them. I'm just baggage. I'm a carry on. Karen Litzy:                   50:52                Yeah. I think, I think you need, you need a little bit more. I don't think that three really qualifies as like a permanent cohost. Greg Lehman:               51:01                Oh yeah, yeah. I don't think I want that. Karen Litzy:                   51:03                No, no, no. You're still like a guest cohost, give it a couple more and then I think you're in. Greg Lehman:               51:08                Okay. Well we're doing like a thing on neurodynamics like their dynamic techniques. And so I wanted to poll people and see what people thought. You know, I was curious what people thought, what the hell we were doing when we do them for that. Karen Litzy:                   51:27                I use them, I use them. And oftentimes in people who are a little fearful of movement. Greg Lehman:               51:33                Yeah. So what does that tell you what you're doing? Or you really like manipulating the nerve to, you know, feed them more oxygen or something. Getting someone moving again? Karen Litzy:                   51:45                I think you're getting someone moving again, I think you're taking them to a place where they can stay within a relative comfort zone and you can kind of see, I think what I use it is because you can see some changes pretty quickly. And so I think patients then get a little more confident that they can move because they can see those changes pretty quickly. So that's why I like to use them is to give people some hope. Greg Lehman:               52:15                It’s a modification. Karen Litzy:                   52:18                So that's why I use them, but I use them quite a bit just because I think, I think that they work very well. The only time I don't use them was really with like one person who said I was doing all these nerve glides and now it made my arm so much worse. Greg Lehman:               52:37                It's like everything. Karen Litzy:                   52:38                You know, but I don't know how many, what they were doing, why they were doing them, what explanation they were given. I have no idea that I just sort of held off for a little bit and had the move a different way. But yeah. So that's why I use them. Karen Litzy:                   52:59                So if no one else has any questions. So Agnes said that she'll play softball with me in Vancouver. Greg Lehman:               53:08                Tell her I’m going trampolining and rock climbing. Karen Litzy:                   53:15                I would go trampolining but I really just like bungee trampoline. Greg Lehman:               53:19                Let's do stuff. Karen Litzy:                   53:20                Well you're attached to a bungee and then you obviously go down and then you can go up and flip like two, three times in the air and come back down again. You can't twist, but I did do a double layout. Yeah, it was pretty cool. But yeah, I would definitely play softball. I will bring my glove and I can do some trampolining. I wouldn't have done it 10 years ago or five years ago because of my neck, but now I can do it. Yeah, totally can. Karen Litzy:                   54:14                Just so people know when Greg and I were at the align conference a couple of weeks ago in Denver, Colorado and he had his daughter Betty with him cause it was her birthday weekend and she was his personal photographer just so that it made him look better than everyone else because he had personal Paparazzi. And she was just super adorable and doing back walkovers and she probably would've done a lot more, but we were at a conference on the first day. Karen Litzy:                   55:21                She was very sweet and that's who we're talking about. All right. And I’m going to edit all of this out before I put it out on a podcast. Thank you everyone so much for listening and sorry for rambling at the end. If no one else has any questions, I just want to thank you all for listening and make sure you go and click on the link on this Facebook page. Should take you to the website for the Third World Conference in sports physical therapy. Again, it's October 4th and fifth, and Vancouver. Greg is speaking with Alex Hutchinson and I think that's going to be a highlight of the conference. You don't want to miss it. So Greg, thanks so much for hopping on the call and sorry for the technical difficulties. Thank you so much and we'll try and put all the information that we spoke about in the comments section here. So thanks everybody. And Greg, thanks again.     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!

Today, I chat with musician Sarah Haag about her education and career in music, playing percussion and recently taking up the dulcimer. Links: Resonate 150 You can also find them on Facebook, Twitter and Instagram Dulcimer player Ted Yoder A website devoted to the memory of Rich Mullins Masterworks Hammered Dulcimers

Dave Wensits and Sarah Haag, Indiana Folk Music and Mountain Dulcimer Society, join me to chat about the 2019 Eagle Creek Folk Festival! For more information, including the festival schedule, visit https://indianafolkmusic.org/folkFestival.html or https://www.facebook.com/events/257147641630115/?event_time_id=257147654963447

Physiotherapist Dr. Sarah Haag joins me to talk about the important role all health professionals play in assessing and treating people with urinary incontinence. She discusses tips on how professionals can help in assessing, treating and when to acknowledge your limitations and refer on. We also have a tangent chat about abdominal separation (diastasis rectus abdominis). Thank you so much to this episode's sponsor - Kenhub - see below for deals For a 20% discount on on all Kenhub Premium learning plans: khub.me/loriforner For a 20% discount on illustration licenses - quote "Lori Forner" when emailing Kenhub to enquire at contact@kenhub.com Understanding and Treating Incontinence - book by Sarah Haag

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Jason Falvey on the show to discuss healthcare fake news.  Dr. Jason Falvey is a physical therapist working as a post-doctoral research fellow at Yale University in New Haven, CT.  Jason’s research interests focus on improving post-acute care quality and outcomes for older adults recovering from major medical events, such as surgery or critical illness. In this episode, we discuss: -The definition of fake news as it relates to healthcare and medical disinformation -What Jason recommends you do when you encounter articles with a high comment to retweet ratio -How you can avoid falling trap to your biases by crowdsourcing to interpretate literature -The importance of seeking information not affirmation -And so much more!   Resources: NY Times Fight Fake News Why Healthcare Professionals Should Speak Out Against False Beliefs Jason Falvey Twitter Jason Falvey Yale Email: jason.falvey@yale.edu  The Outcomes Summit, use the discount code: LITZY For more information on Jason: Dr. Jason Falvey is a physical therapist working as a post-doctoral research fellow at Yale University in New Haven, CT. He holds a bachelors degree in English, and a doctor of physical therapy degree from Husson University in Bangor, Maine and a PhD in Rehabilitation Science from the University of Colorado, Anschutz Medical Campus.  He is also a board-certified geriatric clinical specialist. Jason’s research interests focus on improving post-acute care quality and outcomes for older adults recovering from major medical events, such as surgery or critical illness. To date, Jason has authored or co-authored 18 peer reviewed papers in widely read rehabilitation journals.   Read the full transcript below: Karen Litzy:                   00:01                Hey Jason, welcome back to the podcast. I'm happy to have you back on even though we're not talking about what we usually talk about when you're on these podcasts and we have our specials with Sandy Hilton and Sarah Haag but I think this is still a really great topic and I'm happy to have you on to dive into it. Jason Falvey:                 00:24                It’s great to be back and I have been excited to present this topic for a couple of months. While it’s no sex podcast part five I think we can definitely got come up with some interesting points for the audience. Karen Litzy:                   00:37                Yeah, I think so too. And so everyone today we are talking about fake news as it relates to health care. Because I know a lot of you that are listening are in the healthcare world and if you're not, this is also a great way for you to kind of understand that everything that you read on social media isn't true gasp, right. So, Jason, let's talk about first, what in your opinion, is the definition of fake news as it relates to healthcare and let's say medical disinformation? Jason Falvey:                 01:19                Yeah, I like the term medical disinformation because fakes news is not nearly as common in medicine, you know, as far as the falsified information. But medical disinformation is much more common than people may realize. The context is most of the hundred shared articles of last year, over 50% of them are of poor evidence quality when experts have actually rated that. So when I talk about fake news and medical disinformation, I'm really kind of breaking it down to a handful of categories. So there's fake news that's rare, but it does happen that's false or completely inflammatory, you know, that is completely falsified data, or completely false claims that are created to either scare somebody into making different health care decisions or drive them towards a curative product that may be your marketing. So that’s not common, but that definitely is out there. I think the more common pieces of fake news and medical disinformation are hyperbolic and intentional. Jason Falvey:                 02:34                So the splashy headline that says Bacon Causes Cancer, you know, where people are putting that headline so it’s clicked on and read when the real story behind a lot of that evidence is substantially more nuanced. And then there's also hyperbolic and unintentional where a well meaning university employee publishes a press release on investigators article and misstates or over-interprets the conclusions to be much broader, more sweeping than they are suggesting that a drug cures cancer or Alzheimer when really it was affective in early stage studies for one particular protein in a mouse model. So those are the three definitions I tend to stick with, but really it's medical information that's not fully accurate, that’s shared widely and may influence healthcare decision making. Karen Litzy:                   03:32                When we talk about these flashy headlines and this medical disinformation whether intentional or unintentional, as healthcare professionals, sometimes we're responsible for sharing that. It's not just the lay public. Right. So when you look at these headlines and you read through let's say a press release, is that where it ends? Do you say to yourself, yeah, this sounds good. I'm going to share it. Jason Falvey:                 04:05                I think that should be the focus of what we talk about today and that is how do we as health care providers recognize fake news? How do we kind of avoid unintentionally sharing it and how do we avoid intentionally sharing it? So I think my guiding principle for all of these things, for any healthcare professional, it's Hippocratic oath, it's do no harm. And then health care beyond what we do with patients and beyond the hands on care that we provide sharing misinformation, whether intentionally or unintentionally has the potential to cause harm. Patients for going standard of care treatment and in lieu of an alternative medicine or unproven other therapy that may actually cause their health to decline, you know, or causing them to participate in a treatment that is unlikely to benefit them and causes harm both financially or time and potentially health care harm. So I think Hippocratic oath above all else should really drive our decision making and the impetus for why we should care about this. And the other guideline I use is I really want patients and providers both to be looking at social media and healthcare information that they're sharing and really make sure that they're seeking information, not affirmation. So they're seeking to broaden or challenge their pre held assumptions and not just share things, read things and kind of propagates a worldview that just affirms that are already firmly held biases to harm a patient. Karen Litzy:                   05:58                Okay. Yeah, but so you mean we can't cherry pick things to confirm our own biases to make ourselves look better? Is that what you're trying to say here? Jason Falvey:                 06:16                Yeah, that sounds like a terrible polarizing thing to say, but I'm really going to stand by that I think and just say I really don't think we should be cherry picking evidence and just sharing evidence that is fully supporting our world view. We may have a brand to keep, you know, I don't think I would widely share studies that I think are well done that maybe say physical therapy isn't as helpful as other things, but I certainly would acknowledge that they exist. I don't think I would market them heavily, but I certainly wouldn't ignore them or basically say that they're not accurate either. But I think we have to be really careful, especially when we're talking about vulnerable patient populations, thinking about patients with dementia or patients with cancer who are really hanging on hope that there's something medically that can be done that's outside of what's already been offered to them and kind of have a cure. And I think it's really important that we choose our language and we choose what we share, how we share, and the quality of what we share very carefully. Karen Litzy:                   07:29                Well, and you know, that goes back to do no harm. And I think goes back to being an ethical person because when you look at these vulnerable populations, like you said, the elderly people with possibly terminal diseases, people with chronic pain, these are people who are looking for things that they feel they have not gotten that will fix them. Right? And so that's where snake oil salesmen come in. That's where people sort of touting that they have this great flashy thing that isn't supported with evidence, but it sounds really, really good. And so how do we as healthcare professionals combat that without looking combative and turning off those people that we actually want to help? Jason Falvey:                 08:22                Yeah. How do we combat that information without unintentionally propagating it either. I think when we evaluate information, I think one of the things I really encourage is time, take time to think about the information, take time to research the primary source of that information. Take time to recognize if there is potentially both sides of an issue. So outside of things like, you know, vaccinations causing autism, which is a clearly manufactured result. If you follow back the evidence or if you go ahead and follow back evidence about infant chiropractic work. But I guess generally falsified or highly, highly, highly biased to the point where there really isn't a pro side, but a lot of medical things have a potential pro and con side. So I think it's important to recognize the nuance and carefully layout reasons one why you disagree with something and two the rationale methodologically, not just your opinion of kind of how you came to that conclusion. Jason Falvey:                 09:42                But I think you have to do that without validating what you think is a very poor quality or highly biased or dangerous source to share. If, for example, you saw a tweet about the harms of vaccination and it may be, it was for your older adult population getting the chicken pox vaccine and it caused them Alzheimer's, you know, caused them to get dementia. Let's say you just saw a story like that. Which is not true. How do you, you know, how do you combat that? Some people would just retweet it with a really dismissive comment, like this is garbage. Don't listen to them. Well then doing that, and I'm guilty of this in the past as well, we've actually unintentionally propagated that information. Right now I have not very many followers, so 2000 followers all of a sudden see that and potentially one more retweets it and then another 2000 people. So I unintentionally exposed 4,000 people. Even if I'm dismissing that information, I've lent it credibility by sharing yet. Jason Falvey:                 10:51                I think what I have to do is write something about the study, not actually link or validate in some way and not unintentionally spread fake news. And there's not an easy way to do that. So I think you really have to toe the line between not sharing the primary sources, potentially providing that provider of fake news, financial revenue from clicks, which is a lot of times what they want. Or providing a really misguided researcher, a clinician validation that their technique is not loved by the general medical population because they're jealous of his success, you know, something that they can take it the other way to spin it as a positive for their business. Karen Litzy:                   11:39                Right. And because if you're re tweeting this and clicking on it and retweeting it, you're giving it life, which is what they want. That's what we don't want to do. Jason Falvey:                 11:52                Right. And I think that's one of the ways that propaganda is designed right from the early days of using propaganda as a war tool. It was shared not just for people that believed in it heavily. It was shared in outrage and passed along and whispered about which served the exact same purpose. So really it's hard to discipline ourselves in a really, like we see something, we feel like we immediately have to react on social media and immediately have to comment on it. And I've been guilty of sharing articles that are either satire and actually taking them seriously, which has happened once in a fatigue non-caffeinated state. And also information or studies, which I think in hindsight probably weren't high quality or perhaps overstated its conclusions. My own articles have had overstated conclusions written and press releases that weren't by me or interpretation of written press releases that are perhaps more definitive than I would have wanted, you know, not fake news, but certainly unintentionally declarative about the quality and strength of the evidence versus, you know, the hypothesis generating evidence that it was. Karen Litzy:                   13:16                Yeah, absolutely. You sort of alluded to one way as healthcare providers that we can combat the fake news or the medical disinformation and that's taking time to read the source if it's a press release, to read the article, to maybe look at the methodology and to see how would rate this study? So that's one way we can combat it, which takes time. And like you said, on social media, people often react quickly because it's emotional. So maybe we need to take a deep breath and then take a moment and think about what we want to do. Do we want to share this misinformation or do we want to read it and come up with maybe another way to share more positive information? What else can we do as healthcare providers to get around this fake news? Jason Falvey:                 14:14                When we encounter something that we think is fake news or unintentionally or intentionally hyperbolic to the point where we think it's harmful to patients. And I think that's the line I draw. If I think that potentially sharing or engaging with this information in any way which propagate information that's harmful to patients. I generally take a little extra caution. And one of the things I look at, you know, I see in politically or in health care news, if I see a that goes out that has a really high comments or retweet ratio. So there's this term ratioed and it's not scientific and it's not peer reviewed. But I find that the good starting point when you see a tweet from a government official or a healthcare provider, healthcare related source, and there's more than double the amount of comments, then there is retweets and the likes. Jason Falvey:                 15:18                It makes me go and do a little bit more investigation. You know, sometimes those comments are positive and way to go. And sometimes there's a lot of skepticism or criticism of the findings or people really, you know, offering some real insight into some of the problems in methodologically or otherwise. And often a well done methodological study can be completely blown out of the water on Twitter by a very poorly written headlines. Right. We should care about storylines, not just headlines. And one of the ways we do that, looking at comments, retweets, and the likes, looking at that ratio and look at the source, right? Who's retweeting? And so I pay attention to that because most fake news on the Internet is actually propagated by bots. So there's a very high percentage of fake news that was propagated by automated accounts that are automatically set up to capture certain hashtags or certain language and amplify it. Jason Falvey:                 16:23                You know, if you're a political audience would know that that's how the Russians basically designed the misinformation campaign to influence the 2016 election using bots to amplify certain messages. Well, that happens to a lesser extent in health care. There are certain pockets, you know, of health care professionals, and there may be some in our profession that provide certain treatments. There may be some in other alternative medicine professions, there may be some in mainstream medical professions that are physicians or nurses who use their medical expertise and propagate information about medical techniques like abortion or vaccines in a way that makes them seem more credible. So I look at who's retweeting what the population of people are retweeting is, who the person the primary sources coming from. Right. You said if it's a summary of an article from a press release or somebody's blog, like I want to go and find that primary source and then also look at the bias of the person who may be interpreting that information for me if they're a credible source. Karen Litzy:                   17:40                Yeah. And I think you also want to keep in mind those hot button issues may have more misinformation about them. Like you said, vaccines, abortions, these are hot button issues, right? So you have to I think take a more examining eye to some of these hot button issues then with others. That's not to say that other issues in health care do not have as much misinformation surrounding them. But when you're talking about things that are really emotional for people, I think that's when you have to also take a good editing eye to some of this information being put out there. Jason Falvey:                 18:26                Looking at the source of information is one thing you can see. Cleveland clinic has accidentally posted fake news before where they put in like a really positive result from an innovative experimental therapy for cancer. And they put it in a brain scan and said this person had a miraculous results forgetting to mention that they also were receiving the standard care and this additional therapy would, they didn't know if that was the cause or if it was just a normal reaction to the normal care. But then all of a sudden you created a demand for something that is at best maybe ineffective and at worse, we don't know if it's harmful. By having a high visibility site, your responsibility for news is even higher. So I think that's an important piece. Like know who's tweeting it, but then go back and make sure you have the whole story. If it sounds too good to be true. Jason Falvey:                 19:38                This is the humanities education that a lot of PT students have complained that they've had to take history and literature and policy courses throughout their undergraduate degrees and some have suggested streamlining education to really eliminate those things. My counter argument is those skills you learned from critical thinking and critical reading and analysis and understanding of historical context and how to read hyperbole, how to read marketing and different kinds of language really with a critical eye, you tend to develop a radar for when you're suspicious of information and when you want to go and look a little deeper, even if it's from what you view as a pretty credible source. Karen Litzy:                   20:27                Yeah, absolutely. So we've got taking your time really looking at not only the source of the article but who's re tweeting it and that retweet to comment ratio. Is there anything else that we should be doing as healthcare professionals to make sure that we're not propagating this misinformation? Jason Falvey:                 20:54                Another thing I think would be really helpful is crowd sourcing, right? So most of us are networked on social media with a lot of other really knowledgeable professionals. You know, I know that on my Twitter feed alone, half the people are probably smarter than me. Karen Litzy:                   21:10                Oh, I don’t know about that. Jason Falvey:                 21:14                But that's intentional, right? Like I want to be in a community of really intelligent people who think about issues critically, who may have different opinions than me. And I could say, I just read a study about Xyz and the conclusion seems flawed. Who would want to, you know, and maybe I don't name the article, maybe I don't put a link to it. I just put the tweet and throw out a few names and say, Hey, I would love if some of my community would like to take a look at this and tell me what they think. Right. If I'm on the borderline of whether or not I think this is legitimate or I asked somebody in the profession, you know, lean on them to really make sure that I'm taking that extra step to not share information that is influencing medical decisions in a negative way. Jason Falvey:                 22:03                And I teach my patients these same strategies, right when I'm talking to patients and caregivers who are googling information, WebMDing, looking at blogs, and I've had patients with significant neurological illnesses that are terminal. And one of the places I've practiced, and I won't name that place if it's a relatively rare disease, but this person searched the literature and she was very well educated person, searched the literature high and low for a cure for her neurodegenerative disease and found one that was highly controversial. Probably harmful. And she invested thousands of dollars and hundreds of hours of travel over three months for something that was not beneficial while she was askewing typical medical care. So you know, that kind of taught me how to teach patients, not just how to look for information, right? That's part of the problem. But how to evaluate information, how to triangulate information to make sure that the reference that they found is supported by expert opinion and maybe other articles and making sure that there's a critical mass of support for this particular treatment before they really make a major alteration to their course. Jason Falvey:                 23:21                A single article about a vitamin supplement that might help that has little harm. You know, that may be something that I don't intervene on, but somebody who's thinking about making massive changes to their medical routine, whether it has directly to do with Rehab or not. I encourage people to look at the literature critically and I use the word triangulation and I draw it out. I'm just like, you should be able to verify this information should be similar between these three things. Right? And if they tell me that they've done that and they found those three things, I'm more comfortable, even if I disagree, at least I've done my diligence to make sure they looked at the issue in a robust way and not fallen victim to something that was purely a single tweet or Facebook post of medical disinformation. Karen Litzy:                   24:15                That's a shame. And I think it's important that you brought up that as healthcare professionals, we should be talking to our patients about this and we should be teaching them stuff. Glad that you went through that. Yes, we should be teaching them what to look for. If we can have a more educated patient base and a more educated base of health care professionals that high in the sky view. Of course the amount of misinformation may be less. Jason Falvey:                 24:45                Yeah. And I think there are certain countries that have done a lot of work. Norway for example, has done a lot of work from a country perspective on educating citizenry on medical and you know, general disinformation, both political and medical and teaching, how to recognize it. Giving a lot of the same strategies we've talked about of really time and a little bit of additional resource and that solves so many of the problems. If you don't change some of these decision making process and they still are firm believers in the medical information at that point then you go to some of the other strategies, you know, more targeted intervention. But I think as a general population strategy, those are great places to start and really just, I tell patients all the time, I am going to be telling you seek information, not affirmation. Jason Falvey:                 25:45                If you have a friend who told you about this treatment, you need to remember that everybody responds individually, the medications and treatments and you know, cause I think we've all had patients that say my friend got this therapy and their knee got better, really inappropriate for that patient. But it's really hard to walk that back, you know, from just your professional opinion. So teaching them how to look for information and letting them look for it on their own instead of providing it to them I have found is sometimes a helpful strategy because it feels like I'm not forcing my view on them. At the end of the day you can rest knowing that you put tools in people's hands, you know, health care providers or patients teach them how to do these things. I mean, but it does take some effort on their part too. Jason Falvey:                 26:37                You definitely have to want to read these things carefully and you have to have the mindset that you don't want to just look for information that validates what you already believe. And I've seen this, you know, I don't like to pick on dry needling, but I definitely have seen people who are very strong believers in dry needling, just cherry pick evidence that supports their worldview, without recognizing that there's a lot more nuance to that discussion. And I'm not anti or pro dry needling. I'm pro information. Looking carefully and realizing that there are patients who do benefit from it, but it is certainly not a blanket treatment that everybody should be using and it's a tool in your bag, like everything. So, I think it's really important to just have that seek information, not affirmation. If I can say something a few times on this podcast that will be what it is. Karen Litzy:                   27:40                Well, and then my next question would be, after having this great conversation, is there anything we missed and is there anything that you really want people to stick in people's minds, which I think you just said it, but I'll ask the question anyway. Jason Falvey:                 27:55                Yeah. And I think the other thing is like, when you are a healthcare professional, I think investing money in like high quality sources or whatever source. For me, I tend to read a newspaper in New York Times or Washington Post. I have a subscription to it. I try to support that kind of, you know, to provide financial resources to a place that I trust to provide good information because that is positive reinforcement, right? I try not to provide positive financial rewards to places that are providing this information. And you do that by clicking on their articles, right? You read a headline and it's like vaccines cause autism study says, and I clicked on that headline, I’ve unintentionally propagated and supported financially that fake news provider who now is incentivized to create more fake news. So I think it takes a lot of discipline to not fall victim to our need to read everything. Jason Falvey:                 29:02                And you know, sometimes we have to think about the greater good is not clicking on that article. Shutting it down, blocking that news source or whatever, if you really feel like it's egregious enough and not engaging with it. Creating polarization. Polarization is what creates ratings on television. Polarization is what creates ratings on radio, polarization is what gets people to download podcasts and things that are highly controversial. Polarization, you know, sells books, right? The top selling books on New York Times bestseller lists are generally, there's political books that exist, sometimes multiple political books that are on that list from different points of view. So I think it's really important that we don't support agregious, you know, fake news providers or fake healthcare news providers and don't engage with them on Twitter because that's giving them a form of a positive attention. Even if you're criticizing their work, that they can go ahead and leverage to share more. Karen Litzy:                   30:13                Yeah, I thank you for all that great information. And hopefully the listeners can really take this in and understand that what we do on social media has ramifications one to our profession and two to the people we serve. So before we leave, I have a last question and normally I ask people, what advice would you give to yourself as a new Grad? But I'm going to ask you, what advice would you give to yourself as a new Grad physical therapist in light of fake news? Jason Falvey:                 30:50                Oh, that's a great question. Beyond the sentence I said of seek information not affirmation, which I think is helpful for research and beyond, I think one of the things I would tell myself as a new Grad physical therapist in this era is I would be incredibly thankful for my English education, my bachelor's degree in English, all of the humanities and critical thinking classes that I took and all of the writing that I did because trust me, I wrote enough papers as an undergraduate that probably could have qualified this fake news cause I didn't really read the books very carefully and really had some made up opinions about what I thought was happening. So I think I can recognize the difference in that writing now. And I would tell myself, be appreciative of the education in humanities and the historical context that you've gained and use those skills. Don't forget about them. They are valuable parts of your tool bag. They are not direct patient care skills, but there among the most critical soft skills you can obtain to really do a good service to your patients and teaching them how to use those skills and taking healthcare into their own hands. Karen Litzy:                   32:13                Awesome. Well, thank you so much. This was a great discussion. I'm glad we finally got to do this. Where can people find you if they want more info or to ask you questions? Jason Falvey:                 32:26                Yeah, so I am listed on the Yale site, I am not officially representing Yale now just to put that out there, but my email address is on the Yale division of geriatrics site. I'm also on Twitter at @JRayFalvey and I'm sure you'll put that in your show notes. Those are the two things. And hold me accountable. Do you see me sharing something that you think is not a great source of information? Tell me about it. Right. And I think holding each other accountable is part of this process and doing that in a professional way is all the better. Karen Litzy:                   33:07                Thanks again for coming on. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart.   Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Sex and intimacy can both be impacted by chronic pain, but they aren't topics that are always easily discussed with health care providers. In this month’s episode of the Pain Waves podcast, we’re joined by physiotherapist Sarah Haag, who specializes in pelvic pain and women’s and men’s health. She provides us with a discussion on how chronic pain can impact sex and intimacy, the role of specialized physiotherapists in helping patients with pain who wish to reengage in sex, and practical tips for both people with pain and their partners to explore or maintain the two in their relationship.If you'd like to connect with Sarah to find a local physiotherapist who specializes in pelvic pain, women's health, or men's health, visit her Twitter page: https://twitter.com/sarahhaagpt

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.

Sometimes, there are pain areas that people aren’t always comfortable discussing. Even further, it’s easy for us to compare, for example, our hands to others around us. But some areas… well, let’s just say, we’re not going around comparing those! So we need a safe environment for patients to feel comfortable and confident getting the treatment they deserve. We welcome back Dr. Sandy Hilton to Pain Reframed! Sandy joined us way back on episode 7! Sandy and her business partner, Sarah Haag, of Entropy Physiotherapy, have made a community out of their clinic due to the forward-thinking environment they have created there, helping to ensure the patients feel welcome and comfortable. We will continue the discussion on how to handle sensitive pain topics and best treat our patients. Don’t forget!! It’s almost here!! June 8-10, 2018 in Denver, Colorado, the Align Conference will be taking place, focusing on neuropathic (nerve) pain.  All of the various concepts of calming the nerves down will be covered at this conference. LINKS: http://entropy-physio.com/ @sandyhiltonpt sandy@entropy-physio.com The Pain Science and Sensibility Podcast http://ispinstitute.com http://www.alignconference.com/ http://evidenceinmotion.com @eimteam

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    

Welcome back to Pain Reframed!  This week, we welcome Sandy Hilton of Entropy Physiotherapy to the show!  Sandy and her business partner, Sarah Haag, have done some incredible things at Entropy Physiotherapy.  They have made a community out of their clinic due to the amazing environment they have created there, helping to ensure the patients feel welcome and comfortable.  Sandy is instrumental in the areas of pain management as well and will be discussing her thoughts and expertise on this topic. Sandy, Tim, and Jeff discuss pain sciences, how much we actually know about it, what we can do to continually learn and grow and treat the patient as a whole, and the idea of turning pain science into the “air we breathe and not the thing we do.” LINKS: http://entropy-physio.com/ @sandyhiltonpt The Pain Science and Sensibility Podcast http://ispinstitute.com http://evidenceinmotion.com @eimteam

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!  

Sarah Haag - What does healthcare really cost? -------------------- If you like what you hear, consider Joining the Senior Rehab Project to get access to: Monthly Mastermind Meetup Newsletter Private FB Group *For links & the other podcasts in the Senior Rehab Project, go to http://SeniorRehabProject.com

The MOST Important Issue We DON'T Talk About w. Sarah Haag & Sean Hagey Urinary Incontinence! That's right...the least discussed issue that has the biggest impact on our patients. Luckily, I have Sarah Haag & Sean Hagey to discuss this important topic. They gave a presentation at #APTACSM 2016 - #PantsNotPads. Even if Urinary Incontinence isn't of interest to you, I can guarantee you'll enjoy this conversation!   Relevant Links: @SeanHagey @SarahHaagPT @EntropyPhysio Entropy-Physio.com Section on Women's Health BethShelly.com -------------------- If you like what you hear, consider Joining the Senior Rehab Project to get access to: Monthly Mastermind Meetup Newsletter Private FB Group *For links & the other podcasts in the Senior Rehab Project, go to http://SeniorRehabProject.com

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 this week's episode of the Healthy Wealthy and Smart podcast, Dr. Sarah Haag and Dr. Sandy Hilton join me outside the Disneyland Hotel post CSM to take the taboo out of discussing sex. They are both physical therapists who work with anyone needing to get back to doing what they love and who they love and are making the discussion around sex a little more comfortable and approachable. In this show, we discuss: -What every PT should be asking their patients -Why you shouldn't make assumptions about your patients' sex lives -How to differentiate UTI from DOMS of the pelvic floor -How you can approach your partner who has pain with sex -Guiding principles for pelvic health rehabilitation -How to navigate sex in the nursing home system -And a lot more! Sex is part of normal human function and no other species makes it this complicated. If you are experiencing pain with sex and you want to live a happier and more fulfilled life, there is something you can do about it by seeking help from a pelvic health physical therapist. You can find more on twitter from Sandy (@SandyHiltonPT), Sarah (@SarahHaagPT), and myself (@karenlitzyNYC)!   Thank you for following along and listening to the podcast!   Xo Karen  

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

In this episode Adam talks about pelvic health issues with Sandy Hilton and Sarah Haag, two specialists from Chicago, IL in the US of A. We discuss pelvic pain and incontinence, as well as discussing why there are no male pelvic health physios. Sarah and Sandy also discuss how to overcome the embarrassment of discussing personal and intimate things with patients, and Adam tries his hardest to offend everyone with coming up with as many different terms for male and female genitalia.

In this podcast I am joined by Dr. Sarah Haag, PT, DPT; Dr. Sandy Hilton PT, DPT, and Ann Wendel, PT, ATC for a great discussion on waist trainers, made popular lately by the Kardashians and other celebrities.. We speak about the pros and cons of using a waist trainer to decrease the size of […]