“Sometimes the strength of motherhood is greater than natural laws.”
– Barbara Kingsolver

Hello Mama!

Whether you do Program A or Shift, RX or modified, one workout a week or six, YOU ARE STRONG and YOU CAN DO HARD THINGS. Not only that, but the way you show up for your families and each other through this community every day is so powerful and inspiring! I hope that this Mother’s Day you give yourself permission to RECEIVE all the love and support in the world! You deserve it, mama! Thank you for everything you do!

For this month's newsletter, I’m so excited to be able to feature an interview with a very special guest:Jessie Carter. Jessie is an SP member and a Pelvic Floor Physical Therapist. She is passionate about her work and empowering women with knowledge about their own body. I almost always suggest pregnant and postpartum women visit a PFPT for an in person evaluation. I’m so grateful Jessie took the time to answer my questions about the type of work she does, and I hope that her responses will help clear up some of the mystery around why it is so often recommended and what you could expect from your first visit! There is a ton of helpful info in the interview below, so make yourself comfortable, dive in, and enjoy!

Interview with PFPT, Dr. Jessie Carter

How long have you been a member of Street Parking?

Wodify says I've been a member since May 2018 but I only glanced at the workouts last summer and fall...and did one workout out of guilt! I was "all in" on November 26, 2018, and haven't looked back! Logged my 75 workouts in February and I've got my eyes on 365 next!

What made you decide to become a physical therapist, specifically a pelvic floor physical therapist?

I switched from wanting to be a doctor to wanting to be a PT after going through therapy after an ACL reconstruction in college - I just loved that my PT got to take me from barely walking to running sprints...and got all the credit for it! I never knew the specialty of pelvic floor PT existed until I got to PT school in the late 90s and took a job as a tech at a local private practice that offered pelvic floor PT. Looking back, my two mentors at that clinic were true pioneers in the field of PFPT - experienced, compassionate, and outside-of-the-box thinkers and I wanted to be just like them! Fast forward a few years and I had my first baby 4 weeks after graduating from PT school. All 10 pounds, 2 ounces of her made me instantly aware of the need for PFPT - at that point, there was no looking back!

How long have you been practicing pelvic floor physical therapy?

18 years - I sat in on treatment sessions and attended training in preparation for this specialty during physical therapy school but didn't graduate and start practicing until May 2001. My first 2 years out of school mentoring with highly experienced pelvic floor therapists was invaluable. This specialty has always been a part of my practice along with orthopaedics throughout my career, but I started to exclusively treat pelvic health issues around 2012 and started treating men in 2016.

What is pelvic floor physical therapy? How would you describe it to someone who has never heard of it?

Pelvic floor physical therapy is exactly that - physical therapy for the pelvic floor which is basically a group of muscles at the "bottom" of the pelvis. If you think of the pelvis like a bowl, the bones make up the sides of the bowl and the pelvic floor makes up the base of the bowl. These muscles have several functions: they help support the pelvic organs above them, they help control bowel and bladder, and they play a role in intercourse. Beyond the muscles, however, there are lots of other structures that can't be ignored - connective tissues, nerves, fat, and organs that live nearby. If you've ever had physical therapy, you know we are the musculoskeletal (MSK) experts - it is our job to restore optimal function...whether that be through strengthening, stretching, re-educating, etc. It is no different for the pelvic floor - a pelvic floor PT assesses whether the pelvic floor complex is weak/strong, overactive, shortened, etc. and then tailors the plan of care to address those findings.

What are some common symptoms of pelvic floor dysfunction?

• Stress incontinence (urinary leakage with laughing, coughing, sneezing, jumping, etc.)

• Urge incontinence (leakage when you just can't get to the bathroom in time)

• Dribbling after urination

• Urinary frequency (peeing all the time to the point you are limiting your fluids)

• Fecal leakage

• Inability to control gas

• Difficulty peeing or having a bowel movement

• Chronic constipation (although this can have many causes)

• Pain with intercourse

• Sexual dysfunction

• Pain with orgasm

• Pain with a pelvic exam

• Inability to have penetrative intercourse

• Chronic pelvic pain

• Tailbone pain (coccydynia)

• Noctural enuresis (bedwetting)

Is it possible to have pelvic floor dysfunction without ever having given birth?

Absolutely. Children can have pelvic floor dysfunction which can lead to bedwetting and retention issues. Urinary incontinence is not uncommon amongst female athletes who have never been pregnant (take note StreetParkers)! Men can develop pelvic floor dysfunction and they don't have a uterus so there is that. Pregnancy and delivery are just a few of the factors that can put someone more at risk to develop pelvic floor dysfunction.

What are some of the most common issues that you help women address?

My caseload is about 50% pain issues (pain with intercourse, inability to have intercourse, pain secondary to interstitial cystitis and endometriosis, tailbone pain, etc.) and 50% leakage and support issues (incontinence and prolapse). Since I have been doing this for a long time, I tend to get referrals from other therapists in our region who have exhausted what they know and feel the pelvic floor needs to be assessed. I have seen a recent increase in athletes over the past year who are doing a lot of research on their own and are wanting their pelvic floor or diastasis recti assessed. It's been fun helping them troubleshoot where the problems lie and what to do about it!

Should women see a PFPT during pregnancy?  If so, when is a good time?

I recommend every woman see a PT trained to treat obstetric issues DURING pregnancy - this may or may not be a pelvic floor PT. There are a host of things that can be done to treat and even prevent common aches and pains that pop up during pregnancy - carpal tunnel syndrome, postural deficits due to pregnancy-related body changes, low back pain, sacroiliac joint (SIJ) dysfunction, symphysis pubis dysfunction (SPD) / osteitis pubis / pubic bone pain, coccydynia (tailbone pain), to name a few. If a mama has developed an abdominal separation (diastasis recti) during pregnancy, we can at least educate and hopefully prevent further separation. Many PTs are qualified to treat these issues without specific internal pelvic floor training. If a mom is wanting to have her pelvic floor assessed internally by a trained pelvic health therapist, I recommend 6 weeks postpartum (or when she has been cleared by her healthcare provider for vaginal intercourse). This is not to say she cannot see a PFPT during pregnancy but I choose to refrain from internal assessment during pregnancy. Most of us tend to treat women throughout the lifespan so we're able to address everything above in addition to pelvic floor issues so come on!

How soon after birth should you meet with a PFPT? Is it ever "too late" to get help?

It's never "too late" to get help although the sooner the better in every scenario I can think of! The longer a problem persists, the harder it is to correct imbalances and compensations. I would just hate to see someone opt for surgery if the underlying issue is behavioral or muscular - those are easy fixes that don't require surgical intervention. I am not opposed to surgery - I have had a urethral procedure done myself after managing my symptoms conservatively for 14 years. I do feel strongly that every conservative management option should be exhausted before considering something more invasive and/or permanent. I have seen patients who have dealt with leakage for decades thinking it was "just part of getting older" only to find that simple modifications to diet and bladder habits drastically improved their symptoms. Great words to live by - #GetPT1st...but don't discount it's impact if it ends up being your last choice!

What should a new patient expect at their first physical therapy session?

Short answer - PREPARE TO BE AMAZED! Ha - I love first visits with my patients. I can't think of a patient who has left thinking, "Well that was a waste of time!" Every office is a little different, but we maintain the highest level of comfort and privacy possible. We have patients fill out a short medical history along with a questionnaire specific to pelvic floor issues. This also includes a consent form explaining the internal pelvic muscle assessment. If patients are not comfortable having an internal assessment, I encourage them to hold off giving consent until after they have met me and understand why I feel the internal assessment is important. It's never anything we force and if a patient is absolutely opposed, I do what I can externally. I get to spend a full hour for initial evaluations which includes us talking and me getting a more thorough grasp on what is going on. I perform a normal orthopaedic assessment with specific focus on the low back and hips before performing the internal assessment. Several folks are nervous about the internal assessment but it is different in PT - I don't use a speculum or have my patients in stirrups so they are as relaxed as possible. It is a one-finger exam that allows me to feel what the muscles are doing (contracting, relaxing, involuntarily engaging, etc.) and if there are differences side to side. I'm even able to feel some hip muscles performing this exam which is so valuable! I educate as I examine so it tends to be very eye-opening for the patient. If a patient is dealing with a lot of pain or apprehension, sometimes the internal exam ends up being completely external. It is not my job to create more pain or apprehension so we only go as far as the pelvic floor allows. Keep in mind there are also pelvic floor therapists who do no internal assessment or work whatsoever - they may be harder to find but they do exist. After the physical exam is complete, I finish my visit out with education, treatment if time allows, and homework assignments.

What are some of the treatment options you offer for pelvic floor dysfunction?

Treatment may include strengthening exercises, stretching, relaxation, manual therapy, behavior modification, bladder training, biofeedback (using sensors to see how the muscles are functioning on a computer screen), education, posture training, bracing, dry needling, electrical stimulation, and more!  

Many women are said to have urinary incontinence as a result of weakened pelvic floor muscles and Kegel exercises are often recommended. How effective are Kegels for this symptom?  

Kegels can be highly effective for urinary incontinence if the true cause is straight forward weakened pelvic floor muscles...but if this is not the case, Kegels could make urinary incontinence worse. If a patient is unable to relax or "let go" of a pelvic muscle contraction, the worst thing we could do is make it contract more! Put another way, if you are unable to let go of a bicep contraction to the point you cannot fully straighten your elbow, it is not smart to do Suns Out Guns Out until you can properly relax your bicep and regain full elbow range of motion. Beyond that, there are different types of muscle fibers in the pelvic floor - fast twitch and slow twitch fibers. Fast twitch fibers are like our "jumping muscles" whereas slow twitch fibers are more like our postural muscles that keep us upright all day. It's not enough to just "do Kegels" - they need to be prescribed properly to address the specific issue the patient has.

In your experience, how long does it typically take for a patient to see improvement in their symptoms?

I can give a range but due to the high variance of diagnoses and how long it takes a patient to seek treatment, every outcome is completely different. Some patients see immediate improvement with simple techniques to minimize symptoms. It's amazing to see how quickly patients can improve once they know what to do and how! On the flip side, I have patients who never improve - this can be for many reasons including no desire to improve, wanting a "quick fix" and not wanting to put in the work, or possibly an underlying issue not best treated through physical therapy. I always tell patients to not expect big changes in strength for at least 6-8 weeks (when we are dealing with straight forward strength issues). Similar to the nutrition challenges - consistency is key and non-leakage victories may occur just like non-scale victories. I will say that patients dealing with pain issues tend to take longer to see improvements. These issues are usually very complex and just take longer to work through and solve.

What are some things a patient can do on their own, such as in between appointments, to help alleviate pain and/or promote overall healing?

Trust the process - more is not necessarily better (where have we heard that before?). Do your homework and exercises. Work with your PT to construct a home program that is doable. If you completely drop the ball on your end, be honest with your therapist - it's a team effort so we will adjust and move on! Staying consistent in your workout routine, nutrition, maintenance, and mental health are also super important to promote healing.

What advice do you give women to avoid the issue of weakened pelvic floor muscles, and is there something that pregnant or postpartum women can do to lessen this issue?

Oh, if we were only taught about our pelvic floor muscles in middle school P.E.! Assuming the pelvic floor muscles are completely capable of relaxing, then pelvic floor strengthening exercises (Kegels) can be a valuable part of any daily workout routine. A few signs you may be unable to relax the pelvic floor muscles properly would be any type of pain, difficulty starting the stream of urine or having a bowel movement, or difficulty completely emptying the bladder or bowel. If you develop any of these symptoms after starting Kegels, please stop performing them and set up an appointment with a PFPT. Kegels can be taught many different ways but I find the instructions, "Try to stop the flow of urine" to be effective. Another great cue is, "Act like there is a straw in your vagina...now squeeze your pelvic muscles like you are sucking a thick smoothie up that straw." Crude, I know, but it works! Better yet, have a pelvic floor PT assess whether you are doing the contraction correctly.

A great place to start with Kegels is to do a combination of fast contractions and slow contractions. For fast contractions, start with 24 reps - a quick squeeze/release 1x every 5 seconds for 2 minutes. This is a "quick flick" where you engage and let go without holding the contraction (like you are stopping the flow of urine quickly and then letting it go). You can watch a clock with a second hand and every time that second hand hits a number 1, 2, 3...12, you squeeze/let go quickly - 2x around the clock face = 2 minutes = 24 contractions. For slow contractions, you are doing a more sustained contraction. A good starting point would be a 3-sec hold followed by a 6-sec relaxation for 20 reps in a row. If you are doing 1 set of fast contractions and 1 set of slow contractions per day, it is more than nothing! Yes, this is a very general recommendation but I would not feel comfortable recommending more without being able to monitor contraction quality and symptoms personally.

Do you have any recommendations or words of advice for someone who is looking for or trying to choose a pelvic floor physical therapist?

You can find out a lot about a provider from his/her website - this is a good place to start in regards to training and environment. Also check out Google reviews - quality companies and providers pay attention to patient feedback and respond. Word-of-mouth referrals are also valuable - it's a good sign if a friend raves about his/her experience! The American Physical Therapist Association (APTA) does offer a "Find A PT" tool on it's public website at www.moveforwardpt.com - you simply click on "Find A PT" in the toolbar near the top of the page and enter your search radius. Once that appears, you can filter for Practice Area of "Women's Health." This will most likely not be an all-encompassing list but these are physical therapists who hold themselves to the highest standards of their profession and have invested time and money in making themselves accessible.

If you could communicate one thing to every person dealing with pelvic floor dysfunction, what would you say?

Don't give up hope! I see so many women (and now men) who have either given up hope or just didn't know anything could be done...and neither did their care providers! A lot of patients express anger and frustration asking, "Why didn't my doctor send me for therapy sooner?!?!" I explain that we are RIGHT NOW at the cutting edge of this type of care. And believe it or not, the treatment of pelvic floor dysfunction in females is eons ahead of males. In the big scheme of things, there are so few pelvic health providers out there and most of us are in the trenches every day taking care of patients. Typically, we aren't marketers...we aren't researchers...we aren't knocking on healthcare providers' doors every day selling our services. We are first and foremost clinicians who love pouring into our patients. Our patients are our biggest billboards and they spread our message better than we do! Until we start talking about these issues more openly in platforms like this, we won't reach the people who truly need our help and re-educate the medical community about what can be done. Yes, we are getting better at all of the above but we still have a long way to go!

Do you have any other final thoughts you would like to share that weren’t covered in the previous questions?

I just want to say how thankful I am to be a part of this community! I have loved the knowledge and genuine care I feel from our coaches and fellow members. Thank you guys for continually pushing us to be better humans in and out of the garage!

Jessie is a 2001 graduate of the University of Evansville in Evansville, IN, where she earned both her BS and Masters degrees in physical therapy. In 2014, she completed the Executive Program in Private Practice Management through Evidence in Motion and earned her Doctorate of Physical Therapy (DPT) through the EIM Institute of Health Professions. She has trained extensively in the area of pelvic physical therapy over her 18 years in practice including numerous courses in the management of the obstetric client, pelvic floor dysfunction in men and women across the lifespan, biofeedback, visceral mobilization, and orthopaedic management. Last year, she started serving as a lab assistant for the Herman & Wallace Pelvic Rehabilitation Institute for their "Male Pelvic Floor Function, Dysfunction & Treatment" course. She hopes to serve in a teaching capacity more in the future. Jessie grew up in Columbia, IL, a suburb of St. Louis, MO, but currently resides in Clarksville, TN, where she owns High Pointe Therapy, an outpatient clinic offering physical, occupational, and speech therapy services for adults and children. Jessie and her husband Rusty have three teenagers – Addie, Gracie, and Will, who keep them very busy. Jessie was a doula in a past life and would love to return to it some day…maybe when the kids move out ;-)

As always, I'm grateful for the opportunity to share more tips and ideas for navigating the motherhood transition through these newsletters and the SP Moms Facebook group. Please reach out to me directly anytime if you have any suggestions, questions or concerns regarding your motherhood experience as a Street Parking member, I’m here to support you in any way that I can.

With Love and Support,
Carolina, Your SP Moms Coach
mamas@streetparking.com