27. Supporting the Pelvic Floor with Jeanice Mitchell, PT

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00:00:00 

Jen Milner 

Hello, and welcome to bendy bodies with the hypermobility MD, where we explore the intersection of health  and hypermobility for dancers and other artistic athletes. I'm Jennifer Milner here with co-host Dr. Linda  Bluestein. Before we introduce today's guests, we'd like to first remind you about how you can help us help you  first subscribe to the bendy bodies podcast and leave us a review. This is helpful for raising awareness about  hypermobility and associated disorders. Second, share the bendy bodies podcast with your friends, family, and  providers. We really appreciate you helping us grow our audience in order to make a meaningful difference.  This podcast is for you. Our very special guest today is Jeanice Mitchell, licensed physical therapist, founder of  my PFM president of integrity, rehab and administrator of integrity, home health. She graduated from Loma  Linda university with her bachelor of life sciences and master of physical therapy degrees practicing since 1995,  Jeanice has worked in a variety of settings, including inpatient and outpatient orthopedic, neurologic rehab,  acute rehab facilities, skilled nursing facilities, home health long-term care and sports medicine clinics. 

00:01:17 

Jen Milner 

Jeanice's area of expertise is pelvic floor rehab for men, women and children.  

00:01:35 

Jen Milner 

Jeanice, my first question for you then is how did you become so passionate about education and about pelvic  floor?  

00:01:43 

Jeanice Mitchell 

Yes, absolutely. Well, first let me just say thank you for the honor to be on the podcast today. I'm really excited  to be here and I talk really fast and I have a lot to share. I'll try now try not to go too fast. Basically, I graduated  in 95 and at that time, pelvic health was not discussed in schools and physical therapy school. We, we didn't  dissect the pelvic floor and gross anatomy or anything. I had my first baby in 1999. At that time I saw a little ad  for a course, a pelvic health course in a PT journal. I went to that course to get help for myself after my own  pelvic floor dysfunctions as a result of my first baby. That was really transformative personally and  professionally like understanding our anatomy and our body and how it works. I felt like, wow, I have this  information now, how can I not share this with others? Other people need to know this.  

00:02:38 

Jeanice Mitchell 

That's really been the start of my passion for pelvic health.  

00:02:42 

Jen Milner 

It there's always some personal connection, right? When you experience it yourself, then you go, Oh my  goodness, everybody needs to know about this. How can I share that information and talk about it? That's great.  Let's have you share that information? What is the pelvic floor and why specifically should bendy people be  interested in this topic?  

00:03:03 

Jeanice Mitchell 

Yes. Most of the people here I think are going to be listening. If you could just envision a hammock and so you  have a hammock that's attached to the front and the back, like a tree, right? And the pelvic floor is like a  hammock. It literally connects to the front of the pelvis of the pubic bone stretches back to the tailbone and then  it connects side to side. It's like a little minister trampoline there at the base of your pelvis. So it holds up your  pelvic organ. Most female bodies would have a bladder, a uterus and a rectum. The pelvic floor muscles are one  element to help keep those organs in place. The pelvic floor muscles also help to control our bladder outlet, our  BAU outlet. If the muscles aren't doing the right thing at the right time, then all kinds of things can happen, that  I think we're going to dive deeper into, but bendy bodies specifically are generally more hypermobile, more  flexible.  

00:04:06 

Jeanice Mitchell 

There's a lot of exciting research that's happening, but basically, potentially they're more at risk for that pelvic  floor. Like our little trampoline might get stretched out more or doesn't rebound up quite as well. Some of the  ligaments and so forth that integrity can be affected the college and the fascia. All of these structures work  together to provide that stability and support. That's why Bindi bodies would, I think, especially the interest in  that some of the information we're going to share today.  

00:04:41 

Jen Milner 

I know we're going to go in depth in here, but what kind of problems show up in the pelvic floor? You  mentioned, supporting the organs and you mentioned, controlling the urinary tract. Are there other things that  might be problems? 

00:04:58 

Jeanice Mitchell 

Yeah, absolutely. If you look at it kind of, let's look at it from a muscle dysfunction standpoint, if you kind of  interlock your fingers together. This is an advantage for people that are watching this on YouTube, where you  can see it, but basically if you, on a muscular level, if you're, when you go to make a muscle contraction, those  fibers glide together to make that from hard contraction. When you relax, they returned to baseline and then  those muscle fibers should also be able to stretch. The pelvic floor muscles are a voluntary muscle group and  they're designed to when you contract for those muscle fibers to glide together, relax and stretch. If the muscles  fibers are too lengthened or too stretched out, then you can have issues with a urinary leakage, bowel leakage,  gas leakage, pelvic organ prolapse, and so forth. Those are weak kind of overstretched muscles.  

00:05:57 

Jeanice Mitchell 

Hammock is stretched out, but you can also have overactive pelvic floor muscles that you might have pain, but  you can also have some of those same things with urinary leakage or pelvic organ prolapse. You really want the  pelvic floor muscles to do the right thing at the right time. They need to be able to completely and correctly  contract, but they also need to be able to lengthen and let go.  

00:06:22 

Jen Milner 

Interesting. It's so easy for us to think about, I know when I need to go see a doctor about my calf muscle, cause  it hurts or because I can't walk right. Something that is very easy for me to say, Oh, that's my calf muscle. It  bothers me. I think for a lot of us, we don't think about, Oh, this is an issue. I must go get my pelvic floor  checked out. Cause sometimes you'll say, Oh, I just, my bladder was too full. I sneezed, that's why I had some  leakage or people might say, I just have a hard time getting straight there. That's just me that I'm just weak. We  don't automatically think about our pelvic floor and think, Oh, I should go seek out, help for it. A few of the  things that you listed were, issues with coughing and sneezing, what else would be the type of thing that would  make someone go? Maybe I should go get my pelvic floor checked out.  

00:07:12 

Jeanice Mitchell 

Like the symptoms. Constipation straining really having difficulty to have a bowel movement pain, so pain with  urination pain with intercourse, whether it be so if it's penetrative vaginal intercourse or pain with orgasms, also  difficulty emptying the bladder, urinary urgency, urinary frequency, bladder pain, bowel pain, all of those are  warning signs. Now there may be other things going on too, but definitely if you're having pain kind of in  between the belly button and the hips, the pelvic floor may very well be involved, even hip pain and low back  pain and sacred iliac pain can be a warning sign of pelvic floor dysfunction. You have a muscle inside your  pelvis called the obturator internus muscle. It's a hip muscle technically, but it really shares a fascial attachment  with the pelvic floor. A lot of times with hip pain and sometimes even with pelvic pain, that obturator is affected  and a regular PT really isn't going to be able to go in and access and identify and provide great interventions.  

00:08:23 

Jeanice Mitchell 

That's another sign that a pelvic health physical therapist would be a good check.  

00:08:29 

Linda Bluestein 

That's super interesting for our dancers, especially because they, of course are using their hips a lot. In external  rotation a lot, if they're doing classical ballet, for example. They may be having, I think we are more of those  types of symptoms. That's probably particularly important for that population.  

00:08:51 

Jen Milner 

Absolutely. I, I also see, I, when I trained dancers on their turnout, I, I checked on their pelvic floor within my  scope. Obviously I check on their pelvic floor strength and release work as well. I see a lot of dancers will  actually be a little hypertonic in their pelvic floor. Like they have trouble releasing it completely and they're,  their operators are also turn out muscles that we trained, that we want to train and want to be able to use. The  pelvic floor work that I do breath wise and contraction wise, it's just as important for them to learn how to  release it and let go as well. For dancers and athletes, it's not just your pelvic floor, it's also the thing, like you said, that connects to the hip or that works with your turnout or it's something that you really use every day in  your art as well.  

00:09:44 

Jeanice Mitchell 

No, you're right. You're right. The pelvic floor is part of the core. If you think about your core, the top is the  diaphragm, the front or your deep abdominal muscles that pack your deep, low back muscles. At the bottom are  your pelvic floor. Pressure management and breathing and how you do things is super important, not just for  your abdominals and your back, but also for the pelvic floor.  

00:10:08 

Jen Milner 

Now in the beginning, you mentioned one of the things that pelvic floor does is support your organs and hold it  up. I wanted to just bring up pelvic organ prolapse. Can you talk about that really briefly and why this is particularly relevant again for hypermobile folks?  

00:10:23 

Jeanice Mitchell 

I don't know how brief is going to be. I have a lot, so, okay. I'll try to be brief then. Basically if you think about  the pelvic organs, remember we have the bladder uterus and rectum of for most email bodies. It, each of those  organs has a little canal or tube that, goes to the outside and it goes right through that hammock of pelvic floor  

muscles. Okay. Pelvic organ prolapse is basically where one or more of those organs is starting to drop or  descend into the vaginal canal. It can go so let the bladder is the most common, so the bladder would start to  drop. If you've ever heard of a bladder drop or your mom or your grandma had a bladder suspension surgery,  that's what this was for. That was for pelvic organ prolapse. The bladder can start to drop into that vaginal canal  and it can go in, or even bold depending on the level of descendants outside of the vaginal canal.  

00:11:25 

Jeanice Mitchell 

You can have multi compartment prolapse where you might have the bladder uterus and rectum all starting to  drop. This population is especially prone for that. Like were talking about that very stretchy connected tissue. I  want to give you one more kind of analogy that I think would be helpful. If you think about a bungee, but a  person like when you go to an amusement park or something, they think about a bungee jumping on a  trampoline. How you have kids or adults that get kind of, you get strapped into the bungee and then you're able  to jump up and down on that trampoline. So the trampoline is your pelvic floor. You, the person that's jumping,  that's a pelvic organ. Those bungee cords, those are your pelvic ligaments that help to keep those organs up too.  It's not just the pelvic floor and then looking at the college and content and college in three, and we're not going  to go, dive deep into that research today, but looking at that potential impact and that this population may have  more of that college at three and making even those ligaments, less supportive of those organs and then affecting  that pelvic floor from below.  

00:12:38 

Jeanice Mitchell 

So that was my brief explanation.  

00:12:43 

Jen Milner 

That was fantastic. That was an excellent illustration. That makes a huge amount of sense. It was very clear.  Thank you. You mentioned earlier as well, seeking out physical therapy, what things could pelvic floor physical  therapy help with?  

00:12:59 

Jeanice Mitchell 

Bladder issues, whether it be leaking. I also just wanna say this, like a lot of times people think, Oh, leaking, that  means that you're wearing a diaper. No, even if you're leaking a few drops, if you cough or sneeze, or even if  you're, you've leaked like you were exercising and you went to the bathroom and you realize, Oh, I had some  urine leakage that is leaking. Anytime that urine or gas or stool is coming out, when you didn't intend it to, that's  a warning sign that your body, isn't your pelvic floor and your body isn't doing the right thing at the right time.  Now, does that mean that everyone always has a drop of urine ever in their life has to go see a pelvic PT? No,  but if it's an ongoing and persistent issue, likely it's not going to get better on its own. 

00:13:46 

Jeanice Mitchell 

It's a warning sign that the muscles aren't doing the right thing. So, bladder and bowel leakage, whether you feel  it or whether you don't really rushing to the bathroom. That's one type of leakage called urinary urgency. And,  then we have pain. Hip pain, tailbone pain, remember your pelvic floor muscles connect right to that tailbone.  They're overactive or hypertonic like were discussing earlier that can actually be putting a pole on that tailbone  and be uncomfortable, pubic bone pain with any kind of insertion. Again, pain with, urination or bowel  movements or even pain with orgasm, hip pain, low back pain, pelvic organ prolapse. Some of those symptoms  of pelvic organ prolapse would be like a dragging or a heaviness feeling, even grabbing a mirror and look at it  yourself and seeing if you see a little vaginal bolds there, it's not going to be yellow. Like we think, Oh, the  bladder's yellow.  

00:14:50 

Jeanice Mitchell 

Well, number one, the bladder itself really isn't even yellow urine, but in a lot of our illustrations and  animations, we make the bladder yellow and the bowel Brown just for ease of identification and teaching.  Basically we tell the organ prolapse that bladder can kind of drop down into that canal and make it really  difficult to empty the bladder. If you're someone that's having to shift side to side forward and back, trying to get  that bladder to empty or you where you stand up and then you have a leakage after you sand, that could be one  sign of pelvic organ prolapse, or, some other reason that the bladder isn't emptying all the way and then the  same concept with the house. A lot of times people are constipated and they're straining, but if that bowel has  kind of dropped into the vaginal canal, it can be creating a little pocket of stool there.  

00:15:41 

Jeanice Mitchell 

If you envision that canal, that's coming down from the rectum, right. If you have a little pocket that's, off to the  side, it can be really difficult to empty that. That's another kind of warning sign that Hey, pelvic PT might be  indicated.  

00:16:00 

Jen Milner 

Those sound like a very long list of things that we might want to get checked out if we have pelvic floor issues. I  know a common misconception sometimes is that people who need to see a pelvic floor specialist would be  people who are older, who have had multiple children, especially women of an older age. That who you  typically see, or do you think that this is something that spans all age ranges, especially with hypermobility,  

00:16:27 

Jeanice Mitchell 

Definitely spans all age ranges. In fact, so the youngest person that I've worked with has been three, generally,  we're going to say age five and above, and then the oldest person has been 94. That whole, all genders, all ages,  there's, it can, it may look different in different ages and, different populations might have different types, more  prone to different types of dysfunction. Something that is an interesting study that, they did a study of high  school females that had never had a baby at 40% of them had some kind of urinary leakage. Just because, you're  in that age range doesn't mean that you're dysfunction free. You could very well be having something going on  with your pelvic floor. One other factor here, I think, to consider going to the hormone impact too. You look at  estrogen and when our estrogen peaks in our lives, so certainly, in the teenage years we have huge influx of  estrogen, right? And then also third trimester of pregnancy.  

00:17:33 

Jeanice Mitchell 

Estrogen impact on the tissue makes it more elastic. Especially like if you're in that age range, so you're in teens  and you're a very stretchy person, and then you have all that huge amounts of estrogen flowing through your  system as well. That's one other factor. Just one other piece of the puzzle as we look at,  

00:17:58 

Linda Bluestein 

I'm really glad that you mentioned hormones too, because so many people will be, perhaps seeing ma they may  have seen a gynecologist and talking to them about birth control and things. I feel like gynecologists in my  experience anyway, they don't understand the pelvic floor anywhere near as much as pelvic floor PTs do. I was talking to a gynecologist friend of mine and quite a while ago. And, and she said, I think, for me specifically,  she said, I think you need to say pelvic floor PT. She said, for the rest of us, the pelvic floor is like a black box.  

00:18:33 

Jeanice Mitchell 

That's great. Well, maybe not great. It's a great analogy.  

00:18:39 

Linda Bluestein 

Pelvic floor PT is appropriate for so many different things. What kind of things do people come to you for that  you think, gosh, I need to refer this person back to their physician, or I need to send them on someplace else.  They need some other type of workup. This is not a person that is not appropriate for pelvic floor PT.  

00:18:59 

Jeanice Mitchell 

Yeah. I would start off here by saying that pelvic floor PT is not a magic pill, physical therapy isn't a magic pill.  It's going to take work. It's going to take follow through and you wanting to get better and wanting to go through  these interventions. If your mind isn't there and you're thinking, this is a waste of time. I don't want to be here.  This isn't going to work then already, it's likely not going to be effective. Okay. That in general, there's some red  flags that we have so like unexplained pain or bleeding. It, especially like if you're having constant pain that isn't  changed with movements, isn't changed with position. That's really a warning sign. Like you need to dive deeper  into this pain. And, and where is that coming from? Unexplained weight loss or gain infection, fever, trauma,  that kind of thing. In general, I would say if I'm working with a patient, I expect to see some kind of  improvement within a couple of visits.  

00:20:04 

Jeanice Mitchell 

That doesn't mean the symptoms are resolved, but that means we're on the right track. If I'm not seeing some  improvement, then I need to readjust what I'm doing. If I readjust and I'm not seeing improvement, then if I have  some other providers around me, like, okay, I have this ortho PT, that's really good at SI or whatever. Hey, come  look at this. What do you think? But if I've tried everything that I can do and the symptoms aren't getting better,  then I'm going to send them back to the referral source. Isn't something hormonal. Isn't something else going on  with some of the other body systems. Really, I think I have people reaching out to me, especially on social  media, like, Hey, I think going to pelvic PT for a year, and I'm not seeing any improvement, like, Oh, that's  heartbreaking. As a PTC, I think it's are any kind of health care provider, but it's our responsibility that if we  aren't getting our patients, if we're not helping them achieve their goals and get to where they want to be, then  it's our responsibility to send them back or to say, Hey, maybe check out this.  

00:21:06 

Jeanice Mitchell 

Maybe you meet imaging, you know, whatever. Also in terms of when is pelvic floor PT not appropriate. This  isn't necessarily when it's not appropriate, but it's, who's providing it. Making sure that when you are selecting a  pelvic physical therapist, that they have gone to advance training on the pelvic floor, have they gone to training  for intra-vaginal and intro rectal work, if they haven't, then they really shouldn't be putting their fingers inside  your body. Right. There's even massage therapists out there that are doing intra-vaginal interim rectal work. I  really caution you to make sure that you are researching that pelvic physical therapist and that it's okay to ask  questions like, Hey, what training have you gone through? Do you have any advanced certifications? You would  think that this would be regulated everywhere, but it's not. There's a lot of people out there calling themselves  pelvic PTs that may not have gone to advanced training.  

00:22:06 

Jeanice Mitchell 

That's important if you go to our website, mypfm.com and you click on find a PT, we have links to four free  searchable databases where you can put in your zip code and what kind of therapist you're looking for, or, what  kind of dysfunction you're having. You can see who may be closest to you. That's one way that you can search.  When you find someone, I would definitely recommend reaching out and saying, Hey, asking some of those  questions, what kind of certification training and so forth. 

00:22:37 

Linda Bluestein 

That makes sense. Those are great points. And, and what about men in terms of how their pelvic floor problems  present differently than women? Can you talk about that?  

00:22:47 

Jeanice Mitchell 

Absolutely. The same kind of concept exists with the pelvic floor that stretches front to back and side to side.  Now male bodies are going to have two pelvic organs. We have the bladder and the rectum, and they also have  these tubes that go to the outside of the body. Now, the bladder for male bodies the urethral outlet is going to go  down through the pelvic floor, but then actually goes all the way through the penis. It has a, it's a much longer  that's called the urethra. That's a much longer path to travel to get to the outside of the body. Males can certainly  have leakage and urinary urgency and frequency and pain and constipation and so forth. Some of the sexual  dysfunctions are going to be different on the male side. Erectile dysfunction sometimes can be a pelvic health  issue, pelvic PT issue and premature ejaculation is also another one that you wouldn't see in female bodies.  

00:23:46 

Linda Bluestein 

Okay. In terms of specific indications or contraindications to pelvic floor PT, are there certain things that we  should be aware of there for men specifically.  

00:23:56 

Jeanice Mitchell 

So for erectile dysfunction, think about this hard health is a sign of heart health. Okay. I don't want people to  listen to this and say, Oh, I have ED, I have erectile dysfunction. And my issue is only pelvic health. You really  need to get your cardiovascular system checked out, go to the urologist first, but pelvic PT can help a lot of ED,  but you want to make sure that the heart is doing well and that your system is as well. I think that's one of the  big things is the cardiovascular there.  

00:24:34 

Linda Bluestein 

Sure. That makes sense. What about some of the common problems that people with hypermobility disorders  face? we know that things like constipation are a lot more common in people that have Ehlers Danlos  syndromes, especially for example, classical Ehlers-Danlos syndrome. People can have constipation from a very  young age. Can you talk more detail about how you as a pelvic floor physical therapist would treat that or what  somebody might expect if they went to see a pelvic floor physical therapist, assuming that they've already seen a  physician and a lot of the other things have been ruled out. 

00:25:07 

Jeanice Mitchell 

Yeah. The red flags are cleared. We, we'd want to look at the pelvic floor. It lengthened and weak? Is it  overactive and tight and weak? That's one thing, another comment that I'm just going to interject here is that a  lot of times people think that a tight muscle is a strong muscle and that is a myth. That tight muscle is not a  strong muscle. If you kind of think about like, if you were making a fist and if you kept that fist tight, all the,  even five minutes, like you go to try to use your hands. That's not a strong hand, keep that constant attention  there in the muscle fibers that can reduce blood flow that can sometimes even impact the nerves and certainly  the fascia and the function. So, understanding that a tight muscle is not a strong muscle. Going to constipation  and really looking at what are the muscle, what are the pelvic floor muscles doing? Are we having more of the  laxity issue or is it more of an overactive hypertonic issue? So that's a really important starting point.  

00:26:13 

Jeanice Mitchell 

Once we've determined that, and we do pelvic floor muscle training now, pelvic floor muscle training, it really  depends on the age and on the person's comfort level. So, if we're working with teenagers and they're not  sexually active and we don't want to do anything internal, there's a lot that can still be done externally. We have  a tool that's called biofeedback because I love technology and I using technology to help train the pelvic floor.  For example, let's say that we had a 13 year old that had constipation that wasn't sexually active and we didn't  want to do anything inside. We didn't want to go inside the rectum or inside the vaginal canal. We use these little electrodes that are EKG electrodes, which is the heart testing, right? Where you put those little stickers on  the chest and then you hook it up to the machine and you can see the activity of the heart on the screen.  

00:27:13 

Jeanice Mitchell 

It's the same concept with biofeedback or it's called surface EMG of the pelvic floor muscles. We can put those  little stickers around the outside of the anus and hook it up. What we do in our clinic is we would put the little  stickers on, and then we have the people put their clothes back on because it's kind of an uncomfortable feeling,  I think, to be lying there on the table, even though you're covered, a lot of people are more comfortable once  they put their clothes back on. Getting their clothes back on, hooking you up, and then using that as one way to  help retrain the pelvic floor, either working on the strip, any phase, working on the relaxation phase. One really  key point with constipation too, is are the muscles letting go? We kind of, as the stool is coming out. If those  pelvic floor muscles, if you envision the anus, and this is one of the best ways to find your pelvic floor is to grab  a mirror and look at your anus.  

00:28:10 

Jeanice Mitchell 

When you squeeze that aim is should kind of pucker up and in it kind of pulls up and in, and then you relax and  the anus softens and drops, and that's what should happen during a bowel movement for the anus to kind of  relax and soften. If that anus is tight and closed, for whatever reason, maybe it's pain, maybe it's trauma. Maybe  it's just that it's not coordinated. It doesn't know what to do at the right time. When you go to have a bowel  movement, it's like a stop. Like it's like a plug, nothing is getting through there. You might have to strain even  more and then strain it even more may cause those pelvic floor muscles to activate even more. So it's like a  vicious cycle. So, and think about the impact that straining is having on the pelvic floor and those surrounding  structures.  

00:28:57 

Jeanice Mitchell 

Going back to our bungee trampoline example, the pelvic floor needs to support from below and those ligaments  need to support from below. If we have a lot of force pressing down from above that's straining those tissues and  over time that could even contribute to pelvic organ prolapse. So definitely we don't want that. Squatty potty.  Many people have heard of the Squatty potty, but the squatting position is really effective to help empty the  bowels. Our regular sitting position where we have our hips and knees at a 90 degree angle, some people can  poop in that position, but if you're having difficulty pooping, try squatting more. Elevating your feet on a couple  of stools or a Squatty potty. I mean, you don't have to go out to buy it. It's only like $30, I think, but still you  might have something at home that you can use stack up a couple books.  

00:29:51 

Jeanice Mitchell 

But that's another key thing. Also I have a post on this that has like 14 different tips for constipation. This  constipation could be one whole segment all on its own, but thinking about what you're putting in your mouth,  because what you're eating and drinking is going to affect what comes out because it has to wine, although all  around your digestive system. If you have more water and more foods with fiber, like whole grains and fruits  and vegetables, that food is going to go through your system easier and it's going to be softer to come out. Cause  if you're pooping rabbit pellets once a week, that isn't a good thing on your digestive system or your pelvic floor,  you're likely strain and you maybe have any pain. 

00:30:36 

Linda Bluestein 

That is definitely some of my patients. I can not believe how many of them are yes going once a week. I was  like, Oh my gosh. This is maybe of a side note, but one thing that I wonder about with, and I'm as addicted to  my phone as the next person, maybe even worse than the average person, but do you see any differences as  people are on their phones more and perhaps bringing their phones into the bathroom with them and maybe,  hanging out longer than they used to. I've heard things from some of my other colleagues about, perhaps an  increase in, some of the, maybe not constipation per se, but, like hemorrhoids, for example.  

00:31:15 

Jeanice Mitchell 

Yeah. You know, I don't know. I would love to see some research on that specific topic. Hanging out on the  toilet longer, just think about the position that pelvic floor is in. Your pants are down, you're sitting, the pelvic floor is just hanging there, right? That this hammock is hanging. It's hanging in an unsupported position,  hopefully it's relaxed. If you add straining on top of that, it's a very vulnerable position. The longer that you're  sitting there, the longer you're hanging out, the more potential for possible issues there are. I've heard some  people say, Oh, you shouldn't read on the toilet. You shouldn't do X, Y, or Z. In my opinion, it's important to do  something that's relaxing. If your phone, if you're looking at emails and all of your to-do list for the next day,  that's probably not the best place for you to be doing that as on a toilet, but it is something relaxing, that, I don't  see a big issue with it.  

00:32:20 

Jeanice Mitchell 

It's more the length of time that you're sitting there. That makes sense. Okay.  

00:32:26 

Linda Bluestein 

What about pelvic pain? that's a super common symptom that I see in my patients and, hear people talking  about, how do you work that up? What kind of things can pelvic floor physical therapy help with, in terms of  pelvic pain in hypermobile people specifically.  

00:32:42 

Jeanice Mitchell 

That's just so very broad, right? Because pelvic pain can present because I think really the definition of pelvic  pain is pain between the umbilicus, which is your belly button and like your hips or your knees. So it  encompasses so many things. Do you want to pick one like tailbone pain or pain with insertion, or I guess in  general with whatever the cause of pelvic pain is, we're going to be looking to see if we can help to reproduce  that pain in the assessment. That doesn't mean we're trying to cause you pain, but we want to see if we can find  the pain and if what we're doing reproduces it, then that gives us a much better sense of, okay, let's say that it's  pain with insertion. Like if you think about the vaginal canal and that area, that smooth area of skin in between  the, that the opening of the vagina and the anus, and when you press on that smooth area of skin, that area is  really painful at the sides to, that are painful, but really that areas is be painful.  

00:33:47 

Jeanice Mitchell 

So then that gives us a cue. Okay. Maybe some of the more superficial pelvic floor muscles are involved. If we  drop off, maybe some of the more deeper muscles are involved. We're going to try to find a cause. Once we find  the cause worked out an intervention plan. Most of the time this is going to involve some kind of intra-vaginal  work, but if you're not comfortable for whatever reason with going inside, we can still do a lot of things out  externally. I think that's been kind of a myth in the past, like pelvic PT has to go inside. No, we can do a lot of  things externally. Biofeedback is another one of my favorites hands-on stretching. Like in the clinic where I'm  actually working on a tissue, but then I'm teaching the patients as well. How to do some of, whether it's a scar  tissue mobilization or peritoneal massage, massaging the muscles, we use something called dilators.  

00:34:42 

Jeanice Mitchell 

If going inside the bags, working out is painful, then those dilators are cylinders that start very small, maybe  about the size of a finger. They get larger to like the size of a penis and they're graded, right? So you start small  and you work large. Working with dilators for stretching, if let's say the opturator internus is involved, then in  the clinic, I'm going inside the vaginal canal and kind of hooking my finger over to the operator and turns cause  if you think of that pelvic floor kind of being like a hammock, the opturator internist is way over on the side of  the pelvis. You kind of have to hook over there and get it involved. And then, you know, using a wand. If we're  wanting a patient at home to follow through on some of this, using a wand is a good thing for opturator deep  opturator internist, trigger points, and then ultimately functions.  

00:35:38 

Jeanice Mitchell 

Stretching, strengthening, coordination exercises, and simulating what we're wanting, what the patient's goals is.  What did they want to do? And then helping to simulate that. We may have to break it down into baby activities,  and then grow, unlikely that you're going to be able to go from zero to 60 in one session, but breaking it down  into pieces and, ultimately helping to get them to where they want to be. 

00:36:10 

Linda Bluestein 

That that makes sense. I feel like, when you're talking about insertion, that's a common thing that for my female  patients that they definitely have problems with. So that's so that's very helpful. That could be from a whole lot  of different reasons, too, right. If they have joint instability in their hips, for example, or something, then there  could be a lot of different confounding variables that, so you kind of have to address maybe each one in order to  actually get some improvement.  

00:36:41 

Jeanice Mitchell 

Exactly, exactly. And I hear Jennifer saying yes, exactly. It's a multifaceted approach and sometimes you may  need other disciplines too. So, I think it's very helpful to work with nutritionists and dieticians to work with  mental health, to work with behavioral health and other medical specialists if needed, we'll get the hormones.  

00:37:04 

Linda Bluestein 

Okay. Sounds good. Let's maybe round out this part by talking about the bladder. If someone is having problems  with bladder leakage or bladder pain, is there some component of the workup that you do differently or in terms  of the treatment plan, would your approach be different for that?  

00:37:21 

Jeanice Mitchell 

Absolutely. So let's take leakage. Let's say that when they jump, they leak, they're not leaking at any other time.  Again, I'm looking to see is it is the pelvic floor kind of stretched out and link things or is it overactive and too  tight? So starting there and then, addressing, dressing whatever component that is. Really working on the  coordination piece. We like to call it a pelvic brace or tree contraction or a knack, like there's different names  out there in the pelvic PT world, but basically engaging that pelvic floor just before you're doing that activity to  help brace it. Because if you think about the bladder, it's a water balloon. As it fills, it expands the pelvic floor  muscles are what is wrapping around that bladder outlet to keep it closed. If they are leaking, let's say with a  certain jump, the pelvic floor muscles have the strength and coordination to do what they need to do throughout  all of the other activities of the day.  

00:38:28 

Jeanice Mitchell 

When they put that increased pressure, that increased intra-abdominal pressure with that jump, the pelvic floor  muscles either don't have strength or the coordination to counteract that force that's happening. We're really  going to focus on, pre-K attractions. I would even probably back off, so do a baby jump and then grow that job  right. To be able to be successful and build onto that activity. That would be from a bladder leak standpoint,  that's one piece. Also looking at just healthy bladder habits. Generally we want the urine to be like a very pale  lemonade color, generally urinating two to every two to four hours. If you're someone that's going every hour  throughout the day, then that's called urinary frequency. If you're someone is holding it six or seven hours, then  that can also be problematic on that side. So, healthy bladder habits, a healthy bowel habits because the bowels  do impact the bladder.  

00:39:32 

Jeanice Mitchell 

And then in terms of the pain. There's something called like the bladder is the innocent bystanders. Like 90% of  bladder pain isn't really even coming from the bladder. You think that the bladder is the cause, but most of the  time it's the pelvic floor muscles are involved. Addressing the pelvic floor muscles and the fascia and the tissue,  and don't forget the abdominal wall. If you had an abdominal surgery is a serious section, any kind of scarring  there's all of these things can make an impact or even from a cosmetic standpoint. So, so much of our time, we  don't want to have a pouchy belly, right. We're guarding and holding that belly in all the time and are we really  ever stretching it out? So that can cause some overactivity there too. And, and one other piece to the puzzle.  Interesting. Okay.  

00:40:28 

Jen Milner 

I would add to this, you mentioned that you like to work with a lot of nutritionists and it's a rounded group of  people, kind of all working together on this. The other piece just from my side of the table is working with someone who does conditioning, or is in the ballet studio and can watch them because a lot of times dancers,  bad habits, come from perhaps if they have a pelvic floor issues, then they get bad habits around that. As  athletes and artists are trying to address their pelvic floor, I would encourage them to have a trainer or a coach of  some kind have an eye on what they're doing in class. There's a whole category of hyper mobiles that brace  really hard from their lower back. When I see them bracing from their lower back, I know that their whole core  is not working as well.  

00:41:19 

Jen Milner 

I know that we have to do some work on that and pelvic floor goes with it. If people are working on their pelvic  floor, I would also incur, or whatever issue is coming up, that they need to have worked on bladder issues. I  would encourage them to also get work with their coach or with their trainer, make sure that.  

00:41:34 

Jeanice Mitchell 

They have been doing gets corrected through their technique as well, so that they don't maybe have issues that  come up later down the line. So it's definitely a team approach. If we're just seeing them in the clinic, we're not  seeing how they're, what they're doing and how they're doing it. So that's incredibly valuable.  

00:41:55 

Linda Bluestein 

It's all those day to day things that we do, right. That add up that if you're Jeaniece seeing them, once every  couple of weeks or something, but in between, they have all of these other points that if you're working with  them more frequently, I can see where there would be a lot of benefit in that.  

00:42:09 

Jeanice Mitchell 

Absolutely. It's the straw that broke the camel's back. Right, right. All the little things added up.  

00:42:15 

Linda Bluestein 

Yeah, definitely. Can you talk about the pubic synthesis and what it is, how there can be problems that can  develop with the pubic synthesis and what kind of things you might do with that?  

00:42:29 

Jeanice Mitchell 

The pelvis is like two halves and at the front it joints together with a little Cartlidge disc. Okay. It's at the soft  disc and it's not meant to really move other than, during pregnancy and labor and delivery. It does expand some,  but it's meant to be a very stable structure. Sometimes it does move too much. If you're someone is moving too  much, it might move. So, your pelvis could even rotate. So that can be painful. We want to look at the actual  alignment, but then also look at all of the muscle players that are attaching their on the pelvis. You have the  lakes, you have the quads, you have the hamstrings, you have the hips, you have the glutes, you have the pelvic  floor, you have the obturator internus, you have your other deep hip rotators. How are they all impacting? Are  they overactive hypertonic and tight? Are they stretched out and weak and loose? What, and you might have a  combination.  

00:43:30 

Jeanice Mitchell 

The front is tight, the back is loose, or, so figuring out what that equation looks like, and then addressing those  specific issues and really helping to, control and stabilize the pelvis. Like we kind of have talked about with  other movements and positions. You may have to start small with small graded movements, get successful with  stabilizing and controlling that, and then adding onto that. I think what Jennifer was saying, having that carry  over into the studio is critical because so what if we do fabulous things once or twice or whatever times a  month, if there isn't regular consistent carry over into how you're doing, what you're doing is not going to make  a huge impact. So we don't want that sharing. We don't because some people can even feel poppy in their pubic  synthesis. And that can be incredibly painful. We see that a lot during pregnancy, that's probably the most common, presentation that we see. 

00:44:35 

Jeanice Mitchell 

But, if you're someone that's super flexible that you're at risk because that's not a bow that's a joint that has that  cartridge, connecting it. I can't think of a pubic synthesis problem that I saw in men. That doesn't mean that it  couldn't exist. I just haven't seen it and it's not common.  

00:45:01 

Linda Bluestein 

Sure. I have one male patient that feels that popping and stuff in the pubic symphysis.  

00:45:05 

Jeanice Mitchell 

Yeah. I wouldn't discount it either, because definitely, and especially if you're a person that has those extra, that  extra give in your tissues. I think a good, I like to use external compression too. We want the muscles to do the  stabilizing, but sometimes that may not be enough. Using some external compressions, it's called a sacred iliac  joint, like a belt, a sacred iliac belt. There's a whole lot of different brands out there. You want one that's given,  

that's able to give some compression that also gives so if it's so tight that you're locked down, you can't even  rotate that's too much, but some of these are just so stretchy and flexible, how much impact is that really making  and try out different things?  

00:45:57 

Jen Milner 

I think I lived in my SI belt for my two pregnancies. It felt so different when I wasn't wearing it. It just felt like  everything was like running away. I felt my pubic symphysis sublux a couple of times, but never fully  dislocated. That SI joint that I'm here to tell you find a good belt and it really does make a difference.  

00:46:19 

Jeanice Mitchell 

Yes, absolutely. The nice thing also for pregnancy is that a lot of them have also have like a, a belly lift too. Not  only are you stabilizing that joint, but also giving that belly, because if you, again are someone that has that  spreadsheet tissue, then as that baby is growing, think about all that stretch and that kind of, that pressure and  the gravity that's pulling down on that baby. To support underneath and to give it of help to lift can really give  some relief.  

00:46:51 

Linda Bluestein 

That's a great tie into my next question, which is going to be regarding the sacroiliac joint. I know that a lot of  people don't even appreciate the fact that this is a joint also like the pubic symphysis. Right. If you could maybe  explain how the SI joint works and what kind of problems you see with that.  

00:47:13 

Jeanice Mitchell 

Yeah. Very similar to what were talking about with pubic symphysis, but you have ligaments there in the back  that helped to connect these two halves of the pelvis to your sacrum. Your sacrum is a triangle bone at the base  of your spine. These ligaments connect the pelvis to the sacrum, and yes these ligaments are so strong and stable  that you don't have any movements, but I am here to tell you personally and professionally that movement can  happen. You can have clicking and popping. Then, so then you have these halves that have either rotated or kind  of flipped up and think about the, how that kind of throws everything out, throws your muscle balance off, and it  can be very painful. Finding a PhD, that's good with sacroiliac, joint assessments and stabilization, and the SI  lock brace is a great option. Again, ideally we want to assess all those muscles and how they're doing.  

00:48:15 

Jeanice Mitchell 

Are they tired? Are they weak? Are they and Courtney, and then how are they working when you're doing the  activity, but in the event that you need something more, there's a brace. There are many different options out  there for brace. One of my favorite ones is from a company called OPTP. It's called the SI lock brace, SILOC.  And, and they have a maternity version as well that I used, with certainly my third pregnancy. I don't think I  used it with one or two, but, it can really give a lot of relief and some external compression. Ideally you don't want to have to be able to use that for function, but if you've tried everything and you need some extra support,  what's the downside ultimately of wearing a brace so that you can do X, Y, or Z.  

00:49:04 

Linda Bluestein 

Well, I think there's a misconception that whether it's a brace for your pelvis or for your wrist, I know I hear this  a lot that, well, if I use a brace, then I'm going to develop weakness of the muscles. Sometimes you need that  brace to stabilize the joint in order to use your muscles and your muscles will get weaker without the brace than  if you use the brace. And sometimes yeah. Sometimes you need the brace just to get you over the hump to,  you've got a flare of something, if you put the brace on, then I'll kind of help calm down that local inflammation  and be able to, get you moving ahead more quickly than if you didn't use it. Absolutely. So. Okay. Well, great.  Well, I would love to hear about, the 501c3 that you founded, my pelvic floor muscles. What can you tell us  about that?  

00:49:52 

Jeanice Mitchell 

Yes. Basically, I I've been a pelvic PT since I took that class in early 2000. It's been incredible to work with  people in central Texas and to make an impact on their lives, but then thinking about, okay, how can we impact people outside my sphere of influence? And I always wanted to like have better pelvic floor pictures and pelvic  floor animations to be able to share with my patients. So that was really the start. Like, Hey, let's create some of  these things. Let's create a YouTube video and the use of video, I just knew it was going to go viral and  everything was going to be fantastic. It didn't go viral, but we're getting a lot of good engagement and social  media. I think Instagram has been, wow. And honestly I started off not even wanting to do my own voiceovers.  Like I had stock photos and I had custom images of the pelvic floor, but I didn't even want to do the voiceover.  

00:50:48 

Jeanice Mitchell 

I hired somebody to do the voiceover and I was like, there's no passion enthusiasm for this topic. I started doing  the voiceover and then I started sharing more on social media. Now I'm just out there, you haven't seen my  actual pelvic floor yet, but, it's been really exciting to be able to share my journey and my struggles. And, and I  think that really helps to connect people with you too. Basically now with my PFM, we have three, we have a  lot of different things happening, but we have 35 different language translation groups now. Basically I'll make  an infographic, for example, this one on constipation with the 14 sips, which I'm going to post soon. We give it  to our volunteers and these other groups, and then they translate it, send us back the words, and then we create it  in that language. They're able to share it with their sphere of influence.  

00:51:51 

Jeanice Mitchell 

The ripple effect, that's the ultimate goal is to be able to reach everyone. Pelvic health for all, everyone,  everywhere, everything, which that's really my mission and my vision. I it's taking a different path than I  thought it would initially, but that's okay. I'm I feel like I'm floating on a cloud. Most days. I love doing what  I'm doing and love connecting with people like yesterday. A pelvic PT in Canada reached out and said, Hey, do  of a pelvic PT in Bangalore India? I have someone that's reaching out to me looking for someone they're in my  cohort. I don't know. Let's put it on the Instagram story. I put it up on Instagram story and bam, I had somebody  that said, Hey, I'm a pelvic PT in Bangalore. Here's my clinic information. Here's my number. We're able to  connect people, all over the world. That alone is just, it makes me almost want to cry.  

00:52:47 

Jeanice Mitchell 

It's just such a happy feeling to be able to connect people with hope and help. Many people are out there  suffering and they don't know that there's solutions out there. So that's my PFM. In a nutshell, it's a, non-profit  we have a membership program. We have provider health, pelvic health webinars. And we're just moving  forward with that.  

00:53:11 

Jen Milner 

I love your passion and your enthusiasm. It is so beautiful to see somebody able to live out this passion this way  and to be able to serve so many other people. It's incredible. Thank you so much. 

00:53:22 

Jeanice Mitchell 

Oh, absolutely. My pleasure. And thank for the support. Because you never know who's listening to this that  might be able to share with someone else, even if you're not having a pelvic floor decision dysfunction, rather  three out of four women will have pain with sex at some point in their life like this, isn't a very minute  population, right? And when you look at all of these issues, I would venture to say 99% of people have some  kind of pelvic floor issue at some point in their lives. Just being able to connect those symptoms and being  empowered to know, okay, well I have this, but there's hope there's help. I don't have to live with this forever.  

00:54:00 

Linda Bluestein 

Yeah, that's fabulous. I couldn't help, but chuckle over your story about the voiceovers and stuff, because having  met you fairly recently and seeing your fantastic, quirky videos and things that, take a topic that can be really  challenging and make it so much more interesting and, take out, I think a lot of the anxiety that people might  have going to see a pelvic floor, physical therapist and, making it much easier to have conversations about these  kinds of things. I think it's just fabulous what you're doing.  

00:54:35 

Jeanice Mitchell 

Oh, thank you. Well, you're amazing. Ever since I first reached out to you, Linda, you've been incredible. I can't  wait to continue to do more things with you and Jennifer, you as well, like this is, I'm really honored to be a  guest on here and thank you for the opportunity.  

00:54:51 

Linda Bluestein 

Absolutely. We appreciate you coming on. Could you share with everyone else where they can best find you  learn more about what you're doing, and access some of those resources?  

00:55:07 

Jeanice Mitchell 

Yes, absolutely. My patient kind of consumer oriented social media content is on the Instagram channel,  mypelvicfloormuscles. If you're someone that may be interested in multilingual resources, that Instagram  channel is my PFM. If you're someone that may be interested in some of our provider, pelvic health webinars  and advanced learning that Instagram channel is myPFM.ambassadors. So we have three Instagrams. We have  the YouTube, which is mypelvicfloormuscles, no spaces. And then mypfm.com. And you can always email me  too. So my email is connect@mypfm.com. If you're listening to this and you have a question and you're not sure  about what I said, or you want additional resources, email me, you make my day when you reach out, because  I'd love to connect people with health.  

00:56:07 

Linda Bluestein 

Great. Those courses are they available for both patients and providers?  

00:56:13 

Jeanice Mitchell 

The bulk of the courses at this point are for providers. We are developing courses. I have one right now is sex  after baby. That's for a consumer or a regular person. I make, I'm creating two more for sure in 2021. We'll just  see as time goes on. I definitely want to have more content, but if you go to my Instagram, my pelvic floor  muscles, if you go to the IGTV, I'm doing a lot of free interviews on different topics that may, you may find  your answers in there. So that's free. You don't have to go buy a class. For example, this week we did one on  anal fissures. And so that's like a 30 minute. If, if you're somebody that has anal fissures, that's a good resource  also on, there's just a variety of Linda and I even did one on hypermobility there. So that's on there.  

00:57:08 

Jeanice Mitchell 

I would encourage you to check those out. If you want to see a course on a specific topic, let me know, but I'm  trying to create as much as I can without having to charge for it to ultimately there's costs and everything that  we're doing, right. And all the platforms and so forth. I need to generate some revenue, but it's a nonprofit. And,  and the goal is to reach as many people as possible. Also creating a bunch of free stuff. 

00:57:36 

Linda Bluestein 

Out of material that you have on Instagram alone for free is amazing. I mean, you have such fantastic, videos  and graphics and reels and all kinds of things. In fact, you're the one who taught me how to make a real,  

00:57:52 

Jeanice Mitchell 

Yes, I love it. I love it. So exciting. Thank you.  

00:57:58 

Linda Bluestein 

It’s been fun to chat with you Jeaniece, and we're so grateful to you for coming on the show today and sharing  your insights.  

00:58:06 

Jeanice Mitchell 

With our audience. Absolutely. Thanks again so much for the opportunity Linda and Jennifer, you guys are  incredible. Keep doing what you're doing because, I think some, I, I go off on these tracks, but I am a  hypermobile bendy person. I think that there are some that there's this myth out there that there's just a few of us  that there's not very many of us, but I think that there's way more of us than is even recognized in the medical  community when I've posted some of my stuff about hypermobility and pelvic organ prolapse, you would not  imagine the comments and the feedback that I got on that. I think that, I think it's very important to help connect  to this population and help them to understand, Hey, this symptom may be, impacting this and, making all those,  getting all those pieces of the puzzle together.  

00:59:03 

Linda Bluestein 

Well, it's been so great to chat with you Jeaniece and to see you again, Jen, of course, and you all have been  listening to bendy bodies with the hypermobility MD today. We have been speaking with physical therapist,  Jeaniece Mitchell. Jeaniece. We just are so grateful to you for coming on the bendy bodies podcast today and  sharing your expertise.  

00:59:27 

Linda Bluestein 

Thank you for joining us for this episode of bendy bodies with hypermobility MD, where we explore the  intersection of health and hypermobility for dancers and other artistic athletes. Please leave us a review on your  favorite podcast player. Remember to subscribe so you won't miss future episodes. Be sure to subscribe to the  bendy bodies, YouTube channel as well. Thank you for helping us spread the word about hypermobility and  associated conditions. Visit our website, www.bendybodies.org. For more information, for a limited time, you  could win an autographed copy of the popular textbook disjointed navigating the diagnosis and management of  hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders just by sharing what you love  about the bendy bodies podcast on Instagram, tag us at bendy underscore bodies and on Facebook at bendy  bodies podcast. The thoughts and opinions expressed on this podcast are solely of the co-hosts and their guests.  

01:00:29 

Linda Bluestein 

They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not  constitute medical advice and should not be used in any legal capacity whatsoever. This podcast is intended for  general education only and does not constitute medical advice. Your own individual situation may vary, do not  

make any changes without first seeking your own individual care from your physician. We'll catch you next  time on the bendy bodies podcast.