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

On this episode of the Healthy Wealthy and Smart Podcast, I welcome Dr. Sarah Haag on the show to discuss pelvic health for the non-pelvic health PT. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

In this episode, we discuss:

-Intake questionnaires to screen the pelvic floor for patients with low back pain

-Pelvic health red flags

-How to address pelvic floor health with a conservative population

-Assessing the pelvic floor muscles without doing an internal exam

-And so much more!

Resources:

Oswestry Low Back Pain Disability Questionnaire: http://www.rehab.msu.edu/_files/_docs/oswestry_low_back_disability.pdf

Sarah Haag Twitter

Entropy Physio Website

Home Health Section Urinary Incontinence Toolkit

Rehab Therapy Operational Best Practices Forum

For more information on Sarah:

Sarah graduated from Marquette University in 2002 with a Master's of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women's Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Teacher.

Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span.

Read the full transcript below:

Karen Litzy: 00:01 Sarah, I was going to say doctor Sarah, hey, it just feels weird because we've known each other forever. But Sarah, thank you so much for coming on the podcast to talk about pelvic health for the non-pelvic health PT. So there are a lot of physical therapists who I think are interested in pelvic health, but maybe they don't want to like dive in literally and figuratively. So what we're going to do today is talk about how we as physical therapists can treat people with pelvic conditions, with pelvic issues without necessarily doing internal work. What are the functions of the pelvis, really important for bowel and bladder health, right?

Sarah Haag: 00:49 I mean, it is very important for survival, sex, very important for quality of life and propagation of the species. So these are all things that matter. But also when people come in with low back pain, when people come in with hip pain, I always find it very interesting that people say, but I don't do the pelvis. You know, the pelvic floor is only a musculoskeletal structure. We're not trained in most programs to palpate or to touch. It's just skeletal muscle. That's all we're assessing for really as pelvic floor PT's. So I just think it's interesting. It's like a blurry void when you're looking at a body diagram. Oh, there's your knee. So it's really important I think to understand what's there and you don't have to go there, but you have to know what's there and know that some people need help there and help them find the help.

Karen Litzy: 01:34 So if someone, let's take this person that has low back pain because that's a diagnosis that we can all agree that we see on a regular basis. So what are a couple of questions you can ask during your initial evaluation?

Sarah Haag: So the subjective part of the initial evaluation that perhaps a lot of people are missing or that can take in that pelvic area. There's a couple of ways that you can kind of like cheat your way in where you don't even have to think about what to ask to begin with. If you have a red flag questionnaire, there is a bowel and bladder question on there. So, it's really interesting because people will sometimes circle yes on those and then never discuss it. Like, wait a second, we asked the question, they said yes, it's a thing.

Sarah Haag: 02:22 So there's your in, it was like, I noticed you, you marked yes on the bowel and bladder changes. Can you tell me a little bit more about that? Most of the time it is not truly a red flag. Most of the time it is not a sign they need to be referred to a physician. Most of the time it's like no one's ever asked me that. Yeah. Stuff is different. There's your in. And then also if you use the classic Oswestry. So it was modified I think in 2001 or 2002 to take off a sex questionnaire. The second question of the questionnaire and it was revalidated and all of those things, but if you use the original, it's pretty awesome because now they're like, Huh, nobody's asked me about sex. And then you'd be like, ah, I see that this is an issue.

Sarah Haag: 03:06 One of my favorite Twitter stories is I get a direct message from someone asking me about a patient who was having pain with intercourse and I was like, thanks for reaching out. Absolutely. Can you tell me more about when they're having trouble and where it hurts? Would you like to know where it hurt their knees in one particular position? And I said, fantastic. You can help with that. So, so it's not always, it might be a sex problem, but it's not necessarily that problem. So we have to not be shy about asking those. Low back pain is the most expensive health care problem we have in terms of multibillion dollar, probably millions and millions worldwide. And so of course addressing back pain, we're still working on the best way to do that.

Sarah Haag: 03:52 But there's a high prevalence of urinary incontinence and people who have low back pain. So if you're seeing people who have low back pain and after, if anyone else went to the pregnancy talk this morning, after vaginal deliveries, the prevalence of incontinence goes ways up, goes way up. So if you're seeing someone with back pain, if someone has had babies, all you can eat what you can do. So we were like, well I see this in your history cause that's pertinent history for back pain. Correct. And then it's like, Hey, I noticed this, any issues with this? And here's the reason I'm asking because you can't just go, do you pee your pants? Because people like, do I smell like what happened? Like, so if you're just like, you know, there is a really high prevalence and the nerves in your back go to your pelvis and all of these things.

Sarah Haag: 04:32 So I'd be really curious to know are you having any issues in this area? Cause there's help if you are. And then kind of go from there.

Karen Litzy: And I want to backtrack for just a second. When you were talking about red flags and said some are truly red flags and some aren't. So just so that we're all on the same page, what would be those truly red flags?

Sarah Haag: Truly in the pelvic world or in the entire rest of your body world is any unintentional weight loss or weight gain, 10 or 15 pounds over a short period of time. Also like fever, like temperature issues, loss of appetite when you have those other constitutional symptoms that go along with it. So just having some quirkiness with your bowel and bladder, it's really no reason to panic. But if you have also a fever and also a recent traumatic event, no, no, we want to just make sure everything's okay.

Sarah Haag: 05:26 And the cool thing is that if you go to the doctor, it's like you don't have a UTI. Everything else is looking fine. Awesome. Then I can help with that. But the red flags, there's been a couple of great papers that have come out where it's like, it's not like if you have pain at night, freak out. No, no. If you have pain at night but also a sudden bowel and bladder change and also, okay, now we need to check in for it. But don't panic if it's the only one.

Karen Litzy: And now let's say you're using these questionnaires and someone puts on bowel, bladder or someone circles sex as something that they're having difficulty with. And I love this question because this was something that was brought up last year at CSM. So there was a physical therapist there who said, well, I live in the south and these are not easy questions to ask because people are more conservative or they don't want to talk openly about their bowel and bladder issues or about sex with their partners.

Karen Litzy: 06:28 And so what do you say to those people? Those therapists that, are dealing with a population that's maybe much more conservative and they're not sure how to approach those subject matters.

Sarah Haag: I always say just always with kindness and with a good intention and with a good explanation. So you can't not do it because it's awkward for you. You should be asking for a medical reason, right? So quality of life is in our wheelhouse, right? Like we're doing all sorts of quality of life questionnaires. Pee in your pants is a huge detriment for your quality of life in many cases, not being able to have sex can impact your relationship with your partner, your feelings of ability to even have a partner, having babies. All of these things that end up being huge stresses, which is gonna make a lot of other things not as good either.

Sarah Haag: 07:28 Just start simple if you're asking questions. So if someone comes in with like straight forward knee pain, I'm like, how sex, no, that's not how, that's not where we go with that. But if someone's coming in with low back or pelvic issues, the way I usually approach it is to bring it up anatomically. So this is the anatomy. This is what we're doing. These are where the muscles go. Most people don't think about them. And when they're, if they're having issues like incontinence or have had babies, those pelvic floor muscles are muscles. Like everything else. We're going to work in PT. So I'm going to ask you some questions and I try to do it in a spot where you have some privacy. I know some PT places you're like in the middle of a gym.

Sarah Haag: 08:06 If you can find a quiet corner, do everything you can to put them at ease. But just to be like this is why I'm asking. And if you can see that resistance be like all right, like it's not necessarily the number one priority for this treatment anyway, but if those things happen to be issues there is help, it can get better and you just let me know if you have any questions. Cause not everybody wants to talk about it and it's not my job to convince you to deal with it. It's my job to help you if you want help.

Karen Litzy: And if you're a physical therapist that isn't specializing in pelvic health, it's a little bit different. Cause if you're specializing in pelvic health and people are going to you because you specialize in pelvic health it's way easier, you know, these questions are going to come up. But for those of us who don't specialize in pelvic health, then those questions can be a little bit more sensitive. So I just want you to make that distinction there for people.

Sarah Haag: 08:48 Yeah. And also if you're going to ask if you're going to take that step and be like, all right, I'm going to ask about the incontinence. I mean cause sometimes you're in situations where it is an obvious issue. Other times it's like, well, based on their history they're actually at risk for it. Then you can talk prevention, which has always been kind of fun. But just if they give you some information, especially if you got up the guts to ask them, then please, please do something with it. Don't just be like, oh yeah, so great incontinence noted in the chart. I'll put it on the diagnosis list, like how the plan and there are some things you can do without doing a pelvic floor exam that can make amazing changes.

Karen Litzy: 09:49 How can you evaluate pelvic floor muscles without having to go internally? I think that's a question everybody wants to know.

Sarah Haag: Great question. I'll be honest, some people don't want you to touch him there like full stop. And so I will actually give people, I would say it's kind of like a choose your own adventure. So we can actually, we can all check our own pelvic floor muscles right here. And I would basically talk you through it. You would tell me what you felt. I keep an eye on everything else to see what else you were doing. But it would be very honest that my assessment is going to be, I believe you, it seems you're doing it correctly. Right? But I have to believe you, but you can actually palpate externally. As a clinician you can actually do it and you can do it in sidelying.

Sarah Haag: 10:33 You can do it in hooklying and some people will do it in prone. I'm not a super big fan cause I can't see their faces. And also it can be kind of a vulnerable position. Basically if you just palpate, if you find the ischial tuberosity, you know about where the anal sphincters are. Okay. There's normal human variation. So I always say move slow and make sure you're asking for feedback. But you know, mid line is where the sphincters are going to be. We're not going midline. So you just kind of find that ischial tuberosity and palpate your way around to the medial part of it. And that's where the pelvic floor attaches. So then you can kind of talk them through, like I'd like you to squeeze and there's a bunch of different cues.

Sarah Haag: 11:22 One of the most common cues, especially for the back end, is to like squeeze. Like you don't want to pass gas and that's awesome. But if you're a main problem with urinary incontinence, that's the back side, back side, not the front side. So how do we get it up there? So another cue that has been found to be very helpful, it's only been studied in men, but it is, shorten your penis. But what's interesting is ladies, I know we don't have them, right? Imagine that feeling, right? So like just imagine like pulling in, right? It totally changed where hopefully if this is a class, it would have asked where did you feel it? But like it, it changes it from the back and biases it towards the front of it. So find a cue that gets them to go, oh my God, I felt something.

Sarah Haag: 12:07 You're like, awesome. So if you're doing a Kegel and like this happens, you're probably not doing it right. If that's happening, you're probably not doing right. But if like I'm Kegeling now and then I let go, you shouldn't have seen me get taller or tensor or breathe funny. It should be very sneaky. So as you're palpating on the medial side of the ischial tuberosities your feeling for those muscles to contract. So it's kind of like a gentle bulge and you can totally feel this on yourself here if you're comfy or somewhere else. But when you feel it, it's almost like when you're feeling like if you have your biceps slightly bent and you kind of like contract and you feel at tensioning and like a little bit of a bulge, that's what you're feeling for.

Sarah Haag: 12:51 Okay but it can always be tricky cause I use the word bulge. Some people will have people push down. So we should also be able to like relax your pelvic floor and push down, like having a bowel movement. That shouldn't happen when you're trying to contract. So like when I say bulge, you should feel like a gathering of the muscle. That's what you're feeling. If you feel your fingers get pushed down in a way they're doing the opposite of a contraction. So there they're relaxing. It would kind of depend on what they were doing and the cues you were giving. So it could just be like, I'm pushing down like doing a Valsalva. But it is basically a lengthening into the pelvic floor. I don't know if it's always a relaxation, so to speak.

Karen Litzy: 13:33 It's kind of lengthening. And what is the difference between that Valsalva or lengthening and that small bulge? Like why is that significant?

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

Karen Litzy: Got It. Okay. All right. So now we know how we can kind of feel our pelvic floor muscles without having to do an internal exam. So once you figure out, and kind of what you said sort of leads right into the next question is if you have someone that's coming in with incontinence and you are looking for that sort of tightening or gathering up of the muscle, which I think that's a nice cue for people to understand because bulge can sometimes be a little confusing for people, but I liked the cue you're feeling the gathering of that musculature.

Karen Litzy: 14:45 Is that something that you are then going to add into a home exercise program or like once you find that the pelvic floor muscles working or it's not working, what next? What do you do?

Sarah Haag: Well, so I'll be honest. It's always I like him and people are brave enough and the patients were brave enough to be like, sure you can have a feel like let's figure this muscle thing out. I usually try it in a normal active kid in a normal setting. So not a public one. No pelvic settings are normal too. But in like just a normal like say outpatient therapy, be it or orthopedics or neuro, I would actually have them ask more questions about incontinence before even checking the pelvic floor muscles. Because the different types of incontinence are going to kind of tell you a little bit more about what you should do.

Sarah Haag: 15:35 So some people have incontinence when they tried to go from sit to stand or when they cough or when they go running. So I want to know a little bit more about when is it happening because if it's only ever when you're putting your key in the front door or when you're running into the bathroom, that's more urgent continence. Would pelvic floor muscle exercises help? Maybe, but also probably looking at their overall bladder health, which is where a voiding log would come in very handy. And actually a shout out to the home health section and they have an incontinence urinary incontinence toolkit. It's free for members for sure, but I think it might be free for everyone.

Sarah Haag: 16:15 So it's a pdf that actually talks you through the different types of incontinence because the most common form of incontinence urge incontinence, which is you're an urge incontinence is proceeded by a strong urge to go. So this is one of those things where, so there's a bathroom at the end of the hall. So if you're like, I'm totally fine, but then your eyes wander, you're like, oh, I could go and I didn't have to go. And then I would get up to go and I got to the bathroom and all of a sudden it's like, oh, where did that come from? Like all of a sudden it felt like your kidneys did a big dump, but they don't, that's not how kidneys work.

Sarah Haag: 16:59 It's just how it feels to you. So what that really is, is your detrusor muscle kind of going, I'm so excited. I imagine a puppy, like have you ever like gone to let a puppy out the door? Like, so they're like, hey, I want to go out and you get up and you make a move for that door. And they're like so excited. Your bladder is like that sometimes. So that's more of a behavioral thing because what would you do with the puppy who's now like, wait, every time I do this, she lets me out. Pretty soon you're letting that puppy out every 10 minutes because yeah, because that's what the puppy trains you to do. So that's kind of more of a behavioral thing. And so that's proceeded by a strong urge. So it's not just when you're going to the bathroom, but if you get a strong, unexpected urge and leak, and that's usually a lot of people also experience some urgency and frequency.

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

Sarah Haag: 17:52 You'd go more often, you're like, Ooh, maybe I need to not wait so long. But the thing is that then you're training yourself to go more often, your bladder is perfectly capable of holding more that kind of sensitivity and those signals you're interpreting or like, ah, no, I should go now. And then pretty soon you're that person who can't make it through a movie. You're that person who can't make it past a bathroom without needing to go. And you're the person that no one wants to go on a road trip with because you're stopping every like hour on the hour and every rest stop. But now is that because your brain is interpreting this as such? I know that there's a physical manifestation obviously, but is that like have you trained your brain and to feel that way to interpret that as such? I would say yes because most of the time, even if it wasn't intentional, like it's kind of like a slippery slope. It's like I almost didn't make it that one time. I'm going to plan ahead. And then what starts to happen, especially if you're like, all right,

Sarah Haag: 18:54 your bladder is filling up. You kind of feel like you need to go and you go to the bathroom and it came out and it's like, all right, so that was nice and normal. But then imagine that time where you're like, hold on, I almost didn't make it, but you were stretched this much. You're going to start going when the bladder stretches this much. And then pretty soon if you let it so you're like, Ooh, now I'm going down here. Now I need to go sooner. And this is one way you can tell this is happening. And it can happen sometimes without ending up with a diagnosis of urgency, frequency or incontinence. But where you get to the bathroom and you feel like you've got a goal, but then nothing happened. Goals, like it's the smallest tinkle and you're like, I thought it wasn't gonna make it, but that's ah, that's all that's in there. And so that was like big urge little output. That's kind of a mismatch. And that'll happen sometimes.

Sarah Haag: 19:48 But like if you're paying less than that, that's not much more than your poster board then a nice healthy post void residual. So you don't have to empty at that point if you're bladder's saying, empty me now. And that's all that's in there. Yeah. So it's kind of like you're the sensitivity of your bladder has turned way up. Just like how we would compare that to the pain. So the sensitivity is turned way up so that it takes less of a stimulus in the bladder itself to trigger that feeling of you have to go, even though the bladder is barely full.

Sarah Haag: And there's actually some interesting conversations with urgency and frequency in that feeling of extreme urge, can that be considered a pain? And so it's kind of interesting conversation because there is normal, there is a normal sensitivity of normal urge, but when that urge becomes pathological, yeah.

Sarah Haag: 20:47 Too bothersome. Does that crossover into it? Distressing emotional experience? I would think so. Like can you imagine if you're like on a train or something like that and you have to really, really, you have, you're having that urge. I mean, that's very distressing dressing. That's very distressing. That's like you're suffering. So if you have someone like that what do we have them do? So they keep a diary, which you can get on the home health section and we'll have a link to that in the show notes. You basically ask them to keep track of things for a couple of days. I tend to keep it simple with what are you drinking and when and when, when are you going to the bathroom? If people are willing to measure, that's the best, but not many people are willing to measure.

Sarah Haag: 21:37 So what I try to have them do is to kind of come up with their own plan. And I tell them this is not an exact science because you're not measuring, but that's okay because if you have a strong urge, which is kind of a lot, but you have like a little tinkle, that's kind of a mismatch. If that only happens after your third Mimosa, okay, that might actually be like a normal bladder thing. Do you know what I mean? So we kind of look at things that they're bringing in that may or may not be irritating to them. We look at are they getting enough fluid and bladder loves, loves water. But the first thing most people cut out if they're having urgency, frequency or incontinence is water is they cut out their water. It'll almost always backfires.

Sarah Haag: 22:19 So don't do that anyone watching. It also makes you constipated, which you can increase your urgency and frequency. So, so yeah, so surprise. Everything needs to work well to work well. Okay. But yeah, so you kind of look at that and I just look for patterns and then I have people try to change one thing at a time. If all you're drinking his coffee all day, but actually you have good data, good parts of your day and bad parts of the day. Is it the coffee? Because if you're drinking coffee all day, you're probably not going to be very nice to me if I say, how about you stopped drinking coffee? Um, emotional response up. So you just kind of look at it. It's like, Oh, when does this happen? What do we need to change? And it can really help you narrow down. Is it really urge incontinence? Is it actually just frequency and they're not leaking like they thought they were or you know, is this primarily a stress incontinence issue?

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

Sarah Haag: No, no, it's more behavioral.

Susan: 23:27 Do you ever use pelvic tilting to get the posterior versus anterior pelvic floor?

Sarah Haag: So that's a neat work with from Paul Hodges Group. So however you're sitting, most of us are Slouchy, just do a pelvic floor contraction, however your brain tells you to do that, do it and just feel where you feel it. But then if you get yourself in a situation where you like get more of that Lumbar Lordosis, and so like you stick your tail out, you get more lumber lordosis and then you do the exact same thing. So you're not changing your cue. For most people it's cuts to the front. And it's kind of neat because one of the things, one of my pet peeves is when we were talking about earlier is my pelvic floor therapist get tunnel vision and are just doing pelvic floor exercises, but not reintegrating it into how they're, they're using their body.

Sarah Haag: 24:18 So if you have a runner who's a chronic but Tucker and she's leaking out of the front, obviously, how would it feel if you like got those glutes back a little bit? Because you can't run and Kegel at the same time. You can't, you can try. It's not going to go well. And certainly not for like a 5K and let alone not a marathon. So changing how that is biased because most of us don't think about the pelvic floor until you have a problem, right? But they've been working, right? They've been doing their thing. You're using them when you walk up those stairs you're using them when you're getting up off the floor. So they do something, the key goal is like your bicep curl. You want a stronger bicep, you're going to do some curls, you want a stronger pelvic floor, you're going to have to do some pelvic floor exercises.

Sarah Haag: 25:07 But that's not your management plan. You kind of want to, someone said it yesterday, kind of like the core muscles are there like automatic, like when you get ready to do something you don't think, okay transversus were good. Like it just all happens and you want to kind of get the pelvic floor back into that system and make sure it's strong enough and coordinated enough to do its part. So you don't think about it.

Dave: 25:37 So along those lines then, would you say that if somebody is more lordotic, they're more likely to engage the anterior floor and then flat back more of the posterior floor?

Sarah Haag: 25:47 That tends to be what they're finding on like EMG studies and what I will see clinically with people if they do a ginormous buttock. It's really interesting if you're like, how's your breathing when you do that and, and how good is your squat, let's say when you do that. And it's like, Eh, it is what it is. I'm like, okay, so what if we do kind of take it into where some people, especially if they've been told by other practitioners to like watch your Lordosis, it's kind of huge. Which isn't really a thing. But you know, they kind of, they're kind of like going in there, they're like, I'm so scared but it kind of feels good and then you have them do that movement or try that exercise. Usually they're like, that was way easier than I thought it was going to be.

Sarah Haag: 26:30 But again, if it's not working, then we try something else cause everyone's anatomy is different. Sometimes if they have a lumbar issue, getting into the ideal position for their pelvic floor, may or may not be easy for them, at least at first. But I think you need to play around with how it feels and how it's functioning as opposed to, I mean, I've been guilty of it in my career of like, ah, you need more or less of what you're doing with your spine and were just different. So it's where it works best is where it should be.

Jamie: 27:03 So for a lot of the outpatient conditions and orthopedic setting, there's still an emphasis on giving some kind of qualitative documentation to the muscle contraction, whether it's a manual muscle test or something like that for payment purposes. So what are some strategies or tips for clinicians to be able to take that palpation externally and then relate that into their strengthening documentation?

Sarah Haag: 27:29 So if you're just checking externally, like just palpating outside, it's like a plus minus like, Yup, I felt it. Uh, they couldn't find it. So kind of plus minus, cause you can't give it more than that. We also have to remember, so when I write about pelvic floor strength in my documentation, I have a number I can put and you can grade it. You have to do that internally, which is why if you're like, ah, we need to know more, refer him to a friend or go to the training. But I usually give a lot more information. So like, all right, so they, you know, they had like a three out of four, three out of five squeeze. The relaxation was not very coordinated and kind of slow, but then their subsequent contractions were five out of five.

Sarah Haag: 28:09 All right. Do you know what I mean? We have to, because of payment and insurance and all of those things, we have to write something down. So what I do is I write down what I find and I'm happy to talk about it. So if you want to deny it, I can talk vagina all day with you. And I have, and their questions usually get shorter and shorter. Um, because really they're asking for information that isn't necessarily the most helpful. So if you're checking an externally plus minus, but also I've had people who five out of five but still incontinent,

Sarah Haag: 28:41 So then they're like, well they're not weak but you put down, you're going to do strengthening. I'm like, well yeah, because it's more of a strengthening, not just a strengthening with a functional goal attached to that, if that makes sense. So sometimes it's more words, but don't be shy about one. Well, first of all, please be honest, be as accurate as you can be, but also don't be shy about doing the best care and be willing to stand up for it. If it gets denied. It's not cause you gave crappy care likely. I mean, do you know what I mean? I'm like, I dunno how long you practice, hopefully. Good. But if you get denied, it's not necessarily key because you gave bad care or even did a bad note. It's because they decided they weren't going to pay based on something. Hopefully logical that you can talk about. You can always appeal. So don't let payments scare you away from giving the best care.

Sarah Haag: 29:36 Sorry. Another soapbox of mine. So that was urge incontinence. Stress Incontinence.

Karen Litzy: So let's talk about that because I think that gets the more airtime, so to speak. So that's when you see the crossfitters are the weightlifters or there's a great gymnast pitcher yesterday going backwards where you there backwards over the pommel horse, not the pommel horse. It's the worse just a horse. A spurt. Like it was, yeah. And you're just like, that could be photo shopped, but also it probably isn't. Yeah. Or like we've all seen like the crossfit videos where women are peeing and then everyone high fives them because they worked so hard that they peed, which, you know, not normal. We know that that's been addressed by a lot of a pelvic health physical therapists.

Karen Litzy: 30:32 So I would like to know first I think we just gave the definition of stress incontinence, but I'll have you give the definition quickly. But then I'd like to go back to something that the question that Dave had asked about the positioning and how that works within weightlifting or within, you know, waited or loaded movements. But go ahead and give the definition of stress incontinence first.

Sarah Haag: So stress incontinence is basically when there's an increase in intrabdominal pressure that is greater than the closure of pressure of the urethra. And you have some sphincters as well as the pelvic floor helping keep all of that closed. But if you increase the pressure enough on the insides, and that's why you hear, and again, it's primarily women, but also a lot of men after prostate surgery, they cough and you get a spurt or you know, you jump and you feel it come out.

Sarah Haag: 31:21 Those are usually because the closer pressure has gone down or the intra abdominal pressure has gone up.

Karen Litzy: Okay, great. So now what does that look like? For the average physical therapist who's not a pelvic health therapist. And let's say they are seeing someone for hip pain and you ask them, are you ever incontinent? Or if they are, you know, heavy lifters are, they are adding load and they say, oh yeah, but that's normal. Or they have low back pain and they say, yeah, but that's normal. Everybody does it at my crossfit box or whatever at my gym. So how do you then, if you're not you, you are someone who's not a pelvic health therapist, how do you address that?

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

Sarah Haag: 32:16 Not ever being dry is normal. So we need to get away from this idea that like, well, everyone's doing it. It's like does that make you want to do it? Like I feel like, no, I feel like no is the answer. So first of all, just, and sometimes they don't know that. Like, I know that in some like young girl gymnastic teams, like the color of their leotards are chosen to like, not show the pee because they're incontinent that young. Yeah. And I see a lot of women as adults sometimes before they've had babies sometimes after, right? So like what's the, what came first? But they've had lifelong issues with what's essentially public flourish. She's with incontinence, sometimes pain with intercourse, all of those things. Competitive gymnasts, competitive cheerleaders. Dancers tend to be probably the biggest, runners or another group.

Sarah Haag: 33:12 There's been some studies, there's one study and I cannot recall it. I mean, it's probably like 15 years old now. We're 100% of this division one female track team reported urinary symptoms. 100%. Like every girl. So common. Heck yeah. Normal. So many girls. Yeah. So the biggest thing if you're not a pelvic floor therapist is to check out their function. So if they can identify when they're having issues, it's when I get to this particular weight or it's when I get to mile 17. Okay. And I usually throw in, like if I ran 17 miles, I'm not really sure what my body would do. Like I dunno, but it still shouldn't leak. But if you can find out where that breakdown in the coordination in the endurance and the strength and whatever it is happens and look at what's happening there.

Sarah Haag: 34:04 Because if you can run 17 miles or you can lift 200 pounds without leaking, but then you do, you're not, you're not weak. Right? Like if you can do all of that, something's happening there to make this happen. Cause if you can lift 200 pounds in that league, something's working, it's just not still working when you try to live 210. Okay. So let, let's look at what's changing or number of repetitions. Right? That's what you're looking at.

Sarah Haag: 34:52 So if you collapse your chest and which I would probably do after running 17 miles and I'm like this. And now what happens when I collapse what happens to my bottom half when I collapsed my shoulders? Well my butt just tucked. Cause I'm just trying to get through now. The funny thing is the breathing is also harder. So while I'm doing this as kind of a mechanism to keep going, it's harder to breathe because nothing's working diaphragm to have a full excursion, right? Yeah. So, so I like to look at if you're running fine for 17 miles, I want to see you at mile 16. I want to see what's changing over that mile. I want to see what you looked through my team. And can you, when you start to get to that point, can you make an effort to change something?

Sarah Haag: 35:32 Do you notice a change in your breathing when you're lifting 210 instead of 200 and kind of look at it from that way cause you're not going to kegel why you do that. What do you mean? Oh well say to like precontract and prime and all these things and, and that's fine, but it's like if we go back to the running, you're not kegeling and all that time your pelvic floor after like 30 seconds is like, dude, you don't want me to get that tired. Like it's going to be like, we're going to stop that now. So yeah. So the way I would approach that, if you're not me, yes and not going to do a vaginal exam, is you look at their performance. So if they said, I have knee pain when I do this, when I go from 200 to 210, they're my squat.

Sarah Haag: 36:13 How they do, they're looking at the mechanics. You would look at what's happening, what is different? Cause you know, the joint can do it, you know, the muscles can do it. What's changing. And you would address that. So it's really no different if they can tell when they're leaking, you're just looking what can, what are the things that can change it? Usually the tail lift and looking at their breathing or two really easy ways to go about it.

Karen Litzy: Okay. All right. That's great. And, and, and that goes with that. Does that also work with, let's say instead of you're not a runner weightlifter, but you're like a new mom or something like that and you're okay, but then by the end of the day after you've been maybe lifting the baby or you know, doing whatever you're doing it, it doesn't necessarily have to be sport related is what I'm saying.

Sarah Haag: 37:06 I think about like function, but definitely, I mean, you asked about, but no, just everyday if getting out of a chair makes you leak, that's, but then it's basically a squat. So you are, you're looking at the activity that they're having difficulty with and making small changes got in most cases.

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

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

Sarah Haag: 37:53 So then they're just, I'm squeezing stuff and it didn't work. And it's like, Oh, before we get too far, can we check and see how you're doing them? And I think that's kind of a beautiful segway. So let's say you have your new mom or you have your athlete or whatever and you are, you've tried some stuff, right? Cause none of this is life or death, right? I mean it's fine to try some things. So already not doing anything about it. So trying to change up a couple of things is perfectly within your purview, especially again, you're seeing them for hip or low back. It all, it's all together. You're good. But if it's not changing, if it's not getting better, if when you ask them, you know, can you contract your pelvic floor, what do you feel? They're like, I got no idea.

Sarah Haag: 38:33 And they're like, but please also don't touch me there. Or are you touching there and you're like, yeah, I don't feel anything either. And I've used all my cards but I don't know what to do. That's when you refer. Because just like any other things, somebody coming to see you as a physical therapist, you're going to do some things. And if those things are not working or they're getting worse, you're going to try something different. Or call the doctor or refer to a friend. Right? So if you change some things and you're like, I'm amazing, they're all better. Awesome. Do they need to go to pelvic floor therapy? I'd say no if their incontinence resolves or their pain resolves. But sometimes with especially we see it a lot more in I would say the more active athletic population is a pelvic floor that's more like this.

Sarah Haag: 39:19 So it's like tight and there's a hundred people call it hypertonic or high tone or short pelvic floor and all these things and basically in my brain, the way I categorize it is like you should be able to contract your pelvic floor and you should be able to let it go. And we can all get better at that. But if you're like, I'm here, how good is my contraction going to be? Because I'm not showing you my pelvic floor. Like it's not going to, it's going to taste like it's going to not move very much. But if you get them to relax more or they're like, oh, I didn't know that was there, that's better. Then you all of a sudden you have a good contraction.

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

Sarah Haag: 40:01 Before somebody tells him to relax, the worst thing to do is be like, can you just relax? So I try to have them feel the difference between contracting and not contracting. Because what will happen and people use what the traps all the time is like. So like, ah, so much tension. All right. Again, telling you to relax your shoulders. Things I didn't think of that. But if you squeeze and let go like as a little bit of like, Oh, I feel that, oh, oh there's some more space there. So I start with that. Okay. The pelvic floor. But again, if they're like, I just don't know, that's something that is so easy to feel with a vaginal or rectal exam. So that's where it's like, ah, you're having some trouble. I would recommend, would you see my friend for one visit have this exam, they're checking out your muscles and just see if he can feel that relaxation and then come up with like cueing or a plan that works for them.

Sarah Haag: 40:54 Cause it's not just about like slacking everything out. It's really feeling that that relaxation, that lengthening of the muscles there and being intentional about it. You don't want to lie there would hope like maybe it'll let go at some point.

Audience member: So you talked about kegeling and what about dosage or prescription and quality versus quantity and how you prescribe that to your patient.

Sarah Haag: There is no hard and fast rule as to like how many, how much. So that's where, again, I would have them do some and see how the coordination goes. Cause if they're otherwise neurologically intact and they're kind of getting it, how many do they need to do?

Sarah Haag: 41:57 I would say it's not unreasonable to go kind of basic strength and conditioning principles of, you know, like I know eight to 12 reps three times a day. That's an okay starting point. And actually, I don't know if you know this, so I'm writing a book on incontinence and the PT people have it, but it's the editor just asked me, she's like, well, since we don't have like a hard and fast number, do we, should we put that in there? And I said, I think we do. So that's a good starting point. Not everyone would be able to do that right off the bat, but also some people be able to do that and they're not getting better. So it's kind of like let's start here and see what happens. And then you can kind of titrate it up and down. If I do an exam on somebody and they can't contract for 10 seconds, they can only contract for five, I'm not going to have them contract for 10 seconds at home. I would probably honestly in that case, have them go, I need you to make sure you can feel the good contraction. So you actually also asked about quantity and quality. I want quality, because all of us can do 100 crappy ones. I'm not sure how much it would help. So really looking to be like, okay, so I feel that contraction and I'm breathing

Sarah Haag: 43:10 and I usually actually have stopped counting seconds. I've had people go by breath, so if you, let's do it. We're going to squeeze our pelvic floors and you're just going to keep squeezing as you breathe in and breathe out normally. Nothing, nothing fancy. And then keep squeezing while you breathe in and breathe out and let go. And what I hope you felt was a squeeze to start with maintaining the squeeze. Some people will feel kind of like a little, a little wave as they breathe, which is not unusual. But then when you stop the breathing and you let go, you should feel that let go. So if you didn't feel that, let go. I usually say that's one of two things without feeling right. I can't tell without feeling is that you got tired and you lost it or you forgot to let go.

Sarah Haag: 43:51 So that's okay. Have a wiggle reset and try again. Because if you're not feeling the contraction, what are you doing? Like you might as well take a walk because then you'll actually be using your pelvic floor. I like going with the breath because a lot of people like to hold their breath when they're like, they'll do like they'll just suck at it and it, you'll feel a lift, but it's just a vacuum. It's not really your muscles doing their thing. So by doing the breathing, if you breathe in and out twice nice and slow, it's 10 seconds. You don't have to count. So if I have you do four of those, you just have to like count on fingers, two breaths come and arrest for two breaths. So much easier to keep track of. And then people actually do them. Cause if I could tell them to do ten second holds, one, two, three, four, five, six, nine, done. And that's not really helpful either. So like the too slow breaths. Now you're breathing and don't have to count and you're going to stay honest.

Audience member: 44:57 So trying to bring this into the neuro world for someone who's post stroke and has stress incontinence or they've had neural damage of some sort and have stress incontinence, Are there any PNF techniques where you can incorporate the pelvic floor to help with that?

Sarah Haag: I haven't had PNF stuff since college. And I'm old. So what I would say is, is if I'm recalling that they go through movement patterns and as you're doing those things, there are things will be happening on the pelvic floor. It seems to make sense. What specifically, I don't know, but if you're kind of working more with that tone in general, I've only had a couple of patients come see me like post CVA and feeling their pelvic floors is amazing because while it makes perfect sense that one side might be like hypertonic are nonfunctioning until you feel it.

Sarah Haag: 45:49 It's like, wow, that's so cool. Like once I totally normal springy, they can contract and relax the other side just like they're, they're hemiparetic arm. It's cool. With stuff like CVA or neurological involvement, you really want to make sure you're on board with the physicians and you know that bladder function is still intact because depending on where the stroke is and what exactly happened or where the spinal cord injury is, you don't want to mess around with screwing up the bladder or the kidneys. So if they're not going to the bathroom or they're only leaking during transfers, that could be stress incontinence or it could be overflow incontinence because their bladder is so distended with the effort. So that's something you would really want to make sure you talk with their nurse or their attending physician and make sure, so how are things working?

Sarah Haag: 46:38 Because the other thing we need to remember is a lot of things we're still working on people who have had neurological insults, right? So once you're like, okay, bladder is relaxing as it fills, contracting, as it empties, it's emptied fine. We're not worried about this being overflow incontinence. I would actually start to incorporate stuff like blow before you go. Where you're managing it the same way you would for someone not having a stroke, but half of that, the beam continent and actually going to the bathroom it seems, I can make it sound very simple, but I have a slide and of course that I teach where it has all the like the tracks up to the brain and all the tracks who, the spinal cord to the bladder. But we got the sphincters, we got the detrusor, all of this stuff just happens.

Sarah Haag: 47:25 And when I click the slide from this beautiful simple picture, it's just font about this big, explaining all of the complex things that are happening so far as we know. So again, as long as they're, bladder is functioning on that basic level where it knows when to empty and it can empty, I would treat him like a anyone else and not assume that it's just because of a high tone pelvic floor on that one side. That's the issue. But if you get that person and you do your PNF, please tell me what happens. And if it changes their incontinence, I would really like to know.

Karen Litzy: And when you're looking at the bladder function, that is something the physician is doing through an ultrasound, is that how that works? How did they do that?

Sarah Haag: They can do it through an ultrasound so that that they are, they can look mostly at like post void residual.

Sarah Haag: 48:12 But then also there's a test called neuro dynamics. And this is a test that involves, a catheter and there you're a threat. And then a probe and another orifice down there to help measure for intra abdominal pressure. And it's kind of a neat test. If someone wanted to do it on me for free, I would probably do it. But they're also looking at an EMG the whole time. So they start to fill up your bladder was sailing so you know how much is in there and you're awake for this test because they go tell us when you, when you feel the first urge to go and they mark where that is. And so you can see how much fluid is in there. And I'm like, tell us when you get like the, I should go to the bathroom now urge. And they mark that and then they're like, okay, tell us when you can't take it anymore.

Sarah Haag: 49:00 And they mark that. So then they know how much your bladder can truly hold. But also looking at what's your detrusor doing, which is the smooth muscle around your bladder, what's happening to your pelvic floor, where is the weakness? And usually when they're full, sometimes they'll have people cough to see if anything leaks or if any sphincters happen or sphincters what they're up to. But it's, it's involved. But there's a lot of good information. And interesting side note is that if you do so, that's really I think really helpful for like a neurologic population just to make sure. I did have one patient I was lucky enough to work with a PT who became a physiatrist who specialized in neurogenic bowel and bladder and she let me come down to watch urodynamics of one of my patients who was really against cathing.

Sarah Haag: 49:46 He didn't want to cath. So she came down, she brought him down to the urodynamics and as it and cause he's like, I am voiding 400 to 600 milliliters every time I have a bowel movement. And like that's pretty good. I mean like most are four to 600 CCS and turns out it was only under very high pressure. He was already getting reflects into his kidneys and after he voided four to 600 CC's, he still had four to 600 left, which is too much. So even though he was having some output, that was the test that really made it clear to him like, oh, it's coming out, but it's not healthy. Like I need to cath.

Jamie: 50:41 What are some of the considerations that you might go through in your thought process when you're dealing with a male versus a female pelvic pain or incontinence issue?

Sarah Haag: 50:53 That's a lot. I could talk for days on that. Well I'm not sure. When you're talking about considerations. We need to take into consideration our patient preference and what they're comfortable with. We can tell when our patients are uncomfortable or we should be able to but then kind of try to work out, they might not want to talk to me about this, but who can I get that they would, cause a lot of people would assume that men aren't really comfortable talking to females. But a lot of the men who come to see me, just want help, and we've had several male students come through and you know, they run into like women not wanting a male therapist to do it.

Sarah Haag: 51:36 It's just finding that, right? Just like any other body part, finding the right person to help. But then if we go to, you know, bringing up those subjects, I don't know that in my brain it's so, so different. Male to female, you're going to take into consideration their history for sure. I feel happy saying that because now with we have kind of like a gender spectrum, right? We have people who, who have transitioned in varying degrees and we have people who haven't transitioned but totally identify with the gender. They weren't assigned at birth and all of these things. So basically I take it functional. So can you just walk me through the issues you're having, your questions, concerns when it's a problem, if anything makes it better, does anything in particular make it worse? And then we problem solve from there?

Sarah Haag: 52:26 So I guess I didn't really have a good, a good answer, man. Male to female. Their situations are usually different, but it's kind of different across one gender or the other. Anyway. Is that kind of answer it? Yeah. Great question.

Karen Litzy: Well, thank you so much. Thank you. I think we covered a lot and I thank you guys for being here and I hope that you guys got a lot out of this and can kind of take this back to your patients now. So last question that I ask everyone and it's so knowing where you are now in your life and your career, what advice would you give to yourself as a new Grad?

Sarah Haag: Ask more questions. To be honest on, I came out of school pretty much like, like the teachers know best and what I learned is right.

Sarah Haag: 53:16 And then when you get into the real world, I ended up thinking I was not very good at my job for awhile because like you would do what you were taught to do but it wouldn't work. And then, you know, some things happen and I got older and more comfortable and when you start asking questions you realize there isn't one answer. So if you start asking those questions, you're part of, you're part of the solution. By kind of pushing those boundaries and not like, I wish I would've just asked more questions sooner. I'd be so much smarter than I am now.

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

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

Sarah Haag: 54:07 I don't know what my picture looks like right now, but I'm friends with Karen, so if it says I'm friends with Karen, that's probably me.

Karen Litzy: Awesome. And just so that everyone knows a lot of this stuff that Sarah spoke about, we will have links to it. We'll have links to the home health section. We'll have links to the testing, the urogenic testing. Is that neurodynamic testing? You could just send me a link or something about it. So we'll have it all in the show notes. Thanks everyone for watching the live. We appreciate it and everybody, thanks for listening. Have a great couple of days. Stay healthy, wealthy, and smart.

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