Episode 70 - What Is Abdominal Pelvic Health Therapy? Find Out From And Expert Meet Donna Pagano PT

Welcome. I'm Diane Carbo with Caregiver Relief, and today's topic is going to be on what is abdominal pelvic health therapy. Today, we're going to find out from an expert. I'd like to welcome Donna Pagano, a physical therapist who specializes in a very underserved branch of PT, abdominal pelvic health.

Donna, I'm so glad to have you here with me today. When I learned of your specialty and realized people don't know what your services are. I just thought it was really important to educate people out there. So let's get started. Again, welcome. I'm excited to be here. Thank you and I'm glad you're having me because it is, like you said, such an underserved area and people just have no idea what it's about.

I'm always saying when they come in with a script, they look like Mickey Mouse at 630 on a watch because his arms are crossed over as profits at that time. But, so it's one of those things that I love to get out into the community and this is such a wonderful opportunity to do so. In fact, I'm treating a physician right now who had no idea it even existed.

It's a part of physical therapy that you don't really learn in physical therapy school or physical therapy assistant school. It's all continuing education and the way we're instructed is really up close and personal. Your pants are off the whole time. So we learn on each other both vaginally and rectally we do treat men and women. Children we usually don't treat internally unless there's an absolute need. But anyway, so there's not a whole lot of people up for going into that kind of thing. And that being said, it is absolutely growing. So it's getting to be more and more in the community but for all intents and purposes, there's still not enough of us.

So that's what it is and what we treat are any kind of things that happened in this area, whether it be incontinence of urine or feces, or the inability to keep either or in get it out. So urinary retention, urinary incontinence, both fecal incontinence and constipation. A lot of digestive work.

That's where the abdominal part comes in. So if people happen to have any kind of issues with scar tissue from abdominal surgeries that may include colon resections may include appendectomies, gallbladders, hernia repairs, C sections anything you can think of and even if it's not scars, fascial adhesions, which is connective tissue.

We'll talk about fascia in a minute, but those adhesions can form simply because of inflammatory responses in an abdomen. So whether it's inflammation from chronic constipation, chronic diarrhea, maybe about a food poisoning that you had, that gets to be really important in how we treat. So it's easy to think just about, a bowel or bladder or it coming out.

But when you think about the fascia. In an abdomen, when you're a little embryo being made, the intra abdominal fascia in your abdomen turns into the second of the three layers of our pelvic floor muscles. That's why you can stick your finger in your belly button and feel something weird downstairs. So fascia is under the control of an involuntary nervous system.

So if I tell you for instance, Diane, straighten your elbow out for me, you can do that. But if I say digest that sandwich you ate, you're not in control of that, right? So fascia is under that involuntary control system. And so the way you work with it is very different than just stretching muscle.

So over time, fascia can tighten up to 2000 pounds of pressure per square inch. What makes it tight? Some people can be born with tight fascia, but for the most part, it's surgeries, it's pain, it's chronic inflammatory stuff. Even emotional stress or sometimes chemical changes with medication can tighten fascia.

So just even think about emotional stress and what does one do? Even if you're not even conscious of it, but when you're stressed, you have just an angst, a tightening of clenching of the jaws or things like that. Where you're not your body's just not want to be relaxed. So sometimes people who even deal with anxiety just chronically typically have tightness because of those factors.

When we go in there to examine what's going on in the pelvic floor, we look at tightness in the pelvic floor muscle via the rectum via the vagina and we look at the external things that attach to the hips. Those are important and we look at what's on top of all those pelvic organs, therefore the intestinal system or your guts.

So when we consider what's going on with the fascia, if you had tightness from scar tissue up above or just inflammatory response from IBS or whatever, if you imagine slowly over time above that pelvic floor, 2, 000 pounds of pressure pulling that can squeeze nerves, call it cause and pain that can move bony things like leading to a stenosis of a back where one vertebrae will slip forward on another.

It can just lead to closing off things like the colon, or think about a female who just has painful periods. They're not the most fun thing every month. Over time in the the lower part of the abdomen where have tightening so that can actually tighten over fallopian tubes which can lead to infertility because the eggs cannot get through a tube that is now squeezed and shut. So big issues in whether your poop is moving through the large intestine properly your food is moving through the small intestine properly. There's studies now where we work to decrease small bowel adhesions, hopefully by our hands, this way we treat in therapy, versus you having to go in to have a small bowel blockage removed because when you go in, you're going to create more scar tissue and the chances of having another blockage in two or three weeks because of scar tissue are high.

So this is absolutely worth a try to manually reduce that without having to go in with surgery. We use our hands to do that. It's very strange, it's very gentle, it's not painful. So that's a lot of what we do in the abdominal sector of that. But all of that, considering the fact that, that tissue connects to the second layer of the pelvic floor, that can also cause the sphincters that should remain closed, keeping you continent of urine and feces.

But if something up above is pulling that much, maybe that sphincter no longer shuts completely, or it has a hard time shutting because of that pulling. Therefore, we have some incontinence issues, or the pulling offsets the muscle tissue and the balance, and we have pelvic pain. Pain is one of those things, again, that's certainly going to cause the fascia to tighten up.

Let's say in a female who has painful sex, you just end up robbing Peter to pay Paul if you're trying to continue with a sex life, it's painful. We got to fix that for you because each time you try to do that's, sex is supposed to be a comfortable part of our life. And if it's not, then we're going to tighten up.

Nobody's going to want to put their hand on the hot burner. So even if you've experienced painful sex, the thought that it may happen again, or even the subconscious worry that may happen again can lead to those muscles closing down on you. And in severe cases, that can lead to what's called vaginismus, where the muscles literally close down like a venus fly trap and they don't allow for proper penetration of whether it be a penis for sex, whether it be toys, whether it be a speculum or tampons for women.

So that's something that we frequently treat, believe it or not. A lot of people don't want to talk about that. And they think something's wrong with them. That's not always the case. That's a lot of what we treat with pelvic pain. So it's not all about leaking urine. A lot of people have heard of it as, oh, they just work with if you leak urine when you cough and laugh and sneeze.

That's not all we work with. We certainly do work with that a lot, but there's a whole lot more to abdominal pelvic health. So I like to know what conditions do you treat and then I want to know, we talk about pelvic health, the first thing you think of is women, but I know from my personal experience that you do treat men.

So tell me more about that. Men have less issues than women do simply because they're not birthing those things. That is not an easy thing to do. But with men, we, if we treat them in an area in which we live is a high retirement area. So we have a lot of issues, with post prostate removal, prostate cancers, and that leads to some leakage afterwards.

So we do work a lot with that. Men can absolutely have pelvic pain, although it's less common than in women, but they can have one that's more common in men, hernia repairs, inguinal hernia repairs, umbilical hernia repairs, that scar tissue can do the same thing, leading to pain. It can be pain at the side of the lower quadrant of the abdomen or the belly button, or that tightening then leads to penal pain and things like that.

Obviously men have to have a bowel movement too. So we treat constipation. That's a common thing that we treat as well. And that is something that's one of my favorite topics to talk about is elimination of stool because let's just say we need a stool for your stool and I don't know if you've ever heard of it, but a squatty potty got famous on the show shark tank.

And yeah, it's not a new concept though. It's been around forever. My 1st course in 2003 of pelvic health, I bought my 1st book on pelvic health and it shows little cow milking stools under each foot, but the point of it is, if you think about it, most of the world squats to the ground to defecate.

Yes, what is a 2 year old doing still in a paper? They're squatted behind the recliner over there. Correct? Yep. That is the most natural position in which to eliminate stool and what happens in that position where your knees are well above your hips The 3rd layer in of the pelvic floor muscle is called the levator ani group.

It elevates your anus, but there's a particular muscle in that group called the puborectalis. Men and women, it goes from your pubic bone around your rectum and basically it serves a little bit like a noose around that rectum to keep poop from just falling out of us when we're living our life. But when you're in that squatted position and those knees are well above the hips.

What happens is the noose falls off of the rectum falls into a straight line, allowing for less pressure to defecate, whether you're a strainer or not, period. And it also allows for full evacuation of the stool. So you treat men and constipation. I have to tell you, that's a big 1 for the aging population. In fact I just wrote a book about everything you need to know about constipation. I haven't finished it yet. And I'm going to include information about physical abdominal pelvic floor information and I wrote down squatty potty.

Yeah. I'm going to look into it because that is a big issue with so many of my seniors is and then urinary incontinence. What other conditions do you treat? Let's back up for just a second to the Squatty Potty again. Okay, yeah. So with the Squatty Potty, it not only allows for less pressure for your stool to evacuate, but it also allows for full emptying of the colon, which does not happen if you're on a regular toilet.

So we have a lot of things to consider. If you live in a retirement area, the toilets are likely built in a house, at least one of them already quote comfort size or height, for the aging hips and knees. So you consider that in fact that we're all getting shorter as we get older, that, that adds to it too.

But that taller toilet may be good for your aging hips and knees and easier to stand up, but it's bad for your colon because you can't get low on the toilet. You're already too high. All the more reason why we need a stool under our feet to elevate the knees up above the hips. So one of the big things we, we use that for, we should just be using it period.

But with women, again, that helps decrease the opportunity of pelvic organ prolapse. So when your bladder drops or your uterus drops or your rectum drops, those are all forms of organ prolapse. It can help decrease the opportunity that hemorrhoids come into play because we're taking less pressure off.

The other thing is, again, when you're not in that position, we're not fully evacuating. So there's still some stool left in there and we're going to see that stool take up room against the bladder. That is one of the biggest reasons why I go to the flip side of this age group and look at new moms and kids, because when kids are potty training they're less likely to go do number two for a while.

And one of the reasons why I feel like is a bigger reason than they're playing and they don't want to give up their playtime, but they figure out that they can eliminate squatting behind the recliner in their pamper. But they can no longer do it because you put them on the big toilet or even the little kid toilet.

The ratio of their leg does not allow for their needs to be higher than the hips. With pediatrics, that's 1 of the biggest reasons for bedwetting because they're not fully eliminating. The colon fills up with stool because you've taken them out of their most perfect position and now put them on the other potty, rewarded them for it.

And now they can't get it all out. They're sitting there grunting, they appear constipated. You add that to today's kid's diet. That's probably a little bit true, but it's the mechanical position in which they are on the toilet that prohibits that passage of stool. So it fills up and then in the night they roll over in the night and that big bolus of poop that now has piled up in the rectum pushes into the bladder and it causes them to bed wet.

It's not at all that they can't learn to wake up. The brain never got an appropriate signal to void of urine. They just have so much stool in there. The same thing happens recently, I just discharged a little 88 year old lady and she was actually tall, thin. She had both hips and knees replaced over the last four or five years.

So she was weak, but they had gotten her one of those big plastic toilet things with the handles that I'm familiar with them. She was now, using the restroom at a level of which she could help herself up easily from aging hips and knees. But the only reason she was in there to see me, it wasn't that she had urinary incontinence.

She was bed wetting. She was no different than a child because now she was raised too high and could not eliminate the stool. She actually didn't need me. That was an easy fix. We just got to figure out how can we get her feet up. It's fine for her to have that so she can get up easily and safely from the toilet.

But how can I position her mechanically to empty her colon? Does that make sense? Yes. Yes. Yeah so it's one of the biggest teaching factors. And sadly, you can't go to Walmart, Walgreens, CVS, wherever right now and go pick one up. You still have to get online and order them. Sadly, this was one of the things that the physician in which I was working with was sort of son and he was like, how come we weren't taught this in medical school?

And it really is sad, it's such a simple fix. You retire, you move to your retirement place. You build your retirement home. You have tall toilets, anticipating aging. Suddenly you're at the doctor for constipation. Did anybody tell you put a stool under your feet? You don't need so that some of the time this is a big issue.

Wow. You know what? I've been in rehab. I'm an old as in season. I've been a nurse for 50 years and this is the first time I've heard that. And you are not alone. I had a young mom. She was a PA, three kids and her little bit older one was upset that the three year old was out of pull ups already at night and he was still in them.

And I told her, I said, you gotta get a squatty potty. The problem is, especially when they're four and five and they're dry during the day, but they still need to pull up at night. That's the problem. So she got one and within two weeks we were out of pull ups. That saves you a lot of money. Oh, yeah.

And yes, it does. And the other thing I think of is my seniors, how many seniors are becoming incontinent and they're still awake and alert and it must be because of the constipation that they're experiencing because that's such a big thing. And let's just make something else clear with that note, because you can absolutely have a dry bolus of constipated, what we think of as constipated stool in your colon.

But then if you're taking laxatives, the liquid stool can push around that. So you can actually be constipated and have diarrhea at the same time. And liquid stool is harder to keep in they can be in cotton and a liquid stool harder to keep in than solid stool. If we can eliminate having to take so much laxative, then we can eliminate a lot of the fecal leakage.

So just to tell you a little success story. I had one lady who was 81, this was several years ago. She had a back surgery. They accidentally nicked a nerve when they were in there that caused her to be fecally incontinent. It was what it was. I'm not going to bring back a dead nerve. So the person that she was seeing told her that pelvic PT wasn't going to work, but she had a granddaughter who lived on the West Coast who told her you need to go find a pelvic PT.

So she insisted. I just want to try one in order because they were looking at doing a new stimulator that's new on the market that is supposed to help with fecal incontinence or constipation, but she's I'm 81, it's new. I don't want to buy the new car. If we can work the kinks out, I really don't want a surgery.

I've dealt with this for 11 years and I'm older. So she was somebody who had dealt with some constipation issues over her life. So again, I didn't bring back that dead nerve. She had fecal leakage every day. What I did was do the hands on techniques where we mobilize the type fascia, let go those tight loops that had formed in her colon causing stool to do hairpin turns, which was harder for the stool to move through.

Then we loosened up all the pipe stools moving through better. She required less laxatives. Less laxatives meant less liquid stool. Therefore, when we discharge her, she was down to 1 fecal accident about every 2 weeks versus day. Wow, that's a big quality of life improvement. Trust me.

I know I absolutely do. And that's something that I deal with all the time are laxative dependent people. And if you think about all the things as we age that causes or potentially adds to the likeliness of constipation as you age things that you just don't think about, like medications that may cause dry mouth.

Those are also going to dry your colon out. Colon dries out, you're going to have a harder time defecating. We're going to end up with that dry, harder stool. Also, you think about the fact that as you age, you're not moving around as much. You go, you may be in assisted living. You're sitting, you're not moving around as much.

You're not stimulating the colon as much. Even if they tell you, which is the number 1 thing, drink more water to help with constipation. If your urine is a clear yellow, you're drinking enough water, but what happens as you age you lose a half a pound of muscle per year after age 30. Okay, so then that's like sponge in your body okay, if we're losing that then we're not able to hold the water, your skin is thinning and everything so everything's gonna evaporate through your skin much easier anyway so you're drinking enough water or you've been told to drink water and you don't realize don't guzzle it, because if you have a dry sponge and you pour water on it, it's just going to run over it.

If you have a dry sponge and you just sip the water onto it, it's going to sink into your muscle and that's how you hydrate your body. You can't just go gunk, that's going to go right through you. So when you're hydrating, a lot of people are on these diets where they need to get in so much water, but they don't like it or whatever

and they just guzzle. Yeah, you're going to be quicker. It's going to go through you. It's not doing what it's intended to do in hydrating your body if you do it that way. So we have those things. It's just also things that happen in life. Typically, people have a harder time sleeping as they get older. And at night, when you reach that REM sleep, the rapid eye movement, hard sleep, which is about 3 or 4 hours in, that's also when your body secretes growth hormone repair, but it's also the time when your body has its highest velocity contractions of your colon to move poop through you. Therefore, that's why most people are morning poopers because people's colons have worked hard all night to move stool through them. So in the morning, typically people have a cup of warm coffee. Warm is going to help move it. Coffee can be a stimulant to stool so that people usually go.

But have you ever noticed how uncanny your bowels are if you go out of town for a weekend, like you don't have trouble with going, but then you go out of town and suddenly you don't poop for two days. Here's why, because. In a hotel room, you're out there, you're probably not sleeping as well as you do in your bed.

There's noisy air conditioner, it's too hot, it's too cold, there's noisy people in the room next to you, the mattress isn't comfortable, you're probably not hitting that REM sleep. If you're out of town, you're also probably eating out. It's going to be much saltier. It's going to dry you out. So you combine those factors and then suddenly come home after your little weekend trip and your colon's I'm ready now you're back in your normal situation. It happens all the time, but those are part of the reasons why that we seem to have that. And so in, in older populations, another thing that leads to not seeing still move is you age your old factory system ages and you don't smell as easy.

You don't taste as much. So you don't desire food. You ever notice when people make it to 85, 90 years old, they get thinner that they don't want to eat. They don't taste it. They don't smell it. They get thinner. If you're not putting the food in, it's not going to come out. So it's okay for those people to not have a bowel movement every day.

So just FYI, having one to three bowel movements a day is considered normal and not having one by third day is considered not normal. So anywhere in that little normal spectrum it, you don't have to be obsessed with having one every day. So people don't need to be popping laxatives like crazy.

It takes 20 to 72 hours for what goes in mouth to come out the other end for a normal person . So just know that if you've had something that's a lot of cheese and bagels that's constipating, it might be 48 hours before you're struggling or it might be that night that the kid has problem bedwetting.

Awesome, I've worked in so many different areas of nursing, and one of the things we did in rehab, and one of the things we do in the nursing homes is you follow a bowel, you find markdown every time somebody has a bowel movement. And if they don't go, and on the third day, then you initiate simple things, maybe stool softeners like a Benefiber or a MiraLax.

And if they don't go we take it 1 step further and you do the duplex depository and then you go to an animal. So I had people come into the ER that haven't gone in 3 or 4 weeks. So what I suggest, one of the other things we teach is how to manually do a colon massage, so you can learn that to help the stool move through your body because if you're in the hospital, the chances of you being stuck in the bed and not moving around, not going to make stool move.

Chances of you being on pain medication, probably high, that's going to constipate you. So our rule of thumb in pelvic PT is we like to say, okay, a cap of your likes per pain pill that you have to take to help ward that off because, they're not gonna let you go home to your poop, right? Exactly.

So if you learn how to manually stimulate your colon and manage that, then you can go ahead and offset that from the get go because your restrictions that way. That is good to know and I'm going to add all this into my little booklet that I'm making on consultation because I think that's fascinating to me. It is fabulous information, we should all talk about peeing and pooping. I do all the time and it's the nurse in me and I don't have any problems with talking about, like sexual dysfunction or anything. Now, do you address a sexual dysfunction?

Absolutely. Absolutely. So one thing we touched on just briefly earlier where there's painful sex. Yeah, we do address that and again, just to go to another success story. Other things that may cause that to happen, it can be sexual assault. It can be bad experiences. I had a lady who was married. She was a virgin when she got married, did not want to have kids right away, went in for her very first speculum exam to get on birth control so that they could prepare for the honeymoon and not get pregnant, but had a bad experience with the physician.

She was you know, old enough that most people have probably had sex, but she had never been through that and the speculum exam was horrific for her, caused the muscles to close down and she was not able to consummate her marriage. Years went by, she wanted kids. She found out about pelvic PT came in.

We worked with her to stretch out the muscles, get the muscles to relax so that she could allow some penetration. Taught her spouse how to work with her at home with this and fortunately they were eventually able to conceive. So absolutely work with sexual dysfunction. One thing I have to admit that is just if I had a success story for this, I would be a millionaire, but it can increase blood flow for the men to a degree, but it really does not fix erectile dysfunction in men. A lot of that. I think it's sad that we're not taught to do pelvic floor exercises our entire life. Like we're taught to keep our arms and our legs strong. I always tell my little man, I said, it's funny when you were young and you could high five your other half with your penis.

And now it does not stand up at all when you try to squeeze those muscles, that's a weak pelvic floor in men. So had we been addressing this all along, maybe the blood flow could have been better. A lot of the blood flow that's responsible for erectile dysfunction actually is cardiac related. And that's actually how the birth of Viagra came along.

It used to be used as a cardiac medication and once the people had their cardiac surgeries, they didn't want to give up their medication because. It helped them with erection. Therefore, the birth of Cialis and Viagra came to be. Interesting, that is something I did not know. I wonder how that came about because I really did.

That's interesting. Tell me, what can somebody expect from a PT session with you? PT sessions usually last about 45 minutes to an hour. The first visit is usually heavy on education, simply because it's personal, people are scared, they've never heard of it and we tell them what they can expect.

If we never do anything that somebody is not okay with, if they're not okay with the pelvic exam, we're certainly not going to do that. We'll work around it as best we can. But in general, we do get into the second or third visit, doing an exam of the internal muscles, figuring out what's going on so that we can help them with whatever situation that they have. So it's a lot of hands on work. It's very gentle because again, we don't want to cause pain, making the fascia tighten up because that creates havoc with a lot of what we do. So we don't want to cause pain. So can throw out the window, the no pain, no gain idea about pelvic PT.

That's not on the radar for us, but yeah, that's what we do. So tell me what kind of benefits are your patients seeing with after seeing you, tell me some stories. Those little success stories along the way I was talking about, people are able to not deal with fecal incontinence as much or if at all because that's harder to hide than urinary incontinence. It smells and you end up in jail in your own home. We are able to help with the urge incontinence of urine where you get that urge and you can't make it in time. Again that's because we're not taught in life to work on endurance muscles of pelvic floor. If you lose a half a pound of muscle per year, after age 30, you're losing the endurance to hold that bladder full to get to the bathroom and then a ton of things happen with that, you end up with just a host of other things that we haven't even talked about but we deal with urgent continence, we deal with the stress incontinence, which is where you call flap sneeze or you lift something heavy and you leak lifting is another big thing that contributes to prolapse. Think about, in people weak where they gain weight, their knees hurt they can't get up from a lower surface and when they go to get up they sound like this come on, we're going to go to grandma's house as they stand up.

That's half the time when people are leaking a little bit of urine, because that grunting is your diaphragm pushing down on those pelvic organs, creating a stress on the bladder, leading to some leakage. So that is something that gets to be more common as we get old that, that diaphragmatic push happens a lot in the morning.

Your bladder actually holds more at night because you don't have the weight of your organ sitting down on the bladder. But how many people are stiff in the morning? They're grunting, trying to roll, get out of the bed. And when they do that, the already full bladder or gets pressured and the next thing, they're trying to run to the bathroom can't make it, but they're trying to get up quickly as well. What happens when you get up too fast, your blood pressure drops. You're either going to fall because of that. You're going to fall because you slide in your urine. We all know there's a lot of falls in the bathroom. So this is a big thing to teach.

How can we get up and not activate that bladder so fast that I'm scared, I'm going to wet my britches on the way to the bathroom. I always tell all my patients that falls are the number one independence robber of seniors and you're right, absolutely happens in the bathroom, so that my elderly clients are afraid to get into the shower.

They're afraid to go into the bathroom because of the floor or whatever. And I think that you're right, they want to rush to go pee. Some people already have a towel by the bed every morning because they know they're not going to make it and that's really sad. And that prevents you from going to spend the weekend with your kids.

You're afraid you're going to wet the bed and a lot of times people just, like I said, end up in jail in their own home. Yeah, I actually had a little old lady in a very well to do assisted living in Pennsylvania and she had a scooter, but they put her room all the way down this long hall, maybe a football field length of rooms, and she was at the very end and here she is paying these huge amount of money to be in this posh continuing care retirement community and she had fecal incontinence and I felt so bad for her and this was 10 years ago.

I felt so bad for her because she was actually in jail. When you get to that point, the fecal incontinence or a little bit of what we call fecal smearing, where you just, you have skid mark here and there that E coli loves to cause bladder infections and the more infections you have, the more inflammation you have, the more inflammation you have, the more weakness you have, and the snowball just starts.

Yes. So it's really important to talk about it and talk with your doctor and even with the pelvic pain patients. Doctors don't ask you, if you're still sexually active when you go to the doctor, like, when you have an exam, but it's usually within that first 5 to 10 year period after people become less sexually active when they age, whether it's dryness of the vagina, whether it's my husband has erectile dysfunction, whether it's the spontaneity is gone. I got to get my lubricant. He's got to get his Viagra. You time it out. It is what it is, but those pelvic floor muscles are like your legs. If you don't use them, you lose them. So that leads to more opportunities for urinary incontinence because you're weak or prolapse because you're weak.

So simple education of, okay, if you're not sexually active anymore, that's okay, but let's teach you some exercises so that we don't land in this boat where we have these issues simple as that or, like, when some woman has like a hysterectomy and they've been told, you don't need a pelvic exam anymore you don't have your parts. Guess what? You still have a bladder and you still have a rectum up there. If someone had seen that it was falling out, we could have taught you how to defecate better, how to not hold your breath. It's when you do things that's pushing out your organs, we could help you lift that up before it was at a level where you required surgery.

So it's important to have these conversations with your doctor, even if they don't bring it up and we need to educate the doctors on your services. Absolutely. Completely the doctors, if they've heard of it at all, they may be heard that we deal with urinary leakage, but there's absolutely so much more to pelvic PT than just that. Absolutely. So Donna, how do we find a pelvic floor for abdominal? That's a great question. Since it's very underserved bigger cities, you tend to see more of them smaller cities. You have to look around. We have people that drive an hour to come in. But there's a couple of places, Herman and Wallace is a great group. That's kind of one of the Cadillacs for public for education. If you go to Herman and Wallace online, they will have a place on their website. I think it may be Herman and Wallace dot com. Absolutely positive, but if you plug in Herman and Wallace, it'll pop up, but there's a zip code finder you plug in and it will show you pelvic PTs close to your zip code. Also you can do the same thing on American Physical Therapy Association. So APTA.org or a wonderful site with excellent information is pelvicguru. com, that's put up by a therapist, who's amazing in Orlando. Her name is Tracy Share and there's ways through her website as well that you can locate pelvic PTs.

Awesome. Yeah. Now, I know one of the big questions everybody's going to ask is, okay, how do I get a referral to have it done? And so I want to bring that up because I think people will want to know what do they need a referral specifically? Sometimes that can vary a little bit state to state.

Some states have direct access to physical therapist and you can go in and be treated for 30 days, which you may need more than that without a prescription. And if we can't fix you in 30 days, then you may need to obtain one. But where we live I work under a hospital system and the hospital system requires a referral from a doctor to come in for this, no matter what you're coming in for, whether it's a total knee or whatever.

Some places do require a referral. I would just suggest calling to find out, but you do not have to these referrals. I get referrals from so many different kinds of doctors. It can be OBGYN. It can be urology. It can be colorectal. It can be gastroenterology. It can be absolutely a family practitioner.

If they heard of us, nurse practitioners can send, PAs can send. Right now, we can even take from midwives. For therapy. I've even had prescriptions from allergists where people sneeze a lot, cough a lot, causes them to leak. It can come from any physician that knows what we do. Okay. What is the average length of treatment time would you say?

It greatly varies person to person based on your age how long you've put this off and habits have developed, how much scar tissue surgery you may or may not have had. But if I had to say an average length of time that we probably work with somebody. It's so hard to say, depending on the diagnosis, but the average, probably 5 or 6 weeks total, but sometimes we only like new moms.

I'd love to see postpartum. That's another thing. That's so underserved. It's very much part of your maternity package in Europe, and it's not here, but new moms are recovering. We work with their scar tissue if they've had a piece of me, so we often will spread out those visits, giving them time to heal and time to work on the exercises and sometimes if somebody just has a little bit of stuff going on, I just call it, let me put the tools in your toolbox. And then once you have the tools to help yourself, don't pay me to do it. But you have to do the exercises that we give you to get past it. The homework's really important. You know what I was thinking about when you were talking about postpartum.

I had and I'm going to get personal here. I'm 70. I don't care anymore. But when I was, my 1st child was at 23 and he was big and I did have an episiotomy and everytime I had a period after that, I had such severe perineal pain. Yes, it's not normal and we treat stuff like, oh my God. I was like a hot poker was sitting there and I lived with that.

For my entire life. Yeah, because you think you got little Johnny and that's part of having a baby and it's not. It was terrible. And my second one just made it worse. My second child made it worse. Because again, look how long you were dealing with that. Exactly. And I can tell you right now that it was terrible because I did have uncomfortable periods.

But that the biggest, the hardest thing for me to deal with is I couldn't even stand and here I'm trying to find to take care of kids and the pain was so terrible. And I'm sure it's from the blood flow and every well, and all that did year after year was tighten your fascia. Muscles too tight are also going to be weak.

So you end up with incontinence issues, prolapse issues, what have you, because you lived forever with that. Yes. Yeah, it was very challenging and nobody ever addressed it. They would just, the doctors and everything said that's just a result of having children. That's not the answer.

Trust me. I know, and it was so frustrating for me. So I'm really excited and proud to be able to tell people about what you do, how you do it, because they need to know and even if they're not sure if it's something that they have needs to be treated in that area, it's really important just to ask the doctor for a referral.

Simple, simple education is so much of it. Just there's so much help just by coming in for a visit and just hearing all this even stuff that's hard to find. You just don't go into Walgreens and find these amazing vaginal moisturizer things that you can use because you've lost your hormones or postmenopausal that work with you.

If you got lotion on your hands because your hands are dry. This area of your body needs love too. That can be so helpful for people or education like products. It's not going to fix the problem. So you still need to come to PT and find out, but there's a product by poise, it's called Impressa. It acts like a giant tampon would inside and it pushes against the urethra, which can help with a little bit of leakage. I've had a great success story with a lady who was 64 running marathons for the first time. She was almost ready to do it and started leaking every time she would bare her foot hit the ground because the pounding took its toll, but she was able to absolutely get through her marathon by wearing one of these to keep her from leaking all over the place while we were in the process of let's fix this problem. So yeah, so there's products out there that are unheard of that I've never seen them on the shelves, that's again where we come in.

Awesome. Awesome. Donna, I'm so excited. I think that I may have you back at another time to maybe deal with certain specific issues. And I think I'm going to be calling you because I want to learn more about the constipation approach to put in my book. Yeah, that would be awesome. Great.

Thank you so much for having me. I really enjoy talking about this and getting the word out and this is a great opportunity to do thank you again for having me. Thank you and I know I'll talk to you soon. Thanks again. ​