Podcasts Health Healthy Wealthy & Smart 469: Dr. Sarah Haag: Pelvic Health for Non Pelvic Health PT

469: Dr. Sarah Haag: Pelvic Health for Non Pelvic Health PT

Published: Dec. 23, 2019, 10 a.m.

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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.\\xa0 Sarah has pursued an interest in treating the spine, pelvis with a specialization in women\\u2019s and men\\u2019s health.\\xa0 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:\\xa0http://www.rehab.msu.edu/_files/_docs/oswestry_low_back_disability.pdf

Sarah Haag Twitter

Entropy Physio Website

Home Health Section Urinary Incontinence Toolkit

Rehab Therapy Operational Best Practices Forum

For more information on Sarah:

Sarah graduated from Marquette University in 2002 with a Master\\u2019s of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women\\u2019s and men\\u2019s 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\\u2019s Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women\\u2019s Health from Rosalind Franklin University in 2008. In 2009 she was awarded a\\xa0Board Certification as a specialist in women\\u2019s health (WCS). Sarah also completed a\\xa0Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010.\\xa0\\xa0Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a \\xa0Registered 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa000:01\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Sarah, I was going to say doctor Sarah, hey, it just feels weird because we\\u2019ve 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\\u2019t want to like dive in literally and figuratively. So what we\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa000:49\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019t do the pelvis. You know, the pelvic floor is only a musculoskeletal structure. We\\u2019re not trained in most programs to palpate or to touch. It\\u2019s just skeletal muscle. That\\u2019s all we\\u2019re assessing for really as pelvic floor PT\\u2019s. So I just think it\\u2019s interesting. It\\u2019s like a blurry void when you\\u2019re looking at a body diagram.\\xa0 Oh, there\\u2019s your knee. So it\\u2019s really important I think to understand what\\u2019s there and you don\\u2019t have to go there, but you have to know what\\u2019s there and know that some people need help there and help them find the help.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa001:34\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So if someone, let\\u2019s take this person that has low back pain because that\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s a couple of ways that you can kind of like cheat your way in where you don\\u2019t 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\\u2019s 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\\u2019s a thing.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa002:22\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So there\\u2019s 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.\\xa0 Most of the time it\\u2019s like no one\\u2019s ever asked me that. Yeah. Stuff is different. There\\u2019s 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\\u2019s pretty awesome because now they\\u2019re like, Huh, nobody\\u2019s asked me about sex. And then you\\u2019d be like, ah, I see that this is an issue.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa003:06\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019re 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\\u2019s not always, it might be a sex problem, but it\\u2019s 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\\u2019re still working on the best way to do that.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa003:52\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 But there\\u2019s a high prevalence of urinary incontinence and people who have low back pain. So if you\\u2019re 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\\u2019re 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\\u2019s pertinent history for back pain. Correct. And then it\\u2019s like, Hey, I noticed this, any issues with this? And here\\u2019s the reason I\\u2019m asking because you can\\u2019t just go, do you pee your pants? Because people like, do I smell like what happened? Like, so if you\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa004:32\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So I\\u2019d be really curious to know are you having any issues in this area? Cause there\\u2019s help if you are. And then kind of go from there.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019t. So just so that we\\u2019re all on the same page, what would be those truly red flags?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s 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\\u2019s okay.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa005:26\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And the cool thing is that if you go to the doctor, it\\u2019s like you don\\u2019t have a UTI. Everything else is looking fine. Awesome. Then I can help with that. But the red flags, there\\u2019s been a couple of great papers that have come out where it\\u2019s like, it\\u2019s 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\\u2019t panic if it\\u2019s the only one.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And now let\\u2019s say you\\u2019re using these questionnaires and someone puts on bowel, bladder or someone circles sex as something that they\\u2019re 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\\u2019t want to talk openly about their bowel and bladder issues or about sex with their partners.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa006:28\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And so what do you say to those people? Those therapists that, are dealing with a population that\\u2019s maybe much more conservative and they\\u2019re not sure how to approach those subject matters.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 I always say just always with kindness and with a good intention and with a good explanation. So you can\\u2019t not do it because it\\u2019s awkward for you. You should be asking for a medical reason, right? So quality of life is in our wheelhouse, right? Like we\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa007:28\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Just start simple if you\\u2019re asking questions. So if someone comes in with like straight forward knee pain, I\\u2019m like, how sex, no, that\\u2019s not how, that\\u2019s not where we go with that. But if someone\\u2019s 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\\u2019re doing. These are where the muscles go. Most people don\\u2019t think about them. And when they\\u2019re, if they\\u2019re having issues like incontinence or have had babies, those pelvic floor muscles are muscles. Like everything else. We\\u2019re going to work in PT. So I\\u2019m 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\\u2019re like in the middle of a gym.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa008:06\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019m asking. And if you can see that resistance be like all right, like it\\u2019s 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\\u2019s not my job to convince you to deal with it. It\\u2019s my job to help you if you want help.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And if you\\u2019re a physical therapist that isn\\u2019t specializing in pelvic health, it\\u2019s a little bit different. Cause if you\\u2019re specializing in pelvic health and people are going to you because you specialize in pelvic health it\\u2019s way easier, you know, these questions are going to come up.\\xa0 But for those of us who don\\u2019t 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa008:48\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Yeah. And also if you\\u2019re going to ask if you\\u2019re going to take that step and be like, all right, I\\u2019m going to ask about the incontinence. I mean cause sometimes you\\u2019re in situations where it is an obvious issue. Other times it\\u2019s like, well, based on their history they\\u2019re 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\\u2019t just be like, oh yeah, so great incontinence noted in the chart. I\\u2019ll 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa009:49\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 How can you evaluate pelvic floor muscles without having to go internally? I think that\\u2019s a question everybody wants to know.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Great question. I\\u2019ll be honest, some people don\\u2019t want you to touch him there like full stop. And so I will actually give people, I would say it\\u2019s 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\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa010:33\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 You can do it in hooklying and some people will do it in prone. I\\u2019m not a super big fan cause I can\\u2019t 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\\u2019s normal human variation. So I always say move slow and make sure you\\u2019re asking for feedback. But you know, mid line is where the sphincters are going to be. We\\u2019re 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\\u2019s where the pelvic floor attaches. So then you can kind of talk them through, like I\\u2019d like you to squeeze and there\\u2019s a bunch of different cues.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa011:22\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 One of the most common cues, especially for the back end, is to like squeeze. Like you don\\u2019t want to pass gas and that\\u2019s awesome. But if you\\u2019re a main problem with urinary incontinence, that\\u2019s 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\\u2019s only been studied in men, but it is, shorten your penis. But what\\u2019s interesting is ladies, I know we don\\u2019t 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa012:07\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 You\\u2019re like, awesome. So if you\\u2019re doing a Kegel and like this happens, you\\u2019re probably not doing it right. If that\\u2019s happening, you\\u2019re probably not doing right. But if like I\\u2019m Kegeling now and then I let go, you shouldn\\u2019t have seen me get taller or tensor or breathe funny. It should be very sneaky. So as you\\u2019re palpating on the medial side of the ischial tuberosities your feeling for those muscles to contract. So it\\u2019s kind of like a gentle bulge and you can totally feel this on yourself here if you\\u2019re comfy or somewhere else. But when you feel it, it\\u2019s almost like when you\\u2019re 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\\u2019s what you\\u2019re feeling for.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa012:51\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019t happen when you\\u2019re trying to contract. So like when I say bulge, you should feel like a gathering of the muscle. That\\u2019s what you\\u2019re feeling. If you feel your fingers get pushed down in a way they\\u2019re doing the opposite of a contraction. So there they\\u2019re relaxing.\\xa0 It would kind of depend on what they were doing and the cues you were giving. So it could just be like, I\\u2019m pushing down like doing a Valsalva. But it is basically a lengthening into the pelvic floor. I don\\u2019t know if it\\u2019s always a relaxation, so to speak.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa013:33\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 It\\u2019s kind of lengthening. And what is the difference between that Valsalva or lengthening and that small bulge? Like why is that significant?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 When you feel it, you\\u2019ll know it\\u2019s significant because if they\\u2019re pushing down in a way that\\u2019s not a contraction. So if you\\u2019re going for strengthening or more closure to hold things in, yeah, you want that kind of like tensioning and bulge. But if you\\u2019re actually the problems, constipation, I can\\u2019t get things out, you want them to be able to relax and link them.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s coming in with incontinence and you are looking for that sort of tightening or gathering up of the muscle, which I think that\\u2019s a nice cue for people to understand because bulge can sometimes be a little confusing for people, but I liked the cue you\\u2019re feeling the gathering of that musculature.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa014:45\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s not working, what next? What do you do?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Well, so I\\u2019ll be honest. It\\u2019s 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\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa015:35\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s only ever when you\\u2019re putting your key in the front door or when you\\u2019re running into the bathroom, that\\u2019s 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\\u2019s free for members for sure, but I think it might be free for everyone.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa016:15\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So it\\u2019s a pdf that actually talks you through the different types of incontinence because the most common form of incontinence urge incontinence, which is you\\u2019re an urge incontinence is proceeded by a strong urge to go. So this is one of those things where, so there\\u2019s a bathroom at the end of the hall. So if you\\u2019re like, I\\u2019m totally fine, but then your eyes wander, you\\u2019re like, oh, I could go and I didn\\u2019t have to go. And then I would get up to go and I got to the bathroom and all of a sudden it\\u2019s like, oh, where did that come from? Like all of a sudden it felt like your kidneys did a big dump, but they don\\u2019t, that\\u2019s not how kidneys work.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa016:59\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 It\\u2019s just how it feels to you. So what that really is, is your detrusor muscle kind of going, I\\u2019m so excited. I imagine a puppy, like have you ever like gone to let a puppy out the door? Like, so they\\u2019re like, hey, I want to go out and you get up and you make a move for that door. And they\\u2019re like so excited. Your bladder is like that sometimes. So that\\u2019s more of a behavioral thing because what would you do with the puppy who\\u2019s now like, wait, every time I do this, she lets me out. Pretty soon you\\u2019re letting that puppy out every 10 minutes because yeah, because that\\u2019s what the puppy trains you to do. So that\\u2019s kind of more of a behavioral thing. And so that\\u2019s proceeded by a strong urge. So it\\u2019s not just when you\\u2019re going to the bathroom, but if you get a strong, unexpected urge and leak, and that\\u2019s usually a lot of people also experience some urgency and frequency.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So if you feel like you\\u2019re not getting to the bathroom in time, what would be a really logical plan to that?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa017:52\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 You\\u2019d go more often, you\\u2019re like, Ooh, maybe I need to not wait so long. But the thing is that then you\\u2019re training yourself to go more often, your bladder is perfectly capable of holding more that kind of sensitivity and those signals you\\u2019re interpreting or like, ah, no, I should go now. And then pretty soon you\\u2019re that person who can\\u2019t make it through a movie. You\\u2019re that person who can\\u2019t make it past a bathroom without needing to go. And you\\u2019re the person that no one wants to go on a road trip with because you\\u2019re 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\\u2019s 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\\u2019t intentional, like it\\u2019s kind of like a slippery slope. It\\u2019s like I almost didn\\u2019t make it that one time. I\\u2019m going to plan ahead. And then what starts to happen, especially if you\\u2019re like, all right,

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa018:54\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s like, all right, so that was nice and normal. But then imagine that time where you\\u2019re like, hold on, I almost didn\\u2019t make it, but you were stretched this much. You\\u2019re going to start going when the bladder stretches this much. And then pretty soon if you let it so you\\u2019re like, Ooh, now I\\u2019m 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\\u2019ve got a goal, but then nothing happened. Goals, like it\\u2019s the smallest tinkle and you\\u2019re like, I thought it wasn\\u2019t gonna make it, but that\\u2019s ah, that\\u2019s all that\\u2019s in there. And so that was like big urge little output. That\\u2019s kind of a mismatch. And that\\u2019ll happen sometimes.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa019:48\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 But like if you\\u2019re paying less than that, that\\u2019s not much more than your poster board then a nice healthy post void residual. So you don\\u2019t have to empty at that point if you\\u2019re bladder\\u2019s saying, empty me now. And that\\u2019s all that\\u2019s in there. Yeah. So it\\u2019s kind of like you\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And there\\u2019s actually some interesting conversations with urgency and frequency in that feeling of extreme urge, can that be considered a pain? And so it\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa020:47\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Too bothersome. Does that crossover into it? Distressing emotional experience? I would think so. Like can you imagine if you\\u2019re like on a train or something like that and you have to really, really, you have, you\\u2019re having that urge. I mean, that\\u2019s very distressing dressing. That\\u2019s very distressing. That\\u2019s like you\\u2019re 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\\u2019ll 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\\u2019s the best, but not many people are willing to measure.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa021:37\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019re not measuring, but that\\u2019s okay because if you have a strong urge, which is kind of a lot, but you have like a little tinkle, that\\u2019s 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\\u2019re 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\\u2019re having urgency, frequency or incontinence is water is they cut out their water. It\\u2019ll almost always backfires.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa022:19\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So don\\u2019t 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\\u2019re 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\\u2019re drinking coffee all day, you\\u2019re 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\\u2019s 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\\u2019re not leaking like they thought they were or you know, is this primarily a stress incontinence issue?

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Well, so it sounds to me like there\\u2019s not a lot of hands on work there.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 No, no, it\\u2019s more behavioral.

Susan:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa023:27\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Do you ever use pelvic tilting to get the posterior versus anterior pelvic floor?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So that\\u2019s a neat work with from Paul Hodges Group. So however you\\u2019re 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\\u2019re not changing your cue. For most people it\\u2019s cuts to the front. And it\\u2019s 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\\u2019re, they\\u2019re using their body.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa024:18\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So if you have a runner who\\u2019s a chronic but Tucker and she\\u2019s leaking out of the front, obviously, how would it feel if you like got those glutes back a little bit? Because you can\\u2019t run and Kegel at the same time. You can\\u2019t, you can try. It\\u2019s 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\\u2019t think about the pelvic floor until you have a problem, right? But they\\u2019ve been working, right? They\\u2019ve been doing their thing. You\\u2019re using them when you walk up those stairs you\\u2019re using them when you\\u2019re getting up off the floor. So they do something, the key goal is like your bicep curl. You want a stronger bicep, you\\u2019re going to do some curls, you want a stronger pelvic floor, you\\u2019re going to have to do some pelvic floor exercises.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa025:07\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 But that\\u2019s 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\\u2019t 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\\u2019s strong enough and coordinated enough to do its part. So you don\\u2019t think about it.

Dave:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa025:37\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So along those lines then, would you say that if somebody is more lordotic, they\\u2019re more likely to engage the anterior floor and then flat back more of the posterior floor?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa025:47\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 That tends to be what they\\u2019re finding on like EMG studies and what I will see clinically with people if they do a ginormous buttock. It\\u2019s really interesting if you\\u2019re like, how\\u2019s your breathing when you do that and, and how good is your squat, let\\u2019s say when you do that. And it\\u2019s like, Eh, it is what it is. I\\u2019m like, okay, so what if we do kind of take it into where some people, especially if they\\u2019ve been told by other practitioners to like watch your Lordosis, it\\u2019s kind of huge. Which isn\\u2019t really a thing. But you know, they kind of, they\\u2019re kind of like going in there, they\\u2019re like, I\\u2019m so scared but it kind of feels good and then you have them do that movement or try that exercise. Usually they\\u2019re like, that was way easier than I thought it was going to be.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa026:30\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 But again, if it\\u2019s not working, then we try something else cause everyone\\u2019s 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\\u2019s functioning as opposed to, I mean, I\\u2019ve been guilty of it in my career of like, ah, you need more or less of what you\\u2019re doing with your spine and were just different. So it\\u2019s where it works best is where it should be.

Jamie:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa027:03\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So for a lot of the outpatient conditions and orthopedic setting, there\\u2019s still an emphasis on giving some kind of qualitative documentation to the muscle contraction, whether it\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa027:29\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So if you\\u2019re just checking externally, like just palpating outside, it\\u2019s like a plus minus like, Yup, I felt it. Uh, they couldn\\u2019t find it. So kind of plus minus, cause you can\\u2019t 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\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa028:09\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019m 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\\u2019re asking for information that isn\\u2019t necessarily the most helpful. So if you\\u2019re checking an externally plus minus, but also I\\u2019ve had people who five out of five but still incontinent,

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa028:41\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So then they\\u2019re like, well they\\u2019re not weak but you put down, you\\u2019re going to do strengthening. I\\u2019m like, well yeah, because it\\u2019s more of a strengthening, not just a strengthening with a functional goal attached to that, if that makes sense. So sometimes it\\u2019s more words, but don\\u2019t be shy about one. Well, first of all, please be honest, be as accurate as you can be, but also don\\u2019t be shy about doing the best care and be willing to stand up for it. If it gets denied. It\\u2019s not cause you gave crappy care likely. I mean, do you know what I mean? I\\u2019m like, I dunno how long you practice, hopefully. Good. But if you get denied, it\\u2019s not necessarily key because you gave bad care or even did a bad note. It\\u2019s because they decided they weren\\u2019t going to pay based on something. Hopefully logical that you can talk about. You can always appeal. So don\\u2019t let payments scare you away from giving the best care.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa029:36\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Sorry. Another soapbox of mine.\\xa0 So that was urge incontinence. Stress Incontinence.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So let\\u2019s talk about that because I think that gets the more airtime, so to speak. So that\\u2019s when you see the crossfitters are the weightlifters or there\\u2019s a great gymnast pitcher yesterday going backwards where you there backwards over the pommel horse, not the pommel horse. It\\u2019s the worse just a horse. A spurt. Like it was, yeah. And you\\u2019re just like, that could be photo shopped, but also it probably isn\\u2019t. Yeah. Or like we\\u2019ve 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\\u2019s been addressed by a lot of a pelvic health physical therapists.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa030:32\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So I would like to know first I think we just gave the definition of stress incontinence, but I\\u2019ll have you give the definition quickly. But then I\\u2019d 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So stress incontinence is basically when there\\u2019s 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\\u2019s why you hear, and again, it\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa031:21\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Those are usually because the closer pressure has gone down or the intra abdominal pressure has gone up.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Okay, great. So now what does that look like? For the average physical therapist who\\u2019s not a pelvic health therapist. And let\\u2019s 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\\u2019s normal. Or they have low back pain and they say, yeah, but that\\u2019s normal. Everybody does it at my crossfit box or whatever at my gym. So how do you then, if you\\u2019re not you, you are someone who\\u2019s not a pelvic health therapist, how do you address that?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Well, first of all, what all of us should know while incontinence is super common, it is not normal.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa032:16\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Not ever being dry is normal. So we need to get away from this idea that like, well, everyone\\u2019s doing it. It\\u2019s 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\\u2019t 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\\u2019re incontinent that young. Yeah. And I see a lot of women as adults sometimes before they\\u2019ve had babies sometimes after, right? So like what\\u2019s the, what came first? But they\\u2019ve had lifelong issues with what\\u2019s essentially public flourish. She\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa033:12\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 There\\u2019s been some studies, there\\u2019s one study and I cannot recall it. I mean, it\\u2019s probably like 15 years old now. We\\u2019re 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\\u2019re not a pelvic floor therapist is to check out their function. So if they can identify when they\\u2019re having issues, it\\u2019s when I get to this particular weight or it\\u2019s when I get to mile 17. Okay. And I usually throw in, like if I ran 17 miles, I\\u2019m not really sure what my body would do. Like I dunno, but it still shouldn\\u2019t 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\\u2019s happening there.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa034:04\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Because if you can run 17 miles or you can lift 200 pounds without leaking, but then you do, you\\u2019re not, you\\u2019re not weak. Right? Like if you can do all of that, something\\u2019s happening there to make this happen. Cause if you can lift 200 pounds in that league, something\\u2019s working, it\\u2019s just not still working when you try to live 210. Okay. So let, let\\u2019s look at what\\u2019s changing or number of repetitions. Right? That\\u2019s what you\\u2019re looking at.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa034:52\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So if you collapse your chest and which I would probably do after running 17 miles and I\\u2019m 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\\u2019m just trying to get through now. The funny thing is the breathing is also harder. So while I\\u2019m doing this as kind of a mechanism to keep going, it\\u2019s harder to breathe because nothing\\u2019s working diaphragm to have a full excursion, right? Yeah. So, so I like to look at if you\\u2019re running fine for 17 miles, I want to see you at mile 16. I want to see what\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa035:32\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Do you notice a change in your breathing when you\\u2019re lifting 210 instead of 200 and kind of look at it from that way cause you\\u2019re 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\\u2019s fine, but it\\u2019s like if we go back to the running, you\\u2019re not kegeling and all that time your pelvic floor after like 30 seconds is like, dude, you don\\u2019t want me to get that tired. Like it\\u2019s going to be like, we\\u2019re going to stop that now. So yeah. So the way I would approach that, if you\\u2019re 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\\u2019re my squat.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa036:13\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 How they do, they\\u2019re looking at the mechanics. You would look at what\\u2019s happening, what is different? Cause you know, the joint can do it, you know, the muscles can do it. What\\u2019s changing. And you would address that. So it\\u2019s really no different if they can tell when they\\u2019re leaking, you\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Okay. All right. That\\u2019s great. And, and, and that goes with that. Does that also work with, let\\u2019s say instead of you\\u2019re not a runner weightlifter, but you\\u2019re like a new mom or something like that and you\\u2019re okay, but then by the end of the day after you\\u2019ve been maybe lifting the baby or you know, doing whatever you\\u2019re doing it, it doesn\\u2019t necessarily have to be sport related is what I\\u2019m saying.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa037:06\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s, but then it\\u2019s basically a squat. So you are, you\\u2019re looking at the activity that they\\u2019re having difficulty with and making small changes got in most cases.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So I think the biggest takeaway here for me is that not everything is solved by doing a kegel.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 I think a lot of non pelvic health PT\\u2019s may have that, that misconception that if someone has incontinence, well Kegel time. Right? And that\\u2019s all you gotta do. That\\u2019s what most people do. If they go to the doctor and they mentioned it\\u2019s like, ah, you know, that\\u2019s pretty normal. It\\u2019s not, it\\u2019s common. And then they\\u2019ll be like, do some kegels and, and a lot of women and men don\\u2019t know how to do them.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa037:53\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So then they\\u2019re just, I\\u2019m squeezing stuff and it didn\\u2019t work. And it\\u2019s like, Oh, before we get too far, can we check and see how you\\u2019re doing them? And I think that\\u2019s kind of a beautiful segway. So let\\u2019s say you have your new mom or you have your athlete or whatever and you are, you\\u2019ve tried some stuff, right? Cause none of this is life or death, right? I mean it\\u2019s 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\\u2019re seeing them for hip or low back. It all, it\\u2019s all together. You\\u2019re good. But if it\\u2019s not changing, if it\\u2019s not getting better, if when you ask them, you know, can you contract your pelvic floor, what do you feel? They\\u2019re like, I got no idea.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa038:33\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And they\\u2019re like, but please also don\\u2019t touch me there. Or are you touching there and you\\u2019re like, yeah, I don\\u2019t feel anything either. And I\\u2019ve used all my cards but I don\\u2019t know what to do. That\\u2019s when you refer. Because just like any other things, somebody coming to see you as a physical therapist, you\\u2019re going to do some things. And if those things are not working or they\\u2019re getting worse, you\\u2019re going to try something different. Or call the doctor or refer to a friend. Right? So if you change some things and you\\u2019re like, I\\u2019m amazing, they\\u2019re all better. Awesome. Do they need to go to pelvic floor therapy? I\\u2019d 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\\u2019s more like this.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa039:19\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So it\\u2019s like tight and there\\u2019s 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\\u2019re like, I\\u2019m here, how good is my contraction going to be? Because I\\u2019m not showing you my pelvic floor. Like it\\u2019s not going to, it\\u2019s going to taste like it\\u2019s going to not move very much. But if you get them to relax more or they\\u2019re like, oh, I didn\\u2019t know that was there, that\\u2019s better. Then you all of a sudden you have a good contraction.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 How do they relax? Do you just say relax?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa040:01\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019t think of that. But if you squeeze and let go like as a little bit of like, Oh, I feel that, oh, oh there\\u2019s some more space there. So I start with that. Okay. The pelvic floor. But again, if they\\u2019re like, I just don\\u2019t know, that\\u2019s something that is so easy to feel with a vaginal or rectal exam. So that\\u2019s where it\\u2019s like, ah, you\\u2019re having some trouble. I would recommend, would you see my friend for one visit have this exam, they\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa040:54\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Cause it\\u2019s not just about like slacking everything out. It\\u2019s really feeling that that relaxation, that lengthening of the muscles there and being intentional about it. You don\\u2019t want to lie there would hope like maybe it\\u2019ll let go at some point.

Audience member:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 There is no hard and fast rule as to like how many, how much. So that\\u2019s where, again, I would have them do some and see how the coordination goes. Cause if they\\u2019re otherwise neurologically intact and they\\u2019re kind of getting it, how many do they need to do?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa041:57\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 I would say it\\u2019s 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\\u2019s an okay starting point. And actually, I don\\u2019t know if you know this, so I\\u2019m writing a book on incontinence and the PT people have it, but it\\u2019s the editor just asked me, she\\u2019s like, well, since we don\\u2019t have like a hard and fast number, do we, should we put that in there? And I said, I think we do. So that\\u2019s 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\\u2019re not getting better. So it\\u2019s kind of like let\\u2019s 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\\u2019t contract for 10 seconds, they can only contract for five, I\\u2019m 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\\u2019m not sure how much it would help. So really looking to be like, okay, so I feel that contraction and I\\u2019m breathing

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa043:10\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 and I usually actually have stopped counting seconds. I\\u2019ve had people go by breath, so if you, let\\u2019s do it. We\\u2019re going to squeeze our pelvic floors and you\\u2019re 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\\u2019t feel that, let go. I usually say that\\u2019s one of two things without feeling right. I can\\u2019t tell without feeling is that you got tired and you lost it or you forgot to let go.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa043:51\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So that\\u2019s okay. Have a wiggle reset and try again. Because if you\\u2019re not feeling the contraction, what are you doing? Like you might as well take a walk because then you\\u2019ll actually be using your pelvic floor. I like going with the breath because a lot of people like to hold their breath when they\\u2019re like, they\\u2019ll do like they\\u2019ll just suck at it and it, you\\u2019ll feel a lift, but it\\u2019s just a vacuum. It\\u2019s not really your muscles doing their thing. So by doing the breathing, if you breathe in and out twice nice and slow, it\\u2019s 10 seconds. You don\\u2019t 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\\u2019s not really helpful either. So like the too slow breaths. Now you\\u2019re breathing and don\\u2019t have to count and you\\u2019re going to stay honest.

Audience member:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa044:57\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So trying to bring this into the neuro world for someone who\\u2019s post stroke and has stress incontinence or they\\u2019ve 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 I haven\\u2019t had PNF stuff since college. And I\\u2019m old. So what I would say is, is if I\\u2019m recalling that they go through movement patterns and as you\\u2019re doing those things, there are things will be happening on the pelvic floor. It seems to make sense. What specifically, I don\\u2019t know, but if you\\u2019re kind of working more with that tone in general, I\\u2019ve 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa045:49\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 It\\u2019s like, wow, that\\u2019s so cool. Like once I totally normal springy, they can contract and relax the other side just like they\\u2019re, they\\u2019re hemiparetic arm. It\\u2019s cool. With stuff like CVA or neurological involvement, you really want to make sure you\\u2019re 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\\u2019t want to mess around with screwing up the bladder or the kidneys. So if they\\u2019re not going to the bathroom or they\\u2019re 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\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa046:38\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Because the other thing we need to remember is a lot of things we\\u2019re still working on people who have had neurological insults, right? So once you\\u2019re like, okay, bladder is relaxing as it fills, contracting, as it empties, it\\u2019s emptied fine. We\\u2019re not worried about this being overflow incontinence. I would actually start to incorporate stuff like blow before you go. Where you\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa047:25\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And when I click the slide from this beautiful simple picture, it\\u2019s 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\\u2019re, 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\\u2019s just because of a high tone pelvic floor on that one side. That\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And when you\\u2019re 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 They can do it through an ultrasound so that that they are, they can look mostly at like post void residual.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa048:12\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 But then also there\\u2019s a test called neuro dynamics. And this is a test that involves, a catheter and there you\\u2019re a threat. And then a probe and another orifice down there to help measure for intra abdominal pressure. And it\\u2019s kind of a neat test. If someone wanted to do it on me for free, I would probably do it. But they\\u2019re 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\\u2019re 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\\u2019m like, tell us when you get like the, I should go to the bathroom now urge. And they mark that and then they\\u2019re like, okay, tell us when you can\\u2019t take it anymore.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa049:00\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 And they mark that. So then they know how much your bladder can truly hold. But also looking at what\\u2019s your detrusor doing, which is the smooth muscle around your bladder, what\\u2019s happening to your pelvic floor, where is the weakness? And usually when they\\u2019re full, sometimes they\\u2019ll have people cough to see if anything leaks or if any sphincters happen or sphincters what they\\u2019re up to. But it\\u2019s, it\\u2019s involved. But there\\u2019s a lot of good information. And interesting side note is that if you do so, that\\u2019s 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\\xa0 urodynamics of one of my patients who was really against cathing.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa049:46\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 He didn\\u2019t want to cath. So she came down, she brought him down to the urodynamics and as it and cause he\\u2019s like, I am voiding 400 to 600 milliliters every time I have a bowel movement. And like that\\u2019s 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\\u2019s, 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\\u2019s coming out, but it\\u2019s not healthy. Like I need to cath.

Jamie:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa050:41\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 What are some of the considerations that you might go through in your thought process when you\\u2019re dealing with a male versus a female pelvic pain or incontinence issue?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa050:53\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 That\\u2019s a lot. I could talk for days on that. Well I\\u2019m not sure. When you\\u2019re talking about considerations. We need to take into consideration our patient preference and what they\\u2019re 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\\u2019t really comfortable talking to females. But a lot of the men who come to see me, just want help, and we\\u2019ve had several male students come through and you know, they run into like women not wanting a male therapist to do it.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa051:36\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 It\\u2019s 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\\u2019t know that in my brain it\\u2019s so, so different. Male to female, you\\u2019re 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\\u2019t transitioned but totally identify with the gender. They weren\\u2019t assigned at birth and all of these things. So basically I take it functional. So can you just walk me through the issues you\\u2019re having, your questions, concerns when it\\u2019s a problem, if anything makes it better, does anything in particular make it worse? And then we problem solve from there?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa052:26\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 So I guess I didn\\u2019t really have a good, a good answer, man. Male to female. Their situations are usually different, but it\\u2019s kind of different across one gender or the other. Anyway. Is that kind of answer it? Yeah. Great question.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019s 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa053:16\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 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\\u2019t 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\\u2019t one answer. So if you start asking those questions, you\\u2019re part of, you\\u2019re part of the solution. By kind of pushing those boundaries and not like, I wish I would\\u2019ve just asked more questions sooner. I\\u2019d be so much smarter than I am now.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Where can people find you on social media if they want to get in touch with you?

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Sarah Haig, PT on Twitter, you can find me on my website, www.entropy.physio and um, I mean Facebook, Sarah Hague.

Sarah Haag:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa054:07\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 I don\\u2019t know what my picture looks like right now, but I\\u2019m friends with Karen, so if it says I\\u2019m friends with Karen, that\\u2019s probably me.

Karen Litzy:\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0\\xa0 Awesome. And just so that everyone knows a lot of this stuff that Sarah spoke about, we will have links to it. We\\u2019ll have links to the home health section. We\\u2019ll 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\\u2019ll 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\\xa0twitter,\\xa0instagram\\xa0 and\\xa0facebook\\xa0to stay updated on all of the latest!\\xa0 Show your support for the show by leaving a rating and review on\\xa0iTunes!

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