Insights on Pelvic Floor Therapy: Interviews with Leading Experts

I've compiled insightful clips from interviews with three leading pelvic floor physical therapists. The focus is on the benefits of pelvic floor physical therapy, with the first clip featuring MJ Strauhal discussing what to expect in the initial therapy visit and the importance of a therapeutic relationship. Prof. Chantale Dumoulin from the University of Montreal emphasizes the effectiveness of pelvic floor exercises, the advantages of group training, and the importance of starting therapy early. Finally, Kari Bo from Norway discusses the specifics of pelvic floor strength training, the impact of high-impact exercises, and recommendations for pelvic floor training during pregnancy. The episode underscores the significance of individualized treatment plans and the benefits of group and one-on-one sessions.

To hear these episodes in their entirety or for more information:
S1E25: PT at Providence Portland with MJ Strauhal DPT
https://www.buzzsprout.com/2112419/episodes/13143516

S2E9: The Path to Aging Gracefully with Chantale Dumoulin
https://www.buzzsprout.com/2112419/episodes/14653291
For information on Prof. Dumoulin: https://www.womenhealthaging.ca/

S2E19: Empowering Women Through Pelvic Floor Strength with Dr. Kari Bo
https://www.buzzsprout.com/2112419/episodes/15087635

Timeline:

00:28 Introduction to Pelvic Floor Physical Therapy
01:13 Interview with MJ Strauhal: First Visit Insights
04:48 Interview with Prof. Chantale Dumoulin: Research and Group Training 
15:39 Interview with Dr. Kari Bo: Strength Training and High-Impact Exercises
23:50 Conclusion and Encouragement

Transcript

Hi there. You've heard me talk a lot about pelvic floor muscle training and the benefits of pelvic floor physical therapy. One of the great things about the work that I do is that I get to work with a lot of physical therapists, and they're great people, but they also do such amazing work. For today's episode, I put together clips from interviews with three different pelvic floor physical therapists.

The first one is with a pelvic floor therapist who is an expert here in Portland and does a lot of clinical work. The next two clips are from women who are pelvic floor physical therapists, but are big international researchers and have done so much Groundbreaking work in this area. The first clip is with MJ Strohhal and this is taken from Season 1, Episode 25.

This episode is one that I did with MJ and it is all about the first visit with a pelvic floor physical therapist and what you can expect in that first visit. visit, and what you can expect kind of going forward. It was an episode I put together, um, to help my patients get comfortable with the idea of physical therapy before they went.

And MJ just has some really great practical thoughts about physical therapy. So let's hear what she has to say. 

But one of my biggest concerns is that patients build a therapeutic relationship with their, the physical therapist that they're going to see because Um, let's face it talking about these private, um, really sometimes very embarrassing, um, symptoms.

You want to only do that with one person if possible, right? And so, um, One of the things 

that I always tell patients when I'm referring them is I always say, you know, this is a really intimate relationship and you may love your physical therapist. You may not. And if you don't, you should tell me and we'll find someone else for you.

And I always interpret that as It's not a good match for whatever reason, but it has nothing to do with that physical therapist's ability. Right? I mean, sometimes, you know, for whatever reason, you're just not jiving with that person, you know, I mean, I've had patients, you know, come in, come back and say, you know, that person was too young for me.

I mean, sometimes it's something super subjective, https: otter. ai  Some intimacies, uh, it has to, it has to feel okay. 

It does. It does. And that's really important. And that's what we want for the patient as well. 

Women. 

And the program has to be very individualized. Not every patient that presents with similar symptoms actually is going to be treated exactly the same, right?

So, um,  Definitely individualize the programs and, and that takes collaboration. Yeah. 

Well, and I think that's what makes it so strong too, right? Because you're not, it's not a cookie cutter approach, right? Exactly. Oh, you have urinary incontinence, you will do this, right? You're looking at that whole person and developing an approach for them.

The one thing I would emphasize is that this is not a quick fix. Right? And so, um, it's not about cagling until the cows come home. It's about learning and understanding your body. How you need to address your symptoms with your body and your symptoms. And that it may take a while. It's, it's not going to be something that you do some cagles, maybe you've never done them for the first time.

Or, um, you know, there's not a silver bullet. And I think that may be the hardest pill to swallow. If I can put it that way, because most of us that have symptoms that have to do with pooping, peeing, or sex really want it fixed. We want to fix now, but it is a journey, not necessarily a destination. And that's why when I mentioned that we might see patients even down to once a month, that's a journey.

for a few months so that we can not only, um, be your coach, but also your cheerleader. Again, I want patients to understand that, that it's a journey and it may take a while and that's okay. 

Yeah. I mean, I think that's really true, right? Where you are the therapist, the coach, and the cheerleader, and that's what makes physical therapy so very, very strong as a therapeutic intervention.

So we're going to switch gears here a little bit. And this next clip is from an interview that I did with Chantal Dumoulin, who is an expert researcher in pelvic floor physical therapy at the University of Montreal. And this is taken from, um, season two, episode nine. So she's done a lot of research looking at physical therapy for urinary incontinence and she's looked at group classes and she is going to talk about how you have to do exercises to strengthen the pelvic floor, that that is really what works.

She'll talk about one on one PT, the benefits of group training and how in some ways group training may even be better than being one on one with a physical therapist. She'll talk about when it's too late. to start doing pelvic floor muscle training. And I'm going to ruin the surprise here, but the answer is it's never too late.

She'll talk about how to age gracefully and then when she thinks you should see a public floor therapist. So let's listen to what she has to say. 

If women don't want to see the physiotherapist because they don't want to, to exercise, I think there's no way around it. If we want the pelvic floor. To get stronger to to be more functional, you have to train the pelvic floor.

So eventually, if the idea of seeing a therapist to do the training is not, you don't want to do it, well, it won't work right now. The evidence are not strong for any other approach like yoga, like Pilates, like the even magnetic chairs or so the first line treatment is to train and this is the same way as training other muscles.

So, I think, but there's different ways of doing it. Like you say, if you have less money, there's the possibility to do it in group. Um, there's also the possibility to do it online. And there's like tele rehab. And there's also the possibility to do it with mobile application. So if we come to the group training, we have done research.

Uh, comparing individual training to group training in, uh, postmenopausal women and menopausal women. And we found that the group training was non inferior, um, meaning that we had the same results as if you were doing the one on one intervention. So, obviously, this is quite exciting because, um, You get the same effect, but also it's less costly for the patient, but also for either the private clinic or the governmental agencies that pay for that.

So this is nice. In addition to that, we found that women were in a group. It was helping them to be adherent to their exercise more than if they were in individually with the physiotherapist. So there's that solidarity with the others that have the same problem  that helps women, um, be more adherent to their exercise to come more to their, um, intervention.

So I think this is something that is new and that's very exciting for incontinence treatment. And what we found was that the women who were in a group perceive their intervention, not as a treatment so much, but as an exercise group that they were doing. With others. So because of that, after the intervention,  they were more keen to continue doing those exercise as a way of life, then the ones that were in the treatment, who might have more.

Uh, I've thought that they needed the physiotherapist to do a treatment. Rather, it was an exercise class for the other. The added benefit of the group, I think, is to be able to see in the same room that you're not alone. There's other women who have the same problem. Also, some of them said, I felt dirty. I felt old.

And just to see other women in the room. Uh, or beautiful, or not so, they don't smell bad. You're kind of encouraged to,  to, to take part of this exercise group and take care of yourself because you see other and you support also each other in, uh, right. I think it's always time to improve. And we add in our studies, women that were 80 years old when they started, uh, eight years ago.

And. Actually, what's interesting is that it's probably less difficult to improve or to give a woman what they need in terms of added strength  when they're older, because their need is a little bit lower than younger women. So if I give you the example. Postnatally, because there were maybe trauma during the delivery,  the pelvic floor weakens.

And if the woman has urinary incontinence  and wants to go back to running and jumping and doing all those things, we will need to work with her to increase the function of her pelvic floor enough so that she can do those activities. And in older women, it might not be. Running and jumping because when she's 80, she's not doing that, but it's just walking around the house doing or gardening going to the store.

So that the added function or strength that she need is lower. So I would say that. It's, it's possible. And that's what we saw. It's possible at any age. The only thing you need to do is to do the exercise to, to train, use the training theory, uh, actually, and to, to, to give an exercise that is difficult enough to build muscle mass.

And to build function, 

what would your advice be for kind of a typical mid forties woman who has maybe a little incontinence, right? Avoids trampolines, nothing excessive, but is looking to have her pelvic floor age as gracefully as possible. I mean, what prevention would you suggest?  

Yeah, I think this this is important to know that although it's it's just a little bit of leakage, it will not get better on its own.

And that's really the best time to start taking care of it because you're not going to be you're not going to have to do that much training. Um, because you're kind of on the line of, uh, you're Of dysfunction of the pelvic floor. So I would tell her to first of all, see a physiotherapist to evaluate the pelvic floor dysfunctions and then either gone to that physiotherapist for training or join a group or maybe also there are some session online, but at least or use an application, but at least Do the assessment first, then do the program that will be more in line with your way of life so that we know that you're going to be doing it completely, that you're going to be able to adhere to it.

And I think that if you have leakage, it's important to do active rehabilitation for at least three months. And this is the training theories that tells us that you need to build muscle mass and it will take time. So at least three months, and then you need to do maintenance. So then you need to know that you have a certain weakness there.

You might not be incontinent anymore. So you need to keep those muscle active at least once a week. That's what we saw in our study that was needed at least once a week. And you also have to be careful of what you're doing. If you're going to be. If you're constipated and you're pushing a lot when you go to the toilet, you have to try to take care of that to reduce that pressure.

If you're doing an exercise that is putting pressure, if you're, if you're doing trampoline again, or if you're playing tennis, it's okay, we want you to be active. But at the same time, you need to compensate by maybe doing a little bit more of exercise so that your pelvic floor is not Can respond to that intra abdominal pressure increase during those sports.

When do you think a woman should see a pelvic floor physical therapist for the first time? Um, this is a 

good question. I, I think that around, uh, maternity is a very, um, important time. Uh, I wish women would be educated about their pelvic floor first than that. There is a study right now from France, um, where they educate in high school, uh, younger women about their pelvic floor, because it's important for them to know that if they're going to be doing certain sport, they will affect their pelvic floor through that.

Intra abdominal pressure. So if that is not possible, I think at least during pregnancy, um, because there's evidence to show that if you're doing prevention exercise during pregnancy, you can reduce the risk of having incontinence, uh, after delivery and, um, incontinence, prolapse, and different other pelvic floor dysfunction problem. 

So I would say yes, Definitely, during pregnancy, you should see a physiotherapist to prevent the, the problem. So pregnancy is the important time. And the other time is menopause. These are the two times where the pelvic floor function will go down. So if you haven't had any problem around maternity, menopause is really the time for you to, um, At least do prevention so that you don't have the problem when you're old.

This last interview is with Carrie Bow, who is a pelvic floor physical therapist and researcher from Norway. And she really has done more research in this area than anyone else. This episode is from Season 2, Episode 19, and she'll talk about how doing pelvic floor training is really strength training and it's no different from exercising any other muscle.

She'll talk about high impact exercises and urinary incontinence and if that's really recommended that you do high impact exercises. Can you do high impact exercises when you have leaking? She'll talk about training the pelvic floor in athletes. She'll talk about pelvic floor muscle training during pregnancy and the benefits of that and then what to look for in an exercise class.

So let's listen to what she has to say. I've heard you say that like all strength training when you're doing pelvic floor muscle straining, um, you, the exercises have to get harder over time. How do you recommend doing that?  

This is the most difficult and challenging thing about the pelvic floor because unlike the biceps or other muscles in the body, you can really not put on resistance.

Uh, so we need to make the patients try to get as high up as possible. to a maximal contraction as possible. And that would be relative because if you are very weak, you, your starting point is a very weak contraction, but still you need to get as close to that as possible. And then when you get stronger, you have to really encourage and make the participants work harder.

And we know that strength training is not going you know, in a linear way, it's like steps. So you end up in a step where you're in a higher step, and then, uh, you have to press and work hard to get up to the next step and up to the next step. Uh, but this is the challenge and that's why we, we can also use different positions and they can choose a position where they feel is more difficult to do the contractions.

We can also change, uh, maybe trying to hold it for a longer period of time and then try to work, uh, on different, uh, ways of doing these muscles. But there is only the, like the biceps, you can only do one thing. And it's the same with the pelvic floor. There is a mass contraction. So you are squeezing and lifting inward.

That's, that's the whole thing, but you have to do it harder and harder. And again, the physiotherapist and the voice of the physiotherapist must encourage them to work hard. And because this is not relaxation training, it's strength training. 

When you see women who, um, want to do really intensive exercises like CrossFit and are doing a lot of high impact exercises, is that something that you think women with incontinence can do?

Because so often they're told not to do anything like that. That's so high impact.  

I'm a strong, uh, emphasizer of regular exercise, so I, I don't think I would ever tell anyone to stop exercising because, uh, it's so important for health, uh, in general, and also so very important especially for mental health.

So if you are on exercises and you were asked to stop exercising, it would really not be good for your health. But we know that Really, very few of any sport women or exercises are also training the peripheral muscles. So I'm quite convinced that if they could add this to their other exercises, this would also help them.

We have very few studies though. We just published one on crossfit or functional training, and we also show that they could be improved by doing peripheral muscle training. But I think they would have been improving even more if we could have followed them up or also if they could be a specific part of their exercise program.

Because women who are exercising, they're quite occupied because they are exercising in addition to something else. And then we add pelvic floor muscle training on top of that. So it has to be included, I think, in their warm up program or as a general part of what else they are doing. So they are training the biceps and the quads and other muscles.

Why not the pelvic floor? It's just because they don't, they are not aware that this muscle group is there and it needs to be trained just as the other muscles. And they need much more strength and much more function of the pelvic floor muscles compared to others. Because if you just are in the  Sitting occupation and you have a cold once a year, uh, and you cough, that's very little compared to everyday exercises with heavy weights.

So these  pelvic floors, they need to be much more, uh, functional than others. 

So what about pelvic floor muscle training during pregnancy? There's been some discussion about how some practitioners think that that may actually make delivery more difficult. Can you comment on that? 

No problems with vaginal birth after peripheral muscle training during pregnancy.

I think that's also a very important message because they have shorter  labor than others. And it has been some reluctance among midwives, obstetricians, and also physiotherapists because they think you can get in a way too tight by doing peripheral muscle training during pregnancy. This is a myth. It's not true.

They have easier birth, uh, and we should also have that message out. You may bulk the muscles because it's been shown, uh, that we can bulk the muscles, but it's, it's actually, uh, in pregnancy when you do peripheral muscle training, there is a wider, uh, uh, levator hiatus area.  

So if someone's looking for an exercise class and they want to do pelvic floor training, what, what did they look for?

Well, no, because 

I, I've been striving with this for many years and trying, I'm teaching at my university, which is a sport university. They, I always taught my students to do it. I know that they will probably most of them do, but I, very seldom see it. If I go to an exercise class, it's so seldom that they also mention or do any peripheral muscle contractions.

And also many instructors and also some of the physios who are teaching this in the class, they try to  Incorporated in other exercises. So they are doing a seat lift or they are doing a squash. And then they try to do pelvic floor muscle training at the same time. The Pilates is also like this, like contract the pelvic floor, breathe in, do this and do that.

And there's so many things at the same time. So instead of, Because they don't do that if they're doing abdominal training. Then they are doing the sit ups or the crunch, but for the peripheral they think differently, which I think is very strange. So you have to do  proper peripheral muscle training just as you do proper back training.

It's the same, same. They are striated muscles and should be trained in the same way. But I know that many Pilates classes now, they also have an emphasis on the pelvic floor, which I think is good. But again, in most of the classes I have seen, they have just done what I just said. So, contract your pelvic floor and do this crunch or do that.

So that's not enough. Uh, you have to do it properly. They think it's too simple just to do  pelvic floor muscle contraction, but it's not simple because you can't see the muscles and they may be injured. Uh, so it's difficult for the participants to do this. So why should we make it so more difficult by doing all this breathing and doing all this other stuff instead of thinking just I 

really love these three interviews with these three expert pelvic floor physical therapists, and I encourage you to go back and listen to them.

The message that I would have for you about pelvic floor physical therapy for urinary incontinence  is that It helps so many women. Working with a physical therapist gives you an individualized plan that will work with your body and the different limitations that your own body might have, different muscle weaknesses, maybe asymmetries that you have.

It's never too late to start strengthening. There are some benefits to group classes, and this was kind of a surprise to me, but I think the data is pretty strong that, you know, working with other women who who have similar problems can be so beneficial for women with urinary incontinence. And then I, I think it's important to realize that pelvic floor strengthening can help everyone, even women who are engaged in, um, extreme athletics.

And that, you know, working your pelvic floor before you have issues is really a great idea because it can prevent you from having issues and prevention is just such a beautiful thing. So I hope this episode has helped you think about physical therapy. If you are considering therapy, Physical therapy. I strongly encourage you to do that.

There are different physical therapy finders. If you're looking for a physical therapist, there's one on my website. And go ahead and get started.