Hey, folks. Welcome back to the Stronger is Better podcast brought to you by Starting Strength News. I'm pretty excited today to talk to Becky. What's your last name, Becky? Medansky. How do you say it? Medansky. Medansky. Becky Medansky from? Lady Bird Physical Therapy. Lady Bird Physical Therapy here in Austin. We're at the Starting Strength Austin, Sunset Valley right now. I met Becky on, I mean, through text, right? Through text because- This morning outside your car. But you guys did, yeah, you were just in the parking lot. I was like, oh, pelvic floor. You want to come in? Yeah, come on in. But you guys came and did an event here at the gym, right? Yeah, we brought our whole team in a couple weeks ago and did a workshop with your coaches where they took us through the lifts and we were talking about pelvic health and lifting and the intersection of those things and that's why we started texting. Let's talk about that. How did the lifting go for you guys? Had you done anything like that before? It was great. So our team, physical therapists in general, are an active bunch at Baseline. Our team is made up of half college athletes, half kind of more late athletes. So we're all pretty familiar with lifting, but we're not all currently barbell lifters. So it was different than what most of us are currently doing in our own fitness programs, but not so unfamiliar that we've never done it before. Gotcha. Gotcha. Yeah. Cool. Yeah, the team here is pretty great. Yeah, they were great. I'm glad you got to work with them. So we're going to have a discussion about a few things. So obviously she's a physical therapist and a pelvic floor specialist, right? Okay. So I thought it would be good to have a talk and a conversation about various things. Myself as a strength coach, I've dealt with quite a few women with things like urinary incontinence, definitely women who've trained through pregnancy. And my general thoughts are, you know, as with a lot of things in the conventional sort of medical industry, your medical system, things are generally geared towards. Please tell me if I'm off base here, but things are generally geared towards someone who is sick, unhealthy, getting them back to a baseline, getting them back to just like normal functioning. And I think that a lot of times the information that's out there isn't really geared towards somebody who's a high performer or somebody who is training hard and just like the needs and circumstances that surround that, right? So when, for example, when I first dealt with somebody who was dealing with stress incontinence, you know, you kind of start reading around, looking around, and there's like really not a lot. There's really nothing at the time that would help guide somebody. And it's like, well, you got to talk to a pelvic floor specialist, and then you do, and then you come to find out that they're used to working with like older women or people who are of a certain demographic. And it's like, so like, who do I talk to about the lifters? Who do I talk to people who are training really hard, right? So for myself personally, and I think a lot of the, probably a lot of the coaches, out there there's there's been some trial and error and i'd love to be able to um maybe give you my thinking and my processes how i've handled things and then kind of bounce that off of you see see what what you would do differently or what's right what's wrong yeah and um and then also obviously your your thoughts on the whole thing so uh basically the main the big big topics uh i think we're going to cover and we'll see where this goes uh stress incontinence for sure and then training while pregnant and then you know anything else that kind of comes comes out of. that so um if you don't mind would you give us just uh where you are what you guys do maybe a little bit of your background yeah for sure um like nick said my name is becky manansky i have a doctorate in physical therapy and i specialize in pelvic health and then i further specialize in perinatal health so i think that's part of where the discrepancy comes from when athletic trainers and fitness professionals are working with physical therapists is that you have to know who you're working with so my background is specifically in perinatal health, meaning pregnancy birth preparation postpartum. recovery and return to sport there are and that's what my clinic does my clinic ladybird physical therapy specializes in that that's what all of our pts specialize in but in pelvic health i mean that is a massive discipline it's a it's a niche but it's a quite wide one you have male pelvic health you have pediatric pelvic health you have pelvic floor physical therapists who specialize in chronic pain so if you are working with a pelvic floor pt as a patient as a pregnant person knowing what that person actually specializes in is really important the same way that i mean that there are. different fitness professionals who specialize in different things like you wouldn't want people coming here for yoga of course it would make sense yeah right so when you say pelvic health professional what does that mean is that i mean pelvis is like a like a whole region right yeah does it does it mean reproductive systems does it mean pelvic floor specifically what yeah what is that so pelvic floor physical therapists globally tend to focus on bladder bowel and sexual function, historically i would say if you asked a pelvic floor, PT five to 10 years ago, what is the pelvic floor PT does, that is what they would tell. you and they'd probably end there. We are, because of a lot of research that's coming out and because of the demands of just, women living their lives, our field has evolved over the last five to 10 years to be way more involved in keeping people active in light of optimizing pelvic health. So with a bladder, bowel, sexual reproductive health lens, but now how do we superimpose what we know to keep somebody in the gym longer? How do we help somebody return to running? So it's expanded. And actually when I started my clinic, which was in 2019, I, the reason I started my clinic. was because in the city of Austin, which is like what, over a million people, there wasn't a single pelvic health clinic that focused on helping pregnant people get back to sport or keeping people in sports, pelvic floor PT clinic that I was part of, which was amazing, was a chronic pain clinic. And we would see pelvic floor, we would see pregnant and postpartum people. But it, there wasn't a gym, there wasn't room for them to move. Like, it wasn't the right space. So it's broad, but that is what we do now. Well, that fits nicely, right? So what's your, so what is your, and, you know, I'm sorry I haven't seen your clinic. What does it look like? What is it, I mean, how does, what does your typical patient go through at your clinic? Yeah, so as far as what our clinic looks like, it's like, it's a pretty intentional departure from, like, a traditional medical space. We have private treatment rooms where people can have a pelvic exam if that's something that they need. We also have a gym space where people can work out. We have a personal trainer who works in our space, too, who tends to work really closely with a lot of our clients and patients. And what was your second question? What is it, what is it? What's a typical person? Typical look like, yeah. Yeah, so our patient population, because we are largely perinatally focused, we see a ton of pregnant patients. We see a ton of postpartum patients. Okay. We will also. Just to kind of round that out, our youngest patients are teenagers who are having leakage with exercise. Typically, our older patients are in menopause, postmenopausal, experiencing symptoms like pelvic organ prolapse, stress urinary incontinence, but by and large, I would say maybe like 70% of the people that come into our clinic are pregnant and postpartum, and the vast majority. of those people are active. They want to stay active. Maybe they're battling nausea and fatigue and all the reasons why it's really hard to be active when you're pregnant, but they are active people who want to continue doing those things. Nice, nice. Yeah, we were talking about this a little before we started recording, but it's kind, of the traditional approach, and we have grandparents and stuff that still think this way, and even parents, but it's like what we were talking about is this idea that pregnancy is a condition or a thing to be managed as like a problem, so to speak, and at least, I mean, I've never. been pregnant, but at least the women that I've worked with and have trained who are, active and who train hard, they can do it. They can continue to train hard, and they look and feel great. Yeah. Which is like typically what you don't expect, like at the seven, eight month, nine month mark of pregnancy, you know, like the picture everybody has in their head of a woman who's very pregnant and very uncomfortable and can't wait to give birth and just like just like kind of slogging through life. Totally. And yeah, that 100 percent has been my experience when people are training and staying active through the whole thing. So so it's interesting to hear that you have a clinic full of people who have been active and want to remain active. Yeah. Is that yeah. Do you have any thoughts or is that is that a thing that you have to talk about or overcome or people just kind of ready to stay with it? Totally. No, I mean, the population that comes to us is probably not the general population because there are folks who, first of all, who know that we exist. Like there are plenty of people out there who don't. But I mean, my we were talking about this earlier. My daughter just turned one. I was just pregnant. I am a specialist in movement and pregnancy and my whole pregnancy. My family was like, don't miss don't lift that chair. Like I remember setting it for my baby. Shower and I was picking up like a bench to put it. next to a table and I had a friend over who was my age she's young she's not my grandma like a young woman who was like what are you doing you're pregnant and I was like first of all I'm lifting, quadruple quintuple this weight in the gym all the time second of all like if you all of the the I shouldn't say all the vast majority of the common pelvic floor symptoms and orthopedic symptoms that arise during pregnancy and postpartum are a result of or made worse by. deconditioning like almost all of them pregnancy is why would you take somebody who is going through a stressful state who's going through a state where they need to work harder where their body needs to do more and tell them to do less it is but but at the same time that's the messaging that people are receiving when they're out in the world right and it is eventually hard to fight that yeah constantly yeah where do you think that comes from because I I mean some of it um and I'll say this but some of it comes from you know whoever they're you know they're, obstetrician is may say something uh you know and then family but what. What do you think? Where does that come from? I think it comes from everywhere. I think it comes from the fact that we have historically had pretty shit and minimal research about women's health. I think it comes from the fact that medicine can be rather paternalistic. That's improving, but it's still true. And I think it comes from like a general, just like the way that we have historically treated women in fitness, which is like, oh, women shouldn't be lifting heavy, right? Like you should be careful. We shouldn't push women. Like we need to be careful around their cycle, around menopause. Like around all these things. I think it's just kind of like a cultural and societal thing. Yeah, and it's actually the opposite. Women can be pushed way harder than men. Well, the more research we're seeing, the more it's being proven. I think a lot of fitness professionals have maybe thought that for a long time, and we're actually seeing the evidence of that now. Right, for sure. Yeah, I guess we can start there. So let me run through sort of my experiences, and then let's talk a little bit. Because in the lifting world, right, it's like I think people who train hard, are are going to make it work right they're going to make it happen so uh and if they're not. feeling um if they're not feeling bad they're going to continue doing what they're doing so like i haven't had to i haven't had to convince anybody to not uh to to continue training right it's just a natural but like i'm going to keep going until and you know their their doctors will tell them to stay active and walk and do whatever they don't have any idea what these people are actually doing right so so yeah we just kind of continue on and what and it's funny because you know obviously first trimester is rough because they don't feel well their their hormones all over the place or stuff like that but again in my experience for people that are training hard that. that tends to be compressed versus the average normal general population per person yeah so in other words they're not experiencing those symptoms for like a long period of time they start to feel pretty good pretty quick i don't know why that is doesn't matter to me like let's just keep going right and then and then they start growing you know obviously because they're growing another human inside of their body, really at the initial, phases. We don't really have to modify anything. We just keep training, keep going, and things generally go really well. And then as their body starts to change, right, because there's the. hormones. Is it relaxin? Is that the? That's one of them, yeah. Yeah, one of them, right? So then they actually start to get, like, looser, basically. Like, their tendons and their ligaments start to change, and they'll start to feel, like, weird aches and pains. And so the one thing that I have to do typically is actually tell them, because people who, again, people who train hard, you know this, right? People who train hard tend to ignore their body signals. Like, you know, something hurts, they just ignore it, and they keep going. So I'll typically tell them, like, look, this is the one time in your life that you're not going to ignore what you're feeling. Like, if something's off, something feels wrong, you get on a bench press. Like, traditionally, women have been told not to bench press, not to lay on their back and bench press. Hasn't been my experience that they need to typically do that until, like, really, really far down the line. Um, but it's the same thing, right? If something feels off, just stop, and we'll, We'll figure it out. We'll deal with it. We'll do something next time, right? And then going into like the third trimester, it's just been incredible to watch women. I had one client who just off the cuff decided to go enter a lifting competition and had never deadlifted 315 pounds before and just did it, you know, eight and a half months. Once had another woman go and do a international level competition at like seven or eight, eight or eight or nine weeks pregnant and, you know, hit PRs and all of her lifts. And it's just that same story over and over and over again. Right. So, yeah, I mean, what's going on? Because in my view, the way I explain it is like your your body is growing. You are a person who takes care of yourself. You're feeding yourself. You're doing the things you need to do. And basically you're taking. Advantage of this like sort of anabolic state where you're like your body's primed to grow and you're just taking advantage of that. Yeah, I mean, I have a couple thoughts. I want to answer that question, but I also want to comment on a couple other things that you said. So relaxin, starting with relaxin, so that is a hormone that promotes laxity in the system. It has historically been, and you didn't do this, but it has historically been blamed for just so many things that it doesn't deserve to be blamed for, or it's like a really small piece of a very complex puzzle. So relaxin is a factor, but relaxin also peaks in the first trimester, which is interesting because that's not actually when a lot of these common symptoms pop up. Usually the first trimester, people feel crappy, they're nauseous, but that's not when they're having the highest rates of pelvic girdle pain or whatever symptom they're popping up with. The other piece is that there are a lot of factors that we can't control in pregnancy. There are a ton of factors that we do not have control over. Those are called unmodifiable factors. They're your genetics, they're luck of the draw, they're pre-existing medical conditions, all the things. But when we look at modifying... Unmodifiable factors during pregnancy activity... level is like one of the biggest ones and being active helps reduce nausea. It helps improve energy. It helps reduce fatigue. And so of course that helps people stay more active and then feel better later in pregnancy, because like you talked about, like your body's changing, your belly's growing, your posture is changing. Your gait is changing. If you're not staying strong as your body's adapting to that change, you're going to feel it as you get bigger. So absolutely people who stay active tend to feel better, but there's also, it's a little bit self-selecting because. there are people who are unable to stay active for all of those unmodifiable factors. And so they won't be able to achieve those results or at least not in the same way. So I think that when we're talking at people who are really successfully lifting heavy through pregnancy, it's important to call out that like, there is a lot that those people have done intentionally to help themselves, but there are a lot of people who would love to be there and could not be for a number of reasons. Yeah. But with that said, and you know, one more comment on what you were saying. Like I wouldn't, and I know you wouldn't either. I would never tell. who wasn't a barbell lifter prior to pregnancy to go out and PR on a deadlift, right? Like that would be crazy, but you also wouldn't tell that to somebody on the street who isn't pregnant. But at the same time, like general guidance during pregnancy is if you are active prior to pregnancy, whatever that may be, whether you're a weightlifter, whether you're a runner, whether you're a CrossFitter, like whatever your thing is, you can continue doing it through pregnancy. I do generally tell people like, we don't want you picking up a new thing, at least not at like a high level. I'm not trying to get somebody who's never lifted a barbell to all of a sudden, who's never lifted a weight to start lifting barbells during pregnancy. Why would we do that to them? But yeah, people who have, who have this like base level of fitness, who've been lifting heavy for a long time, there's nothing about pregnancy that indicates that they shouldn't be doing that. And that used to be a fear, right? There used to be some, like some belief in medicine that if you lift over some, some amount of weight, yeah. And these arbitrary numbers are based on studies. Typically this is. how it goes. There's a study that proves that lifting 20 pounds isn't harmful, doesn't increase the rate of miscarriage. All of a sudden, that's the number we tell people they can lift up to. Not because we know that 30 or 40 or 100 pounds causes problems, but because we know that 20 doesn't. And medicine is about harm reduction, right? And also there's liability. We live in a litigious world. So healthcare providers tend to be really conservative. Right. Sure. Sure. Yeah. And by the way, our recommendation is the same, right? I think it tracks along with all of that. It's like if somebody comes in and, you know, Ripito has been saying this for as long as I can remember. Somebody comes in and they just found out they're pregnant. They want to get started. training. It's like probably not the time, right? Don't add new things. But if you're already trained, you're already doing it. There's no reason at all to discontinue. And so I think my larger point was that, you know, I think the me of six or seven years old, I think I'm going to would have been like, okay, you're pregnant. So let's like still train, but take it. easy. Yeah. Be gentle. And that hasn't been my experience at all. It's actually like, like I'm still approaching it that way, but, but the women will tend to push and I'll let them at this point, like, you know, as a, as a more experienced coach, like if you want to go, go, it's probably going to be okay. Right. And up to, up to now it hasn't, it hasn't been a problem. No. I mean, for people who know how to monitor for symptoms, who know their bodies and who are athletes, like we see CrossFit competitors who are pregnant, who are early postpartum, we've seen Olympians recently who were pregnant or postpartum who crushed it. Like we have anecdotal data and slowly we're getting actual data also, but there is no pregnancy in and of itself, barring all the other factors is not a reason to be scared to push a body. Right. Right. Yeah. And you brought up an excellent point about the self-selection, which is a, which is a great point. I didn't even, you know, I didn't, cause there's always this, this kind of correlation, like a loose correlation with, um, people who continue to train, stay active. and then generally an easier birth process. But again, that's lots of factors, right? And possibly some of that is also that, maybe those folks are self-selecting and they're gonna have an easier pregnancy no matter what, right? To some degree, yes, and to some degree, no. I mean, correlation versus causation is so difficult to prove in research, but we know that being that when you look at the population of folks who are physically active versus not, we see less reproductive, we see fewer adverse outcomes during pregnancy and postpartum. We see typically for people who are active in pregnancy, we see shorter second stage of labor, so shorter push phase. We see lower rates of C-section. We see lower rates of pain during pregnancy, pain postpartum. So I think that yes, of course, there will always be people who do need. to self-select out for various reasons, and we can talk about that separately. But for the people who are able to stay active, I think that that's the aim of this conversation. And there are a lot of people who I think would like it. to be in the category of folks who stay active, who are scared, who are being told by their providers that they shouldn't, who are being told by their moms and their grandmas that they shouldn't, you know? Yeah, I guess to kind of make this, yeah, to make it kind of useful for anybody who's pregnant right now or about to be pregnant, yeah, anything to watch out for. So I think our recommendations right now are whatever you're doing, as far as athletic or physical activity, probably okay to keep doing it, probably preferred, right, keep doing it. Maybe don't pick up a new super stressful thing, right? Because you're pregnant and you're like, oh, I'm gonna go try CrossFit, I'm gonna go try barbell training. Maybe not the best idea. And then along the process, anything else? So I think, you know, I think what I said was, basically like listen to your body. This is one of the times as like a lifter, an athlete, somebody who's working hard that you actually do wanna pay attention to what the hell's going on. Yeah. But outside of that, what else would you, throw in there? I think as far as the basics, like I, what I would want everybody to know is that being active in any way is better than being active in no way. So whether you like to weight lift or whether you like to do Pilates, like keep doing whatever it is that you can do. If you usually like to barbell lift, but that doesn't feel good during pregnancy, like modify and keep going. And then I think the other piece is we generally tell people to monitor for symptoms. So, okay. Monitor for pain, monitor for leakage, monitor for doming or combing in the abdomen, right? Like monitor for these things. But if they appear, this is, this is actually, I think like what I wish people knew. If you have a symptom that does not mean that you should stop doing anything, because that's what I see all the time. You have these people who were super active through their first trimester, through their second trimester, all of a sudden they started having this pain. And instead of a provider or a fitness professional talking to them, how they can modify the movement so that they can keep going, they stop altogether. And so there's the way you respond to symptoms isn't all or nothing either. But yes, of course, like pregnancy is the right time to monitor your body. Sure. Sure. Yeah. And any thoughts on specifically things in the in the barbell training world that people should watch out for? Again, in like speaking from my experience, you have to generally people can squat just fine. You might have to modify the stance as it gets bigger. Right. Turn the toes out a little bit more. More. So there's more room. The deadlift isn't going to work, especially as they get really, really big. So that's an easy modification. We just put them in the rack and rack pull overhead pressing. No problem. Right. Bench pressing that, you know, for the longest time, we've always heard that like laying on your back is not great. Again, like I've recommended against it and I've told people do an incline bench instead. So you're not laying down. But then I have women who just go ahead and bench and they're fine. So other than that. I mean, power cleans and Olympic lifts might be a problem with a giant belly in front of some people. Yeah, it might be, it might not. When it comes to laying on your back, the concern with somebody laying on their back is that you're going to occlude blood flow to yourself and to baby. But the thing is, like, your body's going to tell you if that's happening, right? Like, people who feel fine laying on their back are fine laying on their back. People who feel dizzy, nauseous, uncomfortable should get out of that position, but they will. Right. Like, those are signals that you should not be in that position. If you can't breathe, you're not going to be lifting heavy in that position. And there's also a difference between being on your back to do a set and then being on your back for, you know, 12 hours straight. Like, everything has more gray area than I think we've traditionally allowed for in pregnancy. Yeah, and do women, I mean, so let's just take a situation where you're laying on a couch or laying on your bed as a pregnant woman. Would you stay in that position if it was, like, because you're going to feel something, right? You're going to feel lightheaded. You're going to feel some symptoms. Are women just going to stay there on accident and, like, mess up? themselves on their back yeah no I mean and this is why so much of this advice is kind of like how do you act upon don't lay on your back like I've had so many patients over the years come in freaking out because they woke up on their back yeah you move in the night yeah we all move in the night no I might not advise that somebody goes to sleep on their back during pregnancy but honestly it's because it's probably gonna be uncomfortable with our back yeah and versus sidelining you can use pillows you can use more props and support but no I mean ending up in that position like nobody's gonna end up. laying yeah in other words it's a self-correcting problem it is a self-correcting problem okay all right cool anything else we should think about as lifters coaches gym owners for training while pregnant I mean nutrition we didn't talk about nutrition that's obviously an important factor for sure but anything else I think that one of the concepts that I think a lot about when it comes to my pregnant and my postpartum athletes is relative energy deficiency syndrome so these are people who are their bodies are undergoing a. situation where they're not feeling well they're not feeling well they're not stressed that does not mean that they, can't work out, but what else is going on in their lives? Like, are they sleeping? Are they fueling? Are they so nauseous that they've eaten nothing but bread for the last 12 weeks? You know, like we need to be mindful of that as movement professionals, because it's going to alter their ability to progress. It's going to alter their ability to perform. You may see better and worse days, but you'll have that in your non-pregnant athletes also. So, I mean, we could talk all day about all of the considerations, but I think the big ones are exercise is really, really good for. pregnant people, and it needs to be personalized to the person and modified to the person based on all of their needs. Right, right. Okay, cool. What about postpartum? So, I guess the loose recommendation is, well, whatever the obstetrician tells them, right? And it's usually something like six to whatever weeks, take it easy, you know, and totally fine, right? But they want to get back, like, really quick, right? They want to get back. back sooner. Um, so I'll let them come back as soon as they want to, but it's going to be really, really light. It's going to be really easy. And again, this is one of those things that seems to be a self-correcting problem. Like, um, I don't typically have to hold people back cause it, it doesn't just feel right. Right. So, so yeah, just, just easing them in the way our program is structured, where you can always go back into like the most basic version of the program, start things light and then start working it up. And it fits in nicely. Cause over the, over an eight to 12 week period, you know, you can get somebody back. And I usually expect somebody who's very strong and high performing to be back to, um, you know, pre-pregnancy, uh, performance levels at six month mark, you know, I mean, we're talking about really, really strong people, right. Uh, for just more normal people, it's, it's usually takes way less than that. Right. But yeah. What are your thoughts kind of postpartum? Yeah. I mean, this is a bear of a topic. Yeah, I'm sure. Um, it's a bear of a topic for a number of reasons. One, as a physician, physical therapist, I function within the medical, community. So I have referral sources who are OBGYNs, who are midwives, and being mindful of their comfort levels is important for patient care. Because if you tell a patient something. completely different than what their OB tells them, you're not setting that patient up for success. You're setting them up to mistrust, to not trust somebody, right? But I will tell you what we've been doing as pelvic floor physical therapists for a long time and where we're seeing things moving now. What we've been doing as pelvic floor physical therapists to work with return to sport and postpartum people is that we have been following a relative six-week wait, meaning prior to six weeks, prior to when you see your OB, who's confirming that any stitches that you have are healing, that your uterus has returned to pre-pregnancy size, that there's. no risk of infection, right? Like that is what an OB is checking for a midwife at six weeks. They are not checking for muscular function, but we typically use that as a benchmark historically, to have somebody maybe start with some body weight stuff, maybe start with some mat-based stuff. And then we're going to start with some body weight stuff. And then we're going to start with some body weight stuff. Ideally start increasing. they're walking for those six weeks and then around six weeks we can progress to more functional movement and then we start adding in weight so that's like if I had to put it as a formula which is what pts and health care providers really love the formula for the past what I have been doing. as a clinician for the past like six seven years is zero to three weeks you're primarily working on restoring breath adding in maybe five-ish minutes of being on your feet per week per day, doing some maybe some core stuff on a mat some glute bridges then week three to six we're starting to see people do maybe more like still stuff primarily on a mat but donkey kicks bird dog beast holds getting your core firing your glutes firing increasing walking again so that around six weeks maybe you've worked up to like 30 minutes of walking at a stretch then around. six weeks we start returning to functional movement like squats hinges but typically you're going to be able to do more of those things and then you're going to be able to do more of those things and then you're going to be able to do more of those things and then, plus weeks we start adding resistance 12 plus weeks we start adding impact and that's like that's a a very fast rate of return for the average person because that's somebody who's typically asymptomatic somebody's having pain leakage prolapse symptoms may go a lot slower however as we get more evidence and as i have seen more and more patients the reality is like. you can't tell me that somebody who lifted at 39 and five weeks pregnant is going to have the same speed of return to resistance as somebody who stops lifting at prior to pregnancy because ivf was so hard on their body right like there is no comparison of what that person's baseline fitness is right and so really more and more researchers and also like the clinicians that we see who really specialize in athletes like we're seeing them be a lot a lot less. rigidly connected to a checklist and a lot more connected to well, What's this person doing? What are they feeling? Exactly right. Because my population is not primarily barbell lifters, the idea of somebody lifting weights prior to six weeks makes me very uncomfortable. Oh, no. Yeah, I'm not proposing that people lift weights prior to six weeks. But moving, yes. Moving for sure, yeah. Yeah, moving for sure. Yeah, yeah, so, yeah, 100%. So, yeah, let me be a little bit more clear. So when I say let them come back whenever they want, it's not like get under the barbell prior to six weeks. It's like get cleared by your doctor. They'll give them some recommendation about walking or movement or something. Totally fine. And nobody feels like lifting weights prior to six weeks before training. No, I mean, like you're figuring your life out, right? Exactly, and things are happening. Things are bleeding still. And then also, you know, if they're breastfeeding, they're dealing with all that new lifestyle stuff and everything. So absolutely, yeah. So step one is kind of get cleared for activity. So that's kind of the benchmark for when we're going to start doing stuff. When you get cleared. for, for exercise or activity. Cause the, uh, the OBGYN doesn't know like what activity means for this individual. Right. So you get clear for activity and then we're going to get, we're going to get started. And then again, it's exactly like you said, it depends on the individual. It depends on where they were and, and, um, how things went, right. Especially over the, over the last few weeks and over the, over that, that six weeks of recovery after giving birth and what their goals are. Right. Like there, there are so many factors. Yes. There's like the, how active were you during. pregnancy? But then there's also like, well, what was birth like? Did you have an uncomplicated vaginal birth? Did you have an emergency C-section? Like the way your body is going to respond to also like breastfeeding, whether or not you're producing milk is going to, is going to significantly affect healing and significantly affect your function. And so there are, there are so many factors, but kind of same thing as during pregnancy, like telling people not to move when they're also now caring for a baby, that's just going to get heavier. Is also not productive. For sure. For sure. Yeah. Yeah. the larger point is that there's this there's this period the way i look at it there's this. period of like healing that has to happen right because like your body has gone through a thing a pretty significant thing so there's this period of healing that has to happen obviously like wounds have to close and heal and all that kind of stuff um things have to kind of get back to sort of whatever normal is sure and then um uh and then it's it's just it's just back kind of back into the process but the the point is that the level of detraining that occurs i think is much less than than i think what people expect so in other words you know things are things are different. like things are way different but it's not like um you don't have to start over like yeah at a certain point you can start ramping up and coming up pretty quick yeah it is there is still a lot of rhetoric out there that i hear it's like well don't bother pre-habbing for pregnancy or through pregnancy because like then you're going to give birth and you're going to have to start over and like anybody who's ever lifted or, any, who has any athletic background knows that it doesn't go that way, right? Like, you do decondition, but you build faster when you have a solid foundation. Yeah, especially a strength foundation. It comes back very, very rapidly. And people are kind of shocked with how quickly it comes. But, you know, strength adaptations persist. They're still there. Well, and I see this a lot for folks who are recovering from pregnancy number one, who they know they're planning a second or a third, and they just say, like, well, there's no point. Like, there's no point in me doing anything about this now. But then what we see is whatever symptom it is that they're experiencing tends to get worse, right? Like, if you don't address your stress urinary incontinence from pregnancy number one, then it'll start earlier in pregnancy number two. It'll be worse after that baby is born and so forth until we address it. Yeah, yeah. Yeah, I guess the only, yeah, like you said, it's a bear of a topic. But the other thing is a lot of women want to, after having been pregnant and given birth, they also are kind of in a weight loss mode, too. Like, they want to, you know, depending on how they're doing, they want to find a situation that may or may not be appropriate, but they also want to lose. lose that baby weight. So, you know, that's another factor to layer on top. It's like how, quickly you're going to get back to where you are is if you're losing weight, obviously you're not going to be, you're not going to be performing at the level that you were at eight and a half. months pregnant, right? And that's also, it's a complex topic because there are so many reasons why people want to lose weight postpartum, right? Societal pressure being a big one. And we know that bodies hold onto weight differently if you're producing milk, because we have evolved to try to ensure our ability to ensure our ability to feed our babies, right? So some people will lose weight pretty rapidly with breastfeeding. Others will hold onto it until they stop. And of course there's sleep deprivation and there's healing and there are all the other facts, stress, cortisol, all the other things that go into a healing body. So whenever I'm talking to somebody about that, we try really hard to figure out like, well, what is the goal? Like, is it that, is it the number on the scale? Is it that you want to feel confident in your body? Is it that you want to feel strong? Is it that you want to be pain free? Like how do we tier this so that we are focusing on the thing that is, actually important to you and weight? Weight loss may be the thing, I'm not saying that it's not, but how do we make sure that we are supporting your health as we work towards whatever your goal is? 100%. Yep. Okay, cool. Should we... Anything else? Anything else we should talk about there? I mean, probably, but in the context of this conversation. One thing that I wanted to say about pregnancy and training in pregnancy, just as like kind of a vote of confidence in why lifting during pregnancy is not bad, is there was a study that came out in, I want to say 2020, I could be wrong. Don't quote me on the year. I'll look it up. I promise. You can put it in the show notes if you want. And what they looked at was rates of pelvic organ prolapse in people who lifted during pregnancy, or sorry, not during pregnancy. This is just lifting in general. I'm completing two studies that I was reading earlier this morning. This study was just looking at lifters, at female lifters. And what they found was that they had higher rates of pelvic organ prolapse and symptoms in folks lifting under 15 kilograms as compared to over. Meaning that, I mean, what does that tell us? Like that strength is protective. applies to pregnancy also. We have proof. We have evidence to suggest that strength training is protective for the pelvic floor. And we have evidence to suggest that exercising in pregnancy is not harmful to it. And so staying active is one of the best tools that we have for people who can do it to work towards a healthy pregnancy, birth, and recovery. Right, right. I mean, when we say pelvic floor, I mean, you're essentially referring to a group of muscles and other structures, right? Yeah. I mean, they're muscles and they're going to adapt and they're going to get stronger. And if there's a way to apply a systemic stress that's going to make your whole body stronger, like barbell training does, then it kind of tracks that if you're stronger, your pelvic floor is stronger. Yeah. Well, so yes and no. So because the pelvic floor is a bundle of muscles that folks are not familiar with typically, right? Like unless you've been pregnant, you've been through pelvic floor PT, for some reason you've started to care because. social media now cares about pelvic health. A lot of people don't know how to coordinate their pelvic floor muscles. Yes. And so what we see, is that if you are exercising, I mean, it's the same with any other movement, right? If you are working out and you have control over your muscles, you'll get stronger. If you are working out and you do not have control over your muscles, you may get injured and may get weaker. So the pelvic floor muscles are the same. If we don't know how to take them along for the journey, then we can see increased rates of weakness and stress urinary incontinence and other pelvic health symptoms as somebody is lifting. But if we can ensure better coordination, if we can optimize that coordination function, then yes, absolutely, getting stronger will get them stronger too. Yeah, yeah, no, no, that's a great point and a great segue because it seems to me, if we're ready to talk about stress incontinence, it seems to me that there's a lot of factors, obviously, right? And the coordination aspect of it seems to be a big one. And so then it's like, when does it happen? Why does it happen? In my view, what I do, the why is important. And I have to understand it. But I really have to know, like, when, what are the factors, what are the conditions, and what to do about it, right? So, first thing is, there's a lot of women out there that are experiencing this. You know, and basically what we're talking about is lifting a heavy weight, and then you pee, right? You pee a little bit or you pee a lot. So, there's a large group of women out there who are hiding it or, like, uncomfortable with it or don't want to talk about it or just ignore it. And I'm assuming that's, I mean, that's wrong. Like, don't do that because we've got to do something about it, right? And then there's also, on the flip side of that, there's a group of women who are, and okay is the wrong word, but are, it's almost like when CrossFit, when you have the calluses that are ripped off your hands. Like, it's kind of a cool thing. That's a problem, too. Like, I've achieved the. That's a problem, too. Like, we don't need either end of those things, right? Yeah. So, this is rough because you have to have a coach who. Can either refer you to. somebody or can deal can start to help you deal with it and you have to have a relationship with that coach that will allow you to even be able to have that conversation right because yeah you know if you're a female client member with a male coach that automatically is an uncomfortable deal right yeah so um anyway so there's that and then um in my in my like i've never consulted with anybody uh it's kind of just like hearing various people talk about it and then a lot of practical. experience on the platform dealing with lifters but it seems to me that um there's there can be an element of like a learned response in other words like at a certain stress level it's going to happen um regardless so that's that's one thing and that's maybe minimal like that's like the least one but there's also like i've noticed that um women who are very flexible um and it's not that being flexible is not that being flexible is a is a factor it's usually like okay this woman, experiences stress incontinence and she's also is really really flexible so. there's like a pelvic positioning deal in my view like is like I can watch a set a rough heavy rep pelvic position low back lumbar spine everything stays solid stays in control and there tends to be no or very little like or no stress incontinence and then when that when that same individual loses position almost every time like you know the pelvis moves a little bit right so so and then also breathing right so you got a Valsalva a lot of intra-abdominal. pressure and I'm assuming that the intra-abdominal pressure is overwhelming whatever mechanisms are like holding the urethra closed or something right so so there's that so then there's the breathing aspect of it and then there's also like when you're lifting you if you're strength training you want to lift more weight right so but in the in the context of of a stress incontinence situation there's gonna be periods where a periods of time where you that can't be the goal, like it like it's got to be it's got to be learning to control and coordinate your body and lift a heavier weight without the stress and condoms yeah. right so I know that was a lot but I've lost the points you may have told me bring back so first of all stress incontinence is it's a symptom okay it is a system just like back pain okay and there are a there are a number of reasons why somebody can have stress incontinence there are a number of reasons that people can have back pain as far as causes I mean sure it can be pelvic floor muscle weakness but it can also be a lack of coordination right or it can be that intra-abdominal pressure is overwhelming the pelvic floor or it. can be that they're not actually bracing their core they're just bearing down and that can be really hard to tell okay or it can be because the muscles are really tight and they're not able to activate it can be pelvic floor injury from birth it can be it can be pelvic positioning like you mentioned right it can be a lot of different things, But just like back pain is a symptom. And so if we use back pain as like a corollary, if somebody is deadlifted of back pain, the first thing you're going to do is, I imagine, the first thing I would do is say like, okay, well, can we change something about your form so that you then don't have back pain? Because it's not going to be true that every single person just needs to tilt their pelvis and then it goes away, right? Like the things showing up in that person will be unique to them. And so the solution will be unique to them. And there's a physio out of Australia named Anthony Lowe. He's the physio detective. He does a lot of education in pelvic health and female athletes. And that is like his number one cue is like, okay, you leak, you feel prolapse, you do something with this movement. Can you do something differently? Can you change your stance? Can you change your breath pattern? What can you just shift so that we're not overly pathologizing this and getting you overly in your head? Because leakage, while, sure, ignored and stressed over time and like hidden. And unaddressed can lead to bigger problems down the road, just like. back pain, if ignored and abused over time, can lead to bigger problems down the road. But it's not this like red flag that I think we've historically believed it to be. So I'm trying to wrap this back to other points that you're making, but, but so first, first and foremost, yes, leakage is definitely underreported. Secondly, I think that fitness professionals are in a really, really good position to help. their clients feel more comfortable reporting this, even male fitness professionals, right? Like this is, it is a symptom of musculoskeletal symptom, just like back pain. And it's not necessarily your responsibility to know what to do about it. But I think that it is as all of us, our goal being conscientious practitioners who are able to support our clients. Like it is our, I think it should be something that we strive to, to create an environment where our clients ideally would feel comfortable or may eventually feel comfortable sharing something like that. It's not going to be something they tell you day one. It's not going to be something they may tell you a year in. But that's true for medical providers too. So sorry. Sorry to interrupt you, but if you're, if you're. If you're going to have a long-term relationship with a member or a client, you know, over the course of two, three, four, five years, you know, even if they go engage with a physical therapist or pelvic floor specialist, that relationship is going to be fairly limited in time and scope. Yeah. So, yeah, I mean, layered on top of that, the strength coach, the fitness professional is basically going to be the one to help manage that long-term. Yeah. Right, so there has to be some baseline knowledge because it's a thing and it happens. There's got to be some baseline knowledge and possibly even like a little bit of a process of what to do. We know, yeah, I mean, we know that like, depending on the study, let's say 50% of people may experience leakage with lifting, like higher impact, higher intensity athletes experience it at higher rates. So if you are training people to lift heavy, you will have female patient clients who are leaking. Yep. And yeah, having some idea of what you can do about it. Is really important and also having some idea of questions that you might be able to ask to give. you an idea of whether or not you're like spidey senses should be sure. So like asking your client things like, do you feel any uncomfortable pressure? Like, is it how to, is this uncomfortable in your pelvis? And you're, these aren't like, you're not going to ask every single person this question, but if you have some reason to suspect, like maybe this is an older client, maybe there's somebody who, you know, has recently had a baby. Like you don't need to say like, Hey, are you peeing yourself? Although like, I think for the right person that might work for sure. Um, but having some idea of what questions you can ask them does really impact your ability to then. continue to work with them and get them stronger. And just in minor changes can make a big difference. So like, I know that I know that abdominal bracing is something that folks coach when they're lifting heavier weights. That's not always appropriate right away though. Like sometimes people need the, their pelvis and their pelvic floor and their core muscles to strengthen before they're capable of managing that load from the intra-abdominal pressure. But also leakage is isn't all about the pelvic floor. We know that especially postpartum people with leakage have weak hips. And getting their hips stronger will help address their leakage. You can treat leakage without ever looking at the pelvic floor in a number of cases. Of course, it's helpful to know what's going on, but it's not always required. Yeah, okay. Yeah, it's an interesting and obvious correlation or analogy with something like back pain, right? So I think in the view of a strength coach, it should be sort of treated in the same way. For example, what we're doing here is very controlled, and it's very consistent, and variables are minimal, right? So in terms of the movements that these folks are doing, they're kind of fundamental foundational movements. There's not a lot of need to modify things in terms of the actual delivery, but there are things, even with just the tools we have with barbell training, that you could really... Really effectively modify and make things happen, right? So for example... If somebody experiences a back tweak, we can still have them deadlift. You just modify it, like you said, right? We just put it up in the rack, have them do it higher, and then we start going and we start seeing what happens. So the approach that I recommend to coaches is you have to figure out when. Again, the why is like out of my realm. Right, the why is not your responsibility. Yeah, I don't have the ability to evaluate what the hell is going on. I know that you've got back pain, like it hurts when you do this. Because I know that you're peeing yourself, and I can't stop it. Like, oh man, this woman's peeing herself, and what do I do now? Okay, let's start drilling down. So it's like, when is it happening? What are the other factors? And here's another thing, and I don't know what you think about this, but it seems to me like just general stress tends to make it worse, right? I mean, general stress tends to make back pain worse, right? Well, good point. Yeah, of course. For sure. Good point. So it's like, look at the whole picture, right? It's like, how's your recovery? How's your nutrition? How's your sleep? And if all that's compromised, okay, that's a factor to consider. When does it hurt? Or when does it occur? Is it at the bottom of a squat? Is it on the way down? Is it on the way up? Is it when you're straining through the middle of the squat? Is it positional? Is it when you're in this certain position? It happens every single time. So I think in terms of a process for a strength coach to have, it's just like dealing with an acute injury in some ways, or even a chronic injury. It's like it's start drilling down this process of when, when, what are the other co-factors going around, surrounding the situation? What load? Is it always at heavier loads? Is it at higher reps? And in what positions? And then on top of that, I think as an overarching thing, it's like the breathing. Because I think you were kind of alluding to this. We tend to teach the Valsalvas, take a big breath and then bear down, right? Or however people want to describe that. But, yeah, it needs to happen. instances that's not enough and may make it worse so yeah so there's a lot in there that you just said but to summarize before we get into Valsalva to summarize the first part of what you're saying and how I interpreted it which I. agree is if you have somebody who experiences leakage on the platform then the first thing that I would do if I was seeing them as a PT I think it's really I mean I think it's really quite similar to what the first thing a fitness professional should do in a gym setting is okay we know that you leaked with that last rep like do it again do you leak again yes okay like we know this wasn't right like I'm not terrified by the symptom but like okay it's there I'm aware of it now it's like is it that we progress way too quickly is it that the range of motion is too much right like what is what modifiable factor do we. change ideally the smallest thing right like is it that we need to drop you five pounds is it that we need to raise your deadlift up five inches like what is the smallest thing that we change that gets rid of the symptom and then we use that as our big thing and then we use that as our big thing and then we baseline in our training to progress them back to where they, Or, wow, now there are no symptoms, right? Like, that's our perfect world. And honestly, sometimes it really is that simple. Sometimes it isn't. And that's where, as I would imagine, fitness professionals, you refer out, right? Like, that's why I have a job. Because sometimes it's not that simple. And sometimes there are other factors at play. But that's why I work so closely with fitness professionals. Because, like, I'm not, my job isn't here. Like, I want them to stay active, as active as possible. And also make sure that we're not only keeping them active now, but setting them up to be strong and healthy as they age, right? Like, we know that all of this stuff comes back for people when they're in perimenopause, menopause, and older, later in life. And we know that urinary incontinence is a leading cause of cardiovascular disease. It can lead to UTIs, which can lead to death. Like, there are so many reasons to care about this now. So I think it's really important for fitness professionals and PTs to work together. And for PTs, on my end, to then send the patient, back to the hospital. The gym, right? Keep them active. Keep them doing the thing that they like to do. Well, yeah, I think the ultimate bad outcome, at least in this context, is that somebody's so worried about their incontinence issue that they stop activity, and then it's just a compounding effect, and it gets worse and worse, just like you said. So, I mean, if it's correlated to heart disease and other things, it's probably because they're. inactive and they stop physical activity, right? Yeah, yes. So it's really important to keep people active, and I think that's why if you can't find this little modifiable tweak to reduce their symptoms, then refer them to PT, have them come back to you, and then you'll be able to continue working together for the longer term. But when it comes to Valsalva, there is a difference between Valsalva and bearing down, and that is something. I think that's one of the... Honestly, in my perfect world, every single pregnant... Every single female weightlifter would see a pelvic core physical therapist at some point. to assess what's happening with their intra-abdominal pressure and whether or not they're actually able to Valsalva or whether they are bearing down. Okay. That's obviously far-reaching. It's not going to happen. This is like my dream world. I just think it would be really cool. But when people coach a Valsalva, what they're doing is trying to stabilize the spine, right? You're trying to use intra-abdominal pressure to create stability in the core. What can happen is pressure moves to the path of least resistance, right? So if you have an abdominal wall, if you have a diaphragm, a pelvic floor, I mean, you have your spine in the back, so you're pretty protected there. But whatever area is, if you have a weak strength and balance, that pressure, rather than bracing, is just going to try to exit, right? So that's where we see prolapse symptoms with lifting, sometimes, not always. Sometimes that's why we see urinary incontinence symptoms with lifting. But that is, I think, one of the really, and it was funny when my team was here and we were talking with your coaches, I was like watching it happen. I was like, oh, you guys are doing this? I think you mean the same thing, though. Yeah. Like Valsalva isn't bad. That's not bad for the pelvic floor. It's been steady. Bearing down, however, can create stress on the pelvic floor and aggravate symptoms. Could you give us a little bit more distinction there? Yeah, so think about what you would do if I was going to punch you in the stomach versus what you would do to poop. Okay, yeah. I think that's the biggest difference. There are similarities. You can feel it in your body. Everybody can do it. But for some people, when they go to do this because I'm going to punch you in the stomach, they are also bearing down. Yeah, and it can be really difficult for people to know. It's not always obvious. For a lot of people, it is. For a lot of people, it isn't, particularly for your pregnant and postpartum people because there's already a lot of change going on in that area. So the connection isn't quite there. Right, right, right. Okay. Yeah, I think sort of the hack, so to speak, is at least the way I do it and I think the way a lot of coaches do it is to – and I think it accomplishes the same thing because it's hard to bear down if you're releasing air, right? So take your Valsalva. Valsalva. And this is the way I've coached it for a long time for women with incontinence. It's as you hold your breath, but then as you're coming up, you either make a sound or you let air out. You can't let all your air out when you're lifting. Otherwise, you lose stability, right? So it's like whatever you got to do, grunt, make a noise. It's exactly what we tell people, right? It's exhaling on exertion. And that's funny. That's actually the other thing that we were running into with the coaches is because my team works primarily with pregnant and postpartum people. They're always bringing out. If you're in a vulnerable pelvic health state, and people are coming to us because they have symptoms, right? We have maybe like 15% of our patient population is coming to us for optimization. The majority of people are there because they have symptoms. So we are coaching them to exhale on exertion because then the weakest point becomes your mouth and pressure doesn't go down. That's a great way to think about it. That's exactly what we're doing. But when we were here, your coaches were like, stop breathing out. My team was like, we're physically incapable. It took a lot of coaching. It was funny. Yeah. Awesome. Okay. So that's, yeah, that makes perfect sense in that, in that, with that explanation. So path of least resistance. So if you're opening your mouth, you're letting air out, you're making a sound, then path of least resistance is this way rather than that way. Exactly. That works. Okay. And that, that falls into like, is that the smallest thing you need to tweak? Like, do you just need this person to grunt when they're going for their movement and that takes care of their symptoms? Like fantastic. Then that's what we're tweaking. I think that like, what I hate to see is when somebody is really strong, doing really well, they have this symptom and then we like, we rip the rug out from under them and we're like, well now you can only do a sit to stand from a bench and it's like, that's not what. the body needs. Yeah. Just deep training, right? Yeah. What about, um, so I fail, I cannot understand how, and you'll have to tell me if this is current recommendation, but I cannot understand how doing something like a Kegel will strengthen, anything because it's an isometric movement. You can only, you can only, um, get as strong as you can contract, right? So if you've already got a weakness there, you're. You're not doing anything. Is that, am I on the right track there? Yes and no. I mean, like it's not sufficient for anybody who's trying to do the kinds of things that. people do here. It has its time and place, just like any isometric movement, right? Like you have rotator cuff surgery, you're going to start with probably a four-way isometric against a wall just to get those muscles firing while they're healing. If you are dealing with like a levator aenei avulsion, which is like a tear in the muscles, you're probably in repair. You're probably going to need to start with some isometrics. They have a time and place. There are also people who can lift really heavy. You go to test their pelvic floor muscle strength and it's like zero out of five, no flicker, no activation, or one out of five, like minimal movement. So pelvic floor muscle, the gold standard for pelvic floor muscle testing is a digital exam. So you do finger insert into the vagina, you have them contract their muscles and what you're looking for is the amount of contraction and the amount of lift up towards the head. So a one for the biceps, honestly, I don't know biceps. I haven't done muscle testing. for like orthopedics for a long time so I'm like shit do I know this a one for a bicep would be like I get a flicker but I can't lift my arm right a two would be I can't go through. the full range of motion but I can get motion a three would be I can get the full range of motion and take a little bit of resistance but you can break me a four more resistance a five you can't break me right so we apply that same muscle testing logic to the pelvic floor but it's a little bit different because you can't see the movement so we're going how much you cinch and how much you lift so you can see and it doesn't it doesn't matter for somebody who's doing everything that they want to do asymptomatically if they have a one out of five strength like do I care probably not. like maybe I care a little bit because like maybe it means something for the future but like I barely you'd have to convince me versus if I see somebody who's lifting really heavy and they have a one and their symptoms are of pelvic floor muscle weakness they may need to start with Kegels so that they can get that full range of motion first and then we need to apply that to it got it no that makes perfect, I mean, it's a situation where probably there's not a connection between those structures, like how to control them, right? So when you're dealing with, like, a zero or a one, even in a very strong individual, it could just be, and the Kegels would work great because that's a way to gain, I don't know if awareness is the right word. Is it a neuromuscular issue? Is it that the mind-body connection isn't there, and so the strength is there, but you can't access it? Yeah, right, right. Or is it that the strength isn't there, and thus you can't access it? Got it, got it. So for people who just have this mind-body issue, you see that strength go from a one to a four really fast, and then, like, great, your body just needed the reminder. That's why sometimes some athletes just need to do, like, ten Kegels before a run, and then, like, boom, leakage is gone, right? It's the neuromuscular issue, versus for other people, it's strength, and as you know, strength takes time to build, so we actually do need to strengthen that muscle, and starting isometrically is the very tippy-tip beginning of the rehabilitative program. You'll see a lot of people... hating on Kegels on social media right now and it's deserved. Like we've relied on them for way too much for way too long, but like it's a little bit like a complete answer. Yeah. Okay. But it's like, it's a very small part of the puzzle, but it can be an important one for me. Okay. That makes perfect sense. So are there, are there methods and protocols to directly, and I mean, I mean, I'm probably a strength coach. Can't do this, but to like directly strengthen the pelvic floor? In with, with functional movement? No, no, no. Like within your clinic. Oh, um, protocols, you can find them, but generally in the more evidence we have, like it needs to be applied to the person. So somebody who has pelvic floor muscle weakness, who is symptomatic, who wants to return to running versus somebody who has pelvic floor muscle weakness, who's symptomatic, who wants to return to lifting, they may require some of the same base level. strengthening, but it really depends. Like, is your pelvic floor weak? And also your hips are just like so weak. Is it that your pelvic floor is weak and your core is so weak? Are you really strong? everywhere else and not there. So there's no clear, like, do this, this, and this. But we tend to, what we try to do at my clinic is we try to figure out what is it that you're already doing? Because, like, we're treating mostly moms. Like, they don't have a lot of spare time. So we're not trying to put together, like, your hour-long, like, beautiful rehabby program. We're trying to figure out, like, okay, well, you go to starting strength three times a week. How do I get you to factor this into what you're doing? What can you do between reps? What can you do as your warm-up? Right. So not really. Okay. Got it. There's obviously going to be a point where, based on the individual coaches and lifters' comfort level, it's time to refer out, right? And then you're a resource there, obviously. Is there anything that should be an immediate, like, you see this out of your bailiwick, get in touch with a specialist? I would say, honestly, the majority of the stuff that falls into that category, like, you're not going to find those people here. Okay. Like, people will self-select out. If they're experiencing severe symptoms, I would say, like, complete loss of bladder. Like, that would be, like, we're talking, like, a bladder emptying on the platform. That would worry me a little bit. Anytime anybody is having, like, a new and unexpected change in bladder bowel function, which they may or may not tell you. So I think my number one piece of, my number one recommendation for gym owners and for fitness instructors is getting comfortable and training your staff to get comfortable with asking questions that aren't invasive. That are appropriate and within your scope. But that can allow them to kind of, like, have their feelers out for if anything should happen to tickle their spidey sense. Sure, sure. Like, do you know if these people, and I think you guys do a really good job of that here. And small group training allows you for that. But for other folks, too, like, do you know the pregnancy history of your client? Right. Do you know their athletic history? Do you know what their stress level, nutrition, sleep is like? Do you know what orthopedic injuries they have? Right? Like, do they have, anytime somebody has, like, lingering hip, back. tailbone, pelvic girdle, like pubic symphysis, SI joint pain, that should like, they're in the. pelvic healthy realm. Um, so I would get comfortable asking questions like, Hey, have you been pregnant? Or like, Hey, do you have any pressure in your pelvis? Hey, like, how does this feel through your abdomen and your pelvis? Um, are you experiencing any symptoms you haven't had before? Is there anything that worries you or anytime you're talking to, and this is more common in female athletes. Um, this is why I'm talking out female athletes, but anytime you're seeing like a, a reticence to increase intensity or weight and like a real hesitancy and being honest with you, why? Um, and then this isn't applied to your setting, but same thing with. impact. Like you have somebody that does not want to jump and they will not talk to you about why. Yeah. And, and, yeah. And, um, I think another indicator here would be, um, uh, just running back and forth to the bathroom, you know, multiple times, you know, especially after, uh, after a heavy set. Um, I, you know what, the big thing is, I should have said, I think that this is probably, my, my best indicator that will pop up in a, in a gym setting, no matter how good of a job everybody is doing is any brand new pelvic healthy symptom. Like if you're dealing, if you're working with somebody who, you know, that they've. had chronic leakage and it pops up when they go really heavy, but they're okay with it because they really like lifting really heavy and you've tried all the modifications and maybe they've seen a PT, but like it's, they're, they're okay with that. That's different than somebody who has been working out with you. And then all of a sudden they're like, oh shit, what is that? Like anything new is appropriate for her to roll out. Okay. All right. Cool. What are we missing? The thing we need to talk about is prolapse. I don't know how far into that we want to go. Yeah. Um, it's 1020. Are you okay with that? Yes, I think so. I have like, probably, probably have like five more minutes. Okay, good. Yeah. I've got a 1030 meeting too. Okay. 85% of people who've given birth vaginally have some degree of prolapse. Okay. Like most of us, right? Um, way fewer than that have symptoms. Prolapse is graded. It's graded on a one. to four scale. One being mild, four being more severe, four is like immediate referral to surgery. None of us are seeing those folks. Grade one through three, however, we are in one and two definitely. Okay. The reason I say that is because if 85% of people have some degree of prolapse, way fewer people have symptoms. Let's say most people are in like a one, two, maybe a three, and there can be multiple kinds, right? You could have prolapse of the bladder, the rectum, the uterus. The degree and severity of the tissue change does not directly correlate to the symptom or the function of that person, which means that prolapse in and of itself as a diagnosis doesn't tell us a whole lot about this person. It tells us like, okay, there's some sort of tissue change. If it happens in 85% of pregnancies, it's a pretty normal one. Like we can just assume that this is. an adaptation of the body that has grown and birthed the baby. Sure. So now how do we, look at this person who's going to age, who's going to hit menopause, who's going to have, and menopause, by the way, pregnancy is like, postpartum actually is like baby menopause as soon as the placenta exits the body your estrogen levels plummet and your hormones are that of a menopausal person that is why you see the same symptoms postpartum and menopausal so anybody who has some like lingering postpartum symptom they may see it come back later in life so when i'm talking to these people and thinking of these. people i'm thinking like okay right now asymptomatic prolapse fucking fantastic symptomatic prolapse let's get that under control because your body is only going to continue aging and again if we go back to back pain like we ignore lingering back pain in a 35 year old like what do you think their life's going to look like when they're 60 or 65 you're going to be old for a really long time hopefully yeah um so all that to say prolapse in and of itself is not a risk factor for lifting in fact like we talked about earlier lifting may even be protective for prolapse um. and getting people active, is and getting people stronger and progressing them is really really important so i treat it, similarly to stress incontinence. If you have symptoms, pressure in the pelvis, you feel like there's a ball sitting there and it does not get worse with activity, great. If you are noticing aggravation of symptoms with exercise, how do we modify it? What's the smallest thing that we can modify to allow your body to get stronger so that we can continue progressing your strength? For somebody who is really symptomatic, I would say in this setting, it is always beneficial to. refer to pelvic floor physical therapy just to make sure that that pressure management is being managed appropriately so that we're not just stressing this tissue that's already strained. And also because there's a device called a pessary. Do you know what that is? No. A pessary is an assist. It's essentially an assistive device for the vaginal canal. So it's a, there are a bunch of different shapes of them, but it's a device that you insert that basically pushes the tissue back up. And what it does is it clears it out of the way so that the pelvic floor muscles can get stronger underneath and improve support. We used to believe it was just a bandaid. So we were kind. of like, I don't know, we want to use it. If you feel like you want to use it, you can use it. If you feel really uncomfortable. you can. Now we've seen that wearing it and strengthening can actually help reverse the grade of prolapse of tissue descent. And so that is another reason why I think it is really beneficial to partner with a pelvic floor PT so that this person can figure out, are they a candidate for that device? Can it help keep them stronger, more active, longer, or even just help them stay active now while they are really uncomfortable dealing with symptoms so that when the symptoms get better, they have that baseline strength and they can keep going. Yeah, for sure. Okay. That's super helpful. Cause, um, at least in my view, when somebody comes, uh, somebody brings up prolapse, it's like you need to talk to somebody. I don't have. Yeah. Yeah. But, uh, so will, will the patient, the lifter typically know the grade? Will that, will that be part of the diagnosis? Well, it depends if they've seen, if they've seen an OB who's told, so this can go a couple of ways. Sometimes they'll go in for their six week visit or even for their annual next year. And their doctor will be like, do you have prolapse? And. they're like, no, I don't have prolapse. And they're like, no, I don't have prolapse. And, they're like, what? That sounds terrible. Like, I had no idea. My body feels fine. What? Other times they'll go in because they're having symptoms, and they'll typically then be graded. There are also urogynecologists who will provide, I think, much more particular grades than, like, a typical annual visit. But they may or they may not. Okay. Awesome. All right. Anything else? I don't think. I think for the benefit of time, I don't think so. This was great. How do people – well, a couple questions for you. How do people get in touch with you? So you gave it at the beginning, but let's do it again. You're in Austin. Do you do remote consultations? Yeah. So my business is Lady Bird Physical Therapy. It's www.ladybirdpt, ladybirdpt on Instagram. You can email me directly if you touch the mic if you'd like. It's just rebecca at ladybirdpt.com. So we're pretty easy to reach. If you Google Lady Bird, we do. We're in Austin. Our clinic is here, but we also offer telehealth all over the place. Excellent. Okay. Very good. Thank you so much for having me and for having this conversation. This was great. Really appreciate it. Yeah, thanks. All right. Thank you guys very much. Once again, if you – have any questions or topic ideas, send them to podcasts at ssgyms.com. And, uh, thank you very much. See you guys next time.