Natalie: 0:49

On today's podcast, we're talking with Julia DePaulo about her work as a pelvic floor physiotherapist and how someone should return to exercise in the postpartum period. I'm Natalie and you're listening to the resource doula podcast. Hello and welcome. I'm Natalie, and I'm so excited to have Julia DePaulo on the podcast today to talk about pelvic floor physical therapy. Julia DePaulo is a pelvic health physiotherapist co author of pregnancy fitness author of the labor and birth handbook, international speaker and guest lecture at university of Toronto physiotherapy department. She has created and teaches courses on diastasis, rectus, abdominis, or DRA for short and pelvic floor dysfunction for health professionals. She's worked in private practice for nearly 25 years. Starting first in orthopedics with sports and spine injuries and then evolving into women's health in particular diastasis rectus, a dominance for the last 12 years, her focus has been on the pelvic floor and its relationship to the rest of the body, specifically in pregnancy and postpartum, right through menopause at any age, in all diversities. You can find her at physio excellence, her dedicated women's and pelvic health clinic in Toronto, Ontario, Canada, where she spends her days, curing incontinence, pelvic organ prolapse, and pelvic pain. Welcome Julia. I'm so excited to have you on today,

Julia: 2:18

Oh, Natalie. I'm so excited. I started a podcast. I love it. so happy to be here.

Natalie: 2:25

Thank you for being here. So let's just start with kind of what led you to decide. Now to pursue a women's health career.

Julia: 2:35

it really had to do with being at the spine clinic and how the women weren't getting better as quickly as the men. And, you know, it's, it's fascinating. Cause I want to go back and apologize to all these women. You do, you take their history and you're like, have you had any surgery? They'd say is there. And you're like, I don't care, whatever. And then you keep going, not realizing just how impactful this is, area Inez. And then the children birthing vaginally, how much impact that has. And I had a few patients come in with diastasis and that really got my mind going. And then a patient came in with a prolapse, a cystocele and I had no idea what that was and it was so impactful to her life and it was really difficult to get her pain to go away and. So it kind of led me down the path of, you know, there's something at the bottom of the spine called the pelvis and it's the center of the universe and we're ignoring it and we're not dealing with it and we're not treating it. And once I started thinking more and addressing more, what was going on in the pelvis, Oh, look, all the back pain started to go away and the hip pain. And so it really became this very organic kind of move towards more and more pelvic health. And then of course I got pregnant and had kids and that kind of sets in, in that time as well. But the actually going into the pelvic health came after my own kids and seeing also what just, it changes everything it really does. And so looking at pelvic health and then of course, men have pelvic floor issues as well. And so every now and then they come in with staff and, you know, there's just, it's just the deep dark key of has so, so much potential for healing. And we put so much in there, but that's, that's kinda how it went was just organically as I was working and the women just didn't get better as quickly as some of the men. And they all had the same careers, they had the same jobs, they had the same treatment, they had the same problems, but there's a lot more, a lot more to women's health then than treating them like smaller little.

Natalie: 4:40

Agreed. So talk about what does it, what does a typical session look like? Because I think there might be a lot of misconception of what pelvic PT is. Is it all just vaginal exams and K goals? What are you doing?

Julia: 4:59

Uh, yeah, so I do, I do a lot of vaginal exams. I know my fingers in a lot of vaginas. Um, the, the main, the initially right now is that we're the cool thing is we were actually doing? telehealth a lot more so we can get, um, we can get that initial assessment where we get the whole history. The thing about physical therapy is versus a gynecological exam is I have an hour to an hour and 15 minutes, and I can just take your history in that time. I can get your entire story. In physiotherapy, we tend to pull out more of the trauma, more of the whole body, more holistically versus just sticking a specular and going in, taking some samples and leaving. And so the initial assessment is more, more often right now in tele-health getting that whole story of what happened with the burst. What happened in teenager? What's what's going on with the pain what's going on with the periods what's going on with urination, with deprecation. So we're looking at that whole look at multiple systems and that whole body. And then when they come in person, we do do a vaginal exam. Um, they don't see the video of this. Do they? They just hear it.

Natalie: 6:10

Um, we can post some video. So if you want

Julia: 6:13

I have all that, but I'm locked out of my cupboard. There we go. Of course. You had to do a demo, My lovely vulva cup.

Natalie: 6:24

of course

Julia: 6:26

You have one now.

Natalie: 6:28

I do. I do. Her name is violet.

Julia: 6:31

Oh, I didn't name mine. What a great idea. Well, now I have to think of a name. So this is the one just small velvet, Bubba puppet. And so let me do what I tell all my patients is I truly don't go anywhere uninvited, like literally and figuratively. So it's one of the biggest differences. When you're doing a physio exam versus a gynecological exam, got to college call exam, they'll put the specula in. You kind of look away, you just grin and bear it. They saw the cervix. It doesn't feel good. They come out, you get dressed to go, you know, it's all a five, 10 minutes. Whereas a physical exam with physiotherapy is we go in, we go onto the outside right onto the room. I wait for my invitation. I wait till the muscles soften to the vulva, to the vagina, allow me in and then we'll go in and then we'll test what's going on with the muscles. So all this red on the inside. Well was on the outside. So the, the dark purple labia are the ones with hair, the soft pink ones, certainly ones are with the ones without hair and labia minora inside of a vagina outside of the vulva. And so inside with the red, where you can see where the vagina is, it's all muscular. And so I'm testing every muscle. There's three layers. There's like 15 different muscles, depending on how you name them. And they all have functions and they can get, you can have one side that's tight. You can have both sides, that's tight. You can have the deep ones tied to go to the front. One's tight. You can have all different kinds of differences between you and the girl next door. So we go in and we check what's happening at the level of each muscle we go into, we check the urethra, we check the bladder, we check with our cervixes. We look for collapses, and then we have them do contractions. So then they'll do the Cagle. And we'll grade the Cagle as to if it's weak or strong, if it's actually lifting or not. If it's one side of my big thing is the pelvic floor has five different things that have. But coordination control and endurance are really important. Not just strength. Strength is really not that important. You can have a really powerful pelvic floor and not be continent because you don't have the coordination and the timing. And so timing because a really big issue for incontinence that tension across can be a really big issue for pain also for incontinence. And so we're going in, we're looking at what's going on in the pelvis, and then we can add in the pelvic. Um, I also look at the bones and how the bones are sitting and if they have that flexibility to them. So where the, if they have the pelvis has to have a little bit of mobility to it so that we could walk, we can twist, we can move and we can birth babies. And particularly after birthing a baby, as you know, kids don't put anything back where they found it. So sometimes the pelvis will be stuck in a position. And so if it doesn't have that flexibility, then we want to make sure that that's restored. Pre-birth post-birth post-trauma if you fall on, um, you're in Alaska, everybody falls on the ice. I don't know how many people fell this weekend on the black ice, but I got a bunch of emails. And so every time you fall on the ice and you land on your pelvis, you can jam it that little bit. So you lose that flexibility to it. So we checked for that and we talked about incontinence. We talked about peeing and pooing. We talk about sex a lot because sex is super important. And one of my favorite things that I've learned as a pelvic physio is the clutter is the only job of the clutter. Clarissa's pleasure. And that's how important pleasure during sex is. So if a woman is experiencing pain, now we're not talking SNM and desiring to have pain. That's a whole other podcast for another day, but for sex should be pleasurable and not painful. And so when you're. When you realize that the clutter is, is actually quite extensive. And so she's quite extensive. And her only role in the entire body is for pleasure. No other organ has that role. Every other organ has a function or two or three. And the male counterpart to the, to the clutter is, is the penis. And it has to urinate. So not even in the men, despite all the pleasure, sensation and nerves they have, which we have the akin in our clutters, our clutters doesn't do anything, but give us pleasure. That's how important. So we have lots of conversations about sex as well in the, during their sessions. And it really just depends where their priorities are, what their needs are. And then we tailor each treatment to each person who needs treatment session to that person.

Natalie: 10:46

I love it. I love it. I also love that you have all of those models just within arms reach. That's perfect. I think all pelvic nerds are the same. For real. Yeah. So

Julia: 10:57

Oh yeah.

Natalie: 10:59

this is a question. I, this is a question I get, um, fairly regularly actually, um, or concern on someone's face when I talk about pelvic PT and the internal exam. So what if someone is, is uncomfortable with an internal exam, can you still assess them? Are there ways that you can figure out what their pelvis is doing without that?

Julia: 11:21

Yes. I know. So absolutely I, again, don't go anywhere uninvited. So if I, if they're willing mentally and we get up on the table and their vagina says, no VT, no entry, I don't go in. There is no just grin and bear it with pelvic PT. So the fact that I can't get my fingers into the vagina is an answer that tells me that that pelvic floor is super, super tight and it doesn't want anybody in there. We have the answer. So now we need to discover. And how do we relieve that? Is it the pelvic floor itself that has the problem, or is it a victim of somebody else pushing down on this? Is it the nervous system? Is it with vaginismus? It's really about the nervous system and the anticipation of pain. They get pain before they ever even get touched. And when I explain this to people, I use the example of line five guys up and kick one in the balls. How many guys go down? All five goes down, right? And they all moaned and they all grown. Cause they all know what that feels like. That's vaginismus. You just have to think it or see it or, or, or, or be afraid of it happening. And you will feel the pain. And so it's obviously more complicated than that, but that's a really nice. Easy description of Dionysus. So someone who has vaginismus, I am not going in until the body and her brain say, yes, you may. And yes, there's a million things we can do. So we can really, depending on what her body allows us, we can release on the outside. We can release. Sometimes we can go. Um, some of my patients they'll have a lot of pain internally from the birth in the vaginal canal, but we can go rectally so I can release rectally, particularly if they had, if a lot of their pain is due to the coccsyx. Um, or if they're having a lot of pubic symphysis pain, sometimes going into the Coq, six is a little bit easier. We work on the outside of the bone. So making sure we've got that? flexibility, if they have scars and then we do a lot of breathing, we do a lot of kind of connecting to the system. Why do you have this pain? Why does your vagina say no? Right, So that's super important. And then not all pelvic physios, but most of us go get into. Down the rabbit hole of digestion and nutrition and the microbiome. And so anything that's going on in the gut will have an influence on what's going on in the pelvic floor. Particularly if they have constipation, I have a woman right now whose colon has completely impacted. So most of we checked her floor. Her muscles are pretty good. Her muscles are not stopping the movement from coming down. She's everything is okay. Her bones are okay. Everything's okay. So it's really a lot about diet and a lot about movement through the abdominal wall. I've moved out of her vagina. I don't need to treat her vagina. That's fine. And I moved out and onto her belly. And so physio, pelvic physios, remember our regular physios with extra training, right. So we still have all the basic skills of physio, so we can do spines and flee feet and ribs and heads. The other really important thing is critical. State coal rhythms are super important. So that connection of the cranium to the pelvic floor. So someone particularly vaginismus I'll either start at the feet or start at the head because the feet next are next to the Tavis in the brain. So we can get some movement through there or we can get some trust. And so never, never, if anyone is afraid to go see their pelvic physio, do a tele-health first to meet them. The therapeutic Alliance is absolutely the most important factor, Hans. And so the, you have to be able to connect with that person. And if you can connect with them online, chances are you won't connect with them in person. Um, and that's why I love with my pelvic patients doing the tele-health first. It's like a meet and greet. They don't just take their clothes off. They don't even have to let me touch them because I can't touch them through the screen. And so it's been, it's one of the wonderful silver linings of COVID. Is that in, in Canada for sure. And I think in the U S as well, it's all covered. It's considered real normal, fully fledged, fully licensed physiotherapy. So that's been a huge, huge plus. So earning that trust. So if any of your listeners are going to pelvic PT, they don't feel super uncomfortable. They always have pain after discuss that with her because That's not necessarily a goal. And then if it's not going well, ask for a referral to someone a little different or find out in your community who else there is some places it's really hard. There's not a ton of pelvic PTs everywhere. Um, I have a whole list on my website cause not everybody loves me. And if that relationship isn't there, then it's not going to work for me or for you. And I'd rather, I'd rather send you to one of my friends. Who's maybe calmer, maybe a little softer, maybe a little quieter than I am. I can be a little overwhelming. And so if that's, if someone is really afraid, then I'm going to overwhelm them and that, that Alliance isn't going to be there. And that's okay. I don't take that personally. That's that's not line that's, that's just the way it is. There'll be a, there's a lineup of people that will fit my personality. So don't feel like you're obligated to see somebody, if it's not matching.

Natalie: 16:26

That's really good advice. Yeah. And I think that same goes for any kind of healthcare provider. Right. If you're not having that connection with them and especially your primary care provider or your midwife or your OB or your doula. Right. It's all about that connection. So

Julia: 16:42

and I would even add your counselor. Yep. Any counseling, any MSW, anybody that you're seeing for therapy, any kind of therapy, you have to be able to be free with them. Otherwise it's not going to work. You're wasting time and money.

Natalie: 16:59

Agreed. Okay. So can you talk a little bit about what types of problems people may experience and how those can be benefited by public PT types of symptoms?

Julia: 17:10

So my ideal client is preconception, right? I would love to get these mid to late teen girls really let them know. I think every 14 year old should go to OMG. Yes. Dot com. It's every mother should buy this for her daughter. It's 40 or $60 us. And it teaches you all about the Volvo. It teaches you how to pleasure yourself. They did studies on 2000 women. It's just, every girl should know how her body looks and how it functions. Um, I have two boys. They both have access to this website. They're not dating yet. The boy should also understand. So preconception is one of my ideal clients, because if we can get the body optimized before you have a baby. So if you know where your Cagle, where your pelvic floor is, you know how to do a proper Kegel, picking up a little Berry and releasing it, maybe a little bit of control, some coordination exercises. Um, we know that your pelvis has got that flexibility. We know that your body's moving the way it wants to move and limiting any of the compensations. One of the big issues that we see a lot is, you know, particularly in dancers and athletes, you've had a million injuries, minor injuries, you've recovered your back to competition. You don't really notice it until you put a baby in the uterus and the uterus gets really big and you lose your compensatory mechanisms of your trans versus your floor is working harder. And so whatever you were using to kind of overcome whatever deficiencies you had before from all your previous injuries. No, it's really hitting you. Right? And then we get the hormones involved. So ideally we'd see people, women preconception to just kind of see what's going on with their body, learn where your pelvic floor is, meet your pelvic floor, get introduced, get a really good relationship. And then during pregnancy, I like seeing my women, um, particularly if I saw them preconception, but around six to 12 weeks, somewhere in that span, wherever they feel secure to do an internal in Canada, we are allowed to do internals at any point during a pregnancy, um, unless they cannot have intercourse. So in the, in certain states, the, they don't do a lot of internals, um, during pregnancy or it's, it's kind of a last resort in Canada. We don't have those restrictions. So if someone needs internal, if they get into. So I like doing internals, um, somewhere around six to 12 weeks again, so they can get reconnect with their pelvic floor as the baby's growing or connect for the first time, if they have any kind of pain. And then around 30 to 37 weeks, we really focus in on preparing for birth. And so learning how to push, learning, how to position, we get the partner, the birthing partner, either husband or spouse to come. And sometimes it's even as I've had sisters also come and, you know, in same-sex, so anybody can come and we do all this kind of Dooley stuff where teach them where to put pressure on their. So that they can cope with the pain a little bit longer, particularly if they don't want an epidural or they want to delay their epidural. And so giving their partner, their birth partner, that ability to, um, give them a little hand, like help them either before they do like it's or the midwife, or before they go to the hospital for the OB. And then I like a two week visit. Now I can do it in tele-health. We make sure that the baby's nursing properly. We make sure that she's recovering, she's breathing. She's able to, she's not in a ton of pain. She can start her kegels. And by the way, you can start your kegels within 24 hours after pushing a baby out. If they had a scenario, you could start within that same timeframe, as long as they're not really painful or getting worse and worse with pain. And then we do the six weeks it's around six weeks. I like to do another internal. So we don't do an internal at two weeks. If they, even if they do come in and at six weeks we do another internal medicine. What the Navy left behind. So what's going on with the body postpartum cause it's very, very different. Um, most women have a lot of trouble finding the pelvic floor is even if they were really good before they need a little bit of coaxing, a little bit of coaching they're exhausted. So it's much, much harder to learn this stuff postpartum. So it's much better if we could teach this all prenatally, um, and then whatever presents postpartum, um, and then getting into menopause, It's typically, uh, more typically incontinence, um, pelvic pain and pain during sex. Those are the most typical, um, and collapse. Prolapse can be associated with pain or not associated pain. So on the grand scheme of women's health, the most common things I treat are in current. Um, both urinary and fecal incontinence and even gas continents. So if you, you know, you're on the elevator and you don't want. to let out a fart and you can't stop it, that's what we call anal incontinence. And that's not normal. That is correctable. You just need a better control and coordination with Your anal sphincter. Um, and then we need to figure out why you don't have it. Um, so in continents of all levels and all types, so jumping up and down when you sneeze or leaking, when you jump up and down or sneeze, or just leaking, when you get out of a chair or having that urgency all of a sudden, uh, one second and go, you're fine. Now you've got to run to the bathroom. So all kinds of incontinence, all kinds of prolapse, whether it's uterine, whether it's, uh, the bladder, whether it's the rectum, whatever, whatever is prolapsing. We look at that in any pain associated. So any pain within the pelvis or just outside. Some hip pain is associated with pelvic floor back pain, 80 to 90% of women with back pain, have a pelvic floor dysfunction. Um, and then there's, you know, just that it just doesn't feel right, right. If I'm running or I'm lifting weight, I just don't feel that strength. I just don't feel like I got my body back. Um, diastasis is a big one when that comes in where it just, it just doesn't feel like I'm solid anymore. And that's typically diastasis. Um, so we'll work with that. And then everything else had to tell, instill a physio. So I do less of it, um, that it's, they still come in with their, you know, carpal tunnel from swelling and pregnancy, their plantar fasciitis. Cause they tried to run too early, um, all kinds of stuff. Um, there's, there's a lot of emotion associated with birthing and having medical. And so there, there could be some minor traumas, like small T traumas, and there can be some big T traumas with birth and everything in between. And that's a really important to address as well. There's a, it's kind of a subgroup of physios, not all physios, particularly newly granted new, nearly graduated pelvic physios don't necessarily have the experience to dive into the beginning of the trauma. Um, but it's really important because our tissues do hold trauma. And so the, the there's a fabulous, well, I think it's a tome, the book, the body keeps score. Um, there's some, some Ted talks, I think in a bunch of podcasts, you can go to Coles notes version of it. Um, but it essentially means we especially postpartum the birth happens and you have fight flight and freeze. And you cannot fight off near people, helping you birth. You cannot run away from the birth. And so you freeze. And so that can be traumatic just on its own. And so we can work through that very easily with the tissues in most women. And then when it's a little bit bigger, more capital teeth, then I work with psychologists and psychotherapists and social workers to kind of really work through what that trauma was. But there's, there's a lot of trauma in the pelvis.

Natalie: 24:36

Your work is so, so comprehensive. I kind of just want to clone you and have a copy of you here. Or you could just move here. That would be great.

Julia: 24:45

You've tried a

Natalie: 24:46

We need more people who are doing what you do. I know I have, I have, I'm still working on you.

Julia: 24:55

ended up in the next few years.

Natalie: 24:59

I'll keep trying. Oh, so, um, for our listeners who may not be familiar, can you briefly describe what prolapse is and what diastasis is?

Julia: 25:11

Okay. That's all my vulva puppet out again. I'll describe it in words for those who aren't gonna look at the videos. Um, so for a prolapse, a prolapse is essentially the organ. That's not sitting in its perfect spot and has descended or lowered into the vagina in some way. So what happens in, we graded on four, on a grade of four. So a little grade one prolapse is super common. It's really nothing to get excited about. Your doctor's probably won't even diagnose it or acknowledge it. But as a physio, I'm always looking at prevention. So a little grade, one can easily turn into a grade two grade three or grade four, if it's not managed correctly. And they're very easy to manage when they're grade ones. And so what happens is let's say it's the bladder. And so what'll happen is the bladder will start to discuss. And then it'll descend a little bit more and that would be a great to a grade three would be right at the door. So when you wiping, after going to the bathroom, you'd feel this weird kind of bulge. Also most women will describe the feeling of like a tampon falling out. When they get to a grade two or grade three stage, a grade four stage, it looks like a little scrotum hanging out of your vagina. And so it's, it's very, very bothersome. It's, you know, 12 years in the spine clinic and the most devastating condition I treat is? prolapse. And it's not life-threatening, but it is life altering. And it just gets you to the core of your womanhood. So when the prolapse gets to the point a grade four, and it's sitting outside the body, we can do a little, we can do a lot, but typically we can only get it up about one grade and that's with pessaries, um, which are like little diva cups, but they're designed like sports for us to hold the organs back in. Okay. We can get them up by one grade, but most of the time they'll end up in surgery, depending on who you see first, if it's a physio or a surgeon, then you'll get the options that they're most familiar with. But with the, with the prolapse is the, the hardest part about a prolapse is you may not have symptoms from it. And that's where I get really nervous about new moms running and doing high impact sports, where you could have a little grade, one or a little grade to prolapse and be completely unaware. You don't feel any heaviness. You don't feel like a tampons falling out. You don't notice it when you wait and then you don't really notice it until it's really, really advanced. And so those are, that's why I love the six week or a seven week postpartum check. And then I'll do a lot of checks with my runners who have a little grid, one I'll check them every year or before every big event before a big training, um, increase. Just to make sure that everything's where it is and all is good. And they can just keep status quo going with their training versus, you know, adapting their training or backing off on their training or making sure that there isn't sometimes there's another injury in ankle sprain and that'll throw the system off. And so then they compensate. The biggest predictor is abdominal pressure. So any kind of constipation bloating that will have an influence the way you lift, if you bear down when you lift, instead of as you lift, um, if it's weights or if it's a kid. So with prolapses, I'm very, very mindful that I want to get strength and control and tone in the floor so that we're supporting those organs from the bottom up and making sure that there's not pressure coming down from above, but you can live happily ever after I've had women go back to lifting heavy CrossFit running with their prolapses. You just have to be mindful of how you're managing the prolapse and it shouldn't be. Overwhelming your day. It shouldn't take over every thought that you have, it should just be like, okay, I'm going to breathe properly. As I left this, I'm going to be mindful or I've done a lot of lifting today. I feel really tired. I'm just going to leave this laundry down here and I'll get it tomorrow and not expend extra energy when you're really, really fatigued. Um, diastasis is, um, more about, uh, mismanagement of the tension across the midline. And so when you're doing an exercise, if you see, you'll see this a lot in the pregnant body where the doming happens. So it kinda looks like a little loaf of bread or a little Keno and an early postpartum women will try and do crunches to get their tummy flat and strong again. And they'll see this doming or bulging. That is what we characterize the diastasis, which means that the tension across the mid-line isn't. Isn't accurate, isn't adequate. And so the pressure is coming out instead of being dispersed the way it's supposed to be dispersed. And so that can mean that you just don't have coordination of the core four muscles, which are in fact, my four favorite set of muscles in the whole body. So we have the diaphragm, pelvic

Natalie: 29:44

Surprise surprise.

Julia: 29:47

10th versus of Dominic and multifidus in the back. And relativity is often forgotten, but really important in women. Who've had back problems in the past, but trans versus these four muscles have to work together. So I always treat diastasis first with the pelvic floor, make sure that the floor is coming on and make sure they're connected. And they get pelvic floor connected to transversus and the rest of the abdominals, the obliques internal, external and rectus abdominous is super important in the final stages or in the, in, in getting to a full recovery. We can't ignore it. Um, but we don't want to go hardcore into this domain necessarily for most. There are some newer ideas of especially women that are really struggling or they really lost their connective tissue. We do want to start them at a different place than someone who hasn't lost a connective tissue. So a diastasis just like with pull-ups there's different degrees of, of, uh, severity. And so the start point for each person is going to be very different and the how quickly they attain their desired strength across the midline is also going to be dependent on what's going on in the rest of the body, but also what that connected tissue is doing. So for the most part, for most majority of people, we're not going to go into that. Doming.

Natalie: 31:06

And the endpoint for diastasis recovery. Doesn't always look the same for each person, right.

Julia: 31:13

No, no. And interestingly, I have, um, a little picture of a video of, uh, of a patient of mine. Who's doing a plank and in the picture it looks like she has a crazy diastasis, but in fact, when you palpitate, she's got beautiful tension across. She just needs to work on the connective tissue and the skin because she's had two children and she's getting a little bit older. This skin just goes weird. Like, I don't know, it just comes into a weird pattern. And so when, and it was a tele-health and I'm like, oh, I think we definitely have a diastasis. Let's stop the planks until you come in. And then she came and I was like, oh baby, this is awesome. Like, she's got great, great tension across. It's just the skin. That's not it's being pulled in an awkward way. Cause it said he's down in another area. So, and that's really important too, that just because there's, doming what it looks like. May not be what's showing up. And vice versa. So we want to be really mindful of how the person is moving. If they're cheating in other areas. And that's particularly for, you know, it's tough right now with so much online training that women and, um, people are doing it, which is awesome in some ways, but also problematic because it's very easy to get into a cheating position and not using ideal form for a certain exercise. So my recommendation to people is usually if you're not sure there's a million other ways to strengthen that muscle, let's choose a different one. Right, And then it's, and then we can, if you're, if you're hell bent and heart set on that particular exercise, like my Pilates people who love their roll-ups and roll downs and they're hundreds and their V poses. Well, that's, let's make sure let's take a different route. So let's take a little detour and get you back to there, but barreling through doesn't work with diastasis for the most part.

Natalie: 33:06

right. right. And diastasis can lead to, or oftentimes is alongside other issues and pelvic floor dysfunction. And so we, with the holistic a purchase is necessary.

Julia: 33:18

Yes. The, the literature, the science is a little bit misleading because most of the science up until about 2016 was really based on the distance between the two recti muscles. And it's relatively important. I mean, there's a difference between one, two fingers and five to eight fingers. Big, big difference on how we're going to train them. That's where we're talking about severity and where their start points are and whether we'll allow doming or not. But the. Using that as our outcome measure is not accurate because it's function that's accurate. So you could still have a three or four finger diastasis of separation and still have fantastic tension and function. And you can have a one finger separation and have really poor function. And so not getting, not getting too bogged down with the numbers, um, and more about the form and the function. Then the, the number of the separation itself.

Natalie: 34:13

Cool. Thank you for that clarification. I like that. Um, okay. So. Typically people see their provider at about six weeks postpartum. They get maybe an internal exam to see if they're healed from maybe whatever Terry might have taken place during birth. So if that exam similar to what you're doing and that, that green light to clear people for exercise and sex and regular life, should someone still come see you?

Julia: 34:44

So I have a whole presentation that I do for midwives called the six week green light is irresponsible. And here's why, because they're only looking at tissue healing of the cervix. So we know when something tears, it takes four weeks for the cells to mature, to match rate. And then between four to six weeks, those cells that, that cut or that tear will then solidify and be, get stronger. And over six to eight weeks, it should be strong. And so we know tissue healing only takes six to eight weeks, right? And that's where the six weeks comes from. We have to do other science. It's really about preventing infection. Now is the Volvo ready? Is the vagina ready? Is the cervix ready? Is the person ready? And most of the time. Most of the time, the person is not ready, even though maybe the scar is healed, but in that healing, is it adhesed? So they're not checking to see a Tesion so they're not checking to see function. They're not even checking pain really. I mean, unless you screen, when they insert the specula, then there's really not going to be anything in Canada, particularly the last two years, they're not doing any in-person six week visits. So the doctor just asks you, your eyes just went out of your head, the doctor it's a telehealth call. Yep. Yep. And so at the tele-health call and the doctor asks for, you know, is it going okay? Have you tried this? No, no, no. And any they're really looking for symptoms of infection and poor healing. Um, but that healing. Doesn't give you the green light for activity, right? You need to restore the muscle. So if you've sprained your ankle really severely, like there's actually a tear, maybe grade three grade, three sprain, and you have to walk on crutches, you get support you out the ankle, you do all these great things. Um, now add in like, so do you think at six weeks after an ankle sprain, that you've not put full weight bearing on and you've not really used and that you're ready to go and run a marathon? Well, no, you've lost six weeks of training. First of all, second of all, you haven't done anything. And so you haven't retrained back into that. And so we had this thing of, so women do the most amazing feat of strength and energy possible, and then we expect them to bounce back after six weeks. Despite the fact that they've had poor nutrition, they've had little to no sleep. They've got hormones cursing through their system. And they're ready at six weeks to let have sex and go run marathons. No, no. So the visit with the OB or the midwife at six weeks clears you from infection and tissue healing, right? So that is the, okay. It's now time you can start to do more normal things. You can start thinking about exercise, but you want to retrain or restart just like if you had an injury. And my favorite example is the ACL. And so anyone who's been an athlete or around athletes, or loves to watch sports on TV, know somebody who's had an ACL repair. I have an eight month protocol to follow following ACL surgery. It sales a really importantly going into the knee, really important for ambulation going up and down stairs. What have you sports, but it doesn't breathe for you. It doesn't give life. It doesn't support your entire. It it's like you can't even compare the function of an ACL with the function of the pelvic floor and the pelvis. So to get the ACL eight month it, to it, the topic for six weeks, it just seems absurd in my little brain. So to answer your question, it's a very, very different assessment. So we look at function. We look at, we look at what's happening. We look at pain, we look at healing, but in a different sense, right? We want to make sure the tissues are healed. So in Canada, because I can see patients in person. Um, and I do that. They'll come at their six, seven week postpartum. And I will look at the skin in this issue as a physiotherapist. We're not allowed to diagnose anything, but I just look and go, this looks hunky Dory, or this doesn't look hunky-dory and you need to go back to the doctor for a diagnosis. But most of the time, the women that I see, the patients that I see, haven't seen they're obese now. And so it's, it's a.

Natalie: 39:19

Wow. Yeah. So interesting. And how many things do we miss in online communication versus in-person for mood checks and everything else. In addition to the pelvic floor.

Julia: 39:35

it is. And that's one of the things we're also trained in it as physios is to look for the markers and the doctors do this too, and they see you. But I mean, if I've been speaking to you for half an hour or an hour, I'm going to pick up if you've got baby blues or if you've got postpartum depression, and then we have methods to, you know, we have, um, ideals to do. We have ways to, to get to. We have, um, channels. That's it channels. We follow to actually get you the help you need as if I can do a little bit of trauma, 1 0 1 for the postpartum depression, but I'm sending you off to a specialist. And so a lot, a lot is getting missed. So the beauty of our visits is they're long. They're at least 30 minutes. Most of the time, they're an hour and you get to come back. As often as you want, you can come back daily. If you want to get back weekly, you know, it's really, we're not, we're here. We're here to empower you and get your health back and get you feeling like your new self again. Right? Cause after you've had a baby you're different and that's a good thing. Um, there's, there's a lot of maturity and there's just this beautiful walk through this, walk through this big, these beautiful gates into this new world. And It's spectacular on the other side. And, but it's different and you don't ever get your old body back and you shouldn't want it because now you have a body that's created this new life and it's just spectacular.

Natalie: 40:56

It's miraculous for real.

Julia: 40:59

Oh, seriously.

Natalie: 41:02

So, um, what would you say to someone who is newly postpartum or pregnant even, and thinking about, okay. I want to return to my normal level of exercise postpartum. How would you give guidelines? Like what are the basic few steps for someone who, who wants to return to exercise those? Pardon? If

Julia: 41:24

I have a whole book

Natalie: 41:25

down to a few steps. I know you do. I will link it in the description too, so people can, people can have access to the book.

Julia: 41:34

So in and I wrote that book with Kim Bosnian and Samantha of sequin. And so they did all the exercise programming. So remember, I'm a pelvic floor physio. I don't do fitness. I get you ready for fitness, but I don't do fitness. So the book has a lot more fitness than I'm going to give you now. But essentially what we want to do is we want to. Retrain the body to be able to do the training that you were doing before, whether it was just going to a yoga class or whether you were lifting heavy at a CrossFit gym and trying to go to worlds. So whatever your goals were, or just your Peloton and you like racing the people in your little session. So the first thing to do is once you birth the baby, obviously wrap, um, to give support external support while you heal from the inside. If you're going to rap, then you have to do the exercises. If you're not going to do the exercises, don't rap. Because if you wrap something in, don't strengthen it while it's on, you're actually going to become weaker. So you must do the exercises. If you're going to rap, regardless if you rap or not, it's the exercises are the same. So the first one is breathing so core bruh. So you take your breath in, feel it right down to your pelvic floor. Exhale, do nothing. Now, if you do not have pain with that, then you can add the second part to the core breath, which is picking up a blueberry with your vagina and drawing it up and into your body. If that feels nice enough, then you can do more. If it doesn't feel good, you can try a few more and see if that pain gets less and less. If the pain gets worse and worse, stop immediately. So I have this green, yellow, red traffic light system of how to know if an exercise is safe for me. So if you're doing an exercise and you get pain and you keep doing a few more reps and the pain gets less and less and less think doms, delayed onset, muscle soreness. It's so sore to go and move it. Oh, you move a little bit. Oh, okay. Now you're loosening up. The rust is wearing off and you feel good. That is a Greenlight. You may continue. Red light is easy. You start, it hurts. The more you do, the more it hurts. So absolutely stop. So if you're picking up blueberries and it doesn't feel good, stop, wait a day, wait, two days, come back and see how. The yellow light is the hardest one. And this is the most common one postpartum. It hurts, but it doesn't get better. It doesn't get worse. It just kind of hurts. And so you can do a few more and it doesn't change. So that's a yellow line. Then you have to look at the rest of your body and the rest of your day. Did that help me breathe better? Did that help me move better? Did that make me feel a little looser in the pelvis, then it's a green light or did that actually give me pelvic pain for the next two hours? That's a massive red light. So you get to judge your exercises based on that system. And it's really easy. And if ever you're unsure, just breathe, just breathe. That's all you need to do. If baby's crying, if you're trying to latch and finally get baby latch in Eunice, awkward position. See if you can adjust and just take a breath and it doesn't have to go to your pelvis. It doesn't have to go to your vagina. If you can just breathe into your lungs and exhale. And do a few of those, right. That we underestimate the power of breath. It is so very important. So once you've got the kegels and you can do a few blueberries, you can play, I have 13 types of cables, as you know, so you can play with all the different types of chemicals. Um, and then you can add in, so part of the system, when we did the rap was I wanted exercises that were safe for every single woman to do, even though I wasn't going to assess her. And so we picked a bridge clam except climb. If you have a pubic symphysis, diastasis, postpartum, you're not going to like it, but bridge Clem squats, um, seated Smartsheet. Lunges. And when leg stand and I missing, oh, side, side bent leg lift, there's eight of them and they're all glued exercises. So the focus postpartum is on the glutes because the glutes wrapper around the pelvis at the back and attach and act like a, like a nice SSI or pelvic belt. And that's your natural belt. And the better your glutes are, the better your pelvis will feel. And so engaging the pelvic floor with the glutes is magic and it is so helpful. And so those are my favorite postpartum exercises. You can do. The first three of them are in beds and don't even have to get out of bed. You can be nursing while you're doing them. And then as you get standing, you can be holding the baby and doing them. So they don't take extra time away from baby either, which is really important. But those are the foundational steps is getting that connection of the core four that I love so much the diaphragm for breathing the pelvic floor, the blue. Transversus abdominis moving through these moves and, and multifidus moving through the movements and incorporating them all together slowly. You're not going to win any awards. It's not fitness. It's motor patterning. I don't do fitness in the first six weeks of birth, even with my Olympians, even with my high-end athletes, even with my anybody, it's just my brand new moms. Who've never exercised. Everybody starts at the same start point, but everyone moves through the programming differently because we tailor it to them and their progress and whatever's going on in their body. But everyone starts with breathing and picking up blueberries

Natalie: 46:43

love it. Love it. And the ultimate goal is. Not be on the bed. Right. And getting back to whatever it is that you love and running, jumping,

Julia: 46:54

100%.

Natalie: 46:55

doing pull-ups. Yeah. All

Julia: 46:57

Yes. And it's really important when you, when you pick your physio. After a few visits, she's actually assessing you in standing because most of your life is in standing. So one of my follow-up visits is always by sit on the floor. I put my fingers in their vagina and we go through the exercises. I go through the one leg lift. I go through squat, sometimes lunges depends what they're. I have, um, a couple of Frisbee players, ultimate Frisbee. So they have to sidestep and crossover. So I sit on the floor and we try to do all these movements. Dead-lifts my CrossFitters want to deadlift. Um, and some of them want to lift overhead. So whatever they want, I want to make sure that their Flores coming on automatically. That's the ideal goal. You should not have to think about picking up blueberries every time you move your body, that would be, that would drive us insane. And so the automation is really needed, but you every, I, I I've yet to meet a woman who has not lost it immediately postpartum. If I get to assess them, the they're pretty good. I have a few that are a little bit late on it. It's very, very, very rare that that automation happens right after birth. It takes a few weeks to gain back and I'll usually see it at six weeks, but it's, it's very, very rare.

Natalie: 48:13

So all the more reason to work on it prior to, and learn that motor patterning during pregnancy so that you can be that much better postpartum.

Julia: 48:22

It's it's like getting, writing, getting back on a bicycle instead of learning to ride a bicycle. Yes. You're going to be wildly. Yes. It's going to feel weird. No, you're not going to be as coordinated as graceful, but oh my God, it's So much easier if you've learned it in pro pre-baby versus post-baby yes. A hundred percent.

Natalie: 48:42

So if someone wants to do a little bit more research on all of this, or is looking for a qualified PT in their area, where would you send them? What resources would you record?

Julia: 48:55

So in Canada, probably the most comprehensive, I have a very short list on my website. If you want people that I know there, those are just people I know personally have done courses with love, tried to get to work in my clinics. Um, so I have a short list on my website. Um, there's a much more comprehensive list@pelvichealthsolutions.ca and they have tons of Ontario physios and have kind of branched out to, um, Alberta quite a bit. And there's a few other provinces, um, BC and in the states, he would want to go to the rename. They used to be the women's health. Now they're called the academy of pelvic health and that's with the APTT. And so they will have listings there. And there's some products that are really geared towards pelvic health and pelvic physio. Um, they'll have a list as well. Like my PFM is, um, really they're really great. Um, I believe she's a pelvic physio. She has a lot of resources and, um, intimate rose. Amanda is fantastic public physios. She has a lot of resources, uh, for the U S um, Lynn Sheltie Institute for birth healing, amazing resources, amazing programs. Her summit will come out, um, again in the spring. Um, she's got amazing resources. She has a list of pelvic physios, particularly the ones that do the trauma. Um, I learned most of the trauma stuff from her. Um, who else? Uh, for prolapse there is the, I think it's a pops, Sherri Palm. Um, she has some good. Um, very good. Um, a little bit more Western medicine resources. Um, she's she went through a lot. She's phenomenal. Um, she's been a huge advocate for women with prolapse. Um, Kim has some great programs. I don't think she has a list anymore. Um, but she has great programs. Great app. Um, the bath math, math bath. It's awesome. Um,

Natalie: 51:04

muffler. Yes.

Julia: 51:05

Batman. Yeah. Yeah. I've had a few patients run through it. I've I've looked through it myself. It's awesome. And I've had a few patients run through it. Um, she does way more fitness than I do. Um, obviously she's my co-author. Um, who else? What other kinds of resources? So for, I do like, um, so ongs.com for learning about your Volvo. Self-pleasuring particularly helpful for women who have pain during. Or for women with vaginismus, uh, or who are just afraid who had pain once, and I've never tried it again, have pain with a tampon. Um, that's a great resource. It's a paid resource. Um, what does the other one? Um, another resource that I really she's very, very provocative, but I absolutely adore her. She's now in her sixties. I think I as Susan Bratton, B R a T T O N very provocative. If you think I'm no holds bar, you've got to meet her. Oh, I just adore her. Um, she has a lot of free, um, free mental e-books on intimacy, restoring intimacy after a baby, after pain. Um, during menopause, she has a lot of stuff on menopause as she's going through it now. Um, she is a great resource. She has a lot of paid programs as well to fund her. Friesa um, uh, there's just so many, it's really a world.

Natalie: 52:24

about books? How about

Julia: 52:27

Box. Um, so Jessica Drummond has written some books? on endometriosis. Um, she's a pelvic PT and also functional medicine, a nutritionist. So she gives you that really beautiful holistic world of how to, How to him, how to manage the gut. Um, um, books. Kim has a book on the pelvic floor. Um, I think she has two now and she has prepared a push, which is a program, more online program now than actual in print. It used to be in print. There's not a lot of books. Hm. Um, you would know all the ones on dueling and birthing with NMA. Uh, so you would have those resources for your listeners. That's what I, I'm distracted. Cause I'm obsessed with, I'm reading a book about the liver right now and it's just mind blowing, but, um, uh, yeah. I don't think she's written a book. She does a lot of courses and a lot of presentations, but I don't, um, I really want to Horton and I don't think she's done a book though. Hmm. I may have to sit on that one, but it's pretty extensive.

Natalie: 53:42

You can say you can send me more afterwards if you think. Yeah. Send me a list afterwards. To round out. Well, what is your number one piece of advice for our listeners? What do you want everyone to know?

Julia: 53:58

Um, and that you deserve to know? what's going on in your pelvic floor. You deserve to be connected. It is a piece of your body. There is no shame in any part of your body. You deserve to, you are allowed to touch it. It's your vagina, it's your body part. So you should know how it functions. You should be connected. Our Oregon's have innate wisdom and knowledge. Uteruses are really sassy, little beings. Um, bladders bladders are very obedient. So an overactive bladder will actually do its best to calm down if you ask and if you communicate, so there's this innate wisdom and just being connected to your body instead of, you know, trying to ignore it because it doesn't feel like it's working, your body will never let you down on purpose. It's trying its best. It just needs a little help. So that's probably my biggest advice. Everyone, all women should know and deserve any kind of treatment and work for their body and to connect with their body.

Natalie: 55:06

What a good reminder to just recenter and find, find who you are, again, especially postpartum because you're new, you're a different person. Right.

Julia: 55:15

yes.

Natalie: 55:18

Okay. My next favorite question that I ask people, what is your favorite wellness habit that you incorporate into your own daily?

Julia: 55:27

Uh, well, I have the ball you gave me for my feet. Um, I don't do that when every day. I think the wellness habit I have every day is doing one thing every single day for self-care. So whether it's like taking a beautiful, I have the most spectacular bathtub and just lying in my bathtub with some kind of special, fancy holistic lavender or charcoal salts, um, excellent salt. Um, so I either do a bath or I do a restorative yoga or a meditation, even at the end of the day. If I fall into bed and go, oh, the holiday got away from me, I'll just do a five minute go to sleep meditation. Um, Eating. I eat very, very well. I spend a lot of money on buying really high quality foods. And my guilty pleasure is a little piece of chocolate every day. Um, dark chocolate, of course. And what else do I do? Um, and some days, you know, that whole part of doing something for me every day, the other day was just a shit show. And I opened a bag of chips and I poured it all in the bowl. And I sat down with my electric blanket cause it's cold here. And I like, I'm going to eat a bowl of chips and I'm not going to be guilty and I'm not going to regret it. I'm going to enjoy every tip I eat. And then I won't touch them for a while, but not, I don't, I don't breed myself for stuff like that. If, if I want something. Uh, or I feel like the bullet chips is going to be more soothing than actually having a proper cup of Volti. Then I might just do that. I don't do it often, but it's when one thing every day for me, just me, my self-care, and sometimes I've actually even really recognizing where I am in the day. And some days are hard. Like some days I just, I, I can every now and then I get very heavy patients and I had one last week and I ended up with a two hour nap and a bowl of chips. And it's, it was just because my heart was breaking and I let it get to me. I, I didn't ground enough. So that was on me because she's a beautiful, beautiful soul, but it's yeah. So just recognizing when, what you need when you need it and no guilt. It's mine. Yeah. It's all mine.

Natalie: 57:58

I love it. Thank you for sharing. So I'm sure we could talk about pelvic floor for many more hours.

Julia: 58:07

Dave.

Natalie: 58:08

we will days. Yes. I think we will. We'll have to do, we'll have to do another part, two part three, part four, whatever it is to this, but in the meantime, where can listeners find you online and how would someone book with you or communicate with you? Um, if they're, they're interested in that

Julia: 58:28

The big duke is that I, uh, I do not do social media. Well, I have accounts. You set up my ID account. I think I've posted three times. I,

Natalie: 58:40

I'm so proud of you for it.

Julia: 58:45

I, it just social media doesn't fill me up. So it's very hard to connect with me on social media. I have all the accounts and so you can follow me cause I, I promise not to invest. Um, every now and then I do post something, particularly if I'm in like a, a summit or something, um, or someone's got a really great summit going on, like, you know, retweet or repost, something like that. Um, so social media, you can follow. Most of the handles are just gives you excellent. The one on Twitter is spelled awkwardly with no C I think cause it physio expensive 17 letters. So it was too long. Um, but the website, uh, physio excellence.ca cause I'm in Canada, um, is the easiest way and info@physioexcellence.ca would be the email. Um, I am also not very good at responding to emails. So usually it takes me a day or two. So don't feel offended if I don't respond right away. Um, I, my, my belief is working in the clinic with people. My bliss is not on a computer, so I closed my computer very quickly. And uh, what else? Oh, and I'm in Toronto. So I'm in the west end of town. I actually work out at my house. So it's absolutely just so blissful. And so it's a very quiet, personalized clinic. There's just me here now. And, um, yeah, so it's quiet. It's easy. It's, it's great. Cause despite our restrictions, um, physio is considered essential service, so we've been open and because it's just me, my patients have been allowed to bring their babies or mom or husband to watch the baby in the other room while they get treated. So it's a little bit different than going to a big multidisciplinary clinic like I had before. Um, so that's really nice and homey and lovely. Um, but yeah, I just, I just think.

Natalie: 1:00:36

Well, thank you so much, Julia, for, for joining me and spending your time and energy today, talking about all of this, um, we will, we will definitely talk more in the future.

Julia: 1:00:47

We will. And now that I'm so proud of you, I, this I've always been proud of you, but the, you starting a podcast and broadcasting this message to even more women. I couldn't thank you enough because it's not something I will ever do. So I'm happy to come on. Anytime you want answer any questions your listeners have, because I'll never start my own podcast because that requires social media, computer stuff.

Natalie: 1:01:13

Well, I've got you. I've got you. We'll have you back.

Julia: 1:01:16

Perfect. I love it.

Natalie: 1:01:18

It was great. Having Julia on the podcast today, you can sense her passion for not only educating people about their pelvic floors, but her heart to help them heal as well. My top takeaways are number one, find a qualified PT in your area and book with them, regardless of what life stage you're currently in. Number two, you educate yourself about your body. As Julia said, it's yours and you deserve to know what's happening with it. And finally, number three, make sure you are taking a small part of each day to do something for yourself. No matter how little that thing is.