Healthy Wealthy & Smart

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Gina Kim, PT, DPT to talk about making the move from a physical therapist assistant to a physical therapist. Dr. Gina Kim is the owner of Maitri Physiotherapy, LLC in Central Ohio, the producer and host of The Medical Necessity Podcast, is certified in Integrative Dry Needling, is pursuing certification in MDT, and also uses her 10-year background in Tibetan Buddhism to educate her clients in mindfulness meditation. In this episode, we discuss: How to transition from a PTA to a PT What is a bridge program for PTAs The benefits of being a non-traditional physical therapy student The ups and downs of physical therapy school while juggling work and life commitments. And much more! Resources: Maitri Physiotherapy, LLC Dr. Gina on LinkedIn Dr. Gina on Instagram Dr. Gina on Facebook A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. More about Dr. Gina Kim: Dr. Gina originally wanted to play the trumpet when she grew up. Performance anxiety in high school changed her mind. But what was more worrying was the low back pain that began around that time. She endured that pain for years, but X-rays and muscle relaxers didn't help. She was fortunate to work with a physical therapist. Being free from back pain was so dramatic that she decided that's what she wanted to do with her life: Help people change their lives by treating pain, especially back pain, without drugs or surgery. She stated at the bottom as a rehab aide. Next, she earned her license as a Physical Therapist Assistant and worked for years in settings ranging from outpatient orthopedics to acute care to home health. While working as a PTA, she completed her Doctorate through the University of Findlay Weekend College Bridge Program. Dr. Gina is certified in Integrative Dry Needling, is pursuing certification in MDT, and also uses her 10-year background in Tibetan Buddhism to educate her clients in mindfulness meditation. She is also the producer and host of The Medical Necessity Podcast. Read the Full Transcript below: Speaker 1 (00:01): Hello, Gina. And welcome to the podcast. I'm so happy to have you on, Speaker 2 (00:06): Well, I'm happy to be here, Karen. Speaker 1 (00:08): So you've got two podcast hosts here. So now you're on the other side of the mic. Speaker 2 (00:15): Oh goodness. It's great to be. Speaker 1 (00:20): So today we're going to talk about sort of your non-traditional route to becoming a physical therapist. So as, as a lot of people know, or maybe some listeners don't know the physical therapy profession, we're now a doctoring profession. So people are going to school for an undergraduate degree and then usually going right into physical therapy school as their graduate school of choice. But Gina made a definite detour from college through to where she is now as a physical therapist. So I will throw it over to you, Gina, and just kind of tell us your story, because I'm sure it will resonate with a lot of people. Speaker 2 (01:04): Oh my goodness. So my bachelor's is in computer science and I won't say how long ago, but let's say windows 95 was the hot new thing. Everybody was getting a computer science degree. I was even, I was even a company's webmaster for a time. So here's the thing, here's the thing. I have zero patience for technology longstanding low back issues. Okay. And especially sitting at a desk job, you know, we all, you know, PTs, you know, now I, now I know well when I was working one particular job, you know, and couldn't take the back pain anymore. And what do I do? I go to see my, go, to see my family doctor and it's x-rays and muscle relaxers, and guess what? Didn't help shocker shocker. And I can't tell you how many years passed between then. And finally, someone I remember I had hired a personal trainer who was himself, a physical therapist, and he said, Oh, you need to see someone who really specializes more in the low back, you know, cause so sky was kind of more on the equipment sales end of things. Speaker 2 (02:38): So I found I found my PT and he it's it's so trite, you know, saying he did his magic on me. It's like, I know what he did on me now. But I went from unable to touch my toes. You know, being in pain, you doing, doing that shuffle walk too. Hey, I don't hurt anymore. Yeah. And his reaction was right. And I'm like, wow. And I kind of went away and being kind of in the transitional phase that I was in with a kind of not loving, you know, computer, you know, computer science, you know, that kind of field and also being kind of a gym rat myself. So I was hanging, I was hanging out with with my PT and kind of, you know, kind of doing my own observation hours and doing my due diligence and asking about the education and everything. Speaker 2 (03:46): And he said, well, you know, because I was already I think at that point out of my twenties, right. He S he said, well, you should think about getting, becoming a PT assistant. So I looked into that, it's like, okay, I've got my bachelor's let me go to community college now, which, which involved you know, of course there was like a well years waiting period. And, you know, so I'm taking my anatomy and this, that, and the other completed that in 2013 and then worked as a PTA and all the time thinking, you know, I, I just want to go ahead and be able to practice on my own. So then that led to well basically looking at my, looking at my options for grad school and especially being someone by this time, let's see, what was I doing? Speaker 2 (04:57): I, I was, I w I'm trying to think about my day as a, as a like during my PT assistant time, I was going to school and then going to work as a rehab aid. And that at night I was going to skate with the Ohio roller girls. It's like, I don't know how I did it. So then I'm thinking if I go into a graduate program in, you know, physical therapy, I there's going to be this age difference at age and experience difference. And I remember I interviewed with one school and the she was, she was the admission secretary. And I won't say which school, but she said, you know, people are working later in life. Speaker 3 (05:55): Yeah. Yeah. Speaker 1 (05:58): So I, Speaker 2 (05:59): I had heard about the bridge program up at university of Findlay. We can college bridge program. So that required preparation, as far as retaking physics taking, you know, my chemistry series, you know, thank goodness I had already taken exercise fits, but doing, you know, doing the thing so I could apply. And then that I got in, and at the same time, I was still required to work as a PTA as we went up to Finley every other weekend. And when I say we, I say, I met with my cohort from who came in from all across the country. So I had a two hour drive. There were people flying in from Seattle. Speaker 1 (06:51): And where is, so is Findlay college in Ohio Speaker 2 (06:55): And like colleges in North West. Speaker 1 (06:59): Okay. And can you explain a little bit more about what a bridge program is, should that people kind of understand what that means from like a PTA to a PT? Speaker 2 (07:10): Sure. So it's a bridge in the sense of you're a PTA and you want to become a PT, here's the thing. You will need your bachelor's degree. Okay. So I had that check you know, plus prerequisites, you know, check. And then since part of the requirement for working was to help with assignments that we would have, you know, and we would be given so we could focus more on the evaluation part of because we were all over the treatment part, you know, and there were people in my class who were already directors of rehab. So I, I was in a very very well-experienced and pretty, pretty smart class. It was, it was pretty intimidating. But also you get that benefit from, you know, all this co-mingling. So then it's basically like any other DPT program. It was three years, you know, with clinicals at the end, and then you take your boards and your, then I became dr. Dr. Gina. Speaker 1 (08:38): Right. And so within that, those bridge programs, how many of those programs exist in the United States? Speaker 2 (08:46): My understanding is only two, this one and one in Texas whose name is escaping me. Right. But but yeah, and here's the thing too because I always always kind of had in the back of my mind, well, I can always apply to the bridge program. It was, it was kind of like in my, in my back pocket, right. University of Findlay is a private school. So you also have to keep in mind the two wishes that goes with it, right. Plus travel accommodations, and also time off work when you need to, you know, do certain things, you know, such as your, your research and projects and, and all that. Right. Speaker 1 (09:38): And when it comes to then your clinical affiliations. So at that point, do you have to leave your PTA job in order to do your clinical evaluation or your clinical placements? Speaker 2 (09:50): Yes. And I would say it was a little messy because we were, we were pretty much we work, we were kind of responsible for finding our placements. Right. so yeah, so then you are going off, you know, working someplace now you don't have the income. Okay. So you have, you have that to deal with. And there were Oh, I don't even know how many people in my class had children, some had young children but you know, somehow they managed, you know we got a big heads-up from the class before us, you know, like in our orientation, spoke to us and said, you guys are gonna need a team to help you get through this. You have to rely on each other. You have to rely on your spouses, your partners, your friends, you know, some things as basic as have a food plan. And I'm not even kidding because, you know, between, between working, coming home and studying, you're done, you're done. You know, so my, my husband, you know, I, I started out, you know, like with the food prepping and the making the healthy food and every, by the end, we're eating pizza. Speaker 1 (11:26): Yeah. I was going to say, are you going to be, yeah, Speaker 2 (11:30): Can you, can you please, you know, pick up, pick up something? Yeah, Speaker 1 (11:34): Yeah. It's it's pizza and take out at the end. So I think that brings up a lot of really important considerations for people. So if you are a physical therapist assistant and you are looking to become a physical therapist, we know there are maybe just two bridge programs in the United States. And that there are a lot of considerations that you have to think about before you go into that program. Like when did you do your clinical placements? You kind of can't work at your job as a PTA anymore. Right? Absolutely. And what did you do? What would be your best tips for time management? We know, obviously you just gave away that by the end you're it's pizza and take out now I'm just joking, but what, what are some good tips on, on time management, as you said, you have to study, do research, and you're still working as a PTA. Speaker 1 (12:33): My, my time management, I think number one you know, God love him. I, you know, I have cats, I don't have children, you know, on it, honestly, I didn't know how the parents did it. And I think they were even better time managers than I was. So for them, it was, you know, working around, okay, the kids, the kids are in bed or it's before the kids are up. And for me, it was kind of the same thing. Like if I wanted to, you know, spend time with my, with my husband, you know, occasionally it would be up, you know, first thing in the morning because I'm more I'm and it also depends, you know, if you're morning person, evening person, you know, cause I'm like out like a light, you know, if I've got something to do, I'm up at 5:00 AM, no problem. Speaker 1 (13:32): And I guess the thing that I'm taking away here, and this, this might be my like naive T here, but I thought like a bridge program going from a PTA to a PT would be, I don't want to say easier than your traditional program, but that, because you're already in the field, that it would be easier. Do you know what I mean? And that's clearly not the case. Like I didn't realize it was three years. I thought, Oh, maybe it's like two years and most of it's clinical. So I think this is really painting a clearer picture for people of like, no, this is still a three-year commitment, three years of financial commitments, perhaps loans, everything else that goes along with it. Was there anything about the bridge program that surprised you? Because I'm surprised number one, that it's three years and that it's, you know, I don't, I don't know what I was thinking, but this was not it. So I'm glad that you're bringing all this up. So is there anything about the program that really surprised you? Speaker 4 (14:35): And on that note, we'll take a quick break to hear from our sponsor and be right back with Gina's answer. This episode is brought to you by net health, helping you maintain strong relationships with your patients. The redox patient portal provides secure line of communication between you and your patients conduct virtual visits and have follow-up conversations with your patients via secure messaging. When it's convenient for you, patients have 24 seven secure on-demand access to their therapy, health information without phone calls and voice messages, video conferencing for tele-health secure messaging, shared documents and photos and view health information, and appointments to learn more, contact them@redocatnethealth.com. Speaker 2 (15:23): Biggest surprise for me was for a program that had been a browned, as long as it had been that we still had to work around a university and kind of the cap, the system that I think really, really wanted us to be a traditional program, you know in the sense of, for example, I know after us clinicals were starting to be changed to, I think, get people into the field earlier, which was, which was, you know, once again kinda messing with people's employment. So they were, they were serving us, you know, would you prefer, you know, to do like two weeks at the beginning and we're thinking, well, how, how are we going to do that? If you know, our, you know, our clinic, our staff, you know, wherever we're working needs us. Yeah. Not that, not, not, not what you would have expected. Speaker 2 (16:32): And yeah, I guess the next question is and you sort of alluded to this when you said you were looking at other physical therapy programs and the woman said, Oh, well, you know, people are working later in life, but let me ask you, which is kind of an interesting thing to say, but what, what do you feel like, or would you feel that you're kind of coming into the doctorate of physical therapy, not coming straight out of high school or straight out of college? What advantage did that give to you? Coming into the field as a newly-minted DPT? I think it gave us a huge boost of confidence because I know that in, in my career, as a PTA, I worked for probably a dozen different PTs seeing how they worked you know, what what they could have done better, you know, what they did great how patients responded, you know, and plus you know, I've, I've got all my treating already, they're already in place. Okay. so I even, I even find it a little hard to imagine. Wow. If I were, if I were coming out of a traditional program and I've heard this spoken about a little bit of, you know, just trying to build that confidence in that first year. Well, I came out and it was kind of like, well, you know, I just had evaluations to what I'm doing. Speaker 1 (18:20): And when, let me ask you this, when you were a physical therapist assistant, what was your experience like as a physical therapist? Speaker 2 (18:31): It really depended on the PT. A lot of them, I felt had a lot of trust in me because they, you know, they saw that, you know, their patients were getting results and I had good rapport with them and, and so forth. Had a few, it became, it became a little more interesting once I was in school. Because I know there was, there was one particular person who he was, he was pretty fresh out of school and he seemed to want to challenge me a lot, like, you know, kind of like, you know, pop quizzes and, you know, things like that. It seemed a little light gatekeeping a little bit. But I mean, that was, you know, that was minor compared to, you know, the other the other PTs that I worked with. Speaker 1 (19:33): Yeah. Well, that's interesting. I know, cause I, I, I often wonder what that experience is like. And then, so for you moving from the physical therapist assistant to the physical therapist was all about having a little more autonomy and agency over your career, is that right? Absolutely. Yeah. And when you graduated, what were your, how did you feel then? So, you know, cause it's, it's, it was a difficult to make that transition. Did you kind of fall back into old habits after you graduated? Or was it more like I got this, I'm doing it, Speaker 2 (20:10): You know, I, I would think it, it really felt like I was ready for this. Now, the part that I didn't expect, and I think this was from my experiences in my clinical rotations as a PTA and then do it in doing it again as a PT and also couple of affiliations. They were kind of more in kinda more of those mill like settings. So I didn't go into PT school thinking I'm going to become a owner, but once I was finished, I was adamant that I needed to create my own career. Speaker 1 (20:57): And you knew that. So when did you graduate from physical therapy school? Couldn't get your DPT. Speaker 2 (21:03): So let's grow graduation was end of 2018. Yeah. And then test it for my boards in what was wow. May how, sorry, how soon we Speaker 1 (21:20): Forget. I know you seem to have blocked that out. Speaker 2 (21:22): Yeah. I'm sorry. April, April. Okay. Speaker 1 (21:25): Okay. So, so it sounds like the experience that you have previously really set you up to then say, I'm ready to, to become that entrepreneur. I'm ready to kind of do this. Speaker 2 (21:39): I think as far as mindset. Yeah. Still in our, our business class was kind of the classic. Okay. Let's write a business plan about how to build a brick and mortar clinic. So then the business knowledge some of, some of it I, you know, took away from the free resources on the AP TA website but being a solo clinician and cash based I felt that I needed to look for kind of more support, you know, as far as networking and, and all that. And because I was dealing with different issues than say a larger clinic with, you know, accepting insurance and several therapists and whatnot. Yeah. Speaker 1 (22:38): Right. So, I mean, and of course, like moving on through the business, that's a whole other discussion, which, you know, maybe one day we will have on here as well. But what I think it's important to note is that, you know, you mentioned it briefly is the mindset part of it. You're like, Oh, I had the mindset part and kind of skimmed over that. But that is so important because like I said, when I graduated from PT school, no way in hell, did I ever think I'd be able to own my own business? Just wasn't even on my radar, you know? So what advice would you give to, I guess, newer, newer grads, whether they're traditional or non-traditional like yourself who are thinking about starting their own practice Speaker 2 (23:25): To find people in and hang out with people who, who were doing what you would like to be doing, you know? Yeah, there were already folks in my class who, you know, they were, they were having their plans in place. Like one of them was going to be, become a partner in a clinic. You know, I mentioned several were directors of rehab someplace, another guy he already had, you know, his his athlete and sports training practice up. I mean, he was, I mean, he was running that well, he was doing everything else. Speaker 1 (24:07): Yeah. So it seems, I think what's so interesting is, is that sort of non-traditional path to physical therapy. It seems like it, you know, because people have already gone through so many life experiences or maybe different jobs and they feel like, boy, they're really ready to be in the space that they're in and own it. Yeah, absolutely. Yeah. Yeah. Speaker 2 (24:34): And I definitely, I definitely know that confidence was there. And even, and at the same time, I know of a few classmates, they were already looking at residencies, you know, they were looking at specialization. Speaker 1 (24:54): Yeah. So, I mean, I, so I think to my big takeaway here is to all of the more traditional PTs out there who maybe have a non-traditional student or a physical therapist in their class, or who are in class with people who may be were our, our physical therapists assistants and, and going for that DPT is to make sure that you seek them out and learn from them because they've got these life experiences that when you're 21 and 22, you just don't have, you know, and so seek those people out in your class and, and definitely learn more about them and learn where they're from and where they want to go. Because I think that as a, not as a traditional student, and when I say traditional, I mean, you know, you came out of high school, went to college and now you're in PT school is sort of straight linear track. That there's so much more that the non-traditional student can can offer because you've got some more life experiences under your belt. Absolutely. Speaker 2 (26:05): Let me add another point to that. As far as the confidence part, because especially working with older clients, they seem to have a little bit more comfort working with someone my age. Speaker 1 (26:23): Mm. Yeah. And yeah, that makes sense. Sometimes kind Speaker 2 (26:29): Of already assumed that I was a PT Speaker 1 (26:33): Working there even as you were a physical therapist assistant. Speaker 2 (26:41): Yeah. As I said, I was a student Speaker 1 (26:44): Yo, as you were a student. Yeah. Oh, that's interesting. That's interesting. Yeah, yeah, yeah. I didn't even think about that. So, so the, the confidence, not just that you exude, but that, that the patients can kind of feel it and yeah, that's interesting. Speaker 2 (27:01): Yeah. And also I think the the ability to quickly develop rapport and all those, all those good skills, you know, like listening and responding and, and hearing and seeing how people are presenting instead of, you know, being, you know, well, you know, I'm still learning these basic you know, I have to learn all the things I, I have to learn how to evaluate, you know, but also how to treat and progress and this, that, and the other I've already, I've already got the, you know, I'm already thinking ahead, you know, to what their course of treatment is going to look like, you know, because I've seen it. Right. Speaker 1 (27:47): Yeah. You've got the experience. Yeah. Yeah. And experience, as we know, is, is so important. So, so let me ask you as we start to wrap things up here. So I gave you what my biggest takeaway was, what's your biggest takeaway and what would you like the listeners to take away from, from our discussion of your journey of this, of being a non-traditional PT? Speaker 2 (28:10): My biggest takeaway. So you have the benefit of the non-traditional experience, you know, meeting all these people with different, you know, different knowledge bases and certifications and things like that. Also at the same time, there's a, there's a challenge to doing things such as, you know, say going to a conference, you know, like CSM, because you're, you have to think about, you're going to be in school when a lot of these events happen. So it's like you, if you really, really want to go, you have to plan, you have to make plans for it and, and, you know, get, get an excused absence, you know, for want of a better word. So that, that can really, I, I think you need to then really, really work on your networking when you're finished. I think because of that. Yeah. Speaker 1 (29:20): Yeah. That may be aware of that. Yeah. Yeah. Yeah. That makes a lot of sense. And then, you know, I'll ask you the same question I ask everyone, and that's knowing where you are now in your life and in your career. What advice would you give to your younger self? And let's not say when you graduated PT school. Cause that was like a year ago. So let's maybe go back little bit more like maybe when you graduated undergrad or something. Yeah. Speaker 2 (29:45): Back in the day. Not, not everyone who gives you advice knows what they're talking about. Speaker 1 (29:58): True story. Yes. Speaker 2 (30:00): Because that's how I ended up in computer science, which was not the right career path for you, which was not the right career path. Right? Yeah. So yeah, the thing, the thing that I wish I would have done a lot more of was extracurricular, so I could have, could have known myself a whole lot better. That's great. But to make, yeah. To make make a better guided choice. Speaker 1 (30:29): Mm great advice now, Gina, where can people find you? So first of all, talk about your podcast and then where can people find you? Speaker 2 (30:36): I would be happy to, so I am the producer and host of the medical necessity podcast where I help guide people through the flood of medical information out there. I love it. Yeah. Available on wherever you get your podcasts, pod, bean, Spotify iHeart radio at iTunes and my business is called my tree physio-therapy LLC. You can find me@maitri.physio. And I practice in Ohio. I'm licensed in Ohio. I bring a world-class world-class physical therapy to your home or via tele health. So you can, you can find me there and I would love to treat that Speaker 1 (31:36): Awesome. Well, we will have all of the links to everything at the show notes at podcast out healthy, wealthy, smart.com. So if you didn't, weren't taking notes, don't worry. One click will get you to everything, including your website and your podcast and social media as well. Jean has got a great Instagram page where she shares a lot of great free information with everyone. So you'll definitely want to check out her Instagram, what's your Instagram handle Speaker 2 (32:06): At medical underlying necessity. Speaker 1 (32:09): Awesome. So Gina, thank you so much for coming on. This was great. And I think it gives people a lot to think about, especially those physical therapist assistants out there who may be there on the edge, maybe they're thinking, Hmm. Do I want to go on? So I think you gave a lot of great information, a lot of great insights, so I appreciate it. Speaker 2 (32:30): Well, thank you. And I hope absolutely anyone who has questions about this bridge program, feel free to reach out to me. Speaker 1 (32:39): Awesome. Thank you so much. And everyone who's listening. Thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Smith, PT, DPT to discuss how women can cultivate their core confidence. Dr. Sara Smith specializes in assisting female leaders, healers & creatives re-activate their Core Confidence. Specifically, women who wear many hats and desire to leave a legacy with less burnout and greater personal joy. In this episode, we discuss: -How women focus attention on external approval and achievements/external successes. -Why we need to be connected, aware and in tune with our pelvis. -Messages the pelvis (and body) may be giving us that we are missing -Core Confidence-what it is. why it is so important -How does reducing urgency in daily life payoff- how the mental affects the physical body. -How mental and spiritual Core Confidence and awareness of our Core can affect physical core strength. Resources: Dr. Sarah's Facebook Dr. Sarah's Instagram Dr. Sarah's LinkedIN Activate Your Core Confidence Workbook Discover Your Joy Coaching Session w/ Dr. Sarah A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. More Information about Dr. Smith: Dr. Sara Smith specializes in assisting female leaders, healers & creatives re-activate their Core Confidence. Specifically women who wear many hats and desire to leave a legacy with less burnout and greater personal joy. Her unique approach focuses on connecting women back to their Core which holds authenticity, choice and immediate solutions so one can thrive both personally and professionally in all life situations. This activation is vital so that women leading their families, communities and companies can stay fully present in all situations in order to Communicate & interact authentically and calmly Finally feel their private life & success matches their professional success with greater freedom, confidence, peace, focus and direction. Flow through daily tasks and commitments with more focus, ease and an organized plan Improve physical strength & major health gains Live Wild & Bright- meaning! connected to our true, authentic, soul calling She has blended her professional expertise as a Doctor of Physical Therapy- specializing in Women's Health and Chronic Pain Management, Certified Yoga Instructor & Certified Wellness & Life Coach. With every personal & group experience Dr. Sara Smith offers, she is dedicated to the goal of assisting women of all ages to step back into their Core Confidence. Read the Full Transcript below: Speaker 1 (00:01): Hey, Sarah, welcome to the podcast. I'm happy to have you on, Speaker 2 (00:04): Thank you so much for having me, dr. Litzy. It's glad to be here. Speaker 1 (00:08): Yeah. And so obviously I'm a physical therapist as are you, you have specialized in pelvic health and women's health, and then you have also kind of made that transition for at least part of your career into coaching, mainly other women from around the world. So before we get into the meat of the interview, I would love for you to share with the audience a little bit about your sort of career trajectory. Speaker 2 (00:40): Absolutely. Yes. So it's a, it's a little professional and it's a little personal, so it's the story tends to track with a little bit of both. I also went and got my yoga certification and that was actually the first thing that I did after physical therapy, you know, from, from physical therapy. A lot of that came because you know, in our profession we have a high turnaround and burnout ratio there at times. And I was a chronic fixer and helper and I was good at what I was doing to the point where I, you know, anybody came in and I was ready to, you know, help them with their issue. And so I went to my first yoga class, really just to chill myself out, get a little bit grounded and get, get real. And then from there it really almost overnight, it, it drastically shifted the way I was showing up and treating my patients at the time. Speaker 2 (01:42): I realized that kind of less was more, I realized that it was more important for me to listen instead of coming in with a plan and, you know, my own action sheet and really meeting people where, where we were, I think I was always empathetic, but it, it really enhanced that. And on top of that, I stopped getting sick. I was averaging, you know, a sinus infection once a month and just burned out already and young because I didn't want to, you know, you didn't want to fail having that syndrome. So really yoga kind of came first and then that solidified me for a while. I kept into the physical therapy world. I've always lived in rural areas in Virginia and I was on the Eastern shore of Virginia and I'm an only child. So I do like to be the only one doing something I like to be a little special. Speaker 2 (02:40): And, and so I realized nobody in the area was doing pelvic floor work. I had in all of my internships had some sort of connection to pelvic floor and women's health work. So I, I learned about it. I kind of knew about it. I didn't know if that was something that I wanted to get into. But I knew that it was a niche in the area that I was in. And so it was when I got into pelvic floor physical therapy work that I really professionally started to see this and, and chronic pain management has always been something that I just love helping people that have been to lots of therapists, physical therapists, and in there need assistance with that. But I was just seeing this mind body connection. I was seeing how with all of these individuals, and for some reason, I just happened to be working with a lot of leaders, professionals, directors, CEOs, you know, it just was kind of happening that way. Speaker 2 (03:41): Even some like rockstars lawyers, I don't know, Olympic swimmers, all these different people and stress was also happening mentally. You know, there were things going on either in their personal life or their professional life. That just seemed to be kind of also coming into what I was noticing in their physical body. So I was learning about it personally and just my own interest. And then I also was seeing it professionally and I was seeing when I started incorporating some of the yoga, you know, some of the mindfulness based practices and stress management breathing that I was getting better results. And I just am a result junkie. You know, I'm not interested in putting a patch on something. I want somebody to come back to me six or seven or 10 years later and be like, I'm still using what you did. So there was that. Speaker 2 (04:34): And then on top of that what I got into pelvic floor therapy, my started having children and my, our, our first child who's now seven was we found out at a very young age that he had an ultra rare genetic mutation. So it was de Novo. It wasn't for my husband or myself and severe speech apraxia. So I started getting, you know, deep into the world of executive functioning and,ureally learning more and more about kind of, I always loved the nervous system, but, you know, I became even more fascinated with how to manage that,uand, and work with it. And so that, those two things kind of happening simultaneously are what brought me into, into coaching. Umnd specifically working with female leaders, hecause that, I don't know, that's just like a deep within personal mission is I feel like women are here to make a major contribution. Speaker 2 (05:42): I feel like the time, the time is ripe, the time is now. But we've learned and write in it in a great way. We've learned from a very male dominated structure,uwhich doesn't always work for women. And,uit can, it definitely works. It's not that it's, you know, not working, but there, there are some things that need to slightly shift and,uI'm just, I really want to be able to contribute to women, being able to be in these leadership roles and do it without as much burnout do it without as much self-sacrificing,ufamily sacrificing community sacrificing. Uso yeah. Speaker 1 (06:32): Awesome. Well, thanks for that. Thanks for kind of letting the listeners get a little bit deeper into kind of who you are and why you do what you do, because it all leads into our discussion today. And it's, it's really all about as you say, why we need to be connected, why we need to be aware and in tune with our pelvis. So as a physical therapist, we can all agree that yes, we need to be in tune with that area. Everyone has a pelvis, everyone has that musculature and, and the functions of but coming from, I think your unique perspective of both physical therapist and coach and looking really beyond just the pelvic floor, which we should all be doing anyway. So, so give us your take on why we need to be connected. Speaker 2 (07:25): Yeah. You know, I've seen in, in the realm of success, leadership, entrepreneurship anybody who's, who's type a you know, th there's a lot of overthinking long to do lists. There's a lot of being up in our head, you know, w where do we go next? And I say, we, because this, you know, I've, you're only a great teacher if you've been there yourself, right. And, and are still in the depths of it. And so, you know, we th there's lots, that's constantly swirling up in our head, but we also know, and, and, you know, a variety of different resource research sources have shown us this, that we can't access all of the solutions to our biggest professional, personal life challenges. If we're in constant thinking mode all day long, not to mention, you know, roughly 80% of all thoughts are habitually negative, which is not very helpful for solving problems. And so the reason that I am so drawn to what I call, you know, well, it's not just me calling it a core confidence and getting people specifically into their pelvis and back into their body is, is reducing the overthinking so that we can access again, creativity, focus, productivity, you know, improved, sleep, stress, relieving, you know, hormone responses. You know, I could, I could go on and on. Speaker 1 (09:01): Yeah. And so you brought up the, the the words, core confidence. So can you explain what, what does that mean? Because I have a feeling it may mean a couple of different things to a couple of different people, but in the work that you do in helping people become more productive, improve their leadership, improve their life, what does that, what does core confidence? Speaker 2 (09:28): Yeah. I love how you said that, you know, it means something to, there's lots of different ways to describe it in there. There really is. You know, to me, and also the, the clients that I've worked with for many, many years now, it means freedom. It means expansiveness. It means seeking joy. It means effectively, you know, being effective at what they do. Meanings means also having more energy core confidence really is being able to go within yourself and access that wellspring of inner wisdom really access your, your yes or no. And a lot of times, and this is, this is actually comes from, from those in the research field. Core confidence also is a mixture of self-efficacy of hope of optimism and resilience. External confidence. I don't think we should be talking about core confidence without also touching on external confidence and external confidence is what the majority of us learn to, to seek after. Speaker 2 (10:43): And we're constantly seeking after it. The external confidence is, you know, does dr. [inaudible] Like me, or, you know, what I should be doing right now, or, you know, these are the, the, the dreams that, that others are doing. So this marketing strategy has worked for them. This app has worked for them, let me do this, let me, you know, follow this meal plan. And so, you know, we're constantly as humans chasing others, things that have worked for them. And, and we're very often, again, not realizing we're up in our head and we're not really checking in with the, the little voice that's like, that's kind of a waste of time. Speaker 1 (11:32): Yeah, totally. I, I always find that it's so much easier to look for that external validation and get our confidence from that external validation, then what we do than what we think we are doing. Does that make sense? Solutely yeah, so I, I mean, and, and we're all human and all humans fall into that trap. So can you kind of give us an example of how you might work with someone to help develop this core confidence and help to bring in more joy and help get them a little more grounded into themselves? Are there any sort of exercises or things that you do with people that you can give this as an example? Yeah, Speaker 2 (12:15): That's a, that's a great you know, I I'd say one of the main tips that I, that is probably ended up being my, my signature Sarah move,uhas been really, you know, so listening to somebody, I really love deep listening. I mean, I think when you start listening to someone, at least for me, I don't know this is, this is, h gift that I have is I start reading between the lines. Umnd actually I'm kind of diverting for a moment. A lot of times when I work with people, I don't do it over zoom. We don't do video. Umecause when you look somebody in the eye, sometimes it's hard to be a hundred percent truthful, you know, or again, you kind of fall into the, the external competence trap. Umnd so we do it all over the phone or, you know, with the video off so that I can really deeply listen. Speaker 2 (13:09): And what I'll do is, you know, if there's a belief in there for example, I was working with somebody the other day and she shared, you know, while we were talking about her personal life. And and she was like, you know, if I kind of keep having these, these, if I close the door on this relationship, I'm probably actually going to have to do a lot of hard work on myself to pick up the pieces. And what I asked her was, well, well, is that true? That working on yourself has to be hard. Speaker 1 (13:47): And when Speaker 2 (13:47): We, I call it, like, we've got to, we've got to go. I like going down the rabbit hole with somebody of like, really being like, why, why are we fearful about this? Like, let's, let's talk about it. Let's get to the root and let's shine the light on what, what the narrative is with this overthinking piece. Once we shine the light on it, half of the work is done because we've brought in awareness. And whenever you bring in awareness works time. Speaker 1 (14:18): Absolutely. Yeah. And it's, it's, you know, that you're right. Being able to listen and listen well is a gift, but it's also something luckily that can be practiced and can be worked upon as physical therapists. I think a lot of us, a lot of us are pretty good at listening. But when you work with, like you said, that chronic pain population, you really get, I think, a lot more in tune to what the person is saying. And you also learn how to ask those questions to draw out more thoughts. Speaker 2 (14:54): Absolutely. Yes. And here's the interesting thing that I've found. Okay. and, and I, a lot of this comes from like archetypes and youngian psychology is we have different aspects of our, of our psyche and of our personalities. Right. And a lot of times what you'll find is we learn these skills, we practice these skills professionally, but when it comes to the, behind the scenes for ourselves, we're almost like different people. I had a client the other day, you know, she is a director and has, has a large, very well-known board behind her. And and she's like, you know, if the board was to be a fly on the wall and kind of experience my personal life, they they'd be like what, you're not even the same person. Because suddenly things become matters of the heart. They're no longer again, the, the head, you know, so professionally relating people through this very well yet, we're not really sometimes having that, that advisor, that best friend, that we didn't even know we needed behind the scenes to help us hash out our own stumbling blocks. And that's where I think in, in leadership and entrepreneurship and being a CEO of, you know, your business and your life and trying to be healthy, wealthy, and smart, I think that's, we need that now. Speaker 1 (16:22): And why do you think that's so hard Speaker 2 (16:24): To, Speaker 1 (16:27): To confide in others of, you know, it's, it's a lot easier to say, Oh, you know, I, I didn't have any new patients this month. So, you know, I really w what do you think, how can I help? How can I get more patients? That's easy, right. To talk about our business and, and to talk about our our professional life. But why do you think it's so hard for people to confide in others on a more personal level? Speaker 2 (16:55): Hmm. I love this question. I really love it. Of course, I'm sure it's very multifactorial. I find that I don't, you know, I don't have any research on this, but I find that if you start looking back even into it and not like massively, but you start looking back into childhood, you know, where a lot of habitual patterns are formed and thought patterns are formed. A lot of times you'll see, you'll see trends there, but, you know, one vein of research shows that about half of all CEOs, those at the top are experiencing loneliness and loneliness in the sense that, you know, there has to be a level of healthy ego and confidence, right? B core confidence or confidence in order to want to succeed. You know, all sorts of people are teaching us out there and showing us that, you know, you gotta have some grit, you gotta have some resiliency if you wanna play this game. Speaker 2 (18:01): And it is a game. And so, you know, there there's factors of like, you can't trust everyone, right. If you have team members underneath of you traditionally that's really changing, I think, but traditionally we're taught, you know, you don't mix business and personal life. You don't do that. That's a no, no. Now you'll see that changing. And that's continuing to change because you know, many psychologists are beginning to study really resiliency and entrepreneurship and, and understanding more specifically how they're tied together, because it's, th that's really just a new field of, of understanding. He can't trust people, you know, and I think many have experienced, again, maybe it was in the past or more recently you know, you do share some of those personal moments and it might come back to bite you or suddenly the, the inner critic and other thought thought in the brain comes up and says, Ooh, that was not a good idea. You're probably that is going to backfire. You know, that could make you look weak. So I think it's very multifactorial. Speaker 1 (19:16): And I guess this is kind of where having someone, you know, outside of your direct business to have as a resource and to help you as a coach I guess I would, I'm assuming that that's where coaching comes into play, because you can kind of be that person to sort of help with the personal and the professional, because I can only assume that they're closely related. Speaker 2 (19:44): Right. They are way more closely related than people realize. And your professional self that like the way you act professionally is often different than the way you act and your personal life. Like, can you, can you relate to that? Speaker 1 (20:02): Yeah, of course. Okay. Speaker 2 (20:05): And so, you know, cause I, I, yeah, same thing for me too, but I'm always interested, you know, in what, what somebody, his answer would be. Speaker 1 (20:12): Yeah, no, there's, there's no question that, that we're a little different in our personal life than in our professional life. And, you know, it's funny to say, because I was having thoughts around that yesterday. Because you know, we're all human, right? Every once in a while, like we screw something up, we say something we didn't want to say we regretted afterwards. And yet you're vilified for being a human being. You're vilified for saying something that, yeah, like maybe what you said, wasn't the best thing to say, but you take ownership over it. You say, Hey, listen. Like, yeah. I mean, I, you know, I let my emotions get the best of me, which never ever happens in my professional life. Right. Right. In my professional life never happens. And yet all of a sudden you're demoted in the eyes of so many people, but all you did was you were just a human being and you said something, or you wrote something that you later like, ah, I can't believe I did that. And because it's not a podcast, we can't go back and edit it out. So I think that there is this, this weird kind of, if you start to melt the two together, you're going to be screwed. Speaker 2 (21:33): Yeah. It's a way or another, it's a belief. Absolutely. And I think that we need guidance to blend them appropriately, you know, because the answer is not, well, you'll see this as a marketing strategy now. Right. Where it's like, okay, show the behind the scenes and show yourself and be yourself and dah, dah, dah. Well, I think that there's always a, a middle ground to all of that, that we need to be aiming for. And again, it has to feel true to you, you know, like you have to get back into a state of checking in with yourself and not checking in with the head and the thoughts of like, okay, is this an alignment for me? And so, you know, in a lot of cases when you're blood, when you're, I like drawing on the professional self, like let's say, I might say, okay, what would professional dr. Speaker 2 (22:23): Litzy do when we're talking about something personal, because that's how the, the, the two aspects of you can really start blending together and start working together as a team and be like an integrated, whole healthy, beautiful person, right. Uwho can stay true to your individual values? You know, we get to like explore what those individual values are and being true to those,uin, in order to make it work for us, I've ever really cool example of a client who,ushe's in the hospital system and I'm pretty high up. And she was offered. We had been working for, I don't know, probably three to six months or something we'd been, she had been, and we were mostly working in the personal field, you know, but of course the professional always, always blends in. And she had been offered this incredible opportunity to lead this team. Speaker 2 (23:25): This was just in addition to her goals that she already professionally had for the year. And as she sat with that, and as I sat with that with her, she realized, you know, if this had been last year, I would have said yes to that. And I'm very flattered, but the truth is, is if I say yes to that, then all that I'm doing to take care of myself so that I can show up to meet my professional goals is actually going to be derailed. And so at that moment, it wasn't in alignment for her. And what was even better about that was then she was able to go to her boss and to communicate that I call it like, you know, communicating from the core, but communicate that not from up in the head like, Oh, no, I wonder what I'm doing. I hope, you know, hope I'm not really screwing this up, communicating it with authenticity, with crowdedness, with strength, right. With empowerment. And, you know, her superior was like best decision you ever made. I really appreciate it. Really championed to her now, how awesome would that be if we could have more of that in our small businesses and in all of our workplaces and all of our organizations, Speaker 1 (24:43): I mean, that's an ideal situation when the ideal situation, but I think it's hard when you're constantly kind of seeking out success and seeking to be quote unquote the best at what you do and to get that recognition and to build your business and to make more money. So you can live the lifestyle that you want to live and provide for your family or your friends or whomever is in your, your world. But how does, how does making these decisions, like you said, these sort of more grounded decisions where, where they are emotional versus making these decisions as strictly like pros and cons, like an intellectual pro and con list, you know what I mean? So how do you, how do you coach people in that tug of war? Speaker 2 (25:41): I hope I can answer the question of how do you coach people, because sometimes you just have to see it, you know, and experience it. But you know if you look, if you talk to anyone in the financial world, the stock market is emotional emotions drive everything. That's true. Right. And you know, if we're the faster, we're aware of that, the more tapped in that, that we're going to be. And so that's actually, what's happening is a, is a lot of times where we're making these leadership decisions, we're making these personal decisions when we're in a state of emotion. And often when we're, you know, emotions are coming from thoughts, right. You know, you know, the, the, the little wheel starts going and then suddenly, you know, we have these emotions with us. A lot of times you don't even know what the sensation is in the body, because we're, again, we're kind of more of in the head. Speaker 2 (26:36): And so when you can access, and what I do is often just really helping somebody with very challenging. Like I prefer the challenging situations, you know, where it's like, okay, why do I keep getting into this relationship? Why do I keep not, you know, being able to climb the ladder? Why is it I can't get, get know fit in the self-care pieces of it. And when we get to the root of it, a lot of times it's because things are happening in an emotional realm. And we've got to be aware of that, go down the rabbit hole of the actual, like fear and worry. And why, like, why are we responding the way we're responding? Why are we doing that? And then once you get to that, then you can actually get to the clarity piece where you get the clouds and the, you know, the fog out from your face. Right. You can go, okay, pro this con this dah, dah, dah, dah. Okay. Now I've got my marching orders go. And I, I don't know about you, but I like marching orders. I like to know the next step. Speaker 1 (27:37): Yeah, absolutely. And, and I think, you know, a lot of people who are in leadership positions or who are going out to be that entrepreneur, their dreams, like you are a type a person. I think you are a lot of just pros and cons. But I do think that the emotional segment of things does have to come into play because if your pros and cons from a very sort of robotic sense is, is okay, I guess, but then how is it going to make you feel, how is it going to affect your life? Are you going to be happy with your decision? Are you doing something because you feel pressure to do it because you have to do it, quote unquote. So I think being able to tap into that core confidence in that and your core values in order to help you make decisions is important. So it's like, I don't want to be on either pole, like purely emotional, purely cerebral, but you want to have, you want to be able to kind of get in there and go down that rabbit hole, which is not easy and takes a lot of self-awareness. Speaker 2 (28:44): Yes, no, it does. And that's why it usually takes a guide. Yeah, exactly. It really does. It takes a guide and you know, again, kind of that core confidence model that was not created by me, but having self-efficacy hope, optimism and resiliency, you know, these are things with, with a lot of difficult situations that, that our, our brain just has not been able to figure out the answer to. We tend to go down on the scale of those things, right? We're not trusting ourselves efficacy. We're not feeling very hopeful about it now, fascinatingly enough, you know, those that are fixers and types day and, and, and leaders if we can't fix something, if we don't know the solution to it, we're going to avoid it Speaker 1 (29:25): Totally a hundred percent. So it was easier and it's so much easier. Speaker 2 (29:30): We are to, to help and to show up for others and to fix the things that we know we can fix. And so again, then you see an imbalance and often times it's with the most challenging things that dealing with, again, personally, or professionally that we don't want to talk about. One of my clients, the other day was sharing,uyou know, this situation just resolved, but she was like, you know, I have been sitting on this,uspace like this, this land and space for the last 10 years. And I didn't know what to do with it. Now, when we got to the root of it, it was actually extremely emotional because she's in a family owned business. And it was something that a family member prior to her set up and, you know, really loved. And so it, it, it, it was way too. She couldn't make the decision because of the emotions connected with it. Uyou know, but she was like, I've been sitting on this forever and just avoiding it because I don't know what to do. So I can think of 50,000 other things to spend my time doing. You know, you can fix the kids, you can fix your friends, you can bring it into your professional career. And then meanwhile, some of the, you know, the other aspects are, are, are missing. Speaker 1 (30:44): I know I, when I get into those, those bouts of, Oh God, I can, I like will. And it's what I'm doing right now, which is why, when you said that you could do so, so many things to avoid. I'm like redoing my bookshelves, I'm doing some shredding of papers. I'm like crazy with the home edit. And now everything's in a rainbow, you know, I've got a lot of plastic bins hanging out everywhere. That's what I do when I'm trying to like, avoid looking at deeply at other things, you know? So that's what I've been doing for the past couple of weeks is I have been like cleaning out. Like my doorman was like, are you moving? I was like, Nope, not moving. Just, just finding stuff to do around the apartment. Speaker 2 (31:30): Exactly. Just being a great, you know, leader in the liver of life. Speaker 1 (31:35): Yeah, exactly. Cause I'm like, well, you know, if you come home to a nice clean apartment, it's better for your head. You can concentrate more when, you know, I probably need to go dig a little deeper and see, why am I doing all of this? And I know it's not just from watching the home edit, although it's a nice show. I'm sure it goes a little deeper. Speaker 2 (31:56): Well, it does, you know, and I'm glad you brought that up, you know, your, your personal situation, because I think that that helps all of us so much, you know, it's always nice to know when we're not alone. Right. And but you know, one of the biggest things that I've found in doing this work for as long as I have is people say to me, yeah. You know, I just, you know, everything you do sounds really great. Like that sounds awesome. It sounds like it really be helpful for me. And like, I don't really think I will, but I don't really think I want to go there. Uand we think, again, we think it's going to be hard, right? Like I was mentioning the client, the client earlier,u Speaker 3 (32:40): I have found that, Speaker 2 (32:44): And I think this is just my personality, but it's like, we got to make this fun and we gotta make this. Or action-oriented we kinda got to get the show on the road. So it's like, you know, again, if, if we're, if we're trying to leave a legacy, if you're trying to, you know, be productive and not give up on the idea that we have, you know, have success, then we are in a state in our country and in the world where, where we, we, yes, we can all, you know, afford to sit down on the couch with the weighted blanket and the wine and the ice cream, you know, but, but I just don't believe that, that we can afford too much of that anymore. I really don't, you know, like I, I need, I really feel so strongly that like, I need everybody to be functioning at a high level and it, it can be fun. Speaker 2 (33:40): It doesn't have to be like, Oh gosh, I'm, I'm, doesn't have to be so stressful. Yeah. Or like annoying, you know what I mean? Like, nobody really wants to like, look at themselves and see their shortcomings. And it's not about that. Like anybody that's trying to tell you it's about that. Th that's probably just perfectionist behavior showing up. It's not about that. It's about like, you've got to tap into your greatness. And when I say your greatness, meaning like just our essence, like our purpose of being here on earth, like something greater than ourselves, we've got to tap into that. We've gotten away from that. You know, that, that radical act of self-love that that's not just let me go draw a bubble bath. You know, that that is radically like, you know, we're all beautiful and we're here to share something great. Speaker 2 (34:37): One of the, one of the most upsetting thing, NGS, m don't know if you've ever experienced this, but, you know, as a physical therapist, when somebody has, host a limb or their pelvic floor is not working and they're upset with, you know, they have prolapse and they're like, Ugh, Ugh, this uterus, or, you know, gosh, my arm just looks awful. Now that pains me to my soul because I'm like, Oh, you know, like, gosh, your body has done so many miraculous things. I understand. And I empathize why you feel that way, but it, it makes me sad. And one of the things that has made me sad and being, you know, an advisor and a best friend to, you know, leaders who didn't even know if they needed that. Um,e of the things that makes me sad is when somebody comes to me and they're willing to just for a second share, I don't know if I can keep doing this anymore. Speaker 2 (35:35): I've thought about just giving it all up and going back to a simpler way of life and the same sort of thing. It makes me sad. Cause it's like, no, no, no, no, no, we don't. We don't have to do that. Like, you know, you, we don't have to, we just have to find some balance, right? Like you said, we don't need to be on one extreme. We don't need to be on the other extreme. We need to be somewhere in the middle and finding that is like super, super small finite changes. It's not the giant crazy things that changes that we like to make in our lives that we, you know, we think are going to be the solution. Yeah. Speaker 1 (36:10): I, I agree a hundred percent. And I think on that note, because I could keep talking about this all day. It's sadly, I don't know if the listeners want to listen to it all day. I'll do. I think they might. But I feel like we could keep going on and on here. But that being said before we wrap things up, just a couple of other things, number one, what, what are some of the big takeaways, or if there's one in particular takeaway that you want the listeners to leave this conversation with? Speaker 4 (36:46): Wow. Speaker 2 (36:47): I wasn't prepared for that. Dr. Lindsay. There is what I would say. The big takeaway that I really hope everybody understands is that when we get out of our head a little more often and start listening to the messages of the body, start listening to the messages of within then we really activate that core confidence. We step into a more effective way of leading and living and that's available to everybody and it's time to take it. Beautiful. Speaker 1 (37:26): That's a beautiful takeaway. Now you're welcome. And then of course, the last question that I ask everyone is knowing where you are now in your life and in your career, what advice would you give to yourself right out of PT school, a newbie. Speaker 2 (37:42): Ooh. Oh, this is, this is a fun one. So when I was in PT school, I knew PT was going to be a jump jumping off point for me. Ubut I, I didn't feel confident in that. And so honestly, what I would have said to myself then is, you know, yeah, you're a little bit of a fish. Speaker 1 (38:06): Yeah. You're doing things a little bit differently Speaker 2 (38:08): And it's okay. Just own, own your worst, keeping you which I'm sure I've always been doing, you know, but, but really telling myself that and gifting that to myself, that it's okay. It all starts lining up just one step at one step at a time. Speaker 1 (38:25): Awesome. And where can people find you? So social media or what's the best way? Yeah. So the best to get in touch with you, Speaker 2 (38:36): There are just so many ways to get, to get in touch with me. Of course social media let's see Facebook and Instagram is dr. Sarah Smith official. I'm also on LinkedIn, dr. Sarah Smith. It is Sara without an H. Usually people always are putting an H on my name, which is like, Speaker 1 (38:52): Denise is a Sara without an H. So I am very well aware of it. Speaker 2 (38:56): Thank you. And then www dot dr. Sara, D R dr. Sarah smith.com awesome. And website. Speaker 1 (39:06): Perfect. And we will have all of those links up at the podcast website podcast at healthy, wealthy, smart.com under this episode. And you saw, you also have an activate core confidence workbook that dr. Sara has so generously given as a free gift. So if you go to www.dot dr. Sarah smith.com/core hyphen confidence, did I get it right? You did. Perfect. And again, that will also be in the show notes, if you want your free gift from dr. Sarah, which is very generous. Thank you very much for all of the listeners, go and grab it from the show notes. So Sarah, thanks so much. Like I said, I could talk about this forever. It'll turn into a therapy session and that's not what you're doing here. I will not take advantage of you in that way. Speaker 2 (39:57): We can, we can do it at that. Speaker 1 (40:03): Thank you so much for coming on and sharing all of your knowledge. I appreciate it. Speaker 2 (40:07): Oh, you're so welcome. Thank you for having me. Speaker 1 (40:09): Of course. And everyone listening. Thanks so much. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Smith, PT, DPT to discuss how women can cultivate their core confidence. Dr. Sara Smith specializes in assisting female leaders, healers & creatives re-activate their Core Confidence. Specifically, women who wear many hats and desire to leave a legacy with less burnout and greater personal joy. In this episode, we discuss: -How women focus attention on external approval and achievements/external successes. -Why we need to be connected, aware and in tune with our pelvis. -Messages the pelvis (and body) may be giving us that we are missing -Core Confidence-what it is. why it is so important -How does reducing urgency in daily life payoff- how the mental affects the physical body. -How mental and spiritual Core Confidence and awareness of our Core can affect physical core strength. Resources: Dr. Sarah's Facebook Dr. Sarah's Instagram Dr. Sarah's LinkedIN Activate Your Core Confidence Workbook Discover Your Joy Coaching Session w/ Dr. Sarah A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. More Information about Dr. Smith: Dr. Sara Smith specializes in assisting female leaders, healers & creatives re-activate their Core Confidence. Specifically women who wear many hats and desire to leave a legacy with less burnout and greater personal joy. Her unique approach focuses on connecting women back to their Core which holds authenticity, choice and immediate solutions so one can thrive both personally and professionally in all life situations. This activation is vital so that women leading their families, communities and companies can stay fully present in all situations in order to Communicate & interact authentically and calmly Finally feel their private life & success matches their professional success with greater freedom, confidence, peace, focus and direction. Flow through daily tasks and commitments with more focus, ease and an organized plan Improve physical strength & major health gains Live Wild & Bright- meaning! connected to our true, authentic, soul calling She has blended her professional expertise as a Doctor of Physical Therapy- specializing in Women's Health and Chronic Pain Management, Certified Yoga Instructor & Certified Wellness & Life Coach. With every personal & group experience Dr. Sara Smith offers, she is dedicated to the goal of assisting women of all ages to step back into their Core Confidence. Read the Full Transcript below: Speaker 1 (00:01): Hey, Sarah, welcome to the podcast. I'm happy to have you on, Speaker 2 (00:04): Thank you so much for having me, dr. Litzy. It's glad to be here. Speaker 1 (00:08): Yeah. And so obviously I'm a physical therapist as are you, you have specialized in pelvic health and women's health, and then you have also kind of made that transition for at least part of your career into coaching, mainly other women from around the world. So before we get into the meat of the interview, I would love for you to share with the audience a little bit about your sort of career trajectory. Speaker 2 (00:40): Absolutely. Yes. So it's a, it's a little professional and it's a little personal, so it's the story tends to track with a little bit of both. I also went and got my yoga certification and that was actually the first thing that I did after physical therapy, you know, from, from physical therapy. A lot of that came because you know, in our profession we have a high turnaround and burnout ratio there at times. And I was a chronic fixer and helper and I was good at what I was doing to the point where I, you know, anybody came in and I was ready to, you know, help them with their issue. And so I went to my first yoga class, really just to chill myself out, get a little bit grounded and get, get real. And then from there it really almost overnight, it, it drastically shifted the way I was showing up and treating my patients at the time. Speaker 2 (01:42): I realized that kind of less was more, I realized that it was more important for me to listen instead of coming in with a plan and, you know, my own action sheet and really meeting people where, where we were, I think I was always empathetic, but it, it really enhanced that. And on top of that, I stopped getting sick. I was averaging, you know, a sinus infection once a month and just burned out already and young because I didn't want to, you know, you didn't want to fail having that syndrome. So really yoga kind of came first and then that solidified me for a while. I kept into the physical therapy world. I've always lived in rural areas in Virginia and I was on the Eastern shore of Virginia and I'm an only child. So I do like to be the only one doing something I like to be a little special. Speaker 2 (02:40): And, and so I realized nobody in the area was doing pelvic floor work. I had in all of my internships had some sort of connection to pelvic floor and women's health work. So I, I learned about it. I kind of knew about it. I didn't know if that was something that I wanted to get into. But I knew that it was a niche in the area that I was in. And so it was when I got into pelvic floor physical therapy work that I really professionally started to see this and, and chronic pain management has always been something that I just love helping people that have been to lots of therapists, physical therapists, and in there need assistance with that. But I was just seeing this mind body connection. I was seeing how with all of these individuals, and for some reason, I just happened to be working with a lot of leaders, professionals, directors, CEOs, you know, it just was kind of happening that way. Speaker 2 (03:41): Even some like rockstars lawyers, I don't know, Olympic swimmers, all these different people and stress was also happening mentally. You know, there were things going on either in their personal life or their professional life. That just seemed to be kind of also coming into what I was noticing in their physical body. So I was learning about it personally and just my own interest. And then I also was seeing it professionally and I was seeing when I started incorporating some of the yoga, you know, some of the mindfulness based practices and stress management breathing that I was getting better results. And I just am a result junkie. You know, I'm not interested in putting a patch on something. I want somebody to come back to me six or seven or 10 years later and be like, I'm still using what you did. So there was that. Speaker 2 (04:34): And then on top of that what I got into pelvic floor therapy, my started having children and my, our, our first child who's now seven was we found out at a very young age that he had an ultra rare genetic mutation. So it was de Novo. It wasn't for my husband or myself and severe speech apraxia. So I started getting, you know, deep into the world of executive functioning and,ureally learning more and more about kind of, I always loved the nervous system, but, you know, I became even more fascinated with how to manage that,uand, and work with it. And so that, those two things kind of happening simultaneously are what brought me into, into coaching. Umnd specifically working with female leaders, hecause that, I don't know, that's just like a deep within personal mission is I feel like women are here to make a major contribution. Speaker 2 (05:42): I feel like the time, the time is ripe, the time is now. But we've learned and write in it in a great way. We've learned from a very male dominated structure,uwhich doesn't always work for women. And,uit can, it definitely works. It's not that it's, you know, not working, but there, there are some things that need to slightly shift and,uI'm just, I really want to be able to contribute to women, being able to be in these leadership roles and do it without as much burnout do it without as much self-sacrificing,ufamily sacrificing community sacrificing. Uso yeah. Speaker 1 (06:32): Awesome. Well, thanks for that. Thanks for kind of letting the listeners get a little bit deeper into kind of who you are and why you do what you do, because it all leads into our discussion today. And it's, it's really all about as you say, why we need to be connected, why we need to be aware and in tune with our pelvis. So as a physical therapist, we can all agree that yes, we need to be in tune with that area. Everyone has a pelvis, everyone has that musculature and, and the functions of but coming from, I think your unique perspective of both physical therapist and coach and looking really beyond just the pelvic floor, which we should all be doing anyway. So, so give us your take on why we need to be connected. Speaker 2 (07:25): Yeah. You know, I've seen in, in the realm of success, leadership, entrepreneurship anybody who's, who's type a you know, th there's a lot of overthinking long to do lists. There's a lot of being up in our head, you know, w where do we go next? And I say, we, because this, you know, I've, you're only a great teacher if you've been there yourself, right. And, and are still in the depths of it. And so, you know, we th there's lots, that's constantly swirling up in our head, but we also know, and, and, you know, a variety of different resource research sources have shown us this, that we can't access all of the solutions to our biggest professional, personal life challenges. If we're in constant thinking mode all day long, not to mention, you know, roughly 80% of all thoughts are habitually negative, which is not very helpful for solving problems. And so the reason that I am so drawn to what I call, you know, well, it's not just me calling it a core confidence and getting people specifically into their pelvis and back into their body is, is reducing the overthinking so that we can access again, creativity, focus, productivity, you know, improved, sleep, stress, relieving, you know, hormone responses. You know, I could, I could go on and on. Speaker 1 (09:01): Yeah. And so you brought up the, the the words, core confidence. So can you explain what, what does that mean? Because I have a feeling it may mean a couple of different things to a couple of different people, but in the work that you do in helping people become more productive, improve their leadership, improve their life, what does that, what does core confidence? Speaker 2 (09:28): Yeah. I love how you said that, you know, it means something to, there's lots of different ways to describe it in there. There really is. You know, to me, and also the, the clients that I've worked with for many, many years now, it means freedom. It means expansiveness. It means seeking joy. It means effectively, you know, being effective at what they do. Meanings means also having more energy core confidence really is being able to go within yourself and access that wellspring of inner wisdom really access your, your yes or no. And a lot of times, and this is, this is actually comes from, from those in the research field. Core confidence also is a mixture of self-efficacy of hope of optimism and resilience. External confidence. I don't think we should be talking about core confidence without also touching on external confidence and external confidence is what the majority of us learn to, to seek after. Speaker 2 (10:43): And we're constantly seeking after it. The external confidence is, you know, does dr. [inaudible] Like me, or, you know, what I should be doing right now, or, you know, these are the, the, the dreams that, that others are doing. So this marketing strategy has worked for them. This app has worked for them, let me do this, let me, you know, follow this meal plan. And so, you know, we're constantly as humans chasing others, things that have worked for them. And, and we're very often, again, not realizing we're up in our head and we're not really checking in with the, the little voice that's like, that's kind of a waste of time. Speaker 1 (11:32): Yeah, totally. I, I always find that it's so much easier to look for that external validation and get our confidence from that external validation, then what we do than what we think we are doing. Does that make sense? Solutely yeah, so I, I mean, and, and we're all human and all humans fall into that trap. So can you kind of give us an example of how you might work with someone to help develop this core confidence and help to bring in more joy and help get them a little more grounded into themselves? Are there any sort of exercises or things that you do with people that you can give this as an example? Yeah, Speaker 2 (12:15): That's a, that's a great you know, I I'd say one of the main tips that I, that is probably ended up being my, my signature Sarah move,uhas been really, you know, so listening to somebody, I really love deep listening. I mean, I think when you start listening to someone, at least for me, I don't know this is, this is, h gift that I have is I start reading between the lines. Umnd actually I'm kind of diverting for a moment. A lot of times when I work with people, I don't do it over zoom. We don't do video. Umecause when you look somebody in the eye, sometimes it's hard to be a hundred percent truthful, you know, or again, you kind of fall into the, the external competence trap. Umnd so we do it all over the phone or, you know, with the video off so that I can really deeply listen. Speaker 2 (13:09): And what I'll do is, you know, if there's a belief in there for example, I was working with somebody the other day and she shared, you know, while we were talking about her personal life. And and she was like, you know, if I kind of keep having these, these, if I close the door on this relationship, I'm probably actually going to have to do a lot of hard work on myself to pick up the pieces. And what I asked her was, well, well, is that true? That working on yourself has to be hard. Speaker 1 (13:47): And when Speaker 2 (13:47): We, I call it, like, we've got to, we've got to go. I like going down the rabbit hole with somebody of like, really being like, why, why are we fearful about this? Like, let's, let's talk about it. Let's get to the root and let's shine the light on what, what the narrative is with this overthinking piece. Once we shine the light on it, half of the work is done because we've brought in awareness. And whenever you bring in awareness works time. Speaker 1 (14:18): Absolutely. Yeah. And it's, it's, you know, that you're right. Being able to listen and listen well is a gift, but it's also something luckily that can be practiced and can be worked upon as physical therapists. I think a lot of us, a lot of us are pretty good at listening. But when you work with, like you said, that chronic pain population, you really get, I think, a lot more in tune to what the person is saying. And you also learn how to ask those questions to draw out more thoughts. Speaker 2 (14:54): Absolutely. Yes. And here's the interesting thing that I've found. Okay. and, and I, a lot of this comes from like archetypes and youngian psychology is we have different aspects of our, of our psyche and of our personalities. Right. And a lot of times what you'll find is we learn these skills, we practice these skills professionally, but when it comes to the, behind the scenes for ourselves, we're almost like different people. I had a client the other day, you know, she is a director and has, has a large, very well-known board behind her. And and she's like, you know, if the board was to be a fly on the wall and kind of experience my personal life, they they'd be like what, you're not even the same person. Because suddenly things become matters of the heart. They're no longer again, the, the head, you know, so professionally relating people through this very well yet, we're not really sometimes having that, that advisor, that best friend, that we didn't even know we needed behind the scenes to help us hash out our own stumbling blocks. And that's where I think in, in leadership and entrepreneurship and being a CEO of, you know, your business and your life and trying to be healthy, wealthy, and smart, I think that's, we need that now. Speaker 1 (16:22): And why do you think that's so hard Speaker 2 (16:24): To, Speaker 1 (16:27): To confide in others of, you know, it's, it's a lot easier to say, Oh, you know, I, I didn't have any new patients this month. So, you know, I really w what do you think, how can I help? How can I get more patients? That's easy, right. To talk about our business and, and to talk about our our professional life. But why do you think it's so hard for people to confide in others on a more personal level? Speaker 2 (16:55): Hmm. I love this question. I really love it. Of course, I'm sure it's very multifactorial. I find that I don't, you know, I don't have any research on this, but I find that if you start looking back even into it and not like massively, but you start looking back into childhood, you know, where a lot of habitual patterns are formed and thought patterns are formed. A lot of times you'll see, you'll see trends there, but, you know, one vein of research shows that about half of all CEOs, those at the top are experiencing loneliness and loneliness in the sense that, you know, there has to be a level of healthy ego and confidence, right? B core confidence or confidence in order to want to succeed. You know, all sorts of people are teaching us out there and showing us that, you know, you gotta have some grit, you gotta have some resiliency if you wanna play this game. Speaker 2 (18:01): And it is a game. And so, you know, there there's factors of like, you can't trust everyone, right. If you have team members underneath of you traditionally that's really changing, I think, but traditionally we're taught, you know, you don't mix business and personal life. You don't do that. That's a no, no. Now you'll see that changing. And that's continuing to change because you know, many psychologists are beginning to study really resiliency and entrepreneurship and, and understanding more specifically how they're tied together, because it's, th that's really just a new field of, of understanding. He can't trust people, you know, and I think many have experienced, again, maybe it was in the past or more recently you know, you do share some of those personal moments and it might come back to bite you or suddenly the, the inner critic and other thought thought in the brain comes up and says, Ooh, that was not a good idea. You're probably that is going to backfire. You know, that could make you look weak. So I think it's very multifactorial. Speaker 1 (19:16): And I guess this is kind of where having someone, you know, outside of your direct business to have as a resource and to help you as a coach I guess I would, I'm assuming that that's where coaching comes into play, because you can kind of be that person to sort of help with the personal and the professional, because I can only assume that they're closely related. Speaker 2 (19:44): Right. They are way more closely related than people realize. And your professional self that like the way you act professionally is often different than the way you act and your personal life. Like, can you, can you relate to that? Speaker 1 (20:02): Yeah, of course. Okay. Speaker 2 (20:05): And so, you know, cause I, I, yeah, same thing for me too, but I'm always interested, you know, in what, what somebody, his answer would be. Speaker 1 (20:12): Yeah, no, there's, there's no question that, that we're a little different in our personal life than in our professional life. And, you know, it's funny to say, because I was having thoughts around that yesterday. Because you know, we're all human, right? Every once in a while, like we screw something up, we say something we didn't want to say we regretted afterwards. And yet you're vilified for being a human being. You're vilified for saying something that, yeah, like maybe what you said, wasn't the best thing to say, but you take ownership over it. You say, Hey, listen. Like, yeah. I mean, I, you know, I let my emotions get the best of me, which never ever happens in my professional life. Right. Right. In my professional life never happens. And yet all of a sudden you're demoted in the eyes of so many people, but all you did was you were just a human being and you said something, or you wrote something that you later like, ah, I can't believe I did that. And because it's not a podcast, we can't go back and edit it out. So I think that there is this, this weird kind of, if you start to melt the two together, you're going to be screwed. Speaker 2 (21:33): Yeah. It's a way or another, it's a belief. Absolutely. And I think that we need guidance to blend them appropriately, you know, because the answer is not, well, you'll see this as a marketing strategy now. Right. Where it's like, okay, show the behind the scenes and show yourself and be yourself and dah, dah, dah. Well, I think that there's always a, a middle ground to all of that, that we need to be aiming for. And again, it has to feel true to you, you know, like you have to get back into a state of checking in with yourself and not checking in with the head and the thoughts of like, okay, is this an alignment for me? And so, you know, in a lot of cases when you're blood, when you're, I like drawing on the professional self, like let's say, I might say, okay, what would professional dr. Speaker 2 (22:23): Litzy do when we're talking about something personal, because that's how the, the, the two aspects of you can really start blending together and start working together as a team and be like an integrated, whole healthy, beautiful person, right. Uwho can stay true to your individual values? You know, we get to like explore what those individual values are and being true to those,uin, in order to make it work for us, I've ever really cool example of a client who,ushe's in the hospital system and I'm pretty high up. And she was offered. We had been working for, I don't know, probably three to six months or something we'd been, she had been, and we were mostly working in the personal field, you know, but of course the professional always, always blends in. And she had been offered this incredible opportunity to lead this team. Speaker 2 (23:25): This was just in addition to her goals that she already professionally had for the year. And as she sat with that, and as I sat with that with her, she realized, you know, if this had been last year, I would have said yes to that. And I'm very flattered, but the truth is, is if I say yes to that, then all that I'm doing to take care of myself so that I can show up to meet my professional goals is actually going to be derailed. And so at that moment, it wasn't in alignment for her. And what was even better about that was then she was able to go to her boss and to communicate that I call it like, you know, communicating from the core, but communicate that not from up in the head like, Oh, no, I wonder what I'm doing. I hope, you know, hope I'm not really screwing this up, communicating it with authenticity, with crowdedness, with strength, right. With empowerment. And, you know, her superior was like best decision you ever made. I really appreciate it. Really championed to her now, how awesome would that be if we could have more of that in our small businesses and in all of our workplaces and all of our organizations, Speaker 1 (24:43): I mean, that's an ideal situation when the ideal situation, but I think it's hard when you're constantly kind of seeking out success and seeking to be quote unquote the best at what you do and to get that recognition and to build your business and to make more money. So you can live the lifestyle that you want to live and provide for your family or your friends or whomever is in your, your world. But how does, how does making these decisions, like you said, these sort of more grounded decisions where, where they are emotional versus making these decisions as strictly like pros and cons, like an intellectual pro and con list, you know what I mean? So how do you, how do you coach people in that tug of war? Speaker 2 (25:41): I hope I can answer the question of how do you coach people, because sometimes you just have to see it, you know, and experience it. But you know if you look, if you talk to anyone in the financial world, the stock market is emotional emotions drive everything. That's true. Right. And you know, if we're the faster, we're aware of that, the more tapped in that, that we're going to be. And so that's actually, what's happening is a, is a lot of times where we're making these leadership decisions, we're making these personal decisions when we're in a state of emotion. And often when we're, you know, emotions are coming from thoughts, right. You know, you know, the, the, the little wheel starts going and then suddenly, you know, we have these emotions with us. A lot of times you don't even know what the sensation is in the body, because we're, again, we're kind of more of in the head. Speaker 2 (26:36): And so when you can access, and what I do is often just really helping somebody with very challenging. Like I prefer the challenging situations, you know, where it's like, okay, why do I keep getting into this relationship? Why do I keep not, you know, being able to climb the ladder? Why is it I can't get, get know fit in the self-care pieces of it. And when we get to the root of it, a lot of times it's because things are happening in an emotional realm. And we've got to be aware of that, go down the rabbit hole of the actual, like fear and worry. And why, like, why are we responding the way we're responding? Why are we doing that? And then once you get to that, then you can actually get to the clarity piece where you get the clouds and the, you know, the fog out from your face. Right. You can go, okay, pro this con this dah, dah, dah, dah. Okay. Now I've got my marching orders go. And I, I don't know about you, but I like marching orders. I like to know the next step. Speaker 1 (27:37): Yeah, absolutely. And, and I think, you know, a lot of people who are in leadership positions or who are going out to be that entrepreneur, their dreams, like you are a type a person. I think you are a lot of just pros and cons. But I do think that the emotional segment of things does have to come into play because if your pros and cons from a very sort of robotic sense is, is okay, I guess, but then how is it going to make you feel, how is it going to affect your life? Are you going to be happy with your decision? Are you doing something because you feel pressure to do it because you have to do it, quote unquote. So I think being able to tap into that core confidence in that and your core values in order to help you make decisions is important. So it's like, I don't want to be on either pole, like purely emotional, purely cerebral, but you want to have, you want to be able to kind of get in there and go down that rabbit hole, which is not easy and takes a lot of self-awareness. Speaker 2 (28:44): Yes, no, it does. And that's why it usually takes a guide. Yeah, exactly. It really does. It takes a guide and you know, again, kind of that core confidence model that was not created by me, but having self-efficacy hope, optimism and resiliency, you know, these are things with, with a lot of difficult situations that, that our, our brain just has not been able to figure out the answer to. We tend to go down on the scale of those things, right? We're not trusting ourselves efficacy. We're not feeling very hopeful about it now, fascinatingly enough, you know, those that are fixers and types day and, and, and leaders if we can't fix something, if we don't know the solution to it, we're going to avoid it Speaker 1 (29:25): Totally a hundred percent. So it was easier and it's so much easier. Speaker 2 (29:30): We are to, to help and to show up for others and to fix the things that we know we can fix. And so again, then you see an imbalance and often times it's with the most challenging things that dealing with, again, personally, or professionally that we don't want to talk about. One of my clients, the other day was sharing,uyou know, this situation just resolved, but she was like, you know, I have been sitting on this,uspace like this, this land and space for the last 10 years. And I didn't know what to do with it. Now, when we got to the root of it, it was actually extremely emotional because she's in a family owned business. And it was something that a family member prior to her set up and, you know, really loved. And so it, it, it, it was way too. She couldn't make the decision because of the emotions connected with it. Uyou know, but she was like, I've been sitting on this forever and just avoiding it because I don't know what to do. So I can think of 50,000 other things to spend my time doing. You know, you can fix the kids, you can fix your friends, you can bring it into your professional career. And then meanwhile, some of the, you know, the other aspects are, are, are missing. Speaker 1 (30:44): I know I, when I get into those, those bouts of, Oh God, I can, I like will. And it's what I'm doing right now, which is why, when you said that you could do so, so many things to avoid. I'm like redoing my bookshelves, I'm doing some shredding of papers. I'm like crazy with the home edit. And now everything's in a rainbow, you know, I've got a lot of plastic bins hanging out everywhere. That's what I do when I'm trying to like, avoid looking at deeply at other things, you know? So that's what I've been doing for the past couple of weeks is I have been like cleaning out. Like my doorman was like, are you moving? I was like, Nope, not moving. Just, just finding stuff to do around the apartment. Speaker 2 (31:30): Exactly. Just being a great, you know, leader in the liver of life. Speaker 1 (31:35): Yeah, exactly. Cause I'm like, well, you know, if you come home to a nice clean apartment, it's better for your head. You can concentrate more when, you know, I probably need to go dig a little deeper and see, why am I doing all of this? And I know it's not just from watching the home edit, although it's a nice show. I'm sure it goes a little deeper. Speaker 2 (31:56): Well, it does, you know, and I'm glad you brought that up, you know, your, your personal situation, because I think that that helps all of us so much, you know, it's always nice to know when we're not alone. Right. And but you know, one of the biggest things that I've found in doing this work for as long as I have is people say to me, yeah. You know, I just, you know, everything you do sounds really great. Like that sounds awesome. It sounds like it really be helpful for me. And like, I don't really think I will, but I don't really think I want to go there. Uand we think, again, we think it's going to be hard, right? Like I was mentioning the client, the client earlier,u Speaker 3 (32:40): I have found that, Speaker 2 (32:44): And I think this is just my personality, but it's like, we got to make this fun and we gotta make this. Or action-oriented we kinda got to get the show on the road. So it's like, you know, again, if, if we're, if we're trying to leave a legacy, if you're trying to, you know, be productive and not give up on the idea that we have, you know, have success, then we are in a state in our country and in the world where, where we, we, yes, we can all, you know, afford to sit down on the couch with the weighted blanket and the wine and the ice cream, you know, but, but I just don't believe that, that we can afford too much of that anymore. I really don't, you know, like I, I need, I really feel so strongly that like, I need everybody to be functioning at a high level and it, it can be fun. Speaker 2 (33:40): It doesn't have to be like, Oh gosh, I'm, I'm, doesn't have to be so stressful. Yeah. Or like annoying, you know what I mean? Like, nobody really wants to like, look at themselves and see their shortcomings. And it's not about that. Like anybody that's trying to tell you it's about that. Th that's probably just perfectionist behavior showing up. It's not about that. It's about like, you've got to tap into your greatness. And when I say your greatness, meaning like just our essence, like our purpose of being here on earth, like something greater than ourselves, we've got to tap into that. We've gotten away from that. You know, that, that radical act of self-love that that's not just let me go draw a bubble bath. You know, that that is radically like, you know, we're all beautiful and we're here to share something great. Speaker 2 (34:37): One of the, one of the most upsetting thing, NGS, m don't know if you've ever experienced this, but, you know, as a physical therapist, when somebody has, host a limb or their pelvic floor is not working and they're upset with, you know, they have prolapse and they're like, Ugh, Ugh, this uterus, or, you know, gosh, my arm just looks awful. Now that pains me to my soul because I'm like, Oh, you know, like, gosh, your body has done so many miraculous things. I understand. And I empathize why you feel that way, but it, it makes me sad. And one of the things that has made me sad and being, you know, an advisor and a best friend to, you know, leaders who didn't even know if they needed that. Um,e of the things that makes me sad is when somebody comes to me and they're willing to just for a second share, I don't know if I can keep doing this anymore. Speaker 2 (35:35): I've thought about just giving it all up and going back to a simpler way of life and the same sort of thing. It makes me sad. Cause it's like, no, no, no, no, no, we don't. We don't have to do that. Like, you know, you, we don't have to, we just have to find some balance, right? Like you said, we don't need to be on one extreme. We don't need to be on the other extreme. We need to be somewhere in the middle and finding that is like super, super small finite changes. It's not the giant crazy things that changes that we like to make in our lives that we, you know, we think are going to be the solution. Yeah. Speaker 1 (36:10): I, I agree a hundred percent. And I think on that note, because I could keep talking about this all day. It's sadly, I don't know if the listeners want to listen to it all day. I'll do. I think they might. But I feel like we could keep going on and on here. But that being said before we wrap things up, just a couple of other things, number one, what, what are some of the big takeaways, or if there's one in particular takeaway that you want the listeners to leave this conversation with? Speaker 4 (36:46): Wow. Speaker 2 (36:47): I wasn't prepared for that. Dr. Lindsay. There is what I would say. The big takeaway that I really hope everybody understands is that when we get out of our head a little more often and start listening to the messages of the body, start listening to the messages of within then we really activate that core confidence. We step into a more effective way of leading and living and that's available to everybody and it's time to take it. Beautiful. Speaker 1 (37:26): That's a beautiful takeaway. Now you're welcome. And then of course, the last question that I ask everyone is knowing where you are now in your life and in your career, what advice would you give to yourself right out of PT school, a newbie. Speaker 2 (37:42): Ooh. Oh, this is, this is a fun one. So when I was in PT school, I knew PT was going to be a jump jumping off point for me. Ubut I, I didn't feel confident in that. And so honestly, what I would have said to myself then is, you know, yeah, you're a little bit of a fish. Speaker 1 (38:06): Yeah. You're doing things a little bit differently Speaker 2 (38:08): And it's okay. Just own, own your worst, keeping you which I'm sure I've always been doing, you know, but, but really telling myself that and gifting that to myself, that it's okay. It all starts lining up just one step at one step at a time. Speaker 1 (38:25): Awesome. And where can people find you? So social media or what's the best way? Yeah. So the best to get in touch with you, Speaker 2 (38:36): There are just so many ways to get, to get in touch with me. Of course social media let's see Facebook and Instagram is dr. Sarah Smith official. I'm also on LinkedIn, dr. Sarah Smith. It is Sara without an H. Usually people always are putting an H on my name, which is like, Speaker 1 (38:52): Denise is a Sara without an H. So I am very well aware of it. Speaker 2 (38:56): Thank you. And then www dot dr. Sara, D R dr. Sarah smith.com awesome. And website. Speaker 1 (39:06): Perfect. And we will have all of those links up at the podcast website podcast at healthy, wealthy, smart.com under this episode. And you saw, you also have an activate core confidence workbook that dr. Sara has so generously given as a free gift. So if you go to www.dot dr. Sarah smith.com/core hyphen confidence, did I get it right? You did. Perfect. And again, that will also be in the show notes, if you want your free gift from dr. Sarah, which is very generous. Thank you very much for all of the listeners, go and grab it from the show notes. So Sarah, thanks so much. Like I said, I could talk about this forever. It'll turn into a therapy session and that's not what you're doing here. I will not take advantage of you in that way. Speaker 2 (39:57): We can, we can do it at that. Speaker 1 (40:03): Thank you so much for coming on and sharing all of your knowledge. I appreciate it. Speaker 2 (40:07): Oh, you're so welcome. Thank you for having me. Speaker 1 (40:09): Of course. And everyone listening. Thanks so much. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Helene Darmanin, PT, DPT, CSCS to the program to talk about physical therapy during and after pregnancy. Dr. Helene Darmanin is an orthopedic and pelvic health physical therapist with over a decade of experience facilitating healthy, empowering movement for her clients as a PT, and fitness and pilates instructor. Inspired by her own motherhood and ardent feminism, she specializes in preparing and healing pregnant and postpartum mamas. In this episode, we discuss: - Helene's experience with miscarriage, pregnancy, birth, postpartum - Body positivity in pregnancy and postpartum and how it can optimize outcomes - American College of Obstetrics and Gynecology guidelines for exercise while pregnant - Reasons to go to PT when pregnant - Reasons to go to PT postpartum - And much more! Resources: When & Why To See A Pelvic Floor Physical Therapist 10 Ways to Love your Body Helene's website Helene's Instagram Helene's LinkedIn Helene's Facebook Danford Works A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. More Information about Dr. Darmanin: I am an orthopedic and pelvic health physical therapist who specializes in preparing and healing new and expectant mothers. I am currently seeing clients virtually through Danford Works, and am also the creator of Quarantoned, body-positive HIIT at home. I practice guilt-free PT—physical therapy which fits easily into your day and improves your quality of movement and life. Research has shown that exercise and patient education are the two most effective interventions for positive long-term outcomes, and these can both be offered successfully virtually. I have over a decade of experience facilitating healthy, strong movement in my clients' everyday lives. I have a Doctorate of Physical Therapy from New York University, and a Bachelors in Exercise Science from Smith College, and am a Certified Strength and Conditioning Specialist, and a Kane School-certified pilates mat instructor. I give workshops and webinars about fitness, pelvic health, and being guilt-free in your pursuit of wellness; I am published in peer-reviewed journals, blogs, and have presented at national conferences. Most importantly, I am a proud mama to my one year old son, and my calico cat. Read the Full Transcript below: Speaker 1 (00:01): Hey, Helene, welcome to the podcast. I am thrilled to have you on welcome. Speaker 2 (00:06): Thanks so much, Karen. I'm so grateful to be here. Speaker 1 (00:09): And so today we're going to be talking about pelvic health or women's health after pregnancy, during pregnancy, which, you know, a lot of longtime listeners of this show will know that I've had a lot of episodes on this, but I'm particularly excited about this one, Helene, because you're going to, I think, bravely share a little bit about your story about your birthing experience and, and your experience with your body and how it changes and continues to change even after. So I'm just going to throw it to you and just kind of let you tell your side of the story. Thanks. Speaker 2 (00:48): Yeah, I know that in my, I have a my son is about to be one on Monday in just six days. So I know that in my time, since I gave birth or while I was pregnant hearing other women's stories always helped me to not, not feel alone, even though I knew what to expect because I specialized in pregnancy and postpartum long before I got pregnant. So I am really excited to share some of my story. The biggest, the biggest thing that, that happened when we first started trying to get pregnant was when we were trying to conceive and we got that positive pregnancy test. We were so excited. But then, and I remember, cause it was Thanksgiving. And all my family was so, so, so excited cause we shared right away. Cause I figured no matter what happened, I wanted to have the support of my loved ones. Speaker 2 (01:43): A few days after Thanksgiving, I started to have some bleeding and I started to have some cramping and it, it was before I had even gone for my first prenatal visit with my OB. And when I showed up for my first prenatal visit, she said, congratulations. I said, I'm pretty sure I'm having a miscarriage right now. And, and sure enough I did miscarry at about seven weeks which is early enough that some people don't even call it a miscarriage. It can be called a chemical pregnancy. My OB was incredible. And she said to me, they say, when it's this early, that you shouldn't be comforted because it was probably a chromosomal abnormality. And you know, it, it just naturally aborted itself. She said, but that didn't help me when I had two miscarriages. So I, I feel you that meant the world to me. Speaker 2 (02:36): Cause it was, it was it was a hard thing because we wanted the pregnancy so badly. And then actually I had a lot of trouble with continuing to bleed. And then I ended up needing an emergency DNC because I had a blood clot that was actually blocking the full shedding of the uterus. So that was, you know, in the midst of all the, the sadness, it was also scary and confusing. But I was really fortunate. I had some great practitioners and made it through, made it through. Okay. And then actually we were really lucky because we were able to conceive then the first month that we were allowed to start trying again, I had to get my normal period back, which took about six weeks and then we were able to start trying again. So I feel really fortunate that we were able to do that. And that time I texted my OB right away, I actually used progesterone depositories, which are really uncomfortable. They're like frozen popsicles of progesterone that you have to insert vaginally every night. There's really mixed evidence about them. There's nothing very conclusive, but my OB was like, it'll make you feel like you're doing something at bare minimum. You'll get that great placebo effect. Speaker 1 (03:50): And w what does it, what is the reasoning around using that? Speaker 2 (03:55): So there's some thought that the fetus won't implant, if the progesterone levels are too low, so you're causing a local increase in progesterone to help facilitate the fetus implanting. Got it. Speaker 1 (04:06): Got it. Okay. So sadly, you had a miscarriage, which, you know, for a lot of people listening to this, now, if you follow social media, we were talking about this before Chrissy Tiegen and John legend were very, very open about their miscarriage, which, which happened. I don't know how many months along she was, but enough. And that the comments were, Oh my gosh, I'm so glad you're, you're talking about this. No one talks about this. Women are so ashamed of it. Couples can be ashamed of it. Did you go through any of those feelings or was it like, okay, this happened full steam ahead. Let's keep trying, you know what I mean? I think you've got like both ends of the spectrum. Yeah, Speaker 2 (04:51): Yeah, yeah. I think I was somewhere middle of the road. I think I feel very fortunate that I'm was my awesome support network and my great care that I had from my OB and my acupuncturist to who I saw who helped me recover that I, I didn't feel guilty. I didn't feel like some I've I've heard people talk about feeling like their bodies had failed. But I did feel a lot of sadness. I didn't necessarily share right away, except for, with my very close circle. But I've certainly never kept it a secret. I've never felt like it was a shameful secret. And I I've always wanted to share it in case it does help someone else who has that experience, because as it turns out, the more I talked about it, the more women who I talked to said, Oh, yeah, that happened to me. Oh, that happened to me. Yeah. In fact, a lot of, a lot of my friends were like, I feel like over 30, the first one is like a trial run. And like, you kind of, a lot of women, their pregnancy was that chemical pregnancy or miscarriage. Speaker 1 (06:01): Yeah. So all of a sudden you're not quite so alone. Yes. Oh my goodness. Yeah. So, so now let's talk. So you get pregnant. So let's talk about your pregnancy, the birth postpartum, because all of this, part of your story, we're going to be tying into things that the listeners can do if they're in any of those phases. Speaker 2 (06:24): Yep, absolutely. So I was really lucky during the first trimester. I didn't have too much morning sickness, some slight nausea that usually eating a croissant helped. Unfortunately it was always a croissant. Well, Speaker 1 (06:36): Lucky you. Yeah. And Speaker 2 (06:39): But I was exhausted a hundred percent of the time. My first trimester, like I have always been super energetic. I've been a fitness instructor, like for my whole adult life. And I just wanted to sleep where I was standing all the time. So exercising was really difficult, which was hard for me because it's such a part of my life. And I would like put on an episode of Outlander and get on a stationary bike and be like, as long as your legs are moving, it counts. It's exercise, you know, was like no resistance on the bike. And that would be, I would get to my 30 minutes and counted as a win. So that, that was the first trimester. Second trimester is, was pretty awesome. That's kind of where it's at. Cause you're starting to show, which is fun. And then and energy levels come back up, but you're not like a whale yet, which is great. Speaker 2 (07:32): Well, by the end of the second trimester, when I was starting to get kind of big, then I started to have a very typical pregnancy symptoms of back pain. Interestingly my back pain was the worst kind of at that transition between the second and third trimesters. And then by the end of the third trimester kind of disappeared. My body kind of figured out how to be that size. I felt like I also had extreme swelling in my hands and feet. So I was wearing compression socks wearing wrist splints at night while I was having a lot of risk banks. I was actively working as a physical therapist on my feet and manually treating patients. So that was, that was hard to handle. I tried a cortisone shot, actually. I tried PT, of course. And then I tried a cortisone shot and none of that really helped. I had pretty bad carpal tunnel until I gave birth. And, and it would just like my hands and feet looked like little sausages, which was really pretty funny. And, and by the end of the third trimester, I was again, really tired, but I managed to work until I was 38 and a half weeks pregnant. On my feet demonstrating exercises, even though I gained well over the recommended amount and I gained 47 pounds, which interestingly was exactly what my mother gained with both her pregnancies Speaker 1 (08:51): Beard. And so what is the recommended? Isn't it like 20 to 35 or six 25 Speaker 2 (08:56): To 35 is the midline though. The most recent American college of obstetrics and gynecology recommendation is anywhere from 11 to 40. So there's a little more acknowledgement that now there's a broader range that can be considered normal. Got it. Speaker 1 (09:09): Okay. Great. And so I think it's also, it's also good to note that what you were feeling back, pain, swelling, these are all, like you said, these are pretty typical, right? It's not outside the realm of, of normal to have these symptoms when you're pregnant. Right. Okay. So then you go in, you give birth. Yup. Yup. So, Speaker 2 (09:30): So I I had one day of false labor, which was very frustrating. I wanted that kid out by 39 weeks. I was like, Nope, done out. And then a week later I went into real labor. I had a doula, I was just ready to have my vaginal unmedicated birth. That's what I always wanted. I got to the hospital and luckily I was six centimeters dilated, which is when they consider active labor is starting. So they were able to keep me at the hospital, but Oh my goodness, was I tired? I started having contractions on a Friday, late morning, went into the hospital by about 3:00 AM, Saturday morning. I had gotten maybe three hours of sleep. My duals recommended that I sleep more and I was, and of course that's what I recommend to all my clients. And I was like, no, no, no, I don't need to sleep. I'm going to keep walking cause that'll help my labor progress. So I walked around my block 1 million times. And so by the time I got to the hospital, I was so tired. That's mostly what I remember is just being exhausted. And I had, you know, I advise on changing positions during labor and, and how to best facilitate things. And my doula was like, let's get on hands and knees. And I was like, Nope, Speaker 3 (10:45): Not moving. I am not moving. Speaker 2 (10:49): And then actually did have some complications during labor where my son had a cord wrapped around his shoulder. So every time I would push the cord would become compressed and his heart rate would drop. But my actually it wasn't my OB. I went in just after she got off call that night at midnight. And I got into the hospital at 3:00 AM. And let the OB who delivered me was sent Hastick. She was really, really fantastic and knew that I was really committed to having an unmedicated vaginal birth. So there was never a moment where she was not where she was considering anything else. She just kept kept me charging. And I ended up giving birth in exactly the position I didn't want to, which is lithotomy position. So on my back with my niece, Fred and doing directed bowel salvia breathing, which I also didn't want to do. Speaker 2 (11:39): Cause both of those things increase the likelihood of vaginal tearing. But it was the only way that we were going to get that kid safely out with his heart rate dropping. And, and we did, as she was, she was able to cut his before he was fully out and were able to get him delivered vaginally on medicated and safely. So that was, that was quite an experience. And it was really funny actually, my husband was like, yeah, like that's how you do it. You, you unmedicated. And he like, we're all these sissies who need, who need epidurals. And my doula was like, no, no, no, no, no, no. You don't understand. 90% of women in New York city get epidurals. Like your wife is nuts. So I was like, yeah, you don't get to judge. That's not an experience you'll ever have. Speaker 4 (12:29): Exactly. yeah. So it was, it was, Speaker 2 (12:35): It was a roller coaster and then I still didn't sleep because I was so excited about having my son. And so that was really like a crazy up and down day then that Saturday when he was born that morning. Yeah. Speaker 1 (12:51): Wow. That's dramatic. That's a lot of, that's a lot of drama for, for one birth. But it's, it's also, I mean, I can, I can imagine the relief of having him born safely and there you are, you're in the hospital, you take your baby home, you know, you're, you've been teaching other women on how to work with their postpartum bodies for a long time, but now let's talk about you get home and, you know, a couple of weeks go by and you have the, we all talk about the dad bod, but you know, there's like you have like the mummy tummy or the mom bod. So how do you, what advice do you have for people to kind of stay body positive during this whole period, whether it be during the pregnancy postpartum and, and what, what being body positive can do for you? Speaker 2 (13:50): Yeah. so I have always been an advocate of body positivity and this was the time in my life where I felt like it really paid off. In general, I think that body positivity creates this cycle of self-care where if you take care of yourself, then you feel good about yourself. And if you feel good about yourself, then you're more likely to take good care of yourself. And it becomes a very positive spiral. So I've often used that with my clients and and it was definitely my turn to use it for myself. I was a ballet dancer, so I definitely have had an awareness of body image for most of my life. When I was pregnant, I, I kept, I felt like when I was pregnant, it wasn't as hard to have positive body image because everyone was just telling you how beautiful you are and you're glowing. Speaker 2 (14:43): And it's so exciting and the thrill so you get a lot of positive reinforcement from outside, but I feel like a lot of that ends after you give birth. In fact, just, I was, we were just talking about the New York times in her words newsletter today was a mom who was talking about her experiences postpartum and saying that a lot of times, even if you had a complicated birth that you were in a lot of pain, people say, Oh, well, at least the baby's healthy and they completely brushed aside the mother and her experience and her symptoms. And I'm very much of the thought that, yes, it's wonderful, the baby safe and healthy, but in order to be a good parent and effective caregiver, you need to put on your own oxygen mask first. So starting to take good care of yourself and feeling good about yourself is going to make you a better parent in my opinion. Speaker 2 (15:40): Plus it's just it, regardless of your status as a parent, it's important for especially women because we're often ignored in this regard to feel good about ourselves. So in terms of staying body positive after I gave birth, I actually strangely I found it very helpful to spend some time like with my body and kind of noticing the changes. So I took a little longer in the shower where I w I would kind of be grateful to different parts of my body while I was showering, like, wow, thanks to my stomach that was able to stretch and hold my son, like thank you to my breasts that are able to produce breast milk and nourish my son. We did have a lot of struggles with breastfeeding. So I was very grateful when we got it down, Pat. And you know, I've got rid of a lot of clothing because anything that was squeezing me or making me feel uncomfortable you know, instead of trying to squeeze back into my old clothes where every time I would shift or move, I would feel like the pinching of my old jeans or you know, like the bra cutting into my sides. Speaker 2 (16:52): I got rid of all of that, unless I really thought it was realistic that in which case I put it aside and I didn't even look at it. I lived in leggings and nursing tops for at least three months because it was comfortable. So I wasn't constantly reminded that I was a different shape that I wasn't it wasn't my old body. And I, and then I started moving pretty early in my recovery. I was discharged with the hospital with the very old school instructions of you know, wait six to eight weeks before you start exercising. And then about three weeks I was losing my mind and I was like, Hey, wait a minute. I can give medical advice too. And I can exercise under my own medical supervision. So I I started exercising. I started really gently. And, but there's even, there's at least one study. Speaker 2 (17:46): I believe there are a couple studies that have shown that even one bout of exercise increase, improves your body image. So getting moving and feeling like I was in control of my body and really starting to feel what it was capable of for myself, not just feeling what it was capable of in terms of giving birth to a human, which was also incredible. But, but starting that again, feel like, Oh, look, I can lift this weight. I can do this movement. And, and all the positive feelings that come from exercise definitely also helped. Speaker 1 (18:21): Yeah. And, and kind of again, taking agency over your, over your body. And I really love the, you know, giving yourself a little extra love in the shower. I think that's great advice for anyone, if you had birth, if you gave birth or not, you know, sometimes just getting older things change, you know, and being able to acknowledge that things change and that's okay. And you're still, you know, in love with everything that you have. I love that. That's great advice. So now you talked about exercising. You sort of went back about three weeks after, but let's talk about exercising while pregnant. So there can college of obstetrics and gynecology. They put out guidelines on exercise. So do you want to kind of fill us in on maybe what those guidelines are so that if there are women out there listening that are pregnant at the moment, they can have a better idea of what they can and can't do. Speaker 2 (19:20): Absolutely. I'm really excited about them actually, because there are new ones this year that are much more forward thinking in their recommendations. So there has been a lot of fear-mongering about exercising while you're pregnant in the past. And this year, the recommendations are that virtually everyone can exercise while they're pregnant, whether you exercise before you were pregnant or not. They do recommend that everyone obtain a medical clearance first with a, with a thorough exam to talk about any possible medical complications that could arise from exercising. But you know, there used to be the wisdom used to be that if you didn't exercise before you couldn't start, while you were pregnant and they have completely changed that and they, even to the point where if you are an athlete or someone who regularly exercise at high intensity, they say that you can continue to do that through the third trimester safely. Speaker 2 (20:20): And they recommend exercise because it actually decreases the incidence of diabetes, of gestational diabetes and other blood pressure complications while pregnant like three clamps SIA. It decreases the likelihood of pre of giving birth preterm and decreases actually the incidents of low birth weight, interestingly, and it also decreases recovery time postpartum. So it improves postpartum outcomes kind of sets you up for success, especially during time where you might not have time or might not be able to exercise yet right after giving birth. And it actually increases the likelihood of having a vaginal birth. So if that's something you desire, exercise can help you get there. And it decreases the likelihood of postpartum depressive disorders. So those endorphins that you get while you're exercising kind of carry through to the postpartum period. Well, that's a lot of positives for exercising while pregnant. Are there any sort of big no-nos and on that, Speaker 1 (21:18): No, we're going to take a quick break to hear from our sponsor and be right back. This episode is brought to you by net health, helping you maintain strong relationships with your patients. The redox patient portal provides secure line of communication between you and your patients conduct virtual visits and have follow-up conversations with your patients via secure messaging. When it's convenient for you, patients have 24 seven secure on-demand access to their therapy, health information without phone calls and voice messages, video conferencing for telehealth, secure messaging, shared documents and photos and view health information, and appointments to learn more, contact them@redocatnethealth.com. Speaker 2 (22:05): A lot of it's on an individual basis and getting assessed by a PT who specializes is a great idea to see if you're able to still engage your transversus abdominis and see what positions might be best for you. If they do continue to recommend that you don't stay supine on your back for longer than two to three minutes, past 20 weeks of pregnancy, because you can become hypotensive because of the weight of the fetus on your on your blood supply. And they also recommend that you, they also really emphasize staying well hydrated. And if you're doing anything vigorous for more than 45 minutes to really make sure you have adequate calorie intake before maybe during and after to avoid hypoglycemia, which is not uncommon in pregnancy with my clients, I still recommend avoiding isometric exercises. So planks are awesome. Speaker 2 (23:01): Just make them dynamic somehow to help the body regulate the blood pressure, because it's just a lot of demand if you're holding a position and you're holding that tone in the muscles and you're trying to support a fetus it, it helps a little bit to keep those muscle pumps helping the blood pressure regulate. Besides that it's, it's on a very individual basis. It's what you're familiar with. It's how your pregnancy has been progressing. So it's really a good idea to talk to somebody. Okay. And speaking about talking to somebody, everybody who listens knows I'm a physical therapist, you're a physical therapist. So let's talk about reasons why women should go to a physical therapist when they're pregnant. I mean, it doesn't have to mean you, it doesn't mean you have to go every week of your entire pregnancy, but talk about why Speaker 1 (23:47): Every woman should be seeing a physical therapist when they are pregnant. Yes. Period. Speaker 2 (23:53): I love that. Yes, they should. So in the same guidelines this year, Aycock says that back pain has an incidence of about 60% in pregnancy, but that's extremely under-reported because most women just consider it a normal part of being pregnant. So I think back pain in pregnancy is pretty much universal. So that's one great reason to go to PT because it can help alleviate that back pain. And I did see a physical therapist myself when I was pregnant to help with the back pain. Also if you're having experienced experiencing things like sciatica wrist pain, which I had one kind of wrist pain while I was pregnant, different kind of risk pain after I gave birth, partly just because of the increase in fluid in the body. But then also changing joint mechanics because your ligaments are looser. If you have pelvic pain or pubic synthesis dysfunction, which you would know, cause your doctor would tell you, or you'd have a lot of fat in the front of your pelvis or even sprained ankles have a higher incidence in women who are pregnant. Because again, if those joint changes but also Speaker 1 (24:57): If you are having the perfect Speaker 2 (25:00): And see, which would be amazing and you have no pain whatsoever, you're that miracle person you can still help prepare for giving birth. There are PTs who specialize in helping with things like breathing, breathing techniques, preparing your pelvic floor muscles, and it might be a simple consultation. One time, two time to get some advice on, on what you can do to help yourself prepare. And also if you have any history of injuries or any current pain, then also PTs can help advise on what positions might be good for you and they can help coordinate with your OB or your midwife, whoever your burning professional is. Speaker 1 (25:36): Absolutely. And now all great reasons. Now let's talk about after you give birth the fourth trimester, right? So Aycock has came out with these guidelines about the fourth trimester. So first, can you tell us what the fourth trimester is for those who are not aware and then how, what is the physical therapist's role in the postpartum period? Speaker 2 (25:57): Absolutely. So fourth trimester kind of a tongue in cheek, a way of describing a three months after giving birth. Because the idea is that you're still, your body is still changing and your baby is also still changing a lot. There's some thought that when we were primates, our babies would have just dated for longer and come out further along, but our heads became too large and that's why babies started to be born earlier and earlier. So that's part of the reason that human babies are so vulnerable when they're born, as opposed to other species, like, you know, drafts who like pop out and run away from their mothers. And meanwhile, our kids can't, can't see, or Speaker 1 (26:40): Little blobs on my back. They're adorable blabs, but yeah, Speaker 2 (26:44): They, they can't do anything. So and one thing I hear a lot about the fourth trimester is women trying to get their bodies back which I need to bounce back quickly. I think it's just so depressing because, because you're not going back, why would we ever want to go backwards in your life? So why not take your body forwards with you? I love that. And, and you know what I, I will say just personally, like I, I gained, like I said, 47 pounds while I was pregnant. I have since lost all 47 pounds. I am still breastfeeding though. So we'll see what happens, but I am shaped totally differently than I was. And it's, it's not a good thing or a bad thing, at least to me, like it's just different. My body is totally different now. And that's, that's okay. Speaker 2 (27:38): You know, I, I'm really excited about what it can do. I love being a mom, so that's really important, but anyway, and physical therapy in the world of physical therapies. So again, it's a lot of similar reasons, usually back pain, but that can be again from a, it can be from how you gave birth. It can be from if you're, especially if you're still breastfeeding, you still have a lot of those quote unquote pregnancy hormones that cause the ligaments to be a little bit more flexible. Plus if you're breastfeeding the way that you're holding your child also if you're even just picking the kid up and down and getting on and off the floor and changing diapers, which can like, by the time they can turn over, sometimes it's like a circus you know, that that can cause back pain, wrist pain. Speaker 2 (28:30): And then of course you have your pelvic recovery, which I, for the first week, I, I don't think I was thinking about myself very much, but every once in a while I would realize that I felt like my vagina was on fire and sitting was horrible. It was the worst thing ever. I remember going, we were taking my son to his pediatrician, visit his first pediatrician visit. And I was sitting in the car like sideways on one butt cheek to try to avoid putting my perinatal area on the seat because it was so uncomfortable. So that, you know, that's normal for the first week, unfortunately even if you've had a Syrian birth that can you still have that huge change in, in your pelvis after it, no longer has this weight on it. And you have all these hormones released, so it could still be very uncomfortable and tender in your perinatal area. Speaker 2 (29:25): But yeah, that, that brings me to another point. Scars are big thing that should be treated. You would treat a scar from any other surgery or massive injury. So I don't know why it's not routine to refer for scar therapy after if you've had any vaginal tearing with giving birth or if you've had a cesarean birth those scars that can really cause a change in function. They're not as elastic as the tissue around them. And that excessive tissue that's there can disrupt the function and cause a lot of discomfort. So I had grade two vaginal tearing because of my birth experience. And I, I saw a PT myself to have my scar tissue manually worked on and work on some release techniques from my pelvic floor, which was super tense because it was trying to hold everything together during that postpartum phase. So I'm not, and that also for me, I had pain with penetrative sex after, you know, you go to the opiate and they're like, yup, healed, done. Yeah. You know, go back to doing whatever you want. And I was, I was terrified of resuming sexual intercourse and I'm very grateful for my PT who helped me figure out how to comfortably and safely get back to, to having sex. Yeah. Speaker 1 (30:52): You know, all these things, like you said, like so many women are experiencing these things and I think it's so important to just vocalize that and put that out into the universe so that women could be like, Oh, wait a second. Oh, I can go to a PT and they can help with that. Or I can go to PT and they can help with incontinence afterwards, or they can help, you know, like you said, have sex with my husband or my partner afterwards. I mean, wow, this is revolutionary for a lot of women, you know, to know that this resource exists. And you just have to find that physical therapist, preferably one who is trained in pelvic health and who understands understands the pelvis in a more intimate way. And, and that doesn't necessarily mean that they're, your therapist has to be a woman. There are also men who specialize in pelvic health as well. So I want to give a shout out to all of our colleagues doing that around the country as well. Speaker 2 (31:50): Yeah. Oh, go ahead. Sorry. I was just gonna say you know, also there are PTs who have been trained in helping support breastfeeding in terms of what positions to use treating clog ducks, or even just education on you know, effective techniques. There's also pelvic organ prolapse and incontinence, as you mentioned, which can happen regardless of if you've had a child or not. And that can also be treated with physical therapy. Again, some incontinence after giving birth is actually normal for up to a month or two, but if you're still leaking after that, then you should definitely seek help. And again, even, even like you said, it was pregnancy like why every pregnant woman should get PT. Everyone should get some advice, professional advice on how to safely return to movement, whatever movement you want to do, whether it's, you know a yoga class or a couple of group fitness classes or going back to playing a sport. And that's, that's something where we that's something we specialize in is movement. Yeah. Speaker 1 (32:51): And, and in many countries it's, everyone goes to standard care. It's a standard of care, you know, and, and hopefully now that these are part of the guidelines by a cog, that that is something that will become a standard of care. You know, I interviewed dr. Camila Phillips, who is an OB GYN at Lenox Hill and she recommends all of her patients to see a PT and I love it. And that was awesome. Brilliant. But I don't know. She might be in the minority. I'm not sure I think she is, but, you know, experience. Yeah. But I just, I just love that she is so forward-thinking, and, and for women to know that you have all of these resources, it's so empowering to kind of help you back, get back to not get back to, but help you move forward. I love that. I almost say get back to, well, get back to doing what you like to do. Yeah, yeah, exactly. Get back to doing what you like to do and whether that be any kind of movement or running or, or a high intensity sports, you know, just because you have a child doesn't mean that, that you can't return to the things you were doing before. And I think that's where the PT comes in. Speaker 2 (34:03): Absolutely. And with the help of my PT and like my own expertise at like five months, I was back to boxing and high intensity interval training. And I will tell you though, the first time I tried to do a jump after giving birth, I mean, I don't, I don't remember how long postpartum I was, maybe three or four months. I was like, Oh my God, I am an elephant. Like, I just felt like I had no pep, no spring whatsoever. I felt like every time I landed, I was like sod. It took a good few months for me to feel like I had my, my spring back, my like pep in my step. Speaker 1 (34:36): Yeah. Yeah. And, and again, you know, this is, I think this is all great for people to hear. Like we don't, I think women don't give birth and then, you know, go back to like walking the Victoria secret runway show like Heidi Clume, you know, like it's, that's not normal. No, do that like four weeks after you give birth, not normal. Like that is an exceptional human being there who has very good genetics, I'm assuming. And also it's her job. Speaker 2 (35:04): Yes. And a lot of expensive support Speaker 1 (35:07): And a lot of expensive support that us average Joe's just do not have. Nope. Don't have it. All right. So Helene, what would you like to leave the listeners with, if you could leave them with, you know, your, your top tip or your takeaways from this? From our discussion here, Speaker 2 (35:27): That's a tough one because there's so many good tidbits in there. Yeah, I think my top tip is, is just to love, love where you are. I would love your body, where it is, love it for what it's done, love it for what it can do right now. And, and get some help if you need help loving it. If you need help you know, getting it to do what you wanted to do, there is so much help available. It's just a matter of finding it, which shouldn't be as difficult as it is, but it is there. Yeah. Speaker 1 (36:01): Fabulous. And now last question that I ask everyone, given where you are now in your life and in your career, what advice would you give yourself as a new grad fresh out of physical therapy? Speaker 2 (36:15): Cool. Well, I would say trust your intuition. My program was very into evidence-based physical therapy, which is awesome and everything should be grounded in evidence, but never forget that clinical expertise in clinical experiences, also a level of evidence. Speaker 1 (36:36): And I've heard that many times from people on the show. Speaker 2 (36:40): Sure. You have that. I've heard it. I've heard it on your show too. Speaker 1 (36:43): Yeah. Many times. Well now, where can people find you? Where can people get in touch with you if they have questions or they want to know what you're up to. Speaker 2 (36:50): Ah, great question. I'm on Instagram at Halloween B underscore PT. That's the best place to find me I'm currently practicing at Danford works. And so you can find me there or I would love to hear from anybody via email, it's HD the pt@gmail.com. Perfect. Speaker 1 (37:10): And we will have all of those links in the show notes for this episode at podcast at healthy, wealthy, smart.com. So if you didn't have a pen on you, you didn't write it all down. Don't worry. One click will take you to everything Helene. And I will say she also on her Instagram account, really great exercises, advice, and support. So if you're looking for for that, then definitely follow her on Instagram because you give a lot of great XYZ and support, especially for women throughout an after pregnancy. So definitely give her a follow on Instagram. So Helene, thank you so much for coming on. This was wonderful. And thank you for sharing your story because I know it's not easy. Thanks, Tara and everyone else. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Haag to talk about exercise and urinary incontinence. This interview was part of the JOSPT Asks interview series. Sarah is the co-owner of Entropy Physiotherapy and Wellness in Chicago. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women's Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. In this episode, we discuss: The prevalence of urinary incontinence Is urinary incontinence normal Pelvic floor exercises Pelvic floor exam for the non-pelvic health PT Sports specific pelvic health dysfunction And much more Resources: Entropy Physiotherapy and Wellness JOSPT Facebook Page JOSPT Journal Page More Information about Dr. Haag: Sarah graduated from Marquette University in 2002 with a Master's of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women's Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Teacher. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. Read the full transcript below: Read the Full Transcript below: Speaker 1 (00:06:25): So, and hopefully it doesn't want to lose what we're doing here. We'll see. Okay. Going live now. Okay. Welcome everyone to JLS. PT asks hello and welcome to the listeners. This is Joe SPT asks the weekly chat where you, the audience get your questions answered. My name is Claire Arden. I'm the editor in chief of Joe SPT. And it's really great to be chatting with you this week, before we get to our guest. I'd like to say a big thanks for the terrific feedback that we've had since launching [inaudible] a week ago. We really appreciate your feedback. So please let us know if there's a guest that you'd like to hear from, or if you have some ideas for the show today, we're in for a very special treat because not only are we joined by dr. Sarah hake from entropy physio, but guest hosting [inaudible] asks today is dr. Karen Litzy who you might know from the healthy, wealthy and smart podcast. Dr. Lexi is also a new Yorker. And I think I can speak for many of us when I say that New York has been front of mind recently with the coronavirus pandemic. And I'd like to extend our very best wishes to everyone in New York where we're thinking of you. So I'm going to throw to Karen now. We're, I'm really looking forward to chat today on pelvic floor incontinence and exercise over to you, Karen. Speaker 1 (00:08:25): Hi everyone, Claire. Thank you so much. I really appreciate your giving me the opportunity to be part of J O S P T asks live stream. So I'm very excited about this and I'm also very excited to talk with dr. Sarah Hagar. Sarah is an educator, a clinician, and an author. She is also co-owner of entropy wellness and our physiotherapy and wellness in Chicago, Illinois, and is also a good Speaker 2 (00:08:56): Friend of mine. So it's really a an honor for me to be on here. So Sarah, welcome. Thank you so much. I was really excited that all this came together so beautifully. Yes. And, and again like Claire had mentioned, we're all experiencing some pretty unprecedented times at the moment. And the hope of these J O S P T asks live streams is to continue to create that sense of community among all of us, even though we can't be with each other in person, but we can at least do this virtually. And as Claire said, last week, we want to acknowledge our frontline healthcare workers and colleagues across the world for their dedication and care to those in need. And again, like Claire said before, a special shout out to my New York city colleagues, we are they are really working like no other. Speaker 2 (00:09:52): And I also want to acknowledge not just our healthcare colleagues and workers, but the scientists, the grocery store workers, the truck drivers the pharmacist, police, firefighter paramedics, they're all working at full capacity to keep the wheels turning around the world. So I just want to acknowledge them as well and thank them for all of their hard work during this time. Okay. So, like Claire said today, we're going to be talking about the pelvic floor, which is something Sarah loves to talk about because what I also, I also failed to mention is she is a certified pelvic health practitioner. So through the American physical therapy association. So she is perfectly positioned to take us through. And as a lot of, you know, we had, you had the opportunity to go onto Slido to ask questions. You can still do that. Even throughout this talk, just use the code pelvic that's P E L V I C, and ask some questions. Speaker 2 (00:10:57): So we do have a lot of questions. I don't know if we're going to get to all of them. So if we don't then certainly post them in the Facebook chat and maybe Sarah can find those questions in the chat below. And we'll try and get to those questions after the recording has finished. All right, Sarah. So like I said, lots of questions and the way the questions were, were written out, kind of corresponds quite well with maybe how you would see a patient in the clinic. So let's start with the patient comes into your clinic. They sit down in front of you. Let's talk about the words we would use in that initial evaluation. So I'll throw it over to you. Okay. So being a pelvic health therapist, obviously most people when they're coming to females, Things that happen in the pelvis, I like to acknowledge it, that there's a lot of things happening in the past. So I have Speaker 1 (00:11:54): Them tell me kind of what are the things that have been bothering them or what are the things that have been happening that indicate something might be going on? Like if something's hurting, if they're experiencing incontinence, any bowel issues, any sexual dysfunction. And, and I kind of go from there. So if the talk that's the title of the talk today includes incontinence. Continence is a super common issue that let's see in general might pop in. And if you would bother to ask there's actually, I think it's like one out of two people over 60 are experiencing incontinence of some kind. The answer is going to be yes, some, so you can start asking more questions. But starting out with what, what is bothering them is really what I like to start with. Then the next thing we need to know is after we vet that issue or that priority list of things that are bothering them in the pelvis, and it's not uncommon actually to have. Speaker 1 (00:13:00): So let's say they start with a discussion of incontinence. I still actually ask about sexual function, any pain issues, any bowel issues, just based on the innervation of the various, the anatomical arrangement of everything. It's not uncommon to have more than one issue, but those other issues might not be bothersome enough to mention. So it's kind of nice to get that full picture. Then the next thing we really want art. So there are times I've met women who come in and they're like, Oh yeah, you know, I have incontinence. And you're like, okay. So when did it start now? Like 25 years ago. Okay. Do you remember what happened then? Typically it was a baby, but sometimes these women will notice that their incontinence didn't happen to like four or five years after the baby. Hmm. So that's information, that's very help if they say my baby that was born six weeks ago, our interventions and expectations are going to be very different than someone who's been having incontinence for 25 years. Speaker 1 (00:14:05): So again, knowing how it started and when it happens, when the issues are happening, I just kind of let them, it's like a free text box on a form. Like just, they can tell me so much more excuse me. And when we are talking about things, we, I do talk anatomy. So when it comes to incontinence, I talk about the bladder and the detrusor, the smooth muscle around the bladder, the basically the hose that takes the urine from the bladder to the outside world. I do talk about the vagina and the vulva and the difference between the two. And then actually we do talk about like the anus and the anal sphincters and how all of that is is all there together and supported by the pelvic floor. Speaker 1 (00:14:54): Cause that's in physical therapy, it's going to be something with that pelvic floor or something. Drought, does it need to be more, more pelvic floor focused or does it need to be behaviorally focused, which is the case sometimes, or is it that kind of finding that perfect Venn diagram of both for those issues that the person's having? And let's say you're in a part of the world. One of the questions was what if you're I think this question came from Asia and they said, what if you're in part of the world where you have to be a little bit, maybe more sensitive around even the words that you use. I know we had gotten a question a couple of years ago about a woman in the Southern part of the United States that was from very conservative area. And do we even use these words with these patients? Speaker 1 (00:15:48): So what is your response to that? My response is that as healthcare providers, we are responsible, I think for educating people and using appropriate words and making sure people understand the anatomy like where things are and what they're supposed to be doing. However, definitely when I'm having this conversation with someone I want them to feel at ease. So like I will use the Ana vagina anus, anal sphincters Volvo, not, it's not a vagina, it's a Volvo it's on the outside. But then if they use different terms to refer to the anatomy, we're discussing, I'm happy to code, switch over to what they're most comfortable with because they need to be comfortable. But I think as, as again, healthcare practitioners, if we're not comfortable with the area, we're not going to make them feel very comfortable about discussing those issues. Right. Speaker 1 (00:16:43): And that makes a lot of sense. Thank you for that. So now let's say you, the person kind of told you what's going on and let's, let's talk about when you're taking the history for women with incontinence, especially after pregnancy, are there key questions you like to ask? Yes. So my, my gals that I'm seeing, especially when they're relatively relatively early in the postpartum period, are the things I'm interested in is did they experience this incontinence during their pregnancy? And did they have issues before pregnancy? And then also if this is not their first, tell me about the first birth or the, or the first two birth. So the first three birth to really get an idea of is this a new issue or is this kind of an ongoing marked by so kind of getting a bigger picture of it. Speaker 1 (00:17:49): And then also that most recent birth we want to know, was it vaginal? Was it C-section with vaginal birth? If there's instrumentation use, so if they needed to use forceps or a vacuum that increases the likelihood that the pelvic floor went over, went under a bit of trauma and possibly that resulted in a larger lab. And even if there isn't muscles, it's understandable that things might work well, if it's really small and if it's still healing you know, different, different things like that. So understanding the, kind of like the recent birth story, as well as their bladder story going back. So you've met first baby or before that first baby so that we know where, where we're starting from. And the, the reason why I do that is because again, if it's a longterm issue, we have to acknowledge the most recent event and also understand there was something else happening that, that we need to kind of look at. Speaker 1 (00:18:58): So would I expect it all to magically go away? No, I wouldn't. There's probably something else we need to figure out, but if it's like, Nope, this onset happened birth of my baby three months ago, it's been happening since then three months is, seems like forever and is also no time whatsoever. It took 10 months to make the baby. So it's you know, if you tear your hamstring, we're expecting you to start feeling better in three months, but you're probably not back to your peak performance. So where are we in that? And sometimes time will cure things. Things will continue to heal, but also that would be a time like how good are things working? Is there something else going on that maybe we could facilitate or have them reach continence a bit sooner. Okay, great. And do you also ask questions around if there was any trauma to the area? Speaker 1 (00:19:56): So if this birth was for example, the product of, of a rape or of some other type of trauma, is that a question that you ask or do you, is that something that you hope they bring up? It's, that's honestly for me and my practice, something, I try to leave all of the doors wide open for them to, to share that in my experience you know, I've worked places where it is on it's on the questionnaire that they fill out from the front desk and they'll circle no to, to any sort of trauma in the past. Speaker 1 (00:20:34): Yeah. They just, they don't want to circle yes. On that form. So and also I kind of treat everybody like they might have something in their past, right. So very nonjudgmental, very safe place, always making them as comfortable in a safe as possible. And I will say that there's anything I can do to make you feel more comfortable and more safe. We can do that. And if you don't feel safe and comfortable, we're not doing this w we're going to do something else. Cause you're right. That it's always one of those lingering things. And the statistics on abuse and, and rape are horrifying to the point where, again, in my practice, I kind of assume that everybody has the possibility of having something in their past. Okay, great. Thank you. And now another question that's shifting gears. Another question that came up that I think is definitely worthy of an answer is what outcome measures or tools might you use with with your incontinence patients? So with incontinence, honestly, my favorite is like an oldie buddy, but a goodie, like just, it's an IC, it's the international continents questionnaire where it's, I think it's five or six questions. Just simple. Like how often does this happen? When does it happen? Speaker 1 (00:21:58): There's a couple of other outcome measures that do cover, like your bladder is not empty. Are you having feelings of pressure in your lower abdomen? It gets into some bowel and more genital function. Can you repeat that? Cause it kind of froze up for a second. So could you repeat the name of that outcome tool as it relates to the bladder and output? Oh, sorry. I see. IQ is one and then, but like I see IQ vs which renal symptoms, right? So there are, there's a lot of different forms out there. Another one that will gather up information about a whole bunch of things in the pelvis is the pelvic floor distress bins questions about bowel function, bladder function, sexual function discomfort from pressure or pain. So that can give you a bigger picture. I'll be honest. Sometimes my, the people in my clinic they're coming in, and even though I will ask the questions about those things, when they get the, the questionnaire with all of these things that they're like, this doesn't apply to me. I'm like, well, that's great that it doesn't apply to you, but they don't love filling, filling it out. So sometimes what I will go with is actually just the pale. Speaker 1 (00:23:24): Can you say that again? Please help me. Oh yeah. Oh, so sorry. The patient's specific functional scale where, where the patient says, this is what I want to have happen. And we kind of figured out where they are talk about what would need to happen to get them there, but it's them telling what better. Right. Cause I've had people actually score perfect on some of these outcome measures, but they're still in my office. So it's like, Oh, I'm so patient specific is one of my one of my kind of go tos. And then there's actually a couple of, most of these pelvic questionnaires finding one that you like is really helpful because, because there's so many and they really all or discomfort. So if you have a really good ability to take a really good history, some of the questions on that outcome measure end up being a bit redundant. Speaker 1 (00:24:26): So I like, and you know the questions on there, make sure people are filling them out. You look at them before you ask them all the questions that they just filled out on the form for you. Yes. Good. Very good advice. So then the patient doesn't feel like they're just being piled on with question after question and cause that can make people feel uncomfortable when maybe they're already a little uncomfortable coming to see someone for, for whatever their problem or dysfunction is. So that's a really good point. And now here's a question that came up a couple of times, you know, we're talking about incontinence, we're talking about women, we're talking about pregnancy. What about men? So is this pelvic floor dysfunction? Is this incontinence a women only problem? Or can it be an everybody problem? So it very much can be an everybody problem. Incontinence in particular for men, the rates for that are much lower. And typically the men are either much older or they are they've undergone frustrate removal for prostate cancer. Speaker 1 (00:25:33): Fleur plays a role in getting them to be dry or at least dryer. And then it's like the pelvic floor is not working right. That can result in pain. It can result in constipation. It can result in sexual dysfunction. It can result in bladder issues. So it's, so yes, men can have all of those things. In fact, last night we had a great talk in our mentorship group at entropy about hard flacid syndrome. So this is a syndrome with men where everything is normal when they go get, get tested, no no infections, no cancers, no tumors, no trauma that they can recall. And, but the penis is not able to become functional and direct. And with a lot of these men, we're finding that it's more of a pelvic floor dysfunction issue, or at least they respond to pelvic floor interventions. Speaker 1 (00:26:30): So having a pelvic floor that does what it's supposed to, which is contract and relax and help you do the things you want to do. If, if we can help people make sure that they're doing that can resolve a lot of issues and because men have pelvic floors, they can sometimes have pelvic floor dysfunction. Okay, great. Yeah. That was a very popular question. Is this a woman only thing? So thank you for clearing up that mystery for everyone. Okay. So in going through your evaluation, you've, you've asked all your questions, you're getting ready for your objective exam. What do you do if you're a clinician who does not do internal work, is there a way to test these pelvic floor muscles and to do things without having to do internal work? My answer for that question is yes, there are things that you can do because even though I do do internal exams, I have people who come to see me who are like, no, we're not doing that. Speaker 1 (00:27:31): So, so where can we start? And so the first one is pants on and me not even touching you pelvic floor, I wouldn't really call it an assessment or self report. So even just sitting here, if you, if you were to call me up and and this actually goes into, I think another question that was on Slido about pelvic floor cues. So there is actually then it seems more research on how to get a mail to contract this pelvic floor then actually females. But I would ask you like like this is one that my friend Julie, we would use. So like if you're sitting there and you just sit up nice and tall, if you pretend you're trying to pick up a Ruby with your PA with your vagina is not on the outside, but imagine like there's just a Ruby on the chair and you'd like to pick it up with no hands, breathe in and breathe out and let it go. So then I would go, did you feel anything and you should have felt something happen or not. So if, if you did it, would you mind telling me what you built? You're asking me, Oh my goodness. Oh yes. I did feel something. So I did feel like I could pick the Ruby up and hold it and drop it. Speaker 1 (00:29:04): Excellent. And that's, and that, that drop is key. Excellent. So what I would say is this is like like a plus, like a, I can't confirm or deny you that you did it correctly, but I like, I would have watched you hold your, like she holding my breath. Is she getting taller? Cause she's using her glutes. Did she just do a crunch? When she tried to do this, I can see external things happening that would indicate you're might be working too hard or you might be doing something completely wrong. So then we'll get into, I mean, you said, yes. I felt like I pick up the Ruby, but if it's like, Hmm, I felt stuffed, but I'm not really sure we would use our words because they've already said no to hands to figure that out. But again, I can't confirm it. People are they're okay with that. Speaker 1 (00:29:48): And I'm like, and if what we're doing based on the information you gave me, isn't changing, we might go to step two. If you can send in step two is actually something, any orthopedic therapist honestly, should not feel too crazy doing. So if anyone has ever palpated the origin of the hamstring, so where is the origin of the hamstring facial tuberosity? If you go just medial to that along the inside part get, don't go square in the middle. That's where everyone gets a little nervous and a little tense, but if you just Pell paid around that issue, tuberosity it's pretty awesome. If you have a, a friend or a colleague who's willing to let this happen is you ask them to do a poll of our different cues with that in a little bit. You say that again, ask them to do what to contract the pelvic floor. Speaker 1 (00:30:44): Okay. And again, figuring out the right words so that they know what you're talking about. We can talk about that in a minute, but if they do a pelvic floor contraction, you're going to feel kind of like the bulging tension build, right there may be pushing your fingers. You should feel it kind of gather under your fingers. It shouldn't like push your fingers away, but then you can be like, well, you could test their hamstring and see that you're not on the hamstring and you can have them squeeze your glutes and you can kind of feel the differences. The pelvic floor is just there at the bottom of the pelvis. So you can palpate externally, even through BlueJeans is a bit of a challenge, but if they're in you know, like their workout shorts for yoga pants, it's actually very, very simple. And, and honestly, as long as you explained to them what you're doing and what you're checking for, it's no different than palpating the issue of tuberosity for any other reason. Speaker 1 (00:31:36): And with that, I tell them that I can, it's more like a plus minus, so I can tell that you contracted and that you let go. That's all I can tell. So I can't tell you how strong you are, how good your relaxation Wells, how long you could hold it for any of those things. And then I tell them with an internal exam, we would get a lot of information we could, we can test left to, right? We can, I could give you more of like a muscle grade. So like that zero to five scale be use for other muscles. We can use that for the pelvic floor. I can get a much better sense of your relaxation and see how was that going and I can even offer some assistance. So so we have two really good options for no touching. Speaker 1 (00:32:19): And then just as long as we understand the information we might gain from an internal exam, we can, we can, the information we gathered from the first two ways, isn't sufficient to make a change for them. And then as let's say, the non pelvic health therapist, which there might be several who are gonna watch this, when do we say, you know, something? I think it's time that we refer you to a pelvic health therapist, because I do think given what you've said to me and you know, maybe we did step one and two here of your exams. I think that you need a little bit more. So when do, when is that decision made to reach the point of, they have a bother that I don't know how to address so we can actually go to like the pelvic organ prolapse. So pelvic organ prolapse is, is when the support for either the bladder, the uterus, or even the rectum starts to be less supportive and things can kind of start to fall into the vaginal wall and can give a feeling of like pressure in with activity the sensation can get. Speaker 1 (00:33:39): So then we have two options, which is more support from below with perhaps a stronger meatier pelvic floor by like working it out to hypertrophy. So like if, if I had someone who had that feeling when they were running and we tried a couple are lifting weights, let's go lifting weights. No, like I feel it once I get to like a 200 pound deadlift. Okay, well, let's see how you're lifting when you're doing 150 and let's take a look at what you're doing at 200 in fresh with your mechanics or what's happening. And if there's something that is in your wheelhouse where you're like, well, can you try this breath? Or can you try it this way and see if that feeling goes away? I'm good with that. And if the, that the person who's having issue is good with that. Awesome. But if you're trying stuff or the incontinence is not changing, send them to a pelvic floor therapist, because what we love to do is we can check it out. Speaker 1 (00:34:41): We're going to check it out. We're going to give some suggestions. And then my, the end of every one of those visits that I get from my, from my orthopedic or sports colleagues is I'm like, excellent. So you're going to work on this, keep doing what you're doing. Cause another really common thing is like, is I don't really believe that they can make a lot of these things worse doing the things that they're doing. And by that, I mean, they can become more simple MADEC, but in many cases you're not actually making the situation worse. So if the symptoms seem to be not getting better or even getting worse, doing the things they're doing, they go come back to the pelvic floor therapist. And then that pelvic floor therapist also has a responsibility that the things I'm asking them to do, isn't helping them get there. Speaker 1 (00:35:29): You can try something a little more intense, still not helping. Then that's when I actually would refer for females, especially with like pelvic pressure. So Euro gynecologist for an assessment in that regard. Yeah. So I think I heard a couple of really important things there. And that's one, if you are the sports therapist or the orthopedic physiotherapist, and you have someone that needs pelvic health support, you can refer them to the pelvic health therapist and you can continue seeing them doing the things you're doing. So just because they're having incontinence or they're having some pressure, let's say it's a pelvis, pelvic organ prolapse. It doesn't mean stop doing everything you're doing. Speaker 3 (00:36:12): Okay. Speaker 1 (00:36:15): Correct. Okay. Yeah. It may mean modify what you're doing. Stop some of what you're doing, listen to the pelvic floor therapist. And I'm also seeing, well now we're, aren't we this great cause we're creating great team around this, around this person to help support them in their goals. So one doesn't negate the other. Absolutely correct. And I, and I think too often even, even within the PT world is people start to get kind of territorial. But it's not about what each one of us is doing. It's that person. Right. so telling them to stop doing something, especially if it's something they love it seems like a bad start. It's like, okay, let's take a look at this. Tell me what you are doing. Tell me what you want to be doing. Tell me what's happening when you do that. And let's see if we can change it. Speaker 1 (00:37:02): Cause like I said, like the, the other, that being something they're going to make worse and worse and worse is if symptoms get worse and worse and worse, but they're not causing damage, they're not causing, I mean, what they're doing and say leaking a bit. Got it. And now I'm going to take a slight detour here because you had mentioned pelvic organ prolapse. You had mentioned, there comes a time when, if that pressure is not relieving, you've tried a lot of different things. You would refer them to a urogynecologist now several years ago. They're so you're, you're a gynecologist. One of their treatments might be surgery. So there was pelvic mesh sweats. It's hard to say pelvic mesh surgery that years ago made some people better and made some people far, far worse with, with some very serious ramifications. So can you talk about that pelvic mesh mesh surgery and where we are now? Speaker 1 (00:38:04): Oh, the last bit cut out a little bit. So the pelvic mess, mess surgery and, and Oh, the most important part and kind of where we are now versus maybe where we were, let's say a decade ago or so. Awesome. Yeah. So, so the pelvic mesh situation certainly here, I think it's not a universal problem. I think it's a United States problem is if you're at home during the day, like most of us are now you will see law commercials, lawyers looking for your business to discuss the mesh situation on what's happening is there was there were, it was mesh erosion and the resulting fact that that was a lot of pain because they couldn't just take it all out. And it was several women suffered and are still sad. Speaker 3 (00:38:55): Mmm. Speaker 1 (00:38:55): But that was from a particular type of surgery with a particular type of surgical kit, which thankfully has, was removed completely from the market and isn't being used anymore and mesh surgeries, I would say at least for the last five to 10 years, haven't haven't been using that and mesh surgeries are being done with great success in resolving symptoms. So I think it's important that if a woman isn't responding Speaker 3 (00:39:27): Yeah. Speaker 1 (00:39:30): Well changing their breath or making a pelvic floor or changing how they're doing things is to have that discussion with the Euro gynecologist because they do have nonsurgical options for super mild prolapse. There are some even like over the counter options you can buy like poise has one where it's just a little bit of support that helps you. Actually not leak because if you're having too much movement of the urethra, it can cause stress or it can be contributing to stress incontinence. But so there's some over the counter things or there's something called a pessary, which I think about it. Like I'm like a tent pole, but it's not a pole. It's a circle don't worry or a square or a donut. There's so many different shapes, but it's basically something you put in the vagina and that you can take out of the vagina that just kind of holds everything back up where it belongs, so it can work better. Speaker 1 (00:40:21): And that it's not awesome. But there are also people who are like due to hand dexterity, or just due to a general discomfort with the idea of putting things in their vagina and living them there that they're like, no, I'd rather just have this be fixed. So, so there are, it's not just surgery is not your only option. There are lots of options and it just depends on where you want to go. But with the surgery, if that's what's being recommended for a woman, I really do. Some women aren't worried at all. They've heard about the mash, but they're sure it won't happen to them, but there are when we're still avoiding surgery, even with significant syndromes, because they're worried about the mesh situation. And I would still encourage those women to at least discuss us, to see if that surgeon can, can educate them and give them enough confidence before they move forward with the surgery. Speaker 1 (00:41:18): Because the worst thing I think is when I had one patient actually put it off for years. Not, not just because of the mesh because of a lot of issues, but the first time the doctor recommended it, she had a grade four prolapse. Like that means when things come all the way out. And she it was so bad. Like she couldn't use the pastory okay, so she needed it, but she avoided it until she was ready and had the answers that made her feel confident in that having the surgery was the right thing to do. So it might take some time and the doctor, the surgeon really should, and most of them that I've met are more than happy to make sure that the patient has all the information they need and understand the risk factors, the potential benefits before they move forward. Speaker 2 (00:42:03): Excellent. Thank you so much for that indulging that slight detour. Okay. Let's get into intervention. So there are lots of questions on Slido about it, about different kinds of interventions. And so let's start with lot of, lot of questions about transverse abdominis activation. So there is one question here from Shan. Tall said studies in patients with specific low back pain do not recommend adding transverse abdominis activation because of protective muscle spasm. What about urinary incontinence in combination? What do you do? So there is a lot on transfer subdominant as you saw in Slido. So I'll throw it over to you and, and you can give us all your share your knowledge. Speaker 1 (00:42:55): Okay, well, let's all do this together. So I don't know how many people are watching, but if we just sit up nice and tall and I'm going to give a different cue for the pelvic floor. So what I want you to squeeze, like you don't want to urinate, like you want to stop the stream of urine. Okay. So as we're pulling that in anything else other than the underneath contract, what did you feel Karen? Speaker 2 (00:43:24): Well, I did feel my TA contract. I felt that lower abdominal muscle wall started to pull in. Speaker 1 (00:43:32): Yes. So, so the, the way I explain it is that the pelvic floor and the trans versus are the best is to friends. And this makes sense when you think about when you remember the fact that the pelvic floor, isn't just there regarding like bowel bladder and sexual function. It's one of our posture muscles. So if we're totally like, like slacked out and our abs are off and all of that, our pelvic floor is pretty turned off as well. And then if I get a little bit taller and like, so I'm not really clenching anything. Right. But this is like stuff working like it should, my pelvic floor is a little more on, but not, I'm not acting. It's just but then I could like, right, if I'm gonna, if I'm expecting to hit, or if I'm going to push into something, I can tend to set up more and handle more force into the system. Speaker 1 (00:44:21): So I like to think about it in those in those three ways, because the pelvic floor, isn't just hanging out, down there and complete isolation it's, it's part of a system. And so in my personal, like emotional approach to interventions is I don't want them to be too complicated. So if I can get someone to contract their pelvic floor, continue to breathe and let go of that pelvic floor, then we start thinking about what else are you feeling? Cause I don't know that there's any evidence that says if I just work my transverses all the time, my pelvic floor will automatically come along for the ride. So a great quote. I heard Karrie both speak once at a combined sections meeting and she goes, your biceps turn on. When you take a walk, it's not a good bicep exercise. So just the fact we're getting activity in the pelvic floor when we're working other muscles, what's supposed to work. And also if you want to strengthen that muscle, you're going to need to work out that muscle. Speaker 1 (00:45:26): And that makes a lot of sense and something that people had a lot of questions around where we're kind of queuing for these different exercises. And I really love the can. You've made it several times comparisons to other muscles in the body. So can you talk about maybe what kind of queuing you might use to have someone on? I can't believe I'm going to say this turn on and I use that in quotes because that's what you see in, in a lot of like mainstream publications for, for layman. So it might be something that our patients may see when they come in. So how do you cue that? To, to turn on the pelvic floor? So honestly I will usually start with floor and I do if I'm able to do a public floor exam, that's usually, again, a lot more information for me, but I'm like, okay, so do that now. Speaker 1 (00:46:27): And I watched them do it or I feel them do it and I'd be like, Oh, okay. What did you, what did you feel move? And I start there. And then I always say it's a little bit, like I get dropped into a country and I'm not sure what language people are speaking. So sometimes excuse me, one of the first cues that I learned was like, so squeeze, like you don't want to pass gas. Okay. So everybody let's try that. So sitting squeeze, like you don't care and you got taller. So I think you did some glutes. Speaker 1 (00:47:00): It's like, OK. So like lift, lift your anal sphincter up and in, but activating mostly the back part. So if you're having fecal issues, maybe that's a good place to start, but most people are having issues a little further front. So then we moved to the, can you pick a upper with your, with your Lavia? I had a, I learned the best things for my patients. One woman said it's like, I'm shutting the church doors. So if you imagine the Lavia being churched doors, we're going to close them up. And that, that gives a slightly different feeling. Them then squeezing the anal sphincter. Now, if you get up to squeeze, like you don't want to like pee your pants, like you want to stop the stream of urine. That will activate more in the front of the pelvis. Look, men who are like if it gets stopped the flow of urine, I wouldn't be here. Speaker 1 (00:47:57): So what else do you get? What's really cool is in the male literature. So this is a study done by Paul Hodges is he found that what activated the anterior part and the urinary sphincter, this rioted urinary speaker, sphincter the most for men. What a penis or pull your penis in to your body now for women. So when I was at a chorus and it's like, so let's, let's think of like other cues and other words, but even if, so, I don't have a penis this fall that probably don't have a penis. Even if you don't have a penis, I want you to do that in your brain, shorten the penis and pull it in. Speaker 1 (00:48:42): And did you feel anything happen? Cause we do have things that are now analogous to the male penis, if you are are a female. So I'll sometimes use that. Like I know it sounds stupid, but pretend to draw on your penis and it works and it does feel more anterior for a lot of people. So I'll kind of just, I'll kind of see what's, like I said, sometimes it's like the 42nd way of doing it that I've asked them to do where they're like, Oh, that, and you're like yeah. So then also just another, it's a little bit of like a little bit of a tangent, but so as you're sitting, so if you're, if you're sitting I want you to pick the cue that speaks most to your pelvic floor, and I want you to slouch really, really slouch, and actually to give yourself that cue and just pay attention to what you're feeling. So when you squeeze, give yourself that cue, breathe in and breath out and then let go, we should have felt a contraction, a little hole and a let go. Now, the reason why I say breathe in and breathe out is if you breathe in and out, that's about five seconds and also you were breathing. Cause another thing people love to do when they're trying to contract their pelvic floors, just basically suck it in. Speaker 1 (00:50:10): And so that's, that's not great, but we want to feel the contraction and we want to feel it, let go. And that's super important. I think that was another question on the Slido is that yes. For any muscle we're working, you should be able to contract it and let it go. There's not a muscle in our body where I just keep it contracted. It's going to do much. It might look great. Eventually, but like I couldn't get my coat on, like getting a drink of water would be a little weird. It's not very functional muscles have to relax so that they can contract. So that's a big, yes, it's just as important that the contraction pelvic floor that cue and we felt where it happened, not tall, like, like you're sitting out at a restaurant and you just saw someone looking at you and you're like, Oh, what are they looking at? And then you're going to do the exact same cue and you're gonna breathe in and breathe out and let it go. Speaker 1 (00:51:07): And then did it feel different than menu or slouch that it did it change position? I feel like Karen's Miami. It feels different. Now what I want you to do is if you can, depending on how you're sitting really give me like an anterior pelvic tilt, really happy puppy and then do the exact same thing and then let it go. And so again, some more EMG work from, from Paul Hodges is that when you're in a posterior pelvic tilt, you tend to activate the posterior portion more, which is fine. And if you're not having problems in the front, if you're having problems activating and maintaining continence in the front, actually increasing that lordosis can favor the front a bit. So this is, that's really awesome when people can feel that difference. Because I want you to think about, if you start to leak on your fourth mile of a half marathon, there's no way, no matter how awesome you are, but you're going to be able to squeeze your pelvic floor for the rest of that race. Speaker 1 (00:52:15): Like there's just, there's no way. But sometimes if, because remember your pelvic floor is still doing its thing while you're running is if you're like, well, hold on, when you're at your fourth mile, are you starting to get tired or hopefully not if it's a half marathon, but you know, like is something changing and how you're using your body. And can you, when you get to that point, remember to stay tall or lift your tail a little bit, or is there a cue or something they can change that will help them favor the front instead of going about four steps with the contracted pelvic floor and then losing it anyway. So there's, there's a lot of different ways you can actually make that your intervention for the issue you're having and then let's just get it functional. Perfect. And since you brought up running a question that's been, got, gotten a couple of likes on Slido is how would you approach return to running after pregnancy? Speaker 1 (00:53:15): Do you have any tips on criteria for progress, timeframe and a recreational runner versus a full time athlete? Because I would think the majority of physiotherapists around the world are seeing the recreational runner versus the professional or full time athlete. So first, how would you approach return to running any tips for progress? So that's going to be after pregnancy, sorry. After pregnancy. Yeah. So this is where I was really excited. So just last year I'm going to say her name wrong, but Tom goom Gran Donnely and Emma Brockwell published returned to running postnatal guidelines for health professionals managing this population. And the reason why I was super excited is because even though it was just published last year, it's the first one. There was definitely a lot of emotion and feelings about, about women getting back into sport after having a baby, but to be perfectly Frank, there's very few actual solid guidelines for recreational or others. Speaker 1 (00:54:30): So I have not personally had a child, but I will tell you of all the women I've seen over the years, basically doctors are like, it's been six weeks ease back into it, see how it goes. I'm not really even mentioning if you have a problem come back so we can figure it out. It's just kind of like good luck with that. And as a result, what happens is a lot of women don't get back into exercise or they get back into exercise and and kind of freak themselves out because stuff feels different. So to get back to the question of what do I do, actually this this guide from Tom and team really, really helpful. I think, and, and it's just basically it's it does have a series of exercises that I've actually started to use with my postpartum moms to go like, look, if you can do these things without feeling heaviness, you're good. Speaker 1 (00:55:30): You're good to start easing back into your running program, but get up, get walking because I'm going to post Sandy Hilton and like, you can't rest this better, like just waiting, isn't going to make it all go away. But it can also be deceiving because again, with polo, you don't feel that heaviness and you don't leak. And so I'm just going to stay right here where everything is fine. So that's obviously not a good option longterm option for a lot of reasons. So, so what do I do? I do look at the patient's goals, their previous running history, and if they're having any options I recently had a patient who she was runner exercise or sr after baby number two for a bit, some feeling of happiness that got completely better, baby number three came along. So I saw her a bit while she was pregnant because she got, I think two thirds of the way through pregnancy before she started to feel that heaviness. Again, she was still running, Speaker 1 (00:56:38): Tried to see if we could change that feeling while she was running. And she could until about the, when did she start? I think she didn't stop running to her 35th week, which is pretty impressive. But then she wanted to do a half marathon. I think it was just three months postpartum. Right. So this is like going from having baby to running 13. You think that a lot of people would probably feel that was too soon, too much too fast, but she was able to do it completely symptom-free. So as she was training and she was really fast, she was timing it so that she could get back in time to breastfeed. Like I was like, Oh my gosh, like I, that would disqualify me. Like, there's no way I could run fast enough to make that happen. But she was able to, to work it out where she could perform at her level without symptoms. And I was really happy that I was able to support her in that she did all the hard work. For general people recreational, where you a runner before, or is this completely new and are you having any symptoms and is there any thing you're worried about? Again, a lot of women are worried about giving. Speaker 1 (00:57:53): It's actually really hard to perhaps to give yourself one baby babies are a great way to do it. But that's like the risk factors I look up for something else a couple of years ago, I haven't looked recently, but like you really have any prolonged lifting. So not like your CrossFit three days a week, but like your, your physical labor for eight, eight hours, 10 hours a day every day could eventually do it also having babies. So like once you get to every baby increases your risk of pelvic organ prolapse, which makes good sense. And that, and that is what it is. So kind of looking at what are their risk factors, are there any, and letting them know that if they feel it more, it doesn't mean they made it worse. They just made it more symptomatic. Got it. Great. Speaker 1 (00:58:40): All right. So we have time for maybe one or two more questions, and then I'm going to throw back to Claire. Cause we're coming up onto an hour here, maybe time for one more it's so w what am I going to ask? I think I'm going to go with the gymnasts I work with all believe it's normal to leak a little urine during training or competition. And this is something we talk about a lot. It might be common, but is it normal? You already gave me the answer. What is it, Karen? No, no, no. And so, yeah, so the, the short answer for that is no. Or I agree with the question where it is very, very, very common, and it is still, I would say, not to leak urine. Unfortunately, so there's any researchers out there who want to get together. Speaker 1 (00:59:26): Let me know. We haven't, we have information on athletes and incontinence, but mostly it's prevalent that it happens a lot and gymnastics and dancing and volleyball. There's, there's even some swimmers who have it, right? So there's, there's incontinence across the spectrum, which basically tells me, yep. People have incontinence. Some of the some of the sports are more likely to have urgent continents. A lot of them though, we're looking at stress incontinence, however, for none of the athletes, have, we really had a great study that says, this is what we're finding. We're thinking, this is the cause of this incontinence. And we certainly haven't gotten to the point where it's like, and this is what we should be doing for these women in particular. So I'm, I'm pretty curious as to what we would have to do as, as a profession, as, as a team with researchers to figure out what do we need to look at in these athletes, especially the female athletes, because most of these are also they've never had babies, right? So a lot of these athletes are the liberos. And so we can't, we can't blame them. There's something with how things are working. That seemed to be the situation it's not necessarily trauma or anything like that. So what do we need to look at? What do we think is happening? Can we measure it and assess it? And then can we get an intervention? Speaker 1 (01:00:56): My brain, obviously, something isn't working as well as it could. So could something like that improve their performance, even I don't, I don't know. I'd like to think so. Yeah. That would be distinct study. Yeah. But we ultimately don't know. So if anyone has any ideas for studies or doing studies, let me know, because I can't wait to read them. But I think maybe the first step is to let coaches and parents and young gymnast know very common. Don't be ashamed. Don't let it stop you from doing what you want to do. But also don't just ignore it. Maybe we can figure this out. Speaker 2 (01:01:30): All right. One more question with a short answer, if you can. So, and I'm going to ask this question because I feel like the person who posted this I think posted this in earnest. So that's why I'm asking, this is the last question. So a female patient age, 20 years still bedwetting from her childhood, otherwise she is normal, no incontinence. So other than this, just while sleeping, she tends to urinate any thoughts on this or any place you can direct this. Speaker 1 (01:02:04): Yeah. So I did, I was like, Oh, great question. And I did actually do a little research for this specific question. There's a lot of reasons why nocturnal enuresis, which is what bedwetting is called in the literature happens. And I think it's really important. So I don't know what kind of tests or studies this person has had done or what other issues they may be having. So things like sleep apnea is is something that could be related if there's any medications, any sort of diuretics, any kind of sleeping medications. Again, the fact it's kind of carried on since childhood, I, I would really wonder about how, how is the bladder functioning? The fact that it's working fine throughout the day makes me wonder what's changing at night. And I did find a study where it talked about when they look compared adolescents or adults who were bedwetting to people who weren't, they did have like detrusor overactivity. So like basically like an overactive bladder that they could see on the testing. So I would, I would really encourage this person to find a urologist that they trust if they haven't already and really to maybe investigate some of those other, other factors that could be contributing so that they can get some better sleep and not have that problem anymore. Speaker 2 (01:03:28): Excellent. Excellent. Oh, okay. Claire says we can go for one more question. So I'm going to listen to the boss here. Speaker 1 (01:03:36): And, Oh boy, are you ready? Because this is a question that did kind of get a lot of thumbs up. Okay. So we spoke about Speaker 2 (01:03:44): Briefly before we started. Speaker 1 (01:03:47): So let's see treatment of nonspecific, pelvic girdle pain, not related to pregnancy, which strategy with no susceptive pain mechanisms and which strategy with non nociceptive pain mechanisms would you incorporate with this patient? Okay. So I would say in the clinic, it's, it can be pretty hard. Like, I don't know how I would distinguish being nociceptive and non nociceptive or what even like non nociceptive might be if we're talking more central issues or stuff like that. I don't, I don't know. But honestly I would just look at, so in Kathleen's Luca has a great book about looking at the different types of pain or the different categories of pain and the most effective medications for it. Right. So we're really good in pharmacology. Like if you had this inflammatory process and, and inflammatory and anti-inflammatory should help, if you're having neuropathic pain, you want a drug that addresses that when we get into like physical therapy interventions, what's really cool is exercise is in all the categories. Speaker 1 (01:04:59): And it's one of the things we have the best evidence for. So regardless of pelvic girdle pain in pregnancy or not pregnancy, and regardless of how it may have been labeled by somebody else is I would, I would mostly want to know when did the pain start? Is there anything that makes it better? Anything that makes it worse and see if I could find a movement or change something for that person. Or that made me sound like I was going to do a whole lot of work. If I could find something for that person to change for themselves to have that hurt less and have the I tend, I would tend to keep it simple, mostly cause in the clinic again, we could do a lot of special tests that might say, Oh, Nope, they definitely hurt there, but it's still, if we're looking at what's going to be an effective intervention, that that patient is going to tell me what that is. Speaker 1 (01:05:54): Sorry. It would help a fire mute myself. So looks like we have time for one more. And I, I really, Claire was not clarity did not pop up yet. So we've got time for one more and then we're going to work. We're wrapping it up. I promise stroke patients, dementia patient. We just got the no go. Yes, no, it's a super short answer if you want Claire super short answer. Okay. So stroke dementia patients with urinary incontinence, any useful ideas for the rehab program? Yes, but not get an idea of their bladder habits, their bowel habits, their fluid intake. Because a lot of that's going to end up being outside caregiver help with the, with the stroke, it's much different. It depends on the severity and where it is and all of that. But for people with dementia is if you just get that, like if you can prompt them or take them to the toilet, a lot of the times that will take care of the incontinence. Speaker 1 (01:06:48): It's not a matter of like Cagle exercises. It's more management. All right, Sarah, thank you so much. I'm going to throw it back over to Claire to wrap things up. Thank you both for a wonderful and insightful discussion. Sarah and Karen. So many practical tips and pointers for the clinician, especially I was loving learning about all of the things that I could take to the clinic. So I hope our audience find those practical tips really helpful as always the link to this live chat will stay up on our Facebook page and we'll share it across our other social media channels. Don't forget. You can also follow us on Twitter. We're at Dow SPT. You can also follow us here on Facebook. Please share this chat with your friends, with family colleagues, anyone who you think might find it helpful. And if you like JSP T asks, please be sure to tell people about it at that what we're doing so they can find this here, please join us. Speaker 1 (01:07:46): Next week when we host our special guest professor Laurie from the university of Southern California, Larry is going to be answering questions on managing shoulder pain. We'll be here, live on Wednesday next week. So Wednesday, April the eighth at 9:00 AM Pacific. So that's noon. If you're on the East coast of the U S it's 5:00 PM. If you're in the UK and at 6:00 PM, if you're in Europe, before we sign off for the evening, there's also really important campaign that I'd like to draw your attention to. And it's one that we at Joe SPT supporting and it's get us PPE. So we're supporting this organization in their quest to buy as much a, to buy much needed personal protective equipment for frontline health workers who are helping us all in the fight against the coronavirus pandemic. So if you'd like to support, get us PPE, please visit their website, www dot, get us ppe.org, G E T U S P p.org as always. Thanks so much for joining us on this stale SPT asks live chat, and we'll speak to you next week. Bye. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Sarah Haag to talk about exercise and urinary incontinence. This interview was part of the JOSPT Asks interview series. Sarah is the co-owner of Entropy Physiotherapy and Wellness in Chicago. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women's Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. In this episode, we discuss: The prevalence of urinary incontinence Is urinary incontinence normal Pelvic floor exercises Pelvic floor exam for the non-pelvic health PT Sports specific pelvic health dysfunction And much more Resources: Entropy Physiotherapy and Wellness JOSPT Facebook Page JOSPT Journal Page More Information about Dr. Haag: Sarah graduated from Marquette University in 2002 with a Master's of Physical Therapy. Sarah has pursued an interest in treating the spine, pelvis with a specialization in women's and men's health. Over the years, Sarah has seized every opportunity available to her in order to further her understanding of the human body, and the various ways it can seem to fall apart in order to sympathetically and efficiently facilitate a return to optimal function. Sarah was awarded the Certificate of Achievement in Pelvic Physical Therapy (CAPP) from the Section on Women's Health. She went on to get her Doctorate of Physical Therapy and Masters of Science in Women's Health from Rosalind Franklin University in 2008. In 2009 she was awarded a Board Certification as a specialist in women's health (WCS). Sarah also completed a Certification in Mechanical Diagnosis Therapy from the Mckenzie Institute in 2010. Sarah has completed a 200 hour Yoga Instructor Training Program, and is now a Registered Yoga Teacher. Sarah looks at education, and a better understanding of the latest evidence in the field of physical therapy, as the best way to help people learn about their conditions, and to help people learn to take care of themselves throughout the life span. Read the full transcript below: Read the Full Transcript below: Speaker 1 (00:06:25): So, and hopefully it doesn't want to lose what we're doing here. We'll see. Okay. Going live now. Okay. Welcome everyone to JLS. PT asks hello and welcome to the listeners. This is Joe SPT asks the weekly chat where you, the audience get your questions answered. My name is Claire Arden. I'm the editor in chief of Joe SPT. And it's really great to be chatting with you this week, before we get to our guest. I'd like to say a big thanks for the terrific feedback that we've had since launching [inaudible] a week ago. We really appreciate your feedback. So please let us know if there's a guest that you'd like to hear from, or if you have some ideas for the show today, we're in for a very special treat because not only are we joined by dr. Sarah hake from entropy physio, but guest hosting [inaudible] asks today is dr. Karen Litzy who you might know from the healthy, wealthy and smart podcast. Dr. Lexi is also a new Yorker. And I think I can speak for many of us when I say that New York has been front of mind recently with the coronavirus pandemic. And I'd like to extend our very best wishes to everyone in New York where we're thinking of you. So I'm going to throw to Karen now. We're, I'm really looking forward to chat today on pelvic floor incontinence and exercise over to you, Karen. Speaker 1 (00:08:25): Hi everyone, Claire. Thank you so much. I really appreciate your giving me the opportunity to be part of J O S P T asks live stream. So I'm very excited about this and I'm also very excited to talk with dr. Sarah Hagar. Sarah is an educator, a clinician, and an author. She is also co-owner of entropy wellness and our physiotherapy and wellness in Chicago, Illinois, and is also a good Speaker 2 (00:08:56): Friend of mine. So it's really a an honor for me to be on here. So Sarah, welcome. Thank you so much. I was really excited that all this came together so beautifully. Yes. And, and again like Claire had mentioned, we're all experiencing some pretty unprecedented times at the moment. And the hope of these J O S P T asks live streams is to continue to create that sense of community among all of us, even though we can't be with each other in person, but we can at least do this virtually. And as Claire said, last week, we want to acknowledge our frontline healthcare workers and colleagues across the world for their dedication and care to those in need. And again, like Claire said before, a special shout out to my New York city colleagues, we are they are really working like no other. Speaker 2 (00:09:52): And I also want to acknowledge not just our healthcare colleagues and workers, but the scientists, the grocery store workers, the truck drivers the pharmacist, police, firefighter paramedics, they're all working at full capacity to keep the wheels turning around the world. So I just want to acknowledge them as well and thank them for all of their hard work during this time. Okay. So, like Claire said today, we're going to be talking about the pelvic floor, which is something Sarah loves to talk about because what I also, I also failed to mention is she is a certified pelvic health practitioner. So through the American physical therapy association. So she is perfectly positioned to take us through. And as a lot of, you know, we had, you had the opportunity to go onto Slido to ask questions. You can still do that. Even throughout this talk, just use the code pelvic that's P E L V I C, and ask some questions. Speaker 2 (00:10:57): So we do have a lot of questions. I don't know if we're going to get to all of them. So if we don't then certainly post them in the Facebook chat and maybe Sarah can find those questions in the chat below. And we'll try and get to those questions after the recording has finished. All right, Sarah. So like I said, lots of questions and the way the questions were, were written out, kind of corresponds quite well with maybe how you would see a patient in the clinic. So let's start with the patient comes into your clinic. They sit down in front of you. Let's talk about the words we would use in that initial evaluation. So I'll throw it over to you. Okay. So being a pelvic health therapist, obviously most people when they're coming to females, Things that happen in the pelvis, I like to acknowledge it, that there's a lot of things happening in the past. So I have Speaker 1 (00:11:54): Them tell me kind of what are the things that have been bothering them or what are the things that have been happening that indicate something might be going on? Like if something's hurting, if they're experiencing incontinence, any bowel issues, any sexual dysfunction. And, and I kind of go from there. So if the talk that's the title of the talk today includes incontinence. Continence is a super common issue that let's see in general might pop in. And if you would bother to ask there's actually, I think it's like one out of two people over 60 are experiencing incontinence of some kind. The answer is going to be yes, some, so you can start asking more questions. But starting out with what, what is bothering them is really what I like to start with. Then the next thing we need to know is after we vet that issue or that priority list of things that are bothering them in the pelvis, and it's not uncommon actually to have. Speaker 1 (00:13:00): So let's say they start with a discussion of incontinence. I still actually ask about sexual function, any pain issues, any bowel issues, just based on the innervation of the various, the anatomical arrangement of everything. It's not uncommon to have more than one issue, but those other issues might not be bothersome enough to mention. So it's kind of nice to get that full picture. Then the next thing we really want art. So there are times I've met women who come in and they're like, Oh yeah, you know, I have incontinence. And you're like, okay. So when did it start now? Like 25 years ago. Okay. Do you remember what happened then? Typically it was a baby, but sometimes these women will notice that their incontinence didn't happen to like four or five years after the baby. Hmm. So that's information, that's very help if they say my baby that was born six weeks ago, our interventions and expectations are going to be very different than someone who's been having incontinence for 25 years. Speaker 1 (00:14:05): So again, knowing how it started and when it happens, when the issues are happening, I just kind of let them, it's like a free text box on a form. Like just, they can tell me so much more excuse me. And when we are talking about things, we, I do talk anatomy. So when it comes to incontinence, I talk about the bladder and the detrusor, the smooth muscle around the bladder, the basically the hose that takes the urine from the bladder to the outside world. I do talk about the vagina and the vulva and the difference between the two. And then actually we do talk about like the anus and the anal sphincters and how all of that is is all there together and supported by the pelvic floor. Speaker 1 (00:14:54): Cause that's in physical therapy, it's going to be something with that pelvic floor or something. Drought, does it need to be more, more pelvic floor focused or does it need to be behaviorally focused, which is the case sometimes, or is it that kind of finding that perfect Venn diagram of both for those issues that the person's having? And let's say you're in a part of the world. One of the questions was what if you're I think this question came from Asia and they said, what if you're in part of the world where you have to be a little bit, maybe more sensitive around even the words that you use. I know we had gotten a question a couple of years ago about a woman in the Southern part of the United States that was from very conservative area. And do we even use these words with these patients? Speaker 1 (00:15:48): So what is your response to that? My response is that as healthcare providers, we are responsible, I think for educating people and using appropriate words and making sure people understand the anatomy like where things are and what they're supposed to be doing. However, definitely when I'm having this conversation with someone I want them to feel at ease. So like I will use the Ana vagina anus, anal sphincters Volvo, not, it's not a vagina, it's a Volvo it's on the outside. But then if they use different terms to refer to the anatomy, we're discussing, I'm happy to code, switch over to what they're most comfortable with because they need to be comfortable. But I think as, as again, healthcare practitioners, if we're not comfortable with the area, we're not going to make them feel very comfortable about discussing those issues. Right. Speaker 1 (00:16:43): And that makes a lot of sense. Thank you for that. So now let's say you, the person kind of told you what's going on and let's, let's talk about when you're taking the history for women with incontinence, especially after pregnancy, are there key questions you like to ask? Yes. So my, my gals that I'm seeing, especially when they're relatively relatively early in the postpartum period, are the things I'm interested in is did they experience this incontinence during their pregnancy? And did they have issues before pregnancy? And then also if this is not their first, tell me about the first birth or the, or the first two birth. So the first three birth to really get an idea of is this a new issue or is this kind of an ongoing marked by so kind of getting a bigger picture of it. Speaker 1 (00:17:49): And then also that most recent birth we want to know, was it vaginal? Was it C-section with vaginal birth? If there's instrumentation use, so if they needed to use forceps or a vacuum that increases the likelihood that the pelvic floor went over, went under a bit of trauma and possibly that resulted in a larger lab. And even if there isn't muscles, it's understandable that things might work well, if it's really small and if it's still healing you know, different, different things like that. So understanding the, kind of like the recent birth story, as well as their bladder story going back. So you've met first baby or before that first baby so that we know where, where we're starting from. And the, the reason why I do that is because again, if it's a longterm issue, we have to acknowledge the most recent event and also understand there was something else happening that, that we need to kind of look at. Speaker 1 (00:18:58): So would I expect it all to magically go away? No, I wouldn't. There's probably something else we need to figure out, but if it's like, Nope, this onset happened birth of my baby three months ago, it's been happening since then three months is, seems like forever and is also no time whatsoever. It took 10 months to make the baby. So it's you know, if you tear your hamstring, we're expecting you to start feeling better in three months, but you're probably not back to your peak performance. So where are we in that? And sometimes time will cure things. Things will continue to heal, but also that would be a time like how good are things working? Is there something else going on that maybe we could facilitate or have them reach continence a bit sooner. Okay, great. And do you also ask questions around if there was any trauma to the area? Speaker 1 (00:19:56): So if this birth was for example, the product of, of a rape or of some other type of trauma, is that a question that you ask or do you, is that something that you hope they bring up? It's, that's honestly for me and my practice, something, I try to leave all of the doors wide open for them to, to share that in my experience you know, I've worked places where it is on it's on the questionnaire that they fill out from the front desk and they'll circle no to, to any sort of trauma in the past. Speaker 1 (00:20:34): Yeah. They just, they don't want to circle yes. On that form. So and also I kind of treat everybody like they might have something in their past, right. So very nonjudgmental, very safe place, always making them as comfortable in a safe as possible. And I will say that there's anything I can do to make you feel more comfortable and more safe. We can do that. And if you don't feel safe and comfortable, we're not doing this w we're going to do something else. Cause you're right. That it's always one of those lingering things. And the statistics on abuse and, and rape are horrifying to the point where, again, in my practice, I kind of assume that everybody has the possibility of having something in their past. Okay, great. Thank you. And now another question that's shifting gears. Another question that came up that I think is definitely worthy of an answer is what outcome measures or tools might you use with with your incontinence patients? So with incontinence, honestly, my favorite is like an oldie buddy, but a goodie, like just, it's an IC, it's the international continents questionnaire where it's, I think it's five or six questions. Just simple. Like how often does this happen? When does it happen? Speaker 1 (00:21:58): There's a couple of other outcome measures that do cover, like your bladder is not empty. Are you having feelings of pressure in your lower abdomen? It gets into some bowel and more genital function. Can you repeat that? Cause it kind of froze up for a second. So could you repeat the name of that outcome tool as it relates to the bladder and output? Oh, sorry. I see. IQ is one and then, but like I see IQ vs which renal symptoms, right? So there are, there's a lot of different forms out there. Another one that will gather up information about a whole bunch of things in the pelvis is the pelvic floor distress bins questions about bowel function, bladder function, sexual function discomfort from pressure or pain. So that can give you a bigger picture. I'll be honest. Sometimes my, the people in my clinic they're coming in, and even though I will ask the questions about those things, when they get the, the questionnaire with all of these things that they're like, this doesn't apply to me. I'm like, well, that's great that it doesn't apply to you, but they don't love filling, filling it out. So sometimes what I will go with is actually just the pale. Speaker 1 (00:23:24): Can you say that again? Please help me. Oh yeah. Oh, so sorry. The patient's specific functional scale where, where the patient says, this is what I want to have happen. And we kind of figured out where they are talk about what would need to happen to get them there, but it's them telling what better. Right. Cause I've had people actually score perfect on some of these outcome measures, but they're still in my office. So it's like, Oh, I'm so patient specific is one of my one of my kind of go tos. And then there's actually a couple of, most of these pelvic questionnaires finding one that you like is really helpful because, because there's so many and they really all or discomfort. So if you have a really good ability to take a really good history, some of the questions on that outcome measure end up being a bit redundant. Speaker 1 (00:24:26): So I like, and you know the questions on there, make sure people are filling them out. You look at them before you ask them all the questions that they just filled out on the form for you. Yes. Good. Very good advice. So then the patient doesn't feel like they're just being piled on with question after question and cause that can make people feel uncomfortable when maybe they're already a little uncomfortable coming to see someone for, for whatever their problem or dysfunction is. So that's a really good point. And now here's a question that came up a couple of times, you know, we're talking about incontinence, we're talking about women, we're talking about pregnancy. What about men? So is this pelvic floor dysfunction? Is this incontinence a women only problem? Or can it be an everybody problem? So it very much can be an everybody problem. Incontinence in particular for men, the rates for that are much lower. And typically the men are either much older or they are they've undergone frustrate removal for prostate cancer. Speaker 1 (00:25:33): Fleur plays a role in getting them to be dry or at least dryer. And then it's like the pelvic floor is not working right. That can result in pain. It can result in constipation. It can result in sexual dysfunction. It can result in bladder issues. So it's, so yes, men can have all of those things. In fact, last night we had a great talk in our mentorship group at entropy about hard flacid syndrome. So this is a syndrome with men where everything is normal when they go get, get tested, no no infections, no cancers, no tumors, no trauma that they can recall. And, but the penis is not able to become functional and direct. And with a lot of these men, we're finding that it's more of a pelvic floor dysfunction issue, or at least they respond to pelvic floor interventions. Speaker 1 (00:26:30): So having a pelvic floor that does what it's supposed to, which is contract and relax and help you do the things you want to do. If, if we can help people make sure that they're doing that can resolve a lot of issues and because men have pelvic floors, they can sometimes have pelvic floor dysfunction. Okay, great. Yeah. That was a very popular question. Is this a woman only thing? So thank you for clearing up that mystery for everyone. Okay. So in going through your evaluation, you've, you've asked all your questions, you're getting ready for your objective exam. What do you do if you're a clinician who does not do internal work, is there a way to test these pelvic floor muscles and to do things without having to do internal work? My answer for that question is yes, there are things that you can do because even though I do do internal exams, I have people who come to see me who are like, no, we're not doing that. Speaker 1 (00:27:31): So, so where can we start? And so the first one is pants on and me not even touching you pelvic floor, I wouldn't really call it an assessment or self report. So even just sitting here, if you, if you were to call me up and and this actually goes into, I think another question that was on Slido about pelvic floor cues. So there is actually then it seems more research on how to get a mail to contract this pelvic floor then actually females. But I would ask you like like this is one that my friend Julie, we would use. So like if you're sitting there and you just sit up nice and tall, if you pretend you're trying to pick up a Ruby with your PA with your vagina is not on the outside, but imagine like there's just a Ruby on the chair and you'd like to pick it up with no hands, breathe in and breathe out and let it go. So then I would go, did you feel anything and you should have felt something happen or not. So if, if you did it, would you mind telling me what you built? You're asking me, Oh my goodness. Oh yes. I did feel something. So I did feel like I could pick the Ruby up and hold it and drop it. Speaker 1 (00:29:04): Excellent. And that's, and that, that drop is key. Excellent. So what I would say is this is like like a plus, like a, I can't confirm or deny you that you did it correctly, but I like, I would have watched you hold your, like she holding my breath. Is she getting taller? Cause she's using her glutes. Did she just do a crunch? When she tried to do this, I can see external things happening that would indicate you're might be working too hard or you might be doing something completely wrong. So then we'll get into, I mean, you said, yes. I felt like I pick up the Ruby, but if it's like, Hmm, I felt stuffed, but I'm not really sure we would use our words because they've already said no to hands to figure that out. But again, I can't confirm it. People are they're okay with that. Speaker 1 (00:29:48): And I'm like, and if what we're doing based on the information you gave me, isn't changing, we might go to step two. If you can send in step two is actually something, any orthopedic therapist honestly, should not feel too crazy doing. So if anyone has ever palpated the origin of the hamstring, so where is the origin of the hamstring facial tuberosity? If you go just medial to that along the inside part get, don't go square in the middle. That's where everyone gets a little nervous and a little tense, but if you just Pell paid around that issue, tuberosity it's pretty awesome. If you have a, a friend or a colleague who's willing to let this happen is you ask them to do a poll of our different cues with that in a little bit. You say that again, ask them to do what to contract the pelvic floor. Speaker 1 (00:30:44): Okay. And again, figuring out the right words so that they know what you're talking about. We can talk about that in a minute, but if they do a pelvic floor contraction, you're going to feel kind of like the bulging tension build, right there may be pushing your fingers. You should feel it kind of gather under your fingers. It shouldn't like push your fingers away, but then you can be like, well, you could test their hamstring and see that you're not on the hamstring and you can have them squeeze your glutes and you can kind of feel the differences. The pelvic floor is just there at the bottom of the pelvis. So you can palpate externally, even through BlueJeans is a bit of a challenge, but if they're in you know, like their workout shorts for yoga pants, it's actually very, very simple. And, and honestly, as long as you explained to them what you're doing and what you're checking for, it's no different than palpating the issue of tuberosity for any other reason. Speaker 1 (00:31:36): And with that, I tell them that I can, it's more like a plus minus, so I can tell that you contracted and that you let go. That's all I can tell. So I can't tell you how strong you are, how good your relaxation Wells, how long you could hold it for any of those things. And then I tell them with an internal exam, we would get a lot of information we could, we can test left to, right? We can, I could give you more of like a muscle grade. So like that zero to five scale be use for other muscles. We can use that for the pelvic floor. I can get a much better sense of your relaxation and see how was that going and I can even offer some assistance. So so we have two really good options for no touching. Speaker 1 (00:32:19): And then just as long as we understand the information we might gain from an internal exam, we can, we can, the information we gathered from the first two ways, isn't sufficient to make a change for them. And then as let's say, the non pelvic health therapist, which there might be several who are gonna watch this, when do we say, you know, something? I think it's time that we refer you to a pelvic health therapist, because I do think given what you've said to me and you know, maybe we did step one and two here of your exams. I think that you need a little bit more. So when do, when is that decision made to reach the point of, they have a bother that I don't know how to address so we can actually go to like the pelvic organ prolapse. So pelvic organ prolapse is, is when the support for either the bladder, the uterus, or even the rectum starts to be less supportive and things can kind of start to fall into the vaginal wall and can give a feeling of like pressure in with activity the sensation can get. Speaker 1 (00:33:39): So then we have two options, which is more support from below with perhaps a stronger meatier pelvic floor by like working it out to hypertrophy. So like if, if I had someone who had that feeling when they were running and we tried a couple are lifting weights, let's go lifting weights. No, like I feel it once I get to like a 200 pound deadlift. Okay, well, let's see how you're lifting when you're doing 150 and let's take a look at what you're doing at 200 in fresh with your mechanics or what's happening. And if there's something that is in your wheelhouse where you're like, well, can you try this breath? Or can you try it this way and see if that feeling goes away? I'm good with that. And if the, that the person who's having issue is good with that. Awesome. But if you're trying stuff or the incontinence is not changing, send them to a pelvic floor therapist, because what we love to do is we can check it out. Speaker 1 (00:34:41): We're going to check it out. We're going to give some suggestions. And then my, the end of every one of those visits that I get from my, from my orthopedic or sports colleagues is I'm like, excellent. So you're going to work on this, keep doing what you're doing. Cause another really common thing is like, is I don't really believe that they can make a lot of these things worse doing the things that they're doing. And by that, I mean, they can become more simple MADEC, but in many cases you're not actually making the situation worse. So if the symptoms seem to be not getting better or even getting worse, doing the things they're doing, they go come back to the pelvic floor therapist. And then that pelvic floor therapist also has a responsibility that the things I'm asking them to do, isn't helping them get there. Speaker 1 (00:35:29): You can try something a little more intense, still not helping. Then that's when I actually would refer for females, especially with like pelvic pressure. So Euro gynecologist for an assessment in that regard. Yeah. So I think I heard a couple of really important things there. And that's one, if you are the sports therapist or the orthopedic physiotherapist, and you have someone that needs pelvic health support, you can refer them to the pelvic health therapist and you can continue seeing them doing the things you're doing. So just because they're having incontinence or they're having some pressure, let's say it's a pelvis, pelvic organ prolapse. It doesn't mean stop doing everything you're doing. Speaker 3 (00:36:12): Okay. Speaker 1 (00:36:15): Correct. Okay. Yeah. It may mean modify what you're doing. Stop some of what you're doing, listen to the pelvic floor therapist. And I'm also seeing, well now we're, aren't we this great cause we're creating great team around this, around this person to help support them in their goals. So one doesn't negate the other. Absolutely correct. And I, and I think too often even, even within the PT world is people start to get kind of territorial. But it's not about what each one of us is doing. It's that person. Right. so telling them to stop doing something, especially if it's something they love it seems like a bad start. It's like, okay, let's take a look at this. Tell me what you are doing. Tell me what you want to be doing. Tell me what's happening when you do that. And let's see if we can change it. Speaker 1 (00:37:02): Cause like I said, like the, the other, that being something they're going to make worse and worse and worse is if symptoms get worse and worse and worse, but they're not causing damage, they're not causing, I mean, what they're doing and say leaking a bit. Got it. And now I'm going to take a slight detour here because you had mentioned pelvic organ prolapse. You had mentioned, there comes a time when, if that pressure is not relieving, you've tried a lot of different things. You would refer them to a urogynecologist now several years ago. They're so you're, you're a gynecologist. One of their treatments might be surgery. So there was pelvic mesh sweats. It's hard to say pelvic mesh surgery that years ago made some people better and made some people far, far worse with, with some very serious ramifications. So can you talk about that pelvic mesh mesh surgery and where we are now? Speaker 1 (00:38:04): Oh, the last bit cut out a little bit. So the pelvic mess, mess surgery and, and Oh, the most important part and kind of where we are now versus maybe where we were, let's say a decade ago or so. Awesome. Yeah. So, so the pelvic mesh situation certainly here, I think it's not a universal problem. I think it's a United States problem is if you're at home during the day, like most of us are now you will see law commercials, lawyers looking for your business to discuss the mesh situation on what's happening is there was there were, it was mesh erosion and the resulting fact that that was a lot of pain because they couldn't just take it all out. And it was several women suffered and are still sad. Speaker 3 (00:38:55): Mmm. Speaker 1 (00:38:55): But that was from a particular type of surgery with a particular type of surgical kit, which thankfully has, was removed completely from the market and isn't being used anymore and mesh surgeries, I would say at least for the last five to 10 years, haven't haven't been using that and mesh surgeries are being done with great success in resolving symptoms. So I think it's important that if a woman isn't responding Speaker 3 (00:39:27): Yeah. Speaker 1 (00:39:30): Well changing their breath or making a pelvic floor or changing how they're doing things is to have that discussion with the Euro gynecologist because they do have nonsurgical options for super mild prolapse. There are some even like over the counter options you can buy like poise has one where it's just a little bit of support that helps you. Actually not leak because if you're having too much movement of the urethra, it can cause stress or it can be contributing to stress incontinence. But so there's some over the counter things or there's something called a pessary, which I think about it. Like I'm like a tent pole, but it's not a pole. It's a circle don't worry or a square or a donut. There's so many different shapes, but it's basically something you put in the vagina and that you can take out of the vagina that just kind of holds everything back up where it belongs, so it can work better. Speaker 1 (00:40:21): And that it's not awesome. But there are also people who are like due to hand dexterity, or just due to a general discomfort with the idea of putting things in their vagina and living them there that they're like, no, I'd rather just have this be fixed. So, so there are, it's not just surgery is not your only option. There are lots of options and it just depends on where you want to go. But with the surgery, if that's what's being recommended for a woman, I really do. Some women aren't worried at all. They've heard about the mash, but they're sure it won't happen to them, but there are when we're still avoiding surgery, even with significant syndromes, because they're worried about the mesh situation. And I would still encourage those women to at least discuss us, to see if that surgeon can, can educate them and give them enough confidence before they move forward with the surgery. Speaker 1 (00:41:18): Because the worst thing I think is when I had one patient actually put it off for years. Not, not just because of the mesh because of a lot of issues, but the first time the doctor recommended it, she had a grade four prolapse. Like that means when things come all the way out. And she it was so bad. Like she couldn't use the pastory okay, so she needed it, but she avoided it until she was ready and had the answers that made her feel confident in that having the surgery was the right thing to do. So it might take some time and the doctor, the surgeon really should, and most of them that I've met are more than happy to make sure that the patient has all the information they need and understand the risk factors, the potential benefits before they move forward. Speaker 2 (00:42:03): Excellent. Thank you so much for that indulging that slight detour. Okay. Let's get into intervention. So there are lots of questions on Slido about it, about different kinds of interventions. And so let's start with lot of, lot of questions about transverse abdominis activation. So there is one question here from Shan. Tall said studies in patients with specific low back pain do not recommend adding transverse abdominis activation because of protective muscle spasm. What about urinary incontinence in combination? What do you do? So there is a lot on transfer subdominant as you saw in Slido. So I'll throw it over to you and, and you can give us all your share your knowledge. Speaker 1 (00:42:55): Okay, well, let's all do this together. So I don't know how many people are watching, but if we just sit up nice and tall and I'm going to give a different cue for the pelvic floor. So what I want you to squeeze, like you don't want to urinate, like you want to stop the stream of urine. Okay. So as we're pulling that in anything else other than the underneath contract, what did you feel Karen? Speaker 2 (00:43:24): Well, I did feel my TA contract. I felt that lower abdominal muscle wall started to pull in. Speaker 1 (00:43:32): Yes. So, so the, the way I explain it is that the pelvic floor and the trans versus are the best is to friends. And this makes sense when you think about when you remember the fact that the pelvic floor, isn't just there regarding like bowel bladder and sexual function. It's one of our posture muscles. So if we're totally like, like slacked out and our abs are off and all of that, our pelvic floor is pretty turned off as well. And then if I get a little bit taller and like, so I'm not really clenching anything. Right. But this is like stuff working like it should, my pelvic floor is a little more on, but not, I'm not acting. It's just but then I could like, right, if I'm gonna, if I'm expecting to hit, or if I'm going to push into something, I can tend to set up more and handle more force into the system. Speaker 1 (00:44:21): So I like to think about it in those in those three ways, because the pelvic floor, isn't just hanging out, down there and complete isolation it's, it's part of a system. And so in my personal, like emotional approach to interventions is I don't want them to be too complicated. So if I can get someone to contract their pelvic floor, continue to breathe and let go of that pelvic floor, then we start thinking about what else are you feeling? Cause I don't know that there's any evidence that says if I just work my transverses all the time, my pelvic floor will automatically come along for the ride. So a great quote. I heard Karrie both speak once at a combined sections meeting and she goes, your biceps turn on. When you take a walk, it's not a good bicep exercise. So just the fact we're getting activity in the pelvic floor when we're working other muscles, what's supposed to work. And also if you want to strengthen that muscle, you're going to need to work out that muscle. Speaker 1 (00:45:26): And that makes a lot of sense and something that people had a lot of questions around where we're kind of queuing for these different exercises. And I really love the can. You've made it several times comparisons to other muscles in the body. So can you talk about maybe what kind of queuing you might use to have someone on? I can't believe I'm going to say this turn on and I use that in quotes because that's what you see in, in a lot of like mainstream publications for, for layman. So it might be something that our patients may see when they come in. So how do you cue that? To, to turn on the pelvic floor? So honestly I will usually start with floor and I do if I'm able to do a public floor exam, that's usually, again, a lot more information for me, but I'm like, okay, so do that now. Speaker 1 (00:46:27): And I watched them do it or I feel them do it and I'd be like, Oh, okay. What did you, what did you feel move? And I start there. And then I always say it's a little bit, like I get dropped into a country and I'm not sure what language people are speaking. So sometimes excuse me, one of the first cues that I learned was like, so squeeze, like you don't want to pass gas. Okay. So everybody let's try that. So sitting squeeze, like you don't care and you got taller. So I think you did some glutes. Speaker 1 (00:47:00): It's like, OK. So like lift, lift your anal sphincter up and in, but activating mostly the back part. So if you're having fecal issues, maybe that's a good place to start, but most people are having issues a little further front. So then we moved to the, can you pick a upper with your, with your Lavia? I had a, I learned the best things for my patients. One woman said it's like, I'm shutting the church doors. So if you imagine the Lavia being churched doors, we're going to close them up. And that, that gives a slightly different feeling. Them then squeezing the anal sphincter. Now, if you get up to squeeze, like you don't want to like pee your pants, like you want to stop the stream of urine. That will activate more in the front of the pelvis. Look, men who are like if it gets stopped the flow of urine, I wouldn't be here. Speaker 1 (00:47:57): So what else do you get? What's really cool is in the male literature. So this is a study done by Paul Hodges is he found that what activated the anterior part and the urinary sphincter, this rioted urinary speaker, sphincter the most for men. What a penis or pull your penis in to your body now for women. So when I was at a chorus and it's like, so let's, let's think of like other cues and other words, but even if, so, I don't have a penis this fall that probably don't have a penis. Even if you don't have a penis, I want you to do that in your brain, shorten the penis and pull it in. Speaker 1 (00:48:42): And did you feel anything happen? Cause we do have things that are now analogous to the male penis, if you are are a female. So I'll sometimes use that. Like I know it sounds stupid, but pretend to draw on your penis and it works and it does feel more anterior for a lot of people. So I'll kind of just, I'll kind of see what's, like I said, sometimes it's like the 42nd way of doing it that I've asked them to do where they're like, Oh, that, and you're like yeah. So then also just another, it's a little bit of like a little bit of a tangent, but so as you're sitting, so if you're, if you're sitting I want you to pick the cue that speaks most to your pelvic floor, and I want you to slouch really, really slouch, and actually to give yourself that cue and just pay attention to what you're feeling. So when you squeeze, give yourself that cue, breathe in and breath out and then let go, we should have felt a contraction, a little hole and a let go. Now, the reason why I say breathe in and breathe out is if you breathe in and out, that's about five seconds and also you were breathing. Cause another thing people love to do when they're trying to contract their pelvic floors, just basically suck it in. Speaker 1 (00:50:10): And so that's, that's not great, but we want to feel the contraction and we want to feel it, let go. And that's super important. I think that was another question on the Slido is that yes. For any muscle we're working, you should be able to contract it and let it go. There's not a muscle in our body where I just keep it contracted. It's going to do much. It might look great. Eventually, but like I couldn't get my coat on, like getting a drink of water would be a little weird. It's not very functional muscles have to relax so that they can contract. So that's a big, yes, it's just as important that the contraction pelvic floor that cue and we felt where it happened, not tall, like, like you're sitting out at a restaurant and you just saw someone looking at you and you're like, Oh, what are they looking at? And then you're going to do the exact same cue and you're gonna breathe in and breathe out and let it go. Speaker 1 (00:51:07): And then did it feel different than menu or slouch that it did it change position? I feel like Karen's Miami. It feels different. Now what I want you to do is if you can, depending on how you're sitting really give me like an anterior pelvic tilt, really happy puppy and then do the exact same thing and then let it go. And so again, some more EMG work from, from Paul Hodges is that when you're in a posterior pelvic tilt, you tend to activate the posterior portion more, which is fine. And if you're not having problems in the front, if you're having problems activating and maintaining continence in the front, actually increasing that lordosis can favor the front a bit. So this is, that's really awesome when people can feel that difference. Because I want you to think about, if you start to leak on your fourth mile of a half marathon, there's no way, no matter how awesome you are, but you're going to be able to squeeze your pelvic floor for the rest of that race. Speaker 1 (00:52:15): Like there's just, there's no way. But sometimes if, because remember your pelvic floor is still doing its thing while you're running is if you're like, well, hold on, when you're at your fourth mile, are you starting to get tired or hopefully not if it's a half marathon, but you know, like is something changing and how you're using your body. And can you, when you get to that point, remember to stay tall or lift your tail a little bit, or is there a cue or something they can change that will help them favor the front instead of going about four steps with the contracted pelvic floor and then losing it anyway. So there's, there's a lot of different ways you can actually make that your intervention for the issue you're having and then let's just get it functional. Perfect. And since you brought up running a question that's been, got, gotten a couple of likes on Slido is how would you approach return to running after pregnancy? Speaker 1 (00:53:15): Do you have any tips on criteria for progress, timeframe and a recreational runner versus a full time athlete? Because I would think the majority of physiotherapists around the world are seeing the recreational runner versus the professional or full time athlete. So first, how would you approach return to running any tips for progress? So that's going to be after pregnancy, sorry. After pregnancy. Yeah. So this is where I was really excited. So just last year I'm going to say her name wrong, but Tom goom Gran Donnely and Emma Brockwell published returned to running postnatal guidelines for health professionals managing this population. And the reason why I was super excited is because even though it was just published last year, it's the first one. There was definitely a lot of emotion and feelings about, about women getting back into sport after having a baby, but to be perfectly Frank, there's very few actual solid guidelines for recreational or others. Speaker 1 (00:54:30): So I have not personally had a child, but I will tell you of all the women I've seen over the years, basically doctors are like, it's been six weeks ease back into it, see how it goes. I'm not really even mentioning if you have a problem come back so we can figure it out. It's just kind of like good luck with that. And as a result, what happens is a lot of women don't get back into exercise or they get back into exercise and and kind of freak themselves out because stuff feels different. So to get back to the question of what do I do, actually this this guide from Tom and team really, really helpful. I think, and, and it's just basically it's it does have a series of exercises that I've actually started to use with my postpartum moms to go like, look, if you can do these things without feeling heaviness, you're good. Speaker 1 (00:55:30): You're good to start easing back into your running program, but get up, get walking because I'm going to post Sandy Hilton and like, you can't rest this better, like just waiting, isn't going to make it all go away. But it can also be deceiving because again, with polo, you don't feel that heaviness and you don't leak. And so I'm just going to stay right here where everything is fine. So that's obviously not a good option longterm option for a lot of reasons. So, so what do I do? I do look at the patient's goals, their previous running history, and if they're having any options I recently had a patient who she was runner exercise or sr after baby number two for a bit, some feeling of happiness that got completely better, baby number three came along. So I saw her a bit while she was pregnant because she got, I think two thirds of the way through pregnancy before she started to feel that heaviness. Again, she was still running, Speaker 1 (00:56:38): Tried to see if we could change that feeling while she was running. And she could until about the, when did she start? I think she didn't stop running to her 35th week, which is pretty impressive. But then she wanted to do a half marathon. I think it was just three months postpartum. Right. So this is like going from having baby to running 13. You think that a lot of people would probably feel that was too soon, too much too fast, but she was able to do it completely symptom-free. So as she was training and she was really fast, she was timing it so that she could get back in time to breastfeed. Like I was like, Oh my gosh, like I, that would disqualify me. Like, there's no way I could run fast enough to make that happen. But she was able to, to work it out where she could perform at her level without symptoms. And I was really happy that I was able to support her in that she did all the hard work. For general people recreational, where you a runner before, or is this completely new and are you having any symptoms and is there any thing you're worried about? Again, a lot of women are worried about giving. Speaker 1 (00:57:53): It's actually really hard to perhaps to give yourself one baby babies are a great way to do it. But that's like the risk factors I look up for something else a couple of years ago, I haven't looked recently, but like you really have any prolonged lifting. So not like your CrossFit three days a week, but like your, your physical labor for eight, eight hours, 10 hours a day every day could eventually do it also having babies. So like once you get to every baby increases your risk of pelvic organ prolapse, which makes good sense. And that, and that is what it is. So kind of looking at what are their risk factors, are there any, and letting them know that if they feel it more, it doesn't mean they made it worse. They just made it more symptomatic. Got it. Great. Speaker 1 (00:58:40): All right. So we have time for maybe one or two more questions, and then I'm going to throw back to Claire. Cause we're coming up onto an hour here, maybe time for one more it's so w what am I going to ask? I think I'm going to go with the gymnasts I work with all believe it's normal to leak a little urine during training or competition. And this is something we talk about a lot. It might be common, but is it normal? You already gave me the answer. What is it, Karen? No, no, no. And so, yeah, so the, the short answer for that is no. Or I agree with the question where it is very, very, very common, and it is still, I would say, not to leak urine. Unfortunately, so there's any researchers out there who want to get together. Speaker 1 (00:59:26): Let me know. We haven't, we have information on athletes and incontinence, but mostly it's prevalent that it happens a lot and gymnastics and dancing and volleyball. There's, there's even some swimmers who have it, right? So there's, there's incontinence across the spectrum, which basically tells me, yep. People have incontinence. Some of the some of the sports are more likely to have urgent continents. A lot of them though, we're looking at stress incontinence, however, for none of the athletes, have, we really had a great study that says, this is what we're finding. We're thinking, this is the cause of this incontinence. And we certainly haven't gotten to the point where it's like, and this is what we should be doing for these women in particular. So I'm, I'm pretty curious as to what we would have to do as, as a profession, as, as a team with researchers to figure out what do we need to look at in these athletes, especially the female athletes, because most of these are also they've never had babies, right? So a lot of these athletes are the liberos. And so we can't, we can't blame them. There's something with how things are working. That seemed to be the situation it's not necessarily trauma or anything like that. So what do we need to look at? What do we think is happening? Can we measure it and assess it? And then can we get an intervention? Speaker 1 (01:00:56): My brain, obviously, something isn't working as well as it could. So could something like that improve their performance, even I don't, I don't know. I'd like to think so. Yeah. That would be distinct study. Yeah. But we ultimately don't know. So if anyone has any ideas for studies or doing studies, let me know, because I can't wait to read them. But I think maybe the first step is to let coaches and parents and young gymnast know very common. Don't be ashamed. Don't let it stop you from doing what you want to do. But also don't just ignore it. Maybe we can figure this out. Speaker 2 (01:01:30): All right. One more question with a short answer, if you can. So, and I'm going to ask this question because I feel like the person who posted this I think posted this in earnest. So that's why I'm asking, this is the last question. So a female patient age, 20 years still bedwetting from her childhood, otherwise she is normal, no incontinence. So other than this, just while sleeping, she tends to urinate any thoughts on this or any place you can direct this. Speaker 1 (01:02:04): Yeah. So I did, I was like, Oh, great question. And I did actually do a little research for this specific question. There's a lot of reasons why nocturnal enuresis, which is what bedwetting is called in the literature happens. And I think it's really important. So I don't know what kind of tests or studies this person has had done or what other issues they may be having. So things like sleep apnea is is something that could be related if there's any medications, any sort of diuretics, any kind of sleeping medications. Again, the fact it's kind of carried on since childhood, I, I would really wonder about how, how is the bladder functioning? The fact that it's working fine throughout the day makes me wonder what's changing at night. And I did find a study where it talked about when they look compared adolescents or adults who were bedwetting to people who weren't, they did have like detrusor overactivity. So like basically like an overactive bladder that they could see on the testing. So I would, I would really encourage this person to find a urologist that they trust if they haven't already and really to maybe investigate some of those other, other factors that could be contributing so that they can get some better sleep and not have that problem anymore. Speaker 2 (01:03:28): Excellent. Excellent. Oh, okay. Claire says we can go for one more question. So I'm going to listen to the boss here. Speaker 1 (01:03:36): And, Oh boy, are you ready? Because this is a question that did kind of get a lot of thumbs up. Okay. So we spoke about Speaker 2 (01:03:44): Briefly before we started. Speaker 1 (01:03:47): So let's see treatment of nonspecific, pelvic girdle pain, not related to pregnancy, which strategy with no susceptive pain mechanisms and which strategy with non nociceptive pain mechanisms would you incorporate with this patient? Okay. So I would say in the clinic, it's, it can be pretty hard. Like, I don't know how I would distinguish being nociceptive and non nociceptive or what even like non nociceptive might be if we're talking more central issues or stuff like that. I don't, I don't know. But honestly I would just look at, so in Kathleen's Luca has a great book about looking at the different types of pain or the different categories of pain and the most effective medications for it. Right. So we're really good in pharmacology. Like if you had this inflammatory process and, and inflammatory and anti-inflammatory should help, if you're having neuropathic pain, you want a drug that addresses that when we get into like physical therapy interventions, what's really cool is exercise is in all the categories. Speaker 1 (01:04:59): And it's one of the things we have the best evidence for. So regardless of pelvic girdle pain in pregnancy or not pregnancy, and regardless of how it may have been labeled by somebody else is I would, I would mostly want to know when did the pain start? Is there anything that makes it better? Anything that makes it worse and see if I could find a movement or change something for that person. Or that made me sound like I was going to do a whole lot of work. If I could find something for that person to change for themselves to have that hurt less and have the I tend, I would tend to keep it simple, mostly cause in the clinic again, we could do a lot of special tests that might say, Oh, Nope, they definitely hurt there, but it's still, if we're looking at what's going to be an effective intervention, that that patient is going to tell me what that is. Speaker 1 (01:05:54): Sorry. It would help a fire mute myself. So looks like we have time for one more. And I, I really, Claire was not clarity did not pop up yet. So we've got time for one more and then we're going to work. We're wrapping it up. I promise stroke patients, dementia patient. We just got the no go. Yes, no, it's a super short answer if you want Claire super short answer. Okay. So stroke dementia patients with urinary incontinence, any useful ideas for the rehab program? Yes, but not get an idea of their bladder habits, their bowel habits, their fluid intake. Because a lot of that's going to end up being outside caregiver help with the, with the stroke, it's much different. It depends on the severity and where it is and all of that. But for people with dementia is if you just get that, like if you can prompt them or take them to the toilet, a lot of the times that will take care of the incontinence. Speaker 1 (01:06:48): It's not a matter of like Cagle exercises. It's more management. All right, Sarah, thank you so much. I'm going to throw it back over to Claire to wrap things up. Thank you both for a wonderful and insightful discussion. Sarah and Karen. So many practical tips and pointers for the clinician, especially I was loving learning about all of the things that I could take to the clinic. So I hope our audience find those practical tips really helpful as always the link to this live chat will stay up on our Facebook page and we'll share it across our other social media channels. Don't forget. You can also follow us on Twitter. We're at Dow SPT. You can also follow us here on Facebook. Please share this chat with your friends, with family colleagues, anyone who you think might find it helpful. And if you like JSP T asks, please be sure to tell people about it at that what we're doing so they can find this here, please join us. Speaker 1 (01:07:46): Next week when we host our special guest professor Laurie from the university of Southern California, Larry is going to be answering questions on managing shoulder pain. We'll be here, live on Wednesday next week. So Wednesday, April the eighth at 9:00 AM Pacific. So that's noon. If you're on the East coast of the U S it's 5:00 PM. If you're in the UK and at 6:00 PM, if you're in Europe, before we sign off for the evening, there's also really important campaign that I'd like to draw your attention to. And it's one that we at Joe SPT supporting and it's get us PPE. So we're supporting this organization in their quest to buy as much a, to buy much needed personal protective equipment for frontline health workers who are helping us all in the fight against the coronavirus pandemic. So if you'd like to support, get us PPE, please visit their website, www dot, get us ppe.org, G E T U S P p.org as always. Thanks so much for joining us on this stale SPT asks live chat, and we'll speak to you next week. Bye. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Leigh Hurst on the show to discuss breast cancer awareness. Leigh Hurst is a breast cancer survivor and the founder of the Feel Your Boobies® Foundation, which she started to educate young women (under 40) by reminding them to "feel their boobies" - a call to action that can save their life. Feel Your Boobies® is one of the largest followed breast cancer awareness foundations on Facebook and has inspired women all over the world to feel for lumps starting before they are formally screened for breast cancer. And, most importantly, it has directly resulted in countless women finding lumps early and giving them a better shot at living a full, meaningful life after their diagnosis. The Feel Your Boobies® Foundation has been featured in The New York Times, New York Daily News, and other national publications. At one point, Feel Your Boobies® was the largest cause on Facebook, with more than 1 million supporters. In this episode, we discuss: -Leigh's experience advocating for her own breast cancer diagnosis -The story behind the Feel Your Boobies Foundation -Why women need to prioritize self-care -The voices of breast cancer survivors in the book Say Something Big -And so much more! Resources Leigh Hurst Website Say Something Big Book Say Something Big Facebook Say Something Big Instagram Feel Your Boobies Website Feel Your Boobies Facebook Feel Your Boobies Twitter Feel Your Boobies Instagram A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information Leigh: LEIGH HURST is a breast cancer survivor and the founder of the Feel Your Boobies® Foundation, which she started educate young women (under 40) by reminding them to feel their boobies - a call to action that can save their life. Feel Your Boobies® is one of the largest followed breast cancer awareness foundations on Facebook and has inspired women all over the world to feel for lumps starting before they are formally screened for breast cancer. And, most importantly, it has directly resulted in countless women finding lumps early and giving them a better shot at living a full, meaningful life after their diagnosis. The Feel Your Boobies® Foundation has been featured in The New York Times, New York Daily News, and other national publications. At one point, Feel Your Boobies® was the largest cause on Facebook, with more than 1 million supporters. Hurst is also the author of the new book, Say Something Big: Feel Your Boobies, Find Your Voice. Stories About Little Lumps Inspiring Big Change (Oct. 2020) Beyond her work with Feel Your Boobies®, Leigh regularly speaks to audiences large and small, sharing her own personal journey and inspiring others to "Say Something Big" amidst life's hurdles and hardships. She resides in Pennsylvania with her family. Feel Your Boobies® uses innovation around media to reach women across the world with their important message. For more information, visit www.leighhurst.com or www.feelyourboobies.com, and connect with Leigh on Instagram, Facebook, and LinkedIn. Read the full transcript below: Karen Litzy (00:01): Hi, Leigh, welcome to the podcast. I'm happy to have you on. Leigh Hurst (00:05): Thanks for having me, happy to be here. Karen Litzy (00:07): Yeah. And now we're in the month of October. And for those of people who don't know October is breast cancer awareness month. And in the past, I've had shows about breast cancer during the month of October, but this is the first time I am speaking to a breast cancer survivor. So thank you so much for coming on and sharing your story because I know it's going to be so helpful for other women and men listening to this podcast. So before we kind of get into everything, I'm going to just throw it over to you so that you can just kind of tell your story how old you were when you were diagnosed. How did you find out? So I'll send it over to you. Leigh Hurst (00:51): Okay, cool. Thank you. So I was officially diagnosed when I was 33 that I had felt the lump for some time leading up to the actual diagnosis. So I think I was probably around 30 or 31 when I started to notice the lump. And I was living in New York city at the time and I was a marathon runner. So really health conscious, certainly educated about my health felt very kind of plugged into that kind of thing. And for a little while, I didn't really think much about it. I just thought it was, you know, something no big deal. I really small breasts. So I felt like when I'd go to the doctors, I'd let them sort of do their exam of my breasts and they would never notice it until I would point it out. So I would literally take their hand, put it on my boob and say, this kind of feels a little different to me. Leigh Hurst (01:39): I don't know if you notice it or not. It's like a ridge on the outer side of my left breast and then they would feel it and then they would say, I don't really think that's anything to worry about. I had no family history, so I wasn't exceptionally worried about it. Although, as I know now, that's not necessarily a primary risk factor. It is, but most women diagnosed don't have a family history. So I was pacified about that for a while. You know, that kind of went on for maybe a year or two. I eventually decided to sort of simplify my life and I moved out in New York city. I was in a really kind of super corporate job, traveled a lot for my work on a weekly basis. And I was just trying to find ways to sort of step out of that. Leigh Hurst (02:20): And so I moved back to central PA, which is where I live now. I'm kinda got set up on a house was back near my family and it came time for my annual exam. And I went again to the doctors and again, it wasn't noticed, but I mentioned it and it was the first time someone's like, Oh, she probably should just get a mammogram. It can't hurt to sort of just see if it's something or not. So that's how it started and ended up having the mammogram showed some areas of concern, took me right in and did an ultrasound and eventually at the biopsy a couple of weeks later and it did turn out to be cancer. So that was 2004. And you know, needless to say, I was very concerned because I knew I had had the lump for quite some time, so I wasn't sure what to expect, but it didn't turn out to be stage one, so early stage breast cancer. Leigh Hurst (03:09): And so, yeah, that's kinda how it started with, you know, finding out that I had a lump and went through treatment. I decided to have a lumpectomy, the lump was small stage one had no lymph node involvement. So that was good. And I did do chemotherapy because I was young. So they suggested that because of being premenopausal and being so young at the time, it was some preventative. So I did chemotherapy than I did seven weeks of daily radiation treatment to the lump site. And then I took five years of a pill called Tamoxifen, which is estrogen reducing medicine at the time they were still prescribing it for five years. I believe now the regimen is 10 years. But so the actual treatment itself was about six months start to finish. And then it was the five years of the Tamoxifen following that. Karen Litzy (03:59): And at the age of 33, you must have been kind of shocked. Right. Cause it's not something that we hear a lot of, you know, like even to get a mammogram, they don't suggest getting a mammogram until you're 40. Leigh Hurst (04:15): Correct. Yeah. And you know, it was, you know, looking back on it, I remember thinking, gosh, I never talked about breast cancer, never talked about it. I didn't know anybody who had had it. I'm not even really sure. I knew anybody who's mother that had had it. So I was really taken aback by that when I was diagnosed and I was single at the time really hadn't thought about having a family quite yet. You know, I was living in the city, it was very common to still be kind of doing your thing. And so there are other issues that came up other than of course the life or death issue with breast cancer. There were the other possibilities of losing your fertility through chemo. Certainly that's a possibility certain decisions that you might be faced with can also, you know, if you decide to remove any of your female organs, ovaries, whatever, to minimize your risk, of course, those are big decisions when you haven't started a family yet. Leigh Hurst (05:08): And I wasn't really sure I was going up, but I didn't want that choice to be taken away from me. I didn't want it to be something that I couldn't do at a later date. So yeah, it was, it was shocking. And you know, out of that, I really started to like, think about why didn't I talk about this? Why didn't I think about this? And so that's kind of how the feel your boobies idea came about is that I just made some t-shirts for friends. Cause I would joke around during my treatment, I was actually still running and I didn't get sick. So I was really happy about that. And I just made sure that said, feel your boobies for fun. I'd always wanted to make t-shirts. I was kinda crafty kind of thing, you know, hobbies on the side. Leigh Hurst (05:47): And so my friend and I mocked up a tee shirt and I got a hundred made, put a website up, my background's in technology based learning. So I was kind of techie and I'm just send it around to my friends that had lived in the cities where I had moved after grad school. And I started selling shirts to people. I didn't know, very quickly, it just kind of went viral. I was getting checks in the mail from people. I had no idea who they were. And so, you know, that whole idea of, of using a message, like feel your boobies, which is lighthearted, but very pointed in terms of what it's trying to get you to do. Made me think about, you know, is this really creating behavior change? Is this creating a meaningful dialogue among a population of women like me that never really talked about it before? Or if they did, it was the third serious town and it was about their mother or it was in the context of a doctor's office. And so to that accidental t-shirt, that was just a hobby sort of evolved in time into something that took over my life quite honestly, and quickly I had to figure out what I was doing with it. So that's how the foundation itself came to be. Karen Litzy (06:53): Yeah. It's amazing. The things that happen to you that can just do a 180 and change your life. Right. So you could have had this diagnosis and then just went on and got a job and just went on your way. Right. But instead you were like, wait a second, like I'm young, I never talked about this. There's gotta be other people out there just like me. So how can I reach them? Leigh Hurst (07:15): Right, right. Sort of back fitting it. Right. Because I didn't create the tee shirt with that in mind, but I watched it happen. And that started to make sense to me with my background in behavior theory and that kind of thing. And so I kind of ran with it and, you know, we were able to support ourselves for quite some time just through t-shirt sales. So fortuitously, unlike other nonprofits that you know, have to submit for grants and you know, really the funding side of it is the tricky part. We were fortunate in those early days the t-shirt sales themselves allowed us to do a lot of creative things through social media before that was a standard way of spreading our message. And so we really tried to leverage the idea of media and the peer to peer sharing because what I saw when somebody would wear the tee shirts, like a happy hour or a cookout was I was watching like a 20 something talk to another 20 something or a guy even who might say your shirt says feel your boobies. Leigh Hurst (08:16): Can I feel your boobies? And then they would say, it's not about that. It's about breast cancer. Or you got to feel your boobs to see if you find a lump. And to me that was a productive conversation. It was somebody articulating something very simple, but in a playful and a more friendly and lighthearted way than trying to impart stats or other types of things that I think a lot of campaigns do, or certainly they have the aesthetic and the sensibility that feels like it's for an older woman. So you may relate to it because you're trying to just be proactive and educate yourself about health. But the messaging itself is not really created for you. It's not created for the younger population, the style of the images, the style of the graphics, and even the use of the channel that you use to spread it. Leigh Hurst (09:01): Right? So a tee shirts, just one way you can not, but you can do that in many other ways. You know, we flew aerial banners up and down the Jersey shore in the summertime on all the very populated beaches. And I'm thinking of these young women that are like dragging themselves out to the beach after going out Friday night. And they see a, you know aerial banner and they say, Oh my God, that says feel your boobies. And I'm like, that's wonderful. That's a great way to kind of intersect with them where they are in a way that they can relate to. And, you know, it's created testimonials from women that say, that's why they found their lumps. So very proud of the campaign. And eventually I went on and left my corporate career and ran the foundation full time. So it really wouldn't do that 180 for me, that you mentioned about changing your life. It was definitely that for me. Karen Litzy (09:50): Yeah. So we can definitely see how your life has changed after diagnosis, but what are the big lessons that you learned? Leigh Hurst (10:00): Well, you know, I definitely learned I'm type A, very much of an ambitious overachiever and, you know, Karen Litzy (10:06): Well, I mean, you were in New York city in a corporate job, we get it, that came across. Leigh Hurst (10:12): Right. And so you kind of like play these scripts out in your head. Like I really should slow down this. Isn't really how I want to spend my time. I'm really too busy. I wish I could make more time for X and part of my move home quite honestly, before breast cancer was in an effort to sort of really operationalize some of that stuff to sort of extract myself out of the environment that wasn't really fueling me anymore. It was draining me. And so, you know, earlier in my career, there's coast to coast flights on a Monday morning to get to a meeting on time. That was exciting. And as I got older, I'm kind of like, I don't really want to do that anymore. I don't care how much money I make. I don't want to be on a plane. I want to be involved in the place that I live. Leigh Hurst (10:55): And so my move was in part to get that going right, to really start to be outside more to, you know, I decided to go part time cause I kept my job in New York city. So I didn't need the amount of money I was making where I lived anymore. But I didn't truly step out like that until breast cancer came. And then I quite honestly, I got depressed at the end of my treatment, I got depressed and I took three months off work. I called it my be nice to me times. So I like got weekly massages. I went to get therapy because I felt like I needed to sort of sort through some things, you know, I felt like I should be getting back to normal, but nothing about my life felt normal. Everything had changed, you know, whether or not. Leigh Hurst (11:39): So I think during that time is when I started to realize what it meant to say no, that you can say no and not give a reason. And that having lots and lots of friends, which I had is great, but having a lot or having fewer really good friends became more important to me. People that I could really keep in touch with and have meaningful conversations. And my family quite honestly, too, was a big part of that. So I would say that that was the biggest thing slowing down. And I still struggle with that because that's not my genetic makeup. My genetic makeup is to, you know, attack a problem, and make a change and go through something like breast cancer, trying to get back to normal is tricky because you really can't change the future. You never know if it's going to come back. Leigh Hurst (12:26): That's just a fact with breast cancer. And so I think learning to live with the ambiguity of not knowing, you know, and accepting that, truly accepting that that kind of translates out into other parts of your life, where you can, if you really allow yourself to sit in that space, you can apply that to other uncomfortable things that come up, right. Things that happen with your job or relationships or other things that make you feel anxious. Like you want to make a change or you want a resolution immediately. I think I have a better sense of pause around that where I trust that in time things will sort themselves out and I will have a greater sense of peace around whatever it is. I'm stressing about things that came out of that period of time in my life. Yeah. That's so powerful. I don't do it well by the way, but I work at it all the time. Karen Litzy (13:19): Well, I mean, I think the fact that you were able to identify that as, Hey, listen, this is something that I know I need to work on. And of course we're all a work in progress. Nothing's perfect. But to just be able to recognize that and say, I need to make a change. Like this is too much, that's so powerful. And then to be able to kind of leave the city, move to central PA and say, I know I'm doing this for me. And that was even before the diagnosis. So you were already, you know, heading in that direction. And I also really appreciate that. You said at the end of treatment that you were depressed, that you were unsure, you know, because I think oftentimes when people see breast cancer survivors or they hear from, or just looking at a picture, let's say, right, it's a person smiling or it's I beat it, or, but you don't really get into the background of that. Leigh Hurst (14:22): I talk about the mental health side all the time, because I think it is something that's not discussed as much as it should be and not everybody gets depressed, but I do think everybody has down days. Of course, I mean, when you're struggling with something that's life or death and that happens at different times for different people. For me, I was fight or flight during the treatment. For me, it was like a project, right. I knew I had a plan and I had to do it. And the tricky part for me was when I entered into that gray space where I was kind of released from all of that care. And I had to make sense of my life on a day to day basis, be my own cheerleader, quiet those voices in my head that would raise all those scary thoughts and realize that this was going to be forever. You know, like you can't let this consume you. And you know, being brave enough to say I'm depressed. I wasn't brave enough to say that right away. You know, I went into therapy, very hesitantly feeling like, what do you have to be upset about? It was stage one, you got through it, shouldn't you be happy with it? Karen Litzy (15:22): That self-defeating language, right? There's someone worse off than you. Leigh Hurst (15:27): Right? So therefore you can't feel any sort of emotion around your own words is not true and very dangerous by the way. And so, you know, I really try to bring that up when I speak to women who are going through it or who have gone through it, who I sense might be struggling with a little bit of that, because there's so much, and it's different for everybody. If you might be balancing kids, I wasn't, but it might be balancing kids, little children and trying to mask what you're going through to keep them from being afraid. And so that you're hiding your own emotions for some period of time, or same thing goes for spouses that can have issues. So finding a place where you can be truly honest with your own feelings and dealing with that is I think really important because it delays your ability to heal. If you don't find your way. Karen Litzy (16:18): You have to say to yourself, okay, this is the situation and I need to live with this. What's the best way I can move forward. Right. We discussed that a lot with people who have like chronic pain. So the pain may never go away, but can you get to a point where you're still doing all the things you want to do, but in order to do that, you kind of have to accept it. Leigh Hurst (16:48): Yeah. And the way you choose to do that, whatever steps you take to make that possible in your life. The biggest thing for me was realizing that other people don't have to get it right. Like if I had a choice, things that make me able to have good days or days that I need to step out for a little bit, I don't have, I shouldn't have to worry, or I can't worry if that makes sense to somebody else, because the only thing I can do is reconcile within myself. What makes me the best version of me, the fullest version of me, for the people that need me. And the way I choose to do that is probably not going to be the same as the way someone else chooses to do that, or should it yeah. Nor should it be. Right. So looking for affirmation about those decisions outside of yourself is a real challenge. You know, if you're a pleaser or you're, you know, sometimes you just gotta bone up and do what you have to do, right. You always just satisfy your needs. But the times when you have choices to flake out on plan that you just don't feel up for, or push something that you thought you should do today to tomorrow those things are okay to do, and you don't need someone else to tell you they're okay. Karen Litzy (18:01): Right, right. It comes down to like giving yourself the permission and the grace and the ability to do what you need. Like you said, to do what you need to do in the moment at that time, that's going to be best for you. That's going to allow you to show up fully as the person you need to be. Leigh Hurst (18:20): Right. Yeah. That makes total sense. I thought it was a great way of putting it as like self care is not the same as selfish. So making those choices, you have to be, you know, polite, honest, a good person when you're doing all of those things, but taking care of yourself, the self care part of it is not being selfish. It's about being in touch with what makes you the good person that you are. Karen Litzy (18:46): Right. And I think also being able to communicate that to someone maybe it's your partner or your spouse or your children or work, I think the way you go about communicating, that makes all the difference, right. Because there's a difference between, listen, right now, maybe you might have felt, you know, I just need to be by myself for a couple of hours, you know, that's what's best for me, but if you don't communicate that properly or if you just flake out and go stout on people like that is not that that's how you, you create a lot of friction. Right. So what advice would you give to people if they do have to make these decisions to do what's best for them? What's the best kind of language? Cause I know you're very good at communication and all that other stuff. Leigh Hurst (19:38): So I have two small children. I had kids after breast cancer and I'm a single mom now. And I was since they were very little good friends with their father and all of that, but still, you know, being I'm 50 now, but I was 40 and 42 when I had them. And so, you know, the loss of independence around raising two children alone when you're used to like literally flying coast to coast, you know, rewind five years. And it was like, the world was at your feet. So I found myself becoming extremely protective of my space when they were not with me. And, you know, so I was very cautious about making plans. And I would just be honest about that if it was a weekend that I didn't have them and somebody invited me to go away for example, Oh, we're having a girl's weekend. Leigh Hurst (20:24): We're going to go to a winery. Do you want to come? And I would say, well, I might, I might want to come if you need a commitment though. I can't commit because a lot of times when the kids go away, I just like to have some quiet time to myself. I don't like to come back from a weekend and be tired. So I would, I mean, that's just being honest, you know, some things, those are, it's not as easy as something like that, but you know, I think with work where there's deadlines and it's a little trickier to push things off I've gotten better at prioritizing where I'll say it has not really in it today. I know I said I would have this by two o'clock is it possible I could have it tomorrow by maybe 10. So I'm not telling them all the inner workings of what's going on in my brain, but I'm floating the idea that I'd like to shift the priority around because I think it would work better for my mental state. You know, so those are just some ideas for how I do it. Karen Litzy (21:20): Yeah. That's great. That's great. Thanks for sharing that. And now what I'd also like to talk about is your book. So you're about to release, well, this will be out the first weekend of October. So the book should hopefully be out by then, right? They will be. Okay. Perfect. So say something big, feel your boobies, find your voice stories about little lumps, inspiring, big change. So first of all, congratulations, because writing a book is no joke. So tell us a little bit about why you wrote the book and what's in it. Leigh Hurst (21:57): So I wanted to write this book for quite some time. You know, I do a lot of speaking and people often say, Oh, your story is so inspiring about how you just created something and then you ran with it and you saved lives. And now you have this big foundation. And I do realize that that's inspirational, but I kind of tire of my own story over time. So every time I would sit down and try to write about it, I was like, Oh my gosh. But what I found inspirational enough to get me going this time. And it was really an honor of our 15th anniversary, which was last year. I was hoping to have it done by them, but that's the 15th anniversary of the foundation. And it was also my anniversary from breast cancer is the same as the foundations university. Leigh Hurst (22:39): So I started writing it back then and the way I got inspired to really get into it was as I started writing about my own story, I was things were coming to mind about these other women that I had met over time through my path, as you know, being very involved in the breast cancer community and quite honestly, their stories while different were very similar. So they were young when they were diagnosed, they found their own lump and they made some sort of change that was remarkable that they hadn't really pivoted from one path to another and really in an effort to give back. And so, as I started seeing that sort of common thread through some other women that I respected, I thought, well, what if I wove their stories into mine? And so, you know, our stories are different. So how I felt it, this part of the journey, you know, when I found the lump, the way I found it is different than the way one of the other women found it and how I felt during chemo is a lot different than the way some other people felt during chemo. Leigh Hurst (23:38): So if I can weave their stories in to mine, then it will relate to so many more people because can kind of say, Oh, I really relate to Leigh. When she was deciding if she wanted to have a mastectomy or lumpectomy, but I really, really related to Holly during chemo, cause I'm really struggling with it. And she struggled with it too. And so there's lots of tidbits of inspiration and advice that come out of all of these stories. And so after each chapter, I write a little piece that's called big lessons from little lumps. And it's basically trying to suss out the things that I felt were common through each of the women's stories at each stage of the breast cancer journey. And then of course at the end, you know, they've all sort of found their voice. They've started their own nonprofits, where they started a company to create underwear, lingerie line that's meant to make you feel sexy, even if you've had your breast removed. Leigh Hurst (24:35): And that was because that particular survivor did not feel sexy after she was diagnosed and had surgery and she was a designer. So she decided to do that. And so I just found great inspiration and listening to their stories and trying to weave them into mine. And, really at the end of the entire book, what I found were basically three ideas that I saw across all the women that I think can relate to anybody that's going through any sort of difficult time, not just breast cancer. And one of them was that I really noticed that each woman found a frame for their situation that really focused on the idea of looking forward into the future versus looking only backwards and only wishing they could redo it differently. Right? Like being sad about what had happened. They all had those emotions, but the way they ultimately framed things was with the idea of looking forward. Leigh Hurst (25:31): Then each of them also talked a lot about finding a passion, something that really, you know, gave them those goosebumps or that feeling you get in your stomach when you're doing something right. And that is what they chose to spend their time on. And they really made an effort to strip anything out of their life that got in the way of them being able to focus on that type of activity. And then the thing that we talked about earlier, but the third thing is that they all recognize that change is continuous, right? It's not like you flip a switch and say, I'm going to make this change, or I'm going to start fuel your movies. And all of a sudden I'm happy because I started a nonprofit and it does good things. I mean, it has all the same challenges that a normal job has. Leigh Hurst (26:11): So change is truly this continuous thing, but because of the passion and they're focused on the future, they were able to realize that, sure, there's going to be some bad days throughout this process, but nothing is going to get in the way of my path to create this change towards the way I really want to live my life. And I found that so powerful when I saw that kind of trend throughout each woman. And I really think a lot of people will benefit from watching how each of them kind of, you know, injected that into their own lives. Karen Litzy (26:44): And isn't it amazing how storytelling creates such great learning moments, right? I think that's the way to do it. People they remember the stories, they think it's digestible, they internalize it. Like you said, what someone may not relate to you, but they may relate to someone else in the book. And it's those stories that weave through that come up with these great themes that anyone can relate to. So I just always think that I'm such a huge fan of storytelling and storytelling makes things real and relatable. Leigh Hurst (27:16): And I think that's an important way. It's one of the things we try to do with the foundation too, is when we do provide messaging or things, we try to really make it relatable. And that we're telling a story about someone who is real, someone who was young when they were diagnosed. So when you say that looks like me, I can relate to that. I also think women who are brave enough to share their story and I, by no means think it's wrong to not share your story. I think you're a private person and that's how you heal, then that's what you should pay attention to. But for those who choose to, and they don't always realize they've chosen to one of the women in the books that she never talked about it. The first time she was diagnosed, she was 26 and she was embarrassed. Leigh Hurst (27:56): And then she unfortunately was rediagnosed nine years later with metastatic cancer at 45, which means it's terminal. And at that point she really became braver to start talking about it and she realized how much strength she got from sharing her story. And so I think when women put their stories out there they have no idea how many people they touch when they do it, because no one's gonna necessarily walk up to you and say, I really respect that. You said that, or I want you to know that that really made a change in my life that day, but it does. It does. And it goes beyond what you will ever actually know. Karen Litzy (28:32): Absolutely. Yeah. And I love that sort of women pushing other women forward and building them up and paying it forward. It's just such a lovely, a lovely lesson for anyone. But as we all know, you know, the power of women in groups is very powerful. Leigh Hurst (28:52): Unstoppable. Exactly. Karen Litzy (28:54): Exactly. That's better unstoppable. Yes, absolutely. And so before we kind of wrap things up, what I would love from you is what would you like the audience to sort of take away from maybe from your experience or from our talk today? Cause I know that you do and you also, I also want to point out that you also talked to a lot of young people, college students, things like that, right? Leigh Hurst (29:18): Yeah, I do. I do. Yeah. So one of the aspects of our campaign in the past has been what we call our college outreach program, which we provided free materials to college health centers nationally through sororities and women's centers and so forth. And that was in an effort to get our message out to the college campuses. And we've also started running a media campaign which we did last year called are you doing it was a minority outreach campaign focused on young African American women in low income areas. African American women have a higher, are diagnosed at an earlier age than white women. And once they're diagnosed, they have a higher mortality rate as well. And so it's a very important audience to target. And so we funded a campaign that leveraged billboards, bus shelters, bus wraps, as well as targeted digital outreach to that demographic of women specifically to spread the message and that incorporated five local survivors, real survivors who were diagnosed at a young age, we did a photo shoot, shot a video with them. Leigh Hurst (30:22): And we shared that through all the channels that I mentioned, but we got over 6.2 million impressions with that campaign. Amazing. Very amazing. So, yeah. So we reach out to that younger population, like you mentioned in a lot of different ways, but I mean, I think if you asked me what the one thing is, I want someone to take away is that, you know, it sounds cliche, but I really do believe that one voice matters. I feel like the ripple effect from one person's passion and when one person's devotion to an idea can really make a difference and they don't have to be big actions. The things that you choose to do, don't have to necessarily change the world, but you can start small. And the actions that you choose, the words that you choose and how you choose to navigate your life, I think affects other people. And this book really showed me that in the smallest of ways, people can have the biggest impact in their communities and in other people's lives. And that's, I think that's a really great lesson for anybody to take away. Karen Litzy (31:24): Absolutely. And now if people want to get in touch with you, where can they find you? Where can they find the book? Leigh Hurst (31:31): So the book will be available on Amazon. Starting October 1st, I believe. You can read more about the book leighhurst.com. You can follow the book on Facebook, which is, say something big as well and Instagram to say something big. So those are all the channels. And then of course, if you're interested in feel your boobies and the work that we do, the Facebook pages you know, at feelyourboobies on Facebook, Instagram, and Twitter, and our website is feelyourboobies.com. Karen Litzy (32:08): Awesome. And we'll get all of those links. So for everyone, if you don't have something to take it down, or you're not right in front of the computer, we'll have all of the links. You can go to podcast.healthywealthysmart.com. And we'll have a quick link to everything that Leigh mentioned today throughout the podcast. So not to worry, everything will be right there. So Leigh, thank you so much for sharing your story. I just know, like you said, even if one person hears this and they say, Oh, well maybe I will feel my boobies, mission accomplished. Well, thank you so much for sharing your story and coming on the podcast. I appreciate it. And everyone out there listening. Thank you so much. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Sandy Hilton, David Butler and Bronnie Thompson on the show to discuss persistent pain during COVID-19. In this episode, we discuss: -Shifting current healthcare curriculum to better educate clinicians on persistent pain -Can passive modalities empower people to pursue more active treatment options? -How to create more SIMS during the COVID-19 pandemic -Can telehealth appointments adequately address persistent pain? -And so much more! Resources: International Association for the Study of Pain Website Factfulness Book David Butler Twitter Sandy Hilton Twitter Bronnie Thompson Twitter A big thank you to Net Health for sponsoring this episode! Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020! For more information Bronnie: I trained as an occupational therapist, and graduated in 1984. Since then I've continued study at postgraduate level and my papers have included business skills, ergonomics, mental health therapies, and psychology. I completed by Masters in Psychology in 1999, and started my PhD in 2007. I've now finished my thesis (yay!) and can call myself Dr, or as my kids call me, Dr Mum. I have a passion to help people experiencing chronic health problems achieve their potential. I have worked in the field of chronic pain management, helping people develop 'self management' skills for 20 years. Many of the skills are directly applicable to people with other health conditions. My way of working: collaboratively – all people have limitations and vulnerabilities – as well as strengths and potential. I use a cognitive and behavioural approach – therapy isn't helpful unless there are visible changes! I don't use this approach exclusively, because it is necessary to 'borrow' at times from other approaches, but I encourage ongoing evaluation of everything that is put forward as 'therapy'. I'm especially drawn to what's known as third wave CBT, things like mindfulness, ACT (Acceptance and Commitment Therapy) and occupation. I'm also an educator. I take this role very seriously – it is as important to health care as research and clinical skill. I offer an active knowledge of the latest research, integrated with current clinical practice, and communicated to clinicians working directly with people experiencing chronic ill health. I'm a Senior Lecturer in the Department of Orthopaedic surgery & Musculoskeletal Medicine at the University of Otago Christchurch Health Sciences. I also offer courses, training and supervision for therapists working with people experiencing chronic ill health. For more information Sandy: Sandy graduated from Pacific University (Oregon) in 1988 with a Master of Science in Physical Therapy and a Doctor of Physical Therapy degree from Des Moines University in December 2013. She has worked in multiple settings across the US with neurologic and orthopaedic emphasis combining these with a focus in pelvic rehabilitation for pain and dysfunction since 1995. Sandy teaches Health Professionals and Community Education classes on returning to function following back and pelvic pain, has assisted with Myofascial Release education, and co-teaches Advanced Level Male Pelvic Floor Evaluation and Treatment. Sandy's clinical interest is chronic pain with a particular interest in complex pelvic pain disorders for men and women. Sandy is the co-host of Pain Science and Sensibility, a podcast on the application of research into the clinic. For more information on David: Understanding and Explaining Pain are David's passions, and he has a reputation for being able to talk about pain sciences in a way that everyone can understand. David is a physiotherapist, an educationalist, researcher and clinician. He pioneered the establishment of NOI in the early 1990's. David is an Adjunct Associate Professor at the University of South Australia and an honoured lifetime member of the Australian Physiotherapy Association. Among many publications, his texts include Mobilisation of the Nervous System 1991 The Sensitive Nervous System (2000), and with Lorimer Moseley – Explain Pain (2003, 2013), The Graded Motor Imagery Handbook (2012), The Explain Pain Handbook: Protectometer (2015) and in 2017, Explain Pain Supercharged. His doctoral studies and current focus are around adult conceptual change, the linguistics of pain and pain story telling. Food, wine and fishing are also research interests. Read the full transcript below: Karen Litzy (00:00:23): Hello everyone. And thank you for joining us today for this webinar. For those of you who are here live, you got to hear a little bit of pre-conversation which is great. And of course in that pre-conversation we were talking about all the things happening in the world today, specifically here in the United States with a lot of unrest and protests for very, very good reasons, in my opinion. And so we just want to acknowledge that and that we see it and that we are trying to learn, and we are doing our best to be allies to our fellow healthcare workers and citizens across the country and across the world for all of the other countries who have been showing solidarity. So I'm Karen Litzy, I'm going to be sort of moderating this panel of minds and I'm going to now go round and just have each of them say a little bit about themselves. So Sandy I'll start with you. Sandy Hilton: Okay. Hi, I'm Sandy Hilton. I'm a physiotherapist here in Chicago, Illinois with Sarah Haag. We have entropy physiotherapy and our clinic is predominantly working with pain. It's like a hundred percent of my case load is people in pain and about 80% of that is pelvic pain in particular. But I still see, you know, the rest of humans. David Butler (00:01:49): Hi, I'm David Butler from Adelaide Australia. I'm a physio, although I'm completely a professional and I believe everybody has the exact same role in treating pain. I'm trying to hire, but I can't retire. And then in world, our changing knowledge and our changing potential just keeps me, keeps me on track. So yeah, any sort of pain I'm happy to talk about. Bronnie Thompson (00:02:16): I'm Bronnie Thompson, I'm an occupational therapist by original training with some psychology thrown in, and I'm an educator and clinician as well, but a teeny tiny bit of research, but not much. And I'm a painiac and quite proud of it actually. Karen Litzy: Excellent. So again, everyone, like I said, if you have questions as we go along, please feel free to put them in the Q and a part. And I will be looking at that as we're going through now, like I said, we've got some questions ahead of time, but before we get to some of the questions that some of the listeners and viewers have wanted to ask, I also want to just quickly acknowledge that we've got a bit of a mixed audience, so we've got healthcare practitioners and clinicians and we've also got people living with pain. Karen Litzy (00:03:11): And so as a clinician for me, it's a great opportunity. I think to address people in pain who maybe don't have the access or the ability to kind of get this information that's in their town or where they're living. So I am really, I'm really looking forward to this discussion, especially for those people that are watching that are living with persistent pain. So the first question I'm going to ask is and I'll ask this of all of you. If you were to give a piece of advice to a new professional or a healthcare professional that is sort of newly working with people with persistent pain, what would that piece of advice be? Sandy Hilton (00:04:11): I'm in Chicago. I'm just going to take it. I really like to stress, especially to students that, you know, we get this concept that the longer you've been in the field, the better you are at it. And, I think that maybe we make different mistakes, but everyone is learning this. And there's so much about pain that we're learning. And so if you're just starting in, I don't know that you might have an easier time because you have less bad habits to get rid of and can start with some of the better newer research and avoid some of the mistakes we made. Bronnie Thompson (00:04:50): So she's doing the popcorn approach. She looks at me. And so I think my advice would be, listen, listen very carefully to what people tell you and trust that they're telling you your experience. Don't try and read stuff into it, just listen and reflect, show that you're listening by reflecting what you've heard. So you can give that you've understood one another, because it's really easy to come out of school with all of this knowledge packed up and your brain thinking, Oh, I've got to do an info dump just like that. And it's not that great for the person, stop and listen. David Butler (00:05:37): They are lovely comments. I'd add. I would welcome anybody to the most new and exciting area of health. And there is a true pain revolution out there. And I would say to anybody, when you come in to just lift your expectation of outcome or what, might've been five or 10 years ago, because the clinical trials and our knowledge of the potential for humans to change is just increasing so dramatically. And I say, now we can say think treatment, not necessarily management because for many people recovery or some form of recovery is on the cards and what's leading the charge is the talking and the movement therapies. It's not the drug therapies for chronic pain. And, I just like to reflect as an older therapist now, patients who maybe 10, 15 years ago with maybe complex post pain surgery or Phantom limbs or complex regional pain syndrome would have thought, and I can't really help here. Now we welcome them through the door and you can get such pleasure, pleasure from treating these people no matter how long they've had the problem. Karen Litzy (00:06:48): Great. And, I would echo what Bronnie said is, you know, really listen and also believe, you know, they're giving you their experience. So try and take your bias out of it and believe what they're telling you and try not to talk them out of it because you see this quite a bit of, Oh, I have pain with this. And well, do you really have pain with that? Or is your pain really that much? And as the patient, it's very frustrating to have someone try and tell you what your pain is. So I'm looking at it from the person who has lived with the really chronic and at times debilitating neck pain is just listen, which is good. Believe them, and try not to talk people out of their experiences because it's very frustrating and it's very sort of dehumanizing for the patient, you know? Karen Litzy (00:07:54): And when I look back at when I first met David and went up to him at an APTA event and said, would you like to be on my podcast? And he said, yeah, sure, but I'm going to New York. I said, Oh, well, that's great. Cause that's where I live. And so then he met me at my, where I was working at the time and spent two hours with me. And I just, after that felt like, Whoa, like this is the first time that someone really listened and didn't interrupt and believed what I was saying and really set me on a path that just changed my life. Like, I don't know where I would be, had I not had that encounter with David. I think it was like 2011 or 2012. And so I always reflect on that and try and be that person, because I know what it felt like. Karen Litzy (00:08:45): And then when someone does come in and, and gives you their full attention and their time and their understanding, and then says, well, challenges your beliefs in a positive way, it was something for me that, you know, and I've talked about it many times that just completely changed my pain and my life. And so, you know, try and be that person is what I would say to people. Bronnie Thompson: It's like, we've got to remember that people with pain and I live with fibromyalgia, those of you that don't know that's my reality, it's our experience and what it's like to live without pain. You know, what it feels like to know the things that sit at off things that settle it down and our relationship to it, to that pain and conditions. We come in with a whole lot of knowledge about other people and what we've seen. So we are experts and a whole lot of stuff, but what we're not experiencing as this person's life, their experience via what they're wanting from us even, what's important to them. And that's where when we meet and we can kind of share the hidden paradigms things that we don't know about each other, then we've got a chance to make a huge change and that as we know, I just feel so good about what I do. I just love it. I'm such a pain geek. Sandy Hilton (00:10:09): And I think the pain science or the science of pain really gives as a clinician, a lot of comfort to the listen to them, believe them, you don't have to prove it. You don't have to go. And like they say, I hurt here. You don't have to go poke it to reproduce the symptoms to believe it. And that's how I was taught of you have to reproduce the symptoms so that you can document that it's true. And it was like, that's a giant piece of unnecessary that we don't even have to do anymore, which really saves us a lot of time, not to mention establishing that trust and not being one more person. That's poked them in the sore spot. But, that's the thing that I was taught in school. Bronnie Thompson (00:10:58): So the question is, do you think that all chronic pain patients were not treated particularly when they were having the first or second episodes of their acute pain or are they in any way destined to become chronic pain patients? Well, my story is I hurt my back. I was what, 21, 22, doing a tango with the patient and a doorway patient was bigger than me. I landed on the floor on my back and I had all the best evidence based treatment at the time, maybe not, maybe not all the ultrasound, but you know, they didn't lie. They're really and relax a bit. Bronnie Thompson (00:11:48): But I didn't recover. I was then seeing the Auckland regional pain Center with amazing dr. Mike Butler, who is a rheumatologist and founded, and basically was one of the first in this initiations of bringing the international association for the study of pain to New Zealand, good friend of Patrick Wall knew her stuff very well. Gave me the book the challenge of pain to read. So essentially an explain pain paradigm back in the eighties, I know pain pretty well. My pain has not gone away. So there are some people who will not have a complete recovery of all of their pain, but because none of our treatments provide a hundred percent abolition of pain and actually I'm comfortable with it. I live with the pain and it gives me some stuff that some other people don't have access to. I know what it's like to have every bit of my body feeling really rotten. Bronnie Thompson (00:12:53): At the same time. I'm not limited by my pain. And I think sometimes we look at pain removal is that end goal. But I think our end goal is to help people live full, productive, satisfying, joyful and enriched lives. And some people will bring the pain along with them and many people won't have to and that's amazing. Let's let the person make that decision about what is the most important outcome. But yeah, sometimes we can do all the right things, but if you have a spinal cord injury and you've got a smashed up spine, probability is that at the moment, our technology doesn't give us a solution. We can help, but we can't always take it all away. Karen Litzy: David, what are your thoughts on that, that sort of movement from acute pain to chronic pain? You know, what are your feelings on that is, is like you said, are you destined to have it are I know, cause I get this question a lot from people like, well, you know, it started out with like an ankle sprain or it started out with a knee sprain and now it's turned into this. So did I do something wrong or was something not done? David Butler (00:14:12): I think you're not destined to have it, but I think our treatment or therapies and the politics of treating acute pain probably gets in the way. And I also think if someone's hurt their back or any part of their body bad enough to see a health professional, the data is that 50 or 60 or 70% will have a recurrence in the following year. Now most health professionals think a recurrence is a reinjury, but if they really explored what happened, that reoccurance probably happened at a time when they would look at down and flat the immune system's a bit out of balance and they might've just done something simple, lifted up and picked something we would now from pain science, reconceptualize that as well, that's quite good. It's your body testing yourself out like a fire alarm with all the stuff you've been through in the past. It's no wonder your brain. Wouldn't want to play it again to check out how your systems are working, but that just simple piece of knowledge and usually should check to make sure nothing serious has gone on because you check and you can normally say, well, that should ease in a couple of days. That's an example of a little bit of knowledge dampening down. They don't have to go through the old acute process again of more, x-rays more tests, more power. David Butler (00:15:31): I think if that's correct, that observation was seen for many years, it could save governments Billions. Bronnie Thompson (00:15:37): Oh, absolutely. We've got a great thing. The language we use don't we, is it an injury or is it just a cranky body? David Butler (00:15:46): That whole linguistics? And for me and my treatment, you're now a physio by trade. I feel it says important to help someone change the story, to have a story, to take their experience out into society and let it go. That to me is as important as having healthy movement, although they obviously like go together. Sandy Hilton (00:16:07): I was gonna say that the saving of money for systems, for sure, but also the saving of time for people and the saving in our healthcare system. Every test you go do is going to cost you a lot of money. And, that time that it takes to get it in a time away from work and family and the concern of what the test results will be. If we can divert them wisely to not do that when it's not really indicated, that's just so good. Bronnie Thompson: Yeah. And then I also for, you know, I've had a test now I'm going to wait for the results and now I'm going to wait for what are they going to do as a result of those results? And then, Oh, it's the same. And it just feels very demoralizing to people. And I think that's something we need to think about with make the decision about when and we to stop doing investigations often. That's the sense of the clinician worrying that something, are they going to sue me? It's not a good way to practice. Karen Litzy: Yeah. here's another, we'll do this from Louise. She says, picking up on something David had said earlier, how do we move towards being more, a professional? How do we move the pain industry toward this goal? Excellent question Louise. David Butler (00:17:51): There's a lot of answers to it, but a couple would be, I think you just got a quite badly out there would know sports trainers who could deliver an equally good management strategy to some physios, to some doctors, et cetera, right? This pain thing is across all spectrums, which is why the national pain society meetings are so good. And why everybody there is usually humbled and talks to all the other professionals because they realize the thing we're dealing with is quite hard. And we need all the help that that's a weekend get, but it ultimately comes back to provision of pain education throughout all the professions and that pain education should be similar amongst all the professions it's not happening yet. We've tried pushing it, but it's not out there. And it's incredible considering the cost of pain is to the world is higher than cancer and lung diseases together. Karen Litzy (00:18:51): Yeah. The burden of care is trillions of dollars across the world. And, you know, even in the United States, I think the burden of care of back pain is third behind heart disease, diabetes. And then it was like all cancers put together, which, you know, and then it was back pain. So, and, and even I was in Sri Lanka a couple of years ago and I did a talk on pain and I wanted to know what the burden of disease of back pain was in Sri Lanka. And it was number two. So it's not like this is unusual even across different, completely different cultural and socioeconomic countries. And, you know, David kind of what you said, picks up on a question that we got from Pete Moore. And he said, why isn't it mandatory that pain self management and coaching skills isn't taught in medical schools? Is it because there isn't expertise to teach it? Well, I mean, David's right here. He's semi retired. David Butler (00:19:58): Why isn't that mandatory? That's a big, big question. I would say that the change is happening. Change is happening. I would say that at least half of the lectures or talks I give now are to medical professionals and out of my own profession or even more than half. So yeah, change is happening, but it's incredibly slow. It needs a bloody revolution, quite frankly. A complete reframing of the problem and awareness that this problem that we can do something about it and awareness that there's so much research about it let's just get out and do it now. Sandy Hilton (00:20:40): The international association for the study of pains curriculum and interdisciplinary curriculum would be a nice place to start. And I know some schools here in the States are using it in different disciplines to try and get at least a baseline. Bronnie Thompson: The way we do it as the core for the post grad program, that I am the academic coordinator for it. Doesn't that sound like a tiny, tiny faculty. But anyway the other thing that we know is that looking at the number of hours of pain, education, Elizabeth, Shipton, who's just about completed. If she hasn't already completed her PhD, looking at medical education and the amount, the number of hours of pain, it's something like 20 over an entire education for six to six or more years. In fact, veterinarians get more time learning about pain then we do then doctors medical practitioners do, which suggests something kind of weird going on there. Bronnie Thompson (00:21:50): So I think that's one of the reasons that it's seen as a not a sexy thing to know about and pain is seen as a sign of, or a symptom of something else. So if we treat that something else in pain will just disappear, but people carry the meaning and interpretation in their understanding with them forever. We don't unlearn that stuff. So it makes it very difficult, I think for clinicians to know what to do. Because they're also thinking of pain is the sign of something else not is a problem in its own, right? Persistent pain is a really a problem in its own right. Karen Litzy (00:22:29): Yeah. And wouldn't it be nice if we were all on the same page or in the same book? I wouldn't even say the same chapter, but maybe in the same book, across different healthcare practitioners, whether that be the nurse, the nurse practitioner, the clinical nurse specialist, the physician, the psychologist, the therapist, physical therapist, it would be so nice if we were all at least in the same book, because then when your patient goes to all these people and they hear a million different things, it's really confusing. I think it's very, very difficult for them to get a good grasp on their pain. If they're told by one practitioner, Oh, see, on this MRI, it's that little part of your disc. And that's what it is. So we just have to take that disc out or put it back in or give a shot to this. Karen Litzy (00:23:25): And, and then you go to someone else and they say, well, you know, you've had this pain for a couple of years, so, you know, it may not be what's on your scan. And then the patient's like, who am I supposed to believe? What am I going to do? And, and you don't blame the patient for that. I mean, that's, you'd feel this that's the way I, you know, I had herniated discs and I say, you just get a couple of epidurals and the pain goes away and then it didn't. And I was like, Oh, okay, now there's so my head, I was thinking, well, now there's really something wrong. Sandy Hilton: That's the problem. Because yeah, if you think it's the thing you did that helped you or didn't help you, then you lose that internal control. Karen Litzy (00:24:13): Yeah, yeah. Yeah. So I think, I think it's a great question and, and hopefully that's a big shift, but maybe it'll start to turn with the help of like the international association for the study of pain and some curriculum that can maybe be slowly entered or David can just go teach it virtually from different medical schools, just throwing it out. There is no pressure, no pressure. Okay. Speaking of modalities, we had a question. This is from someone with pain and it's what can be the appropriate regimen for usefulness of tens, for acute and chronic cervical and lumbar pain of nerve origin. So Bronnie, I know that you had said you had a little bit of input on this area, so why don't we start with you? And then we'll kind of go around the horn, if you will. Bronnie Thompson (00:25:24): I think of it in a similar way to any, any treatment, really, you need to try it and see whether it fits in your life. So if you are happy and tens feels good and you can carry it with you and you can tuck it in your pocket and you can do what you want to do. Why not just is, I would say the same about a drug. If you try a drug and it helps you and it feels good and you can cut the side effects, there's nothing wrong with it. Cause we're not the person living life. It's more to think about it in a population. How effective does this? And my experience with tens is that for some people it does help and it gives a bit of medium, like a couple of hours relief, but often it doesn't give long sustained relief and you have to carry this thing around. That's prone to breaking down and running out of batteries, right when you need it. So to me, it's agency, but then I put the person who's got the pain and the driving seat at all times to say, how would this fit in your life? Do you think you want to try this one out? It's noninvasive it's side effects. Some people don't like the experience and sometimes the sticky pads are a bit yuck on your skin, but you know, that's more bad. So yeah, that's my, my take on it. David Butler (00:26:44): I haven't used it for 40 years after the second world war. When you start to stop, when they, I was friendly with the guy who invented it and I'm thinking it'd be happy pet we'll would be happy to, with these comments that I agree with what Bonnie said. Absolutely. I would also say that, hi, wow, you have got something there which can change your pain by scrambling some of the impulses coming in. You can change it, let's add some other things which can change the impulses coming in or going out as well. So let's use that. Let's get you building something, maybe something repetitive or something contextual or something as well. So you you've shown change you're on the track. So I would use it as a big positive to push them on keep using it, but on the biggest things. Sandy Hilton (00:27:32): Yeah, the advantage is it's. So it's gotten so inexpensive. So for something that has minimal to no side effects and has the potential of helping them to move again, which I think is always the thing that we're aiming for. It's not very expensive. But now like several hundred dollars, right? You can order it online. Now you don't even need a prescription or approval or anything like that. Karen Litzy (00:27:59): Yeah. Yeah. That's true. And something that I think is also important is, you know, you'll have people say, Oh, those passive modalities, that's passive. You know, I had a conversation with Laura Rathbone Muirs. Is that how you say the last name? I think that's right. Laura. And we were talking about this sort of passive versus active therapies and, you know, her take on, it was more from that if they're doing these passive modalities, they're giving away their control. And, she said something that really struck and, kind of what the three of you have just reinforced is that no, they still have that locus of control. Cause they're making that conscious effort, that conscious choice to try this, even though it's a passive modality, they still made the choice to use it. Karen Litzy (00:29:03): And I think that coupled with what David said, Hey, this made a difference. Maybe there's some other things that can make a difference that I think that I don't think they're losing that locus of control, or I don't think that they're losing they're reliant on passivity, right. Sandy Hilton: When they have their own unit and they're not coming into the clinic to have it put on you. And you lie there on the bed while you do it. Bronnie Thompson: It's something that you have out in the world. It's not different to sticking a cold compress on your forehead when you're feeling a bit sick, you know, we did it. That's just another thing that we can do. So I see it as a really not a bad thing. And it is in the context, you know, if you can do stuff while you've got it on, then it's the hold up problem, as long as you like. Karen Litzy: Great, great. Yeah. As long as you like it. Exactly. Yep. Okay. so we've got another question that we got ahead of time and then there's some questions in the queue. So one of the questions that we got ahead of time was how do we explain pain responses like McKenzie central sensitization phenomenon in modern pain science understanding. David Butler (00:30:35): I'd answer that broadly by saying that the definition that we've used and shared with the public in the clinical sense is that we humans hurt when our brains weigh the world. And judge consciously subconsciously that there's more danger out there than safety. We hurt equally. We don't hurt when there's more safety out there, then danger. So somebody who's in a clinic and is bending in any way and it eases pain. There will never be one reason for it. So it might just be, that might just be the clinic. It might be the receptionist. It might be all adding up. It might be the movement. They might've done one movement. And so, Oh, I can do that. And then all safety away, we go again, the next movement helps within that mix. There may be something structural. You've done to tissues in the back and elsewhere that might have eased the nociceptors that barrage up. But by answer will always be that when pain changes, it's multiple things are coming together, contributing to them. And they'll never never just be related to nociception. Sandy Hilton (00:31:49): I have to say this to say, I am not McKenzie certified. So this is my interpretation of that. I like the concept of you can do a movement. That's going to help you feel better. And we're going to teach you how to do that throughout the day. Maybe as a little buffer to give you more room, to challenge yourself a little more knowing that you'll have a recovery. And I just pick that part and use that. Bronnie Thompson: I heard the story of how it all came about and it, and it's you know, it's an observation that sometimes movement in one direction bigger than another. And that's cool. It's like, you're all saying, let's make this little envelope a little bigger and play with those movements because we're beasts of movement. Bronnie Thompson (00:32:50): We just forget that sometimes we think we've got to do it one way. And you know, I can't tell my plumbers who crawl under houses. Look, you've got to carry things the way, you know, the proper safe handling thing. And I wasn't, I was the same safe handling advisors like me. But you know, there's so many ways that we can do movements and why can't we celebrate that? And the explanation, sometimes we come up with really interesting hypotheses that don't stand the test of time. And I suspect it might be some of the things that have happened with the McKenzie approach. It's same time. What McKenzie did that very few people were doing at the time was saying, you can do something for yourself that as we are the gold ones, that's what changed. David Butler (00:33:40): Bronnie, what's really helped us to start the shift away from poking the sore bit, come on, do it yourself. And, and I always give great credit to Robin McKenzie for that shift in life. Sandy Hilton (00:33:53): Yeah. And an expectation that it's going to get better. Right. David Butler (00:34:00): You think that's showing something in the clinic that helps. Wow. Let's ride let's rock. Karen Litzy (00:34:07): Yeah. And oftentimes I think patients are surprised. Do you ever notice that Sandy, like, or David, or, you know, when you're working with patients, they're like, Oh, Oh, that does feel better. And they're just sort of taken aback by, Oh, wait a second. That does feel better and it's okay. I can do it. Yeah. And then you give them the permission to do so. And like you said, is it's certainly not one single thing that makes the change. But I think everything that you guys just said are probably the tip of the iceberg of all of the events surrounding that day, that time, that movement, that can make a change in that person. And I think that's really important to remember. That's what I sort of picked up from the three of you. Bronnie Thompson: But the stories like that kind of convenient ways of, for us to think that we know what we're doing, but actually within what this person by what this person feels and how they experience it. And the context we provide us safety, security. And I'm going to look after you, that's, you know, changes, motivations about how important something is and how confident you are that you can do it. We can provide the rationale important part. The person ultimately drives that. So we can also provide that sense of safety and that I'm here. I'm going to hang around while you do this stuff. Let's play with it. Let's experiment. And if we can take that experiment, sort of notion of playing with different movements in, we've got a lot more opportunity for people in the real world to take that with them. We can't do that. Or forgive people are prescribed. You will do this movement. And this way perfectly I salute, but the old back schools, Oh, I know scary, And they did get people seeing the other people were moving. And that's a good thing that we can take from it. It's always good and not so good about every approach. Karen Litzy (00:35:11): Now I have a question for David and then out to the group, but you know, we've been talking about Sims and dims and safeties and dangers. And so for people who maybe have no idea what we're talking about, when we're talking about Sims and dims, can you give a quick overview of what the Sims and dims, what that is so that people understand that jargon that we're using? David Butler (00:36:40): Okay, it's a model we use. There's lots of other similar models out there. So basically based on neuro tag theory, the notion of a network that there's danger danger in me networks out there, and there's safety in me networks, rather simple, structured thinking here, and we've looked at these this has emerged due to the awareness, the pain science that we have a network in our brain. But me as an old therapist, when the brain mapping world came in and we realized, hang on pain, isn't just a little nest up there. There could be thousands of areas of the brain ignited indeed the whole body ignited in a pain experience. And one of the most liberating bits of information for me and my whole professional career, because what it meant was that many things influence a pain experience and a stress experience, move experience lab experience, and many things can be brought in to actually try and change it. David Butler (00:37:39): And all of a sudden means that everything matters. So this is where dims danger in me, safety sims in me, it was just a way to collect them. So an example of a dim with categorize them could be things you hear, see, smell, taste, and touch. So for one person, it could be the smell of something burning or looking at something or hearing something noise. The things you do could be a dim. It could be just doing nothing, but then there's Sims, gradually exercising, gradual exposure seems in things you hear, see, smell, taste, and touch could be going out. One of my most common exercises I now give somebody is to go down to our local market and find four different smells, four different things to taste, four different things to touch. And then they'll say, why should I do that? Because you can sculpt new safety pathways in your brain, which will flatten out some of them, some of the pathways they're linked to pain and it comes to of the things you say important. David Butler (00:38:37): You know, I can't, I'm stuffed, I'm finished. I got mom's knees. We try and change that language too. I can, I will. I've got new flight plans. I can see the future, the people you meet, the places you're with. So it's a way of categorizing all those things in life into either danger or safety, we try for therapy, we try and remove the dangerous. It is often via education. What does that mean? And we try and help them find safety and health professionals out there are good at finding danger, but we're not used to getting out there and finding those liberating safety things. And of course the DIMS SIMS thing. It's also closely linked in, we believe to immune balance. So the more dims you have, the more inflammatory broad immune system, the more sims you have, you move more towards the analgesics or the safety. And so it's the way to collect them. It's a way to collect as we try and unpack and unpack a patient's story listing to it within to unpack it and then to re-pack it again with them in a different way. Did that make sense? Karen Litzy (00:39:49): Absolutely. Yes. I think that made very good sense. And I believe you, there is a question on it, but I believe you answered it in that explanation. It says, have you had patients that cannot find Sims or it's difficult to identify and if so, how can you teach them what a SIM is? But I think you just answered that question in that explanation. David Butler (00:40:11): Once they get it. They're on their way. And we send people on SIM hunting homework. So for example, the same might be places you go, okay, if you can get out, just walk in the park or walk somewhere, then power up the SIM by feeling the grass, touching the box, spelling something. And we pair it up by letting them know that if you do that, your immune system gets such a healthy blast, that it can also help dampen down some of the pain response. Bronnie Thompson (00:40:39): And with regard to our current situation, sort of around the world COVID-19 and all the subsequent stuff. And also the situations in the U S at the moment, is it any wonder that lots of people are feeling quite sore because we're eating this barrage of messages to us. And so I would argue that at the moment it might be worthwhile if you're a bit vulnerable to getting fired up with the stuff said, it's a good idea to ration, how much time you're spend looking at the stuff, not to remain ignorant, but to balance it with those other things that feel good, that make you feel treasured and loved and committed. And for me, it's often spending some time in my studio, walking the dog, going outside, doing something in nature. And there is some really good research showing that if you're out in the green world nature, that there is something that our body's really relish, kind of makes sense to me. Sandy Hilton (00:41:42): So taking that concept into what's going on right now, there's been a challenge clinically of the things that helped people balance that out, got taken away from them. Yeah. So it was a complicated it still is. It was a complicated thing where it wasn't your choice to stop going to the swimming pool because it made you happy and it gave you exercise and balance this out. Someone closed the pool and told you, you couldn't go. And so there's all different layers of loss in that and lost expectations and loss of empowerment and all of these things. So we have had to help people rediscover things that they could access that could be those positives. And that's been hard and really working my muscles of how to help people find joy or pleasure or happiness or safety in an unsafe environment to really get that on a micro level when you've lost the things that used to be there. And, it's been like a lot, but you can do it. It just takes concentration. David Butler (00:42:57): An important thing. That's so important. I think a question for therapists health professionals should be a sane question should be, you know, what's your worldview at the moment. And I would ask that, and it's usually not good, but I chat and have a chat. And actually I'd like to take people through some graphs that the world is not as bad as it really is. And if you look at I've been reading a book by Hans Rosling called factfulness. And really over time, our world is getting better. There's less childhood diseases, a whole range of things, getting better, bad, and bad things, getting better. This is a hiccup. This, for example, I had a musician recently and I had a graph I could show her that say that there's now 22,000 playable guitars to a million people in the world. But 12 years ago, there was only 5,000. All right, this is just one little thing. All right, cool. There's a lot of stats that show that our world is improving, you know, children dying, amount of science, a whole range of things. And this hiccup we have that I'm hopeful humanity can get, can get through, but just a little message I pass on is therapy. Bronnie Thompson (00:44:13): Even though we can't do stuff, we can't access places. What can't be taken away as our memory of being there. So it's really easy to take a moment to back a memory that feels good to say, actually, you can't take that one away from me. I might not be physically getting there, but I can remember it, feel those same feelings. And then being mindful. Sandy Hilton: This is funny because if you look at Bronnie's background, that's one of the memories I've been using. When I lost the lakefront, I was like, okay, I'm just going to sit there and pretend that I'm not at that beach by that pier. So it's, it's fabulous. And even pictures or recordings of things that you've done before is like, okay, now there is still good stuff. I might not have it right here, but they're still good stuff. So that's really funny. As soon as I saw the picture, I'm like, yeah. And gratitude and just, yeah. Bronnie Thompson (00:45:05): The other thing as well, we've always got something that we can be grateful for all that. It might feel trite, you know, I'm living in winter, but I've got a roof over my head. I can have a damn fine cup of coffee and probably a nice craft. I'll at the end of the day, these are things that I can do and can have any way. So we can create the sense of safety insecurity inside ourselves without necessarily having to experience it. David Butler (00:45:38): Right. Just a quick comment. I would share that with patients who can't get out are saying the things you do when you're still can be as important as the things you do when you move. Right? So let's explore. If you can't do things, you can still really work you yourself with the things you do. And you're still calm. The introspection reading, thinking, contemplation memory enhancement, go through the photo album, et cetera. And I'd also like to always say to someone to link that in that is a very, very healthy thing to do to your neuro immune complex. Karen Litzy (00:46:13): And that sort of brings, I think we answered this question. This was from a woman who is living with chronic pain and at high risk with COVID-19. So how do we get past the fear of going out where people are crowding areas to get the exercise we need to maintain our fitness and muscle tone to reduce our pain. She said, even though I'm doing exercises and stretching, I've lost the ability to walk unaided on uneven grounds through weeks of lockdown. And the hydrotherapy pool is closed. She said, she knows, I need to get out and walk more, but shopping centers, which are the best place to find level floors are out. And a lot of places that she used to go are now very crowded because people are, don't have the access to gyms and things like that. Are health professionals able to suggest options when she lives in a hilly area with only a few but all uneven footpaths or sidewalks. And she has a small house. Sandy Hilton (00:47:18): That's the kind of thing that we've been doing since it's like, okay, let's problem solve this out. Because yeah, you have your carefully set way to get through this and then it's disrupted. Bronnie Thompson: Yeah, boy, I like having lots of options for movement opportunities. So we don't think of my exercise, but we think of how can I have some movement today and bring that sense of, we are alike to be like, if I can imagine I'm walking along the beach while I'm standing and doing something and, you know, doing the dishes or watching TV or something that still can bring some of those same neuro tags it's same illusion, imaginary stuff activating in my brain. And that is a really, really important thing because we can't always the weather can be horrible, especially if you're in Christchurch and you can't go out for a walk. Bronnie Thompson (00:48:27): Yeah. But you know, we can think novelty is really good. So maybe this is a really neat opportunity to try some play. And I've been watching some of the stuff that our two chiropractor friends do with you put, let's put, at least try some obstacle courses and the house so that it's not we're not thinking of it as exercise. And I've got, do three sets of 10, please physios change that. Let's do something that feels like a bit of fun. There's some very cool inside activities that are supposed to be for kids. I haven't grown up yet. I'm still a baby. Sandy Hilton (00:49:16): Yeah. A lot of balance and things like that you inside that would help when you have your paths back outside. Yeah, yeah. Karen Litzy: Yeah. Great. And then sticking with since we're talking about this time of COVID where some places are still in lockdown, some places are opening up. Bronnie and David are in an area of the world where they have very, very few cases, very, very few cases, Sandy and I are in a part of the world where we have a lot more than one. So what a lot of practitioners have had to do is we've had to move to tele-health. And so one of the questions David Pulter, I believe, as I hope I'm saying his name correctly is do we perceive that our ability to be empathetic and offer effective pain education is somehow diminished by a tele-health consult. So are we missing that? Not being in person. Sandy Hilton: I have found it equally possible in person or telehealth cause you're still making that connection. We do miss stuff. We can't read the microexpressions in people as easily. So we as therapists have to work harder, but for the person on the other end, think about what the alternative is. Sandy Hilton (00:50:46): And it's been really cool for the people with pelvic pain, that every single time they've gone to a physio it's been painful. And on tele-health it's the first time she has been able to talk to someone about all of her bits and pieces without being afraid that it's going to hurt because there was no way to see somebody inside somebody's home. Bronnie Thompson: You get to know something more about me. I've met more pets than ever thought. It was wonderful. This is a privilege that occupational therapists have had for a long time. And I'm so pleased that other other clinicians are getting that same opportunity, because we know so much more about a person when we can see the environment that they live with. That's just fantastic, but it's harder. David Butler (00:51:39): I find I've come back into clinical practice. I thought I was going to retire because I wanted to go, but also doing it. I was hopeless at first, but I'm really enjoying it. And I actually believe, I actually believe for the kind of therapies we're doing it's equal or better than face to face. Ideally, I think I'd like to have one face to face or maybe two but then to continue on with the tele health, particularly for people are in rural areas and it's almost no this kind of therapy was coming anyway, but the COVID has hastened it. So I found myself getting anecdotally here a much more emotional, closer, quicker link to patients by the screen. They were in a safe place. They're in their house. That's number one. They're not in a clinic you're there. And you can actually look at that face in the screen, as we're doing now, I'm looking at your faces, maybe one or two feet away, and I'm just keep looking at you. David Butler (00:52:46): And there's this connection, which is there. And there's also these other elements it brings in like, you start at 10 o'clock and you finish at 10:45. So there's open and closure, which isn't really there in some of the, in some of the clinics, the difficulty I'm having with it though is I was never in face-to-face practice a very good note taker. I used to make notes at the end. I was talking too much, but what you have to do here, my suggestion with face to face is you really need to plan and make your notes straight after. What did I tell that one on the screen, last clinical context, to sort of remind you of all the little juicy bits that we've got in the interaction. So it's really, for me, it's coming back to curriculum and mind you, I'm glad I'm not doing dry needling or just manipulating it with the talking therapy, but my suggestion is to have the habit curriculum. David Butler (00:53:44): So I've got my key target concepts. I know that I've addressed them in that particular session in the next session. I know I've gone back and I've done teach them the self reflection as well. Then to come back to see if I can get it all, or if I've translated my knowledge into something functional or some change. So I'm really, I'm really loving it. And I think there's something rather new and special with this, with this interaction. But maybe that's just me as a physio who sort of used to the more physical stuff. Maybe this is something more natural to the psychologist, its perhaps, but I'm with it. Bronnie Thompson (00:54:22): I've been doing the group stuff. And I found that has been, I've seen, I like it because they don't have to go and travel someplace. It does mean that we can offer it to people who otherwise can't get here. You know, they can't seek people, especially rural parts of New Zealand, low broadband is not that great in many parts as well. So it gets that it's an opportunity. I'd like to see the availability of it as an option. So we can use like we do with our therapies, we pick and choose the right approach or the right piece at the right time and the right place that doesn't have to be one or the other, like you said, you could see him a couple of times in person and then a couple tele-health and then maybe they come back again and then you do mix and match. Karen Litzy: We have time for one more question here, maybe two. So David, this was one you might be able to answer it really quickly. As a practitioner, what is the utility of straight leg raise slump and prone knee bend test and the assessment of chronic back pain. Is it still relevant? David Butler (00:55:38): Oh gosh. Oh gosh. I'm going to dodge that question and would say it, it would depend on the client who comes in so I think those neurodynamic tests, which I still do. I think the main principle from them is you're testing movement. You're not testing a damaged tissue and anytime you're doing a physical examination, the deeper thing is the patient is testing you. You're not testing them. So what that patient, what that patient offers back in terms of movement or pain responses or whatever, depends on so many things. I might however, have a client and they are out there who do have maybe a specific stickiness or something or something catchy, whatever that may well, the scar around it might well be polarized by action, where I might spend a little bit more time taking a closer look at it. Now that might be relevant. Someone might have, for example, someone might come out of hospital and have had a needle next to the IV drip, next to their musculocutaneous or radial sensory nerve there where it's really worthwhile. Let's explore all the tissues here and see that that nerve can move or slide or glide. But in the second case, I'd made a clinical decision that we probably have issues out in the tissues, which are with a closer evaluation. That's a really broad answer. Karen Litzy (00:57:11): I think it's a tough question to answer because it, sorry, got a cat behind me. I felt my chair moving and I was like, what's going on? Just a large cat. So last question. So how to manage tele-health when the patients may be kind of embarrassed of their house or context or spaces or family it's very common in low socioeconomic patients. So they may not want to turn on their camera. Sandy Hilton: Yeah. I've had that shaking well, and I've had people in their car or very clearly like I'm kind of angled cause there's a lot going on in my house and I don't have a green screen. So where it's like, and there's just a wall behind me and it's one of the reasons like I'll talk to him ahead of time of if I'm in the clinic, it's clearly the clinic, but I'll tell them I'm at my house. Sandy Hilton (00:58:12): Cause of COVID. So, you know, no judgment, you're going to see a wall and probably a cat and just kind of be up front in the beginning of this as a thing, I've had people that start with the phone on or turn it off or whatever, you just, you roll with it. But I have those conversations ahead of time, before we even do the call. Bronnie Thompson: It's about creating a safe space for people. You know, if somebody feels, you know, was not having the video, it won't be that long before. I hope we've got some rapport and it feels better. I'm just, I'm doing a bit of a chuckle because the reason I've got my green screen behind me as my silversmith studio, which has an absolute shambles because it's a creative space. So I'm just disguising it because it's works. David Butler (00:59:07): There is something about delivering a story of some talking in the patient's room and there's cupboard doors open and you're looking in their cupboard at the same time. And you know, looking at that, then I just look at that thing. We're safe here. Karen Litzy (00:59:26): Well, listen, this has been an hour. Thank you so much. I just want to ask one more question or not even a question, more like a statement from all of you that, what would you like the people who are listening and they're, like I said, there were clinicians, there were non-clinicians on here. And I think from the comments that we're seeing in the chat is very valuable and very helpful. So what do you want to leave people with? Sandy Hilton: I'm gonna echo how I started. We're learning more every single week. I'd say, day but I'm not reading that often. So even if you've gone or you've treated someone and you couldn't quite figure out a way to help them, don't give up because there's more information and more understanding and more ways to get to this all the time. And I don't think you're stuck if you hurt. David Butler (01:00:26): I'd like to mirror those comments, explore the power of tele health, lift your expectations of outcome for those patients, people who are suffering and in pain, who are listening for those who are getting into pain treatment there's a science revolution and a real power in that revolution behind what you do. So just go for it. Bronnie Thompson (01:00:52): I think don't be hung up on with the pain changes or not, be hung up on does this person connect with me. We create trust. Am I listening? Can I be a witness? Can I be there for you? Because out of that will come this other stuff. There are some people whose pain doesn't get better. It doesn't go away. And that's a reality, but it doesn't mean that you have to be imprisoned or trapped by your pain. That means you develop a different relationship with your pain. And I think that's a lot of what we are doing is creating this chance to have some wiggle room, to begin to live life. That's what I'm looking for. Karen Litzy (01:01:53): Beautiful. Well, you guys thank you so much. And for everyone that is here listening, I just want to say thank you so much for giving up an hour of your time. I know that time is valuable, so I just want to thank you all and to Bronnie and to David and to Sandy. Thank you. Thank you. Thank you. And kind of on the fly. So I just want to thank you so much and to everyone. I guess the thing that I would leave people with is, if you're a clinician or if you are a patient, the best thing that you can do, if you are in pain is reach out to someone who might be able to help you, find a mentor, find a clinician, ask around Google, do whatever you can try and find someone who like Bronnie and David and Sandy I'll echo everything. You said that number one first and foremost, you connect with and that you feel safe with. You want them to be your super SIM, you know, like Sandy's my super SIM. Karen Litzy (01:02:48): So you want them to be your super SIM. And, if you can find that person, that clinician just know that that there can be help, you know, whether you're struggling as the clinician to understand your patients or your the patient struggling to find the clinician, I think help is out there. You just have to make sure that you be proactive and search for it. Cause usually they're not going to come knock on your door. So everybody thank you so much for showing up. Thank you, everyone who is on the call and to everyone who is watching this on the playback I hope you enjoyed it. If you have any questions, you can find us we're on social media and various websites and things like that. So we're not hard to find. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Eric Miller on the show to discuss how to maximize the value of your physical therapy practice. Eric Miller has been in the financial planning industry for over 20 years. He is the Co-Owner of Econologics Financial Advisors and the Chief Financial Advisor. He has a degree from Capital University and is a Registered Financial Consultant® and licensed insurance agent. He takes pride in helping practice owners become the financial heroes of their own stories and has taken this passion to over 600 families in the past decade. In this episode, we discuss: -How to maximize the value of your practice -The business systems that add the most value and are most attractive to potential buyers -Financial considerations when planning your exit strategy -Simple strategies to minimize your tax bill every year -And so much more! Resources: Econologics Financial Advisors Website Econologics Financial Advisors Youtube Eric Miller LinkedIn Econologics Financial Advisors Facebook A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information Eric: Eric Miller has been in the financial planning industry for over 20 years. He is the Co-Owner of Econologics Financial Advisors and the Chief Financial Advisor. He has a degree from Capital University and is a Registered Financial Consultant® and licensed insurance agent. He takes pride in helping practice owners become the financial heroes of their own stories and has taken this passion to over 600 families in the past decade. During this time, he's had over 15,000 conversations with practice owners regarding money, investing, practice expansion, practice transitions, taxes, asset protection, estate planning, and helping them shape their financial attitude toward abundance. Econologics Financial Advisors is an Inc. 5000 honoree for 2019 as one of the fastest growing companies in the US. Read the full transcript below: Karen Litzy (00:01): Hey, Eric, welcome to the podcast. I am happy to have you on. Eric Miller (00:05): Well, thanks, Karen. I'm really excited to be here. Yeah. Karen Litzy (00:08): Before we get into our talk on, you know, how to maximize the value of our practice, in your bio, I read that you're a registered financial consultant. So can you explain to the listeners what that is and maybe how that differs from a financial advisor, an accountant? What is the differentiation there? Eric Miller (00:31): No problem there. So I think when people hear that I'm a financial advisor, I mean, people kind of have the same impression that all financial advisors are alike, so to speak. And that's not always the case. You know, there's some financial advisors that specialize in working with you know, ministers and teachers and all different kinds of professions. I just happened to work with private practice owners. Now, as far as am I licensed to do what I do in the financial world, there's something called being a fiduciary. And when you're a fiduciary, that basically means that you have to do what's in the best interest of your client, not all financial advisors adhere to that standard. What's called a registered investment advisor and we're held to that standard under the SEC guidelines. And then as a registered financial consultants, it's a designation that I picked up along the way. And it just basically, you know, there's certain criteria that you have to use to be able to get to that designation that's system. Karen Litzy (01:41): Got it. Yeah. So, you know, we were talking before we went on and it's kind of like if you're in the physical therapy world, which I am, and you go on to become, you know, like a clinical specialist in orthopedics or a clinical specialist and in pediatrics, it's like going on for a little bit extra education and certification and what you do is that right? Okay. That's exactly correct. Perfect. Perfect. All right. So now let's get into the meat of this interview. So today we're going to be talking about how to maximize the value of your practice, perhaps plan for an exit of that eventually. And we're going to weave in some critical tax strategies that you might be able to use to save you money. So no one likes to leave money on the table. No one likes to feel like a dope because they didn't know what they were doing. So, let's start with maximizing the value of your practice. So first, what does that even mean? Eric Miller (02:42): That's a great place to start because I think people automatically assume that when I say maximizing your practice value, it's just about money, right? It's just about, Oh, the, you know, what's the enterprise value of my business. And then that leads into, Oh my gosh, he's going to talk about like profit and loss and EBITDA and all these really technical terms. But in my viewpoint maximizing practice value. Isn't just about money. It's about the other parts of owning a business that you get value for like time, right? Like you would want to build a business that gives you a lot of time. You'd want to build a business that gives you great relationships with either your employees or recognition from your community. So when I say, if you're trying to maximize the value of your practice, it's not just about the money. Eric Miller (03:31): It's about all of those other things, because you know, you look at it, most people that own a private practice that is your largest investment. You know, it's like the thing that provides the most cash flow to your household, and it is an investment and anybody that's owned a business for any period of time knows that it's something that you have to care for. And that you have to make sure that you're treating like an investment and putting in the time and the money to make sure that you get the most value out of it. That's our definition for that. Karen Litzy (04:04): Yeah, absolutely. So how can we as practice owners then maximize the value of our practice. If let's say in the event, we want to sell it, we want to exit our practice in whatever way we want that exit to happen. Eric Miller (04:21): There's definitely some key areas like, yeah, you have to kind of assume the viewpoint of a buyer. Like if I'm going to buy your practice, Karen, like what are some of the things that I would like to see in place that would allow me to give you, you know, top dollar for it. And I think number one is your personnel organized? Okay, do you have organized personnel? Do people have job descriptions? Do they know what they're doing? Do they know who to report to? So, you know, I think that that is that's key because obviously if you have people in your organization that are aligned and are all kind of working together, you know, you're going to have a really powerful organization. If you can do that, if you don't, then you're going to have, you know, this scattered business that everyone's kind of doing their own thing and that's not good. Eric Miller (05:13): So that's certainly one thing. And then of course, just having good stable systems that are built in your business so that there's procedures that people have, that they can follow. You know, there should be an organization chart somewhere where people know like who's in charge of what I think that's going to all add value to your business. Certainly if you look at like the facility, what's the facility look like, is it in good shape? You know, do you have, if you lease the building, do you have a good lease on it? You know, is there new carpeting is, I mean, is it a nice place where people feel safe to come to, you know, certainly a buyer's going to think about that. And then I think from an income standpoint, obviously you have to be solvent. Eric Miller (05:57): You certainly don't want to have a lot of, you know, outstanding accounts receivable out there. You want to make sure your books are up to date and current, you don't owe any back taxes on the practice. You have multiple income streams in the business that you like multiple services that you provide because no one wants to be reliant upon one of anything. So I think those are all, some really key areas that if you can get those things in shape and you can get them systematized, you're really going to have something that someone else would want and they would value. And they're going to pay you a much higher amount for that. Karen Litzy (06:33): Yeah, that makes sense. So what I'm hearing is you really want to have an organization that's sort of a well oiled machine where people know why they're coming to work. They know what they're doing once they get there and reasonably happy at their jobs, if not very happy at their job. Eric Miller (06:52): Yeah. And I think that you're exactly right. And I think the key as the person that's in charge of it is that you have to know what your role is in that business. So I think a lot of people that are in private practice, and maybe you can attest to this when you first started out, you're just trying to make things happen and go, right. And, you know, as you go on, you kind of realize, look, I'm not just a practitioner, I'm also an owner and I'm an executive and those are completely different roles. And I think over time, if you can really make sure that you understand that those three roles are separate and that you have to make sure you master them to that degree, or at least hire someone that can do those things, that that's really going to create you a valuable practice, you know? Karen Litzy (07:41): And I mean, when you first start out, like I work with a lot of like first time entrepreneurs, you are the owner, the therapist, the executive, the marketer, the pay, you know, you're everything, right? So, so let's say you have a practice like that, where maybe you are a single owner practice, right. Or maybe you have one person part time person. So you don't have this sort of robust, huge practice. Can you sell that? Eric Miller (08:12): Well, you can, you can sell anything. It's just as a matter of how much you're going to get for it. So, again, looking from the buyer's perspective, he wants to buy something. That's not dependent upon one person. He wants something that's going to be basically, he can assume that there's free cashflow there. That is going to be worthwhile to him as an investment. So if you have like a single doctor practice or you're a single practitioner, I mean, you can certainly sell it. It's just not going to go for a very high, multiple, see, most of the practices that we're talking about, you know, are going to sell for maybe like a one to two times earnings. Whereas if you get a bigger organization that has, you know, seven, eight, nine, 12, 20 PTs on staff, there's executives in the office, it's going to go for a much higher, multiple could go as high as eight to 10 of your earnings. So it is, it is that kind of a game, but that's, you know, that's the journey. Karen Litzy (09:08): Right? And, you know, you had said you want to have a lot of systems in place, in your opinion, what are the most valuable or most important systems to have in place within your business? Looking at it from a value standpoint? Eric Miller (09:23): I think definitely having a good financial system is really key because look at what, you know, a lot of businesses, business owners, don't like to confront the finance part of their business, and that's why they don't have much in reserves. And, you know, they're always kind of struggling for, gosh, I can't make payroll this week. And it's just a constant battle when you don't have good financial systems in place, because they're just, they're not paying attention to their money lines. And unfortunately, when it comes to your practice, that that is the most important thing is keeping that practice solvent, which means that there's more money coming in than what's going out. So that personally, I think that's the most important. Some people would say a marketing system is really key because let's face it. If you don't have more patients coming in and buyers definitely going to want to see that he's going to want to see that you are, you have a system in place where you're constantly getting new patients in the door. Right. And then, you know, I think a good quality control system is, is really, really key. Because if people aren't, you know, getting better and you don't diagnose that quickly of, you know, why aren't people getting better because that's what you do as a physical therapist, your job is to get people pain-free, you know, or reduce their pain. So I think that's a pretty key area too. Karen Litzy (10:42): Nice. Yeah. I just had this conversation about the importance of a financial system. Cause I sort of switched my financial system within my practice around, over the last couple of years and it's made such a huge difference. You know, I started looking at the financial system in percentages sort of going off of Mike McCollough, the book profit first. And so, yeah. So how much stays in the business? How much goes to me as an owner, how much goes to taxes? How much goes to profit, how much goes, and then making sure that when that money comes in, it is automatically divided up into those percentages and it's made a huge difference. Eric Miller (11:22): That's so awesome to hear it, does it because you've instilled control over your money right now. Right. And when you look at like what's a barrier for a lot of practice owners is that they don't feel like they have control over their money. Right. And, when you start putting in good control, it's kind of like when you're adjusting somebody or you're getting someone to feel better, right. You have to kind of put control in on that person. Like, I need you to do this and move here and do that. It's the same thing with your money. You have to kind of allocate it so that you know, your expenses are you channel your money to places where it needs to go to handle whatever expense that would be. Certainly, you know, you're yourself. I think, you know, is the most important person that you need to pay first. Karen Litzy (12:07): Well, that's what profit first says. No, it's true. Like, and once I started doing that, it made everything just lighter. So now like quarterly taxes are coming up September 15th or depending on when this airs that might've just been that September 15th date. And I remember like years ago, I'd be like, Oh my gosh, I don't know how, how do I not have them now? I'm like, Oh, totally fine, my money's where it's supposed to be. I am good. Like, this is exactly where it needs to be. Eric Miller (12:43): That actually is kind of like an underlying goal and purpose that I have is I, you know, people always ask like, what's the product of a financial advisor and people think it's, you know, Hey, you know, you made me 20 or 30% or you know, helped me save in taxes. Not really, you know, I like people to feel relaxed about their financial condition and just what you explained to me right there. You're definitely much more relaxed about your condition now because you have control over it and it doesn't control you. That's really awesome. Karen Litzy (13:13): Yeah. And it's a little stressful at first because it's different and it's a change. So I always tell people if you're starting out now start off this way. And Holy cow you'll be so much easier. Everything is just, I feel so much easier. Yeah, just a sense of ease that I now know, like, yes, I have money set aside for this. It's already paid, like it's basically already paid for. Eric Miller (13:39): That's it that's right. But it also does another thing too. It does make you look at and say, you know what, maybe I'm not making enough money in my business because I can't cover some of these other things. And I think that's the most important thing that people have to realize. And I'll go off on a little tangent here, but there's really two basic rules of, for me, income and expenses. The first one is that just get used to the fact that your business will try to spend every dollar that it makes. And then some, and, and that's not just for a business, that's like a government or any household or organization just, it's just going to try to spend every dollar that it makes. And then some, but at the same time, it will also make the exact amount of money. Eric Miller (14:25): It thinks it needs to make to survive. So when I say that, people are like, what does that mean? I'm like, well, look, you know, if you know that you have expenses coming up, somehow miraculously, the business does make enough to cover it. Doesn't it? It's just like, it's just, that's the way it is. So the trick to it is simply to make sure that your reserves and your profit and your taxes are just part of what the business thinks it needs to make to survive. And if you can get that in as what you said as part of that profit first book, I think that's what he's talking about is that it sets the right income target for what the business really needs to make, because that's the biggest outpoint that I usually see with, with practice owners is that I'll ask them, Hey, what's your income target? They'll say, well, you know, I need to make $30,000 a month to pay my bills. And I'm like, well, no, that's not what you need. You actually need 45. If you want to include your profits and building up reserves and paying your taxes that they're operating on a wrong income target. So I think that's really key is to make sure you're operating on the right number. Karen Litzy (15:30): Right. So don't underestimate it completely because I think oftentimes people will just look at, well, this is my rent. These are my utilities. This is my payroll. If you're paying people and these are, you know, overhead costs that maybe we have to pay, you know, phone bills, things like that. And that's it. And they're like, okay, so that's all I have to make. Eric Miller (15:55): That's right. And that's where their demand for income is. But, and if, but if they put in, Hey, I need another $10,000 a month for myself. I need another 5,000 for taxes. I need another because I want to make sure I have reserves. So if I have to shut down for another month, I can handle that. Right. You start putting all those things in. Now the number changes from Oh, 35, I need to make 50. Oh, right. Okay. Well, that's fine. How many more patients do I need to see a week? Right. To be able to make that number, it just gets them, you know, being a problem solver now, as opposed to like, I can't do anything about it kind of mode. Karen Litzy (16:32): Yeah. And I do that. Like people always ask me, well, how many patients, you know, do you usually see a week? And I said, well, it's not, how many do I usually see it's this is what I need to see to make X amount of money per week. So that I know per month, this is what I'm making. And my costs are a little bit lower because I have a mobile practice. So I'm not paying a lease on a brick and mortar facility, but I still have to pay my own rent for my apartment. And I still got to eat. You know, these are all the things that you have to put in. So it's not just, what does the business need, especially if you're a solo preneur, what do you need to survive? Eric Miller (17:12): Yeah. And I think this is where a lot of people, yeah. A lot, a lot of practice owners and entrepreneurs gets, think that their business is more important than their household. And you know, I'm under the, you know, our philosophy, our viewpoint is that your household is like a parent company. Okay. You think about this, you look at all the big corporations out there and you know, people have opinions of them, but they do understand money pretty well. And they certainly understand that let's take Facebook. For example, Facebook owns, I don't know if you do this, like 83 other companies and they're the parent company to all of those other companies, but everything flows to the parent company. Okay. We're your households, no different, you know, you own, you have a, let's say you own a house, a business, maybe a piece of real estate 401k plan, the bank account. Right. Those are all assets of the household. So you really, you know, once you start treating your household, like the parent company, then you set up the system so that, you know, your household you're meeting the goals and purposes of the household people. I think they don't do that. They don't take care of themselves like they should. Karen Litzy (18:19): Yeah, no, I think that's great advice. Thank you for that. Alright. So we've got those financial marketing quality control systems, obviously three very important systems and we can go on and on and systems. That's a whole other conversation. So we will take those and people can run with them as, as sort of prioritizing their systems. So now we've got, we've got all of our systems in place. We've especially our financial system. So how do we plan? Let's say we're getting towards the end of our treating career, whatever your clinical career, whenever that may come. And it may come at different times for different people. How do we efficiently plan for an exit? What do we do? Eric Miller (19:05): As far as like getting the business ready to exit out. Karen Litzy (19:09): Yeah. Like let's say, let's say you're getting ready to kind of exit out of your business. Now we know that maybe you can try and sell it. Or what if you're just like, this is the business is done. You're just done. What do you do? Eric Miller (19:24): Yeah. Well, I mean, I think the first thing you gotta realize, you gotta look at your own financial readiness. Like, can you afford it? You know? I mean, I think a lot of people, they get into a position where they're tired, they get exhausted, right. Because they've been doing things for themselves or I'm sorry, just for the business. And then they just get burnt out, you know? Well, you know, burnout, you know, what burnout is, it has nothing to do with that. It's just that you don't have a bright enough future in front of you. That's what burnout comes from. Right. And I can see why a lot of practice owners getting that conditions. Like I just keep doing the same thing every day and I can't see a bright future for me, so I might as well just sell the thing. Okay. Eric Miller (20:06): So the first thing that I do is just, I try to rehabilitate, like, do you remember why you decided that you wanted to be a business owner? Do you remember like what the purpose was? And if you can revitalize that, I think you can get that person back on track, but look at the end of the day, if you don't want to do it anymore and you want to sell your business, then you know, certainly, you know, hiring a broker can help. Certainly finding someone or just finding another PT that, you know, in the area that would be willing to take, you know you know, sell, you can sell the business to, for Goodwill or it's not going to be very high price, but certainly you can find someone that would be willing to buy practice for some costs. Right. That may just not be very much. Right. Karen Litzy (20:52): And then what, if you were ready to just wrap it up, you don't want to sell it. Are there things that one needs to think about as they wind it down? Eric Miller (21:02): You mean just like, just close it down? Karen Litzy (21:04): You're closing it down. You're moving on to greener pastures, if you will. So you decided to close it down. Are there any financial considerations that one has to think about in that scenario? Eric Miller (21:16): Well, you know, certainly look at how much money that you make from your business. Even, you know, money that through the cashflow that you make, it's sometimes a lot more significant than what people think. And certainly you can own the business. You can just, I mean, if you're a physical therapist, you can just go work for somebody else if you want to. But you know, I think people just have to realize that, that their business does provide them a pretty good living and they just have to analyze that and say, do I have enough to replace that? Or can I go to work for somebody else and replace that income? You know, it's certainly not a good thing to do. You know, there's seven different ways to exit out of business. And that's one of them just shutting it down. It's probably the most, it's the worst way to do it, but I know that it does happen. Karen Litzy (22:05): Yeah. Yeah. What are the other ways you could just name them? We don't have to go into detail. Eric Miller (22:13): So you can die with your boots on, you can close it down. You can sell to an associate. Okay. You can sell to a competitor. Okay. You can sell to private equity. Okay. You can gift the practice to somebody else. Okay. Or you can have your employees buy it through, what's called a Aesop plan. Those are the seven ways that you can exit out of your practice. Okay. Great. What happens with most practice owners is they either sell to an associate to a private equity group, the size of the practice. Karen Litzy (22:54): Yeah. Yeah. And so now let's talk about taxes. Eric Miller (23:03): Yes. So, Oh, taxes. Hey guys, when you could see your eyes got big. Karen Litzy (23:07): Who likes to pay taxes, right. Nobody likes to do it, but we all do it because we need, we need the services that they provide. Right. So let's talk about some tax strategies that might be able to save us some time. Eric Miller (23:21): Yeah. Yeah. I think the first thing on taxes is that you have to realize that your accountant may or may not understand the tax code completely. And it sounds really weird because everyone assumes that they have an accountant, Hey, he's going to try to minimize my taxes. That's not really what their goal is. Their goal is to make sure that you are compliant, that you file your taxes on time. They're not necessarily doing tax planning for you. They're not trying to minimize your taxes. Okay. So I think that's the first thing is that you really have to make sure you're working with an accountant that has the viewpoint that I want to try to minimize this tax bill as much as I can, because it won't happen by itself. You have to be proactive. You cannot take a passive role in minimizing your taxes, or you're just going to end up paying the most. Eric Miller (24:09): Okay. The tax codes, 3 million words, and, you know, no one's going to know every single passage of it. That being said, there are definitely some strategies out there that you can utilize. One that is that I've been talked about a lot is that you can actually rent your house out for 14 days out of the year and you can collect that money completely tax free. And you're probably thinking like, well, how, how would that benefit me? So where this came about was that in a, I don't know what year it was, but if you've ever heard of the masters golf tournament, there's a lot of, there's a lot of guys that have big houses there and on the golf course and they rent their houses out for thousands and thousands of dollars. Okay, well, legally they can collect all of that money, completely tax free. Eric Miller (25:08): Okay. Because the IRS code says, you can rent your house out 14 days out of the year and get that money complete tax free. And you probably thinking, how do I take advantage of that? Well, if you own a business, your business can rent your house out for 14 days out of the year. And as long as you have a legitimate meeting at your house, maybe you have with a key executive or even with yourself, right. You have an executive meeting at your house and you document that, then you can rent, you can have the business pay for that. Okay. It's a business expense. And then you get that personally. And as long as you do it correctly, you can get that money completely tax free. All right. That would be certainly one strategy you can use. It's called the, it's called the Augusta rule. You can look it up online and, and certainly there's. Yeah, yeah. That's where it came from. That's one and, you know, right there, 14 days, let's say that it's a thousand dollars, that'd be $14,000 that you could expense out in your business. And then you can get that personally. Oh, you have to do it right. You have to have a legitimate meeting. You have to like Karen Litzy (26:14): Say it's $10,000 a night. Eric Miller (26:17): I don't know. In New York, you may be able to write. Karen Litzy (26:20): I don't know. That might be a stretch too. Eric Miller (26:22): If you needed to rent out like a hotel or a restaurant, that's what you would need to do. You need to go get like an estimate like of where you would normally hold that meeting just for documentation purposes, but like anything else it can be done. You just have to follow through and have documentation, you know? And I just have the accountant guide you on how to do that. That's certainly that's one that would be, you know, 14, 15,000. So if people have kids, they can put their kids on payroll and they can, you know, show them that would be another deduction that you can use. You know, there's certainly a lot more, I could probably go on all night. But you know, I think another thing that people can do is just look at how they take their income. Eric Miller (27:06): Like you own a business, right? And most physical therapists are escorts. And you know, a lot of accounts will tell them to take bigger salaries than what they actually need to be taking. Right? So you can actually adjust your salary downs as long as it's a reasonable compensation and then take more an owner draws. That's going to help minimize the Medicare tax as well. So it really just boils down to, you know, finding the right information, finding a right advisor that can help you and, you know, provide tax deductions that your accountant can work with to minimize it. It can happen like you should, it's your responsibility. And I say this a lot. It's like, I've never read anywhere where it's my responsibility to maximum fund the IRS. Right? Like I know I have to pay taxes. I get that. But there's no one that said that I have to like pay, you know an ungodly amount of tax. But that's the way the IRS works. They just assume that your money is their money and you have to be proactive to show them otherwise. Karen Litzy (28:11): Yeah. I know this year when I paid my taxes, when I did my taxes for 2019, I was so excited. Cause I only owed like $309 after doing my estimated quarterly taxes, which I thought, well, this is great because I'm not giving them more throughout the year. And in fact I was almost like, spot on. That's pretty good. Yeah. That was pretty good. Because like, you don't want to, like, I understand when people get refunds, but if you got a refund, that means that you gave them more than was necessary throughout the year. Correct. Right. Yeah. Eric Miller (28:53): So it is something that you have to stay on top of because as your business grows, you know, your tax liability personally is going to be higher. So you really have to make sure you stay in good communication with your accounts. Like you should be talking to them every quarter, especially now recently where I think a lot of people have gotten the PPP loan. And if you, you know, if that gets forgiven well, you know, physical therapists didn't really shut down. I mean, some of them did, but you were still collecting money. So you know, you may have, you really have to make sure that you're not going to have a tax problem for 2020, it could happen. So just, you know, just getting in communication with your accountant. I think that that will help. Karen Litzy (29:32): Yeah. During the PPP loan phase and covert, I was thinking, I was talking to my accountant like literally every other day. Yeah. I'm like, does this make sense? Should I do this? Should we do this? Should I do this? Can I do this? Does this, is this the right form? Do I feel, and I did get a PPP loan because in New York, you know, we were done, like when I say shut down, like shut down, nothing, you know? And eventually I started doing more telehealth visits, but in the beginning it was quite scary. And so I said, you know, I better apply for a loan and, and I did get it. And now they haven't even asked, we haven't even filled out the forgiveness paperwork yet, but now I'm in contact with him like weekly, like, is this the right form? Did I fill this out? Right? Is this the right documentation I need? And he's like, yes, yes, yes. You're all good. So now when the time comes, I'll be able to get that in really quick. Eric Miller (30:27): Yeah. And it won't be a problem and you know, you'll have your attention on other things that'll help expand and that's good. And then that's just, that's not my experience. Most practice owners, they kind of don't confront it, they ignore it. And then it becomes a bigger problem down the line. And that's really needless. Right. Karen Litzy (30:44): I think that's how I used to be, but I have now been rehabilitated financially. So yeah, this was great. Now, what are in your opinion, what are the key messages that you would like the listeners to kind of take away from this conversation? Eric Miller (31:02): Well, I mean, you know, for me look, I mean, you can, regardless of what your financial condition is, like, you can do something about it. Right. And I think that's always been a pretty key, you know, philosophical viewpoint that I have. Like, I don't think that there's such thing as an unwinnable game and I know that even things get a little murky and they get a little dark and you know, sometimes you don't really see, you know, the future as bright as it could be, but if you just kind of like, just do one thing right. And complete that cycle of action and then go onto the next, then I think that starts to create more freedom for yourself. Like people get overwhelmed so fast. Right. And there's like, there's so many different things to do, especially financially. Right. That they just, they don't just do what's in front of them while they're doing it. Like just complete one thing at a time. And then you can go on to the next one. Right. Like do the next thing and then go on to the next one. And then to me, that's the key to success, right? There is, is getting interested in something that you don't want to do. Right. And completing it. And I think once you do that, you'll start to see a much brighter future, better things happening to you. Karen Litzy (32:14): Yeah. Great, great advice. Thank you so much. And before we get going, I'm going to ask you the same question that I ask everyone. And that's knowing where you are now in your life and in your career. What advice would you give to your younger self? Eric Miller (32:29): I would simply tell myself that there are destructive and constructive actions that you can do in life, right. And that those destructive actions, while they may appear fun at the time will certainly prevent you from getting to your potential and leading the life that you want to lead. Right. I know we're all young. We all kind of make stupid mistakes and that's just part of the learning curve. But I would certainly tell myself, you know, your personal ethics is really part of your survival, right? And to the degree that you kind of keep yourself in good shape morally, and you do the right thing better things are gonna happen to you in your life. It's going to create more abundance for you. And I would tell myself that is just make sure you pay attention and do the right thing more often than you do the wrong thing. Karen Litzy (33:22): Excellent. And now, where can people find you on social media website? Eric Miller (33:27): Yeah. So if you want to go for a wealthforpts.com wealthforpts.com, you can download a free ebook that we have. You can certainly go to our website www.econologicsfinancialadvisors.com And then we have a YouTube channel, www.econologicsfinancialadvisors.com. And those would be three places that you can go to connect with us. Karen Litzy (33:48): Perfect. And all of that will be at the show notes at podcast.healthywealthysmart.com under this episode. So one click will take you to everything. So Eric, thank you so much. This was great. I was taking copious notes and you know, every time I have these conversations, I'm always thinking to myself, Hey, what do I need to do? What do I need to act on? And you know, a lot of the conversations that I've had with folks like yourself, accountants, even on this program and in my own personal life have just really been so valuable. So I thank you so much for taking the time out today. Thank you and everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Stephanie Weyrauch on the show to discuss budgeting. An active member of the national physical therapy community, Stephanie has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Stephanie is a nationally sought after speaker and consultant for topics on social media use, generational issues, and organizational membership. In this episode, we discuss: -Stephanie's experience paying off student loans and still enjoying her lifestyle -The budgeting tools you need to manage your expenses -Why an accountability partner can help keep your budgetary goals on track -How to incorporate pro bono work into your practice -And so much more! Resources: Stephanie Weyrauch Instagram Stephanie Weyrauch Twitter Stephanie Weyrauch Facebook Email: sweyrauchpt@gmail.com Dave Ramsey's Complete Guide to Money - Hardcover Book The Total Money Makeover Dave Ramsey Podcast Every Dollar App A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here. For more information on Stephanie: Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis. Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company's workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA) and actively lobbies for healthcare policy issues at the local, state, and national levels of government. Currently, she serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch is also the co-host for The Healthcare Education Transformation Podcast, which focuses on innovations in healthcare education and delivery. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at world-renowned institutions including Stanford University and Washington University in St. Louis. Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation. Read the full transcript below: Karen Litzy (00:00): We are the facebook group so we'll be checking the comments regularly, but just know that we will be checking and we'll probably be a couple seconds behind you guys. So if you are on and you are watching throughout any point in our talk today about setting a budget definitely write your comments down like questions. Whether for me mostly directed to Stephanie and we will get to those questions as well throughout the talk or throughout this very informative talk. I was saying before we went on the air that I'm really excited to listen to this because I have always been impressed with the way that Stephanie and her husband Deland have been able to create their life and their budget, and it's still full and they get to do the things they want to do and go where they want to go all while maintaining a budget and all while they both have student loans. Karen Litzy (01:07): So what I'll do first is it's for people in the group who aren't familiar with you, Stephanie just talk a little bit more about yourself and then we'll talk about how you set your budget and what kind of framework you follow. Stephanie Weyrauch: Well, thanks Karen, for having me on, I'm really excited to talk about this because I'm running a budget as something that was really hard for me to do for a long time. I wasn't really raised to think about money growing up. So it's not, when I went through PT school, I just got my student loans and spent my money as I saw fit. And didn't really think about my money. So I'm Stephanie, Weyrauch, I'm a physical therapist here in Orange, Connecticut. I work at a private practice called physical therapy and sports medicine centers. Stephanie Weyrauch (01:55): And I do a little bit of consulting work privately through four different companies to try to help with occupational medicine and try to prevent any type of work injuries that happened in the workplace. So that's kinda my background a little bit, but when I went to, when I graduated from PT school and went to my first job, and at the time I was working in Minnesota, my student loans were becoming due and my husband is a physician. So he has a lot of student loans as well. So at the time total, we had pretty close to $300,000 in student loans. So quite a bit. And when my student loans were coming due and my boss hands me this little application for my 401k and like all these other very adult things, I just, I panicked. And I was like, I don't even know what a 401k is. Stephanie Weyrauch (02:44): I don't know how to pay my student loans. My husband was in medical school at the time. So I was the only one working. And my boss was just like, hold on. He's like, it's okay. I can help you. And so he handed me this book called the total money makeover by Dave Ramsey. And I read it and it changed my life. It changed the way that I thought about money. It changed the way that I handled money and it really empowered me to pay off my student loans and to not be afraid of debt to basically conquer it. So that's kind of the background behind it in the book. And also on his podcast, the Dave Ramsey show, he talks about how to manage a budget and how to set up a budget and how to stick to a budget. So the app that I use is called every dollar it's free. Stephanie Weyrauch (03:30): You can download it on, you can download it on Apple or Android, it kind of looks like this. So you can kind of set up, you can put in how much money you make and also what your expenses are for the month. Basically, it's very easy to use. You can use it on your phone or your computer. And so I started using that at the time, we were a one income household. I did pick up an extra job in a skilled nursing facility because my goal was, I didn't want to accumulate any more debt. So my goal was to try to make enough money and save enough money that we could pay for my husband's last year of medical school, which he went to an instate school. So his tuition was $25,000, which is very cheap, I think, by medical school standards. Stephanie Weyrauch (04:19): And we were able to cashflow that entire year of medical school, just off of the extra job that I was working at the skilled nursing facility. So every month, basically what I do is I go into the app before the month starts, I put in how much money I'm expected to make. Now, one of the things that happens when you're in private practice, especially if you're starting out is you may not know exactly how much you're going to make. And so it's hard to put in your budget like, Oh, I'm going to make, let's say, as Karen was talking about in the last course, you know, paying yourself by, let's say by biweekly or by month bi-monthly I'm gonna make $2,000 this next two weeks. Like you can't necessarily do that in Dave Ramsey's book. He has a sheet that you can use that lays out how you can do a budget based off of an income that fluctuates. Stephanie Weyrauch (05:11): I've never had a fluctuating income, so I've never used it, but he talks all about that in his book. And it's very easy to follow because he also talks about that if you are in debt and you're trying to pay off your debt, there's a certain amount, certain things you need to pay first. So food, shelter, lights, those are like the main things that you need to make sure that you focus on first. And then also the next thing would be like clothing. If let's say you're, you need to buy clothing. For some reason, I have really don't buy a lot of clothes. So I don't necessarily have to worry about that. And then after that is, comes your debt and any other miscellaneous things. So in this budget, you set up your income. If you were planning on giving any of your money away and like doing some charitable giving, that's something that he puts in there. Stephanie Weyrauch (06:02): If you're saving any money, there's a section for that. So then you can set aside how much money you want to save. And then for housing in my budget, I have my rent electricity. I put my cell phone cause that's my phone bill in there, my internet, and then my laundry. So those are like the five budget items that I have in there. And then in that month I set how much money I'm going to spend. And he thinks of a budget, not necessarily as a restriction, but permission for you to spend your money. So like throughout the month, if let's say your needs change, you can kind of rearrange how much money you're putting aside. So let's say for transportation, I need, let's say I'm taking my car. Cause I'm going to drive to a couple of patients' houses. But this month, most of my patients are within a two mile radius of me. Stephanie Weyrauch (06:53): They're not far away, so I don't have to drive as much. So at the beginning of the month, I thought maybe I have to drive more. So let's say I set a hundred dollars for my gas and auto budget, and now I'm realizing I don't need that much. So what I could do with that is let's say I only need $50. So that extra 50, that I'm saving, I could potentially move to, let's say my savings, or if I have debt that I need to pay, I can move it down towards my debt. So you're giving yourself permission to spend that much money per month. The next item line item is food. So I've had groceries. And then I have, we have a section for restaurants. So if we want to eat out now with the pandemic, one of the things that was kind of nice about the pandemic is we weren't eating out nearly as much, but our grocery bill went like way up. Stephanie Weyrauch (07:38): So I noticed that we've been spending a ton more money on groceries. And I think it's mostly because food has gone up. So I had to adjust our budget based on that. Now this month we're, you know, things are starting to open up a little bit more here in Connecticut and Deland and I really haven't been able to go out and eat very much. And so now we're trying to put a little bit more money towards our restaurant budget because we want to enjoy that experience since we haven't had it for so long. So typically I set aside maybe $150 a month for restaurants, but this month we doubled that just because we haven't hardly eaten out at all in so long. So again, it's permission to use your money in the way that you think is going to be good for that month. Stephanie Weyrauch (08:27): And then there's a section for lifestyle. So I put like my subscriptions in there. So my Peloton subscription and my Netflix subscription, and then I have a vacation with my mom, hopefully coming up. And so I've been, you know, find some hotels and stuff for that. So I've been putting that under that, and then this one's going to be big if you're in private practice insurance and taxes. So there's another section for that. So if you have your, let's say it's the month where you have to pay your quarterly taxes, or let's say, instead of saving all this money and doing it in one month, you divide it up into three months. Well then you can kind of equally divide that four month, and then that way you're not forgetting to pay it. And then of course the last line item is debt. And so how much money you're going to be spending towards your debt that month. Stephanie Weyrauch (09:20): And then what happens is it will take, it'll give you like a picture and a graph of how much you're spending. So let's see if I can bring that up. So, so basically this is my debt and how much I spend this, this past 12 months on different things. So you can see that most of what I've been spending has been on my debt is debt, the green light, this light green color, this big one, that's all how much money that I've spent on debt this year, so far this year. So, you know, Karen had mentioned the other day that deal and I paid a lot on debt and we have, since I've been on this budget, I have been dedicated to becoming debt free. Stephanie Weyrauch (10:09): And our goal has been to be debt free in a total of seven years. So right now we're in year four of that. And within those four years, we've paid off $150,000 in debt, which is a lot. And that includes the cashflowing of Deland's medical school, plus our move that we had to cash flow from North Dakota to here in Connecticut. So I'm not saying it's easy, like I'm not saying I live a luxurious life at all, but I would say that I definitely, like Karen said, I'm able to like go, I'm able to go well before the pandemic, I'm able to go to New York city, like once a month and see Karen and like hang out with my friends. But I plan for that every month. And if something comes up where I'm not able to do that, then I just have to make sure that I don't do it. Stephanie Weyrauch (11:00): And so it takes discipline, which you're all in private practice and you've started your private practice. So you obviously are all disciplined individuals. I will say that when you're managing a budget too, it always helps to have a partner who will keep you accountable. I am a spender and Deland is a saver. And so if I had my choice, I would probably go over our budget every month. But Deland is very good at saying now, Stephanie, do you really need that. And I fortunately must admit many times no. So having an accountability partner is really important. If you're in a private practice, that accountability partner can be your spouse or your partner, or it can be your business partner, or it could be a trusted friend. So having maybe you guys are both managing budgets at the same time and you can kind of be each other's encourager. Stephanie Weyrauch (11:53): So that is something that's how I run our budget. It is definitely, I definitely don't live a very luxurious lifestyle, but I wouldn't say that I'm just sitting at home, eating ramen noodles all the time either. So I'm able to put most of the money that we spend every month goes towards debt. So probably half of our budget each month goes towards debt, but that's just because we are dedicated to making sure that we become debt free within the next four years. So, yeah. And, and there may be people on here who have no debt and don't awesome. Right? And so that part of the budget and the app, I mean, how wonderful, if you don't have student loan debt, maybe you have credit card debt, and you're putting something towards that each month. But I think if you don't have, if you're past the student loans or you didn't have to have, you didn't have to take out any student loans, then you can certainly take that money that would go to debt. Stephanie Weyrauch (12:57): It would be substantially smaller if we're just talking about credit cards and you could say, you know, I'm going to dedicate it to XYZ. Now what happens? Oh, quick question. So what was the Dave Ramsey book? I put two books. One was the total money makeover and the other's complete guide to money. I put them both in the comments section here, but where was the one that said he had like that's total money makeover. Okay. The total variable with the variable income. Yep. That's at the very back of it. And you can just copy and I mean, I'm sure that there's a copy of it too, on the internet. You could Google it and it's palatable. Karen Litzy: Okay, great. Yeah. I think that for me, I look at, you know, this I'm taking care of your budget. I think a big part of it is writing everything down, right? It's the same way when we say to our patients to keep a journal or an exercise log, or if you've ever done weight Watchers, you have to write everything that you eat using weight Watchers. This is kind of the same thing. It sounds like this app, and you're really having to write everything down each month is definitely keeps you accountable, but also gets you into the habit of doing it. Stephanie Weyrauch (13:44): Yes. I definitely agree with that. And you know, the other thing too, that Dave Ramsey talks about in his book is he has these specific baby steps that you work towards to building wealth. So obviously I think all of our goals, some days to be financially stable and successful, right? So even utilizing his principles towards your business, I think is really important, especially because look at what happened to us during this pandemic. Stephanie Weyrauch (14:34): I mean, 80% of Americans are living paycheck to paycheck, and a lot of us needed PPP loans. And like some people's businesses just weren't prepared for this. So in his book, he talks about like having a small saving, like emergency funds, you know, paying off debt so that you can become debt free would be the next step after that. And then saving three to six months of expenses. And, you know, after this pandemic, one of the things I think I've learned is having that six months expenses saved is like so important and notice that it's six months of expenses, not six months of your monthly budget, but expenses. So then when you have an emergency, like something that you just can't even control, like you feel more in control, you're able to maybe provide more for your employees, or if you, you know, or even your help your patients out a little bit more pay your bills. Stephanie Weyrauch (15:31): And then the last three steps, which if you're a business owner, I mean, it's pay for kids' college, which you don't have to worry about that as a business owner, but pay off your mortgage. So if you have a brick and mortar practice paying that off, and then the last one would be to give charitable giving. And if there's one thing I think this will therapist are really good at it's giving to charity, i.e. giving out our services for free sometimes. So, I mean, at that point, when you're in that point in the baby steps, like you hypothetically are set enough that potentially you could do some pro bono work with your business, which would then put your business on the map as being a very solid community practice as well. So, I mean, I think a lot of the day to day principles that he talks about in the total money maker, that's meant for day to day stuff could easily be applied to business. Karen Litzy (16:21): Yeah. And I'm glad that you brought up the pro bono because the question that Gina had was, how do you decide on that pro bono? How does that fit into the budget? What kind of a sliding scale do you use and how do you do that? If you are a private practice, what kind of sliding scale are you using and how do you decide what to charge? And, you know, I say like I have a real Frank discussion with the individual patient. And if they say, you know, listen, I really need the help. If they were referred to me from another therapist who they were seeing using their insurance. And they say, you know, so-and-so says, you're the best person. You're best equipped for this. This is what I can afford. Can you do it? And because my business is at that point now where I don't, I can, I'm able to offer that kind of service. Karen Litzy (17:11): Then I say, yes, I can do it for this price. You know? So that's kind of how, and it's also depends on like, if the person, if I have to travel an hour and a half to get there and an hour and a half back, then it might not be best. Which in which case, I'm happy to find them, someone that will work for them. So I think when you're looking at the pro bono costs, if you're traveling to patients, you have to look at your travel time. You have to look at how that's going to cut into your overall budgeting and your overall key performance indicators, which we'll have a whole other talk about KPIs. But I think the bottom line is you have to know how much does your business need per month to be able to do everything you just said, right Stephanie. Karen Litzy (17:57): To be able to keep the lights on, to have shelter. So how much does your business need each month just in expenses? Have you met that goal, then? How are you able to pay for your insurance and your taxes, which I would say go into just the sheer expense of running the business. Yes. I would agree with that too. So that's the sheer expense of running the business. Do you need another new fancy gym equipment or this, that, and the other thing? No. Right. So if you can forego that to maybe help someone else at a pro bono rate or at a reduced rate, then my inclination is to forgo the fancy new treadmill and to treat the person that needs it. So I think how you decide what that pro bono rate is, I think depends on the person in front of you. Karen Litzy (18:51): And you could say, you know, you can ask, ask around and just say, Hey, listen, this is what other physical therapy practices are doing. This is what I'm comfortable with. This is what the least amount I can charge so that I break even. And I think people understand that. So I think when you're thinking about what's the lowest charge you can give to someone that would be it, or you can go perfectly free. If you can say, you know, I can treat, I can do one session free per week, and I'm still, you know, in the green and I'm not in the red, then go for it, you know, but I think you have to know how much you can make to keep your company in the green, and then you can decide, well, this would be my lowest pro bono charge. Karen Litzy (19:37): And then if someone comes in, who's really, really of need, or you're volunteering through an organization or something like that, where you're treating someone for free, then, you know, I think in my opinion, I think that's the best way to go about it. I'm sure there's some legal aspects around that. But from what I can tell in speaking with lawyers, they say, it's your rate. You know, you just have to be clear about what it is. You, Stephanie, where are you where you are? Do you have a pro bono rate? Stephanie Weyrauch: Yeah, so typically our pro bono rate is like $40 per session is what we'll do, but we are flexible. I mean, again, our practice, luckily my boss, he's been an amazing leader throughout all of this. We didn't have to fully lay off any of our physical therapists and we have five physical therapists, but we were very strategic with how we worked and when we worked. Stephanie Weyrauch (20:30): And so we've had that freedom from kind of how we've been running our practice to allow for us to sometimes even treat patients where they pay like $10 for a session. So, I mean, it varies from situation to situation. Things that we consider is how dedicated is the patient? Is this a patient that's actually going to come to therapy? Or is this a patient that's going to flake out on us because we don't want to save them a spot and then they not show up consistently also we've had instances where we've had maybe some where we've thought the insurance was one thing and it came out somewhere else. And so we ended up using the visits that we were given and the insurance company won't give them any more visits, which is a mistake on our part. So we always want to do, we always want to do right with any mistakes that we make. Stephanie Weyrauch (21:21): That is another thing that we'll consider, or sometimes if we have a Medicare patient that can't afford their copay, you know, we'll exchange services and other ways, you know, whether it be like they come in and maybe fix something in our clinic. And then we exchange that with our services, bartering, bartering. Yeah. So, we've been able to be flexible. But again, we built up our practice enough. We've been in business now for over eight years and we're a well established in the community that we are able to do that if you're starting out, you may not be able to do it right away, but you can work up towards that as you start to manage your money and start to make a profit. Karen Litzy (22:12): Yeah, yeah. Yeah. Thanks for that example. And I think that you'll find that in most physical therapy practices, they have a pro bono rate. They work with people they're flexible. Every practice I've ever been in the owners have been super flexible because in the end, we're all in the business of getting people better. And sometimes that business, maybe doesn't yield a profit of $200 per person. Maybe sometimes it's 10, but if our business is to get people better, then that's what we want to do. And I will also say this just because that person let's say your patient needs that pro bono care, they can't, it doesn't mean that they don't know people who they will scream to the rooftops of how wonderful you are and how great you were and how easy you were to work with too. A lot of their friends or to their communities. And then all of a sudden you're bringing in more business because you did a good thing. Karen Litzy (23:05): So don't discount that. And perhaps, you know, that person can be the stellar Google review you need, they can be that video testimonial on your website. They can be that written testimonial on Yelp or on your website. So these are all ways to like, incorporate your pro bono services by saying, Hey, listen, we're happy to do this. If you're pleased with your service, if you feel better, we would love for you to put up a thing on Google or put up a review on Google or Yelp or on our website, if you're comfortable doing that. Right. I totally agree with that. That's another great way. So that's right. It's the same thing as, like I said what would the other night talking about lead magnets, put something out there that people can use. They then give you their email. And all of a sudden you've made this really fruitful transaction for the both of you. Karen Litzy (24:00): And that's what that pro bono type of situation can do. So just always think there's always ways to leverage a visit that has nothing to do with money. That's right. So, all right. So Stephanie, let's talk about if you would like to sort of wrap it up on the big budget issues that people need to be aware of. And I also put just so people know, I also put every dollar, the app in the comments as well. Stephanie Weyrauch: Perfect. So I would say that the first thing that you need to know is you need to stick with the budget. I mean, there's no point having a budget and you don't stick with it. Accountability partner, I think is key. Having somebody there that will keep you accountable. I mean, you're in private practice. You're probably a very accountable person, but it's still good to have somebody there that asks that says, do you really need that this month? Stephanie Weyrauch (25:02): Or are you sure that this is what you want to spend on this specific line item? So having the accountability, I think is the key and sticking to your budget is the absolute key. I think that if you allow yourself to go over your budget and you're like, Oh, it's just one month that develops bad habits. You just gotta break all your bad habits right now. And that budget is like your gospel. You need to have a monthly budget meeting with your staff. If you have a staff, if you don't have a staff, it's just you with your accountability partner and say, this is what I'm going to spend. You know, I have a little bit of extra money that I can spend it on. What, what should I spend it on? Should I spend it on my charity work? Stephanie Weyrauch (25:48): Should I spend it on my debt? Should I spend it on getting new equipment and have that accountability partner help you with those decisions? If you want somebody to help you, but at least they can be there to basically ask you those questions of is this really necessary? I think if you can stick to your budget, you will feel so much better about your business. You will be less stressed. Like Karen said, you will feel like you've been like you, you have all this extra money because you know where all your money is. And the reason that the every dollar app is called every dollar is because you give every dollar a name. You don't have any extra money floating around in your budget. You put it where it goes for that month. The other thing is, is that to think of the budget as permission to spend money versus being super strict with it. Stephanie Weyrauch (26:41): So you still have the bulk amount of money that you're spending that you, that you have for the month. But, you know, if you notice again, like let's say you don't have to drive as much, you can take that extra money that you would typically spend driving and put it towards a different line item, but just make sure that your budget always adds up to all these total $0. You have nothing left. Everything is going to something in the budget and it has a name. Your budget is your baby. You would not name your baby nothing. Well, no, I'm just kidding. Karen Litzy (27:26): Yeah, no, I think that's a really great point. And even if that money is savings, right, it goes, it has a name. So nothing thing, I'm just going to leave it in the bank. It's going somewhere every month. I love that. All right. So we have stick with it. Don't break it, give it a name, anything else? And just accountability partners. Yeah. All right. Well, this was great, Stephanie, and I hope that people this gives everyone an idea of having a good starting point, downloading the app, maybe reading the book. Like I said again, to repeat the name of the book, the total money makeover by Dave Ramsey, and every dollar.com or every dollar app. And in there, it also has in the book, like Stephanie said, it also has information for people who don't have that steady every two week paycheck. But if you're an entrepreneur, it gives you ways in order to kind of work around that as well. Stephanie Weyrauch (28:27): And if you do end up, if you guys are podcast listeners, and if you download the Dave Ramsey show podcast, a lot of his podcasts focuses on entrepreneurship and on business ownership. And so he has a lot of really great advice on running a business and budgeting for business. The budget that I talked about is more, it can be both used as a personal budget or a business budget, but he does talk a lot about business ownership in his podcast as well. So I would definitely recommend checking that out. If you have extra time and want something to play in the background, it's a good podcast to listen to in the background. You don't have to sit there and like learn from it. It's just kind of there. And he's a pretty entertaining guy. Yeah. I took one of his it was like a longer course a couple of years ago. So I still have all of the materials and everything like that. So yeah, he's very entertaining and he knows what he's doing and it works. Stephanie Weyrauch (29:15): And I will say, you know, you can have a personal budget and a business budget. You don't have to have just one. You can have personal, you can have business and then you'll know exactly where literally every dollar in your business and every dollar in your personal life is going. And like I said, on our talk, you know, after reading profit first from Mike, I just found it amazing of like, yeah, I know now where every dollar is going to. So now that I know where every dollar is going to my big buckets, I can now use this to see where it goes to the very last dollar. Karen Litzy: Right. Yeah. And like I said, when you do a budget, it's amazing how much extra money you have. And you're like, wow, I didn't know. I had all this money. What was I spending on before? Stephanie Weyrauch (30:03): Right. What kind of nonsense was I doing before? Karen Litzy: Yeah. That's one thing that I have to tell you after instituting profit first, I was like, the hell was I doing like, seriously? What was I doing before? Because I have so much more money in savings. I don't have to worry about paying taxes. Everything's awesome. Like, what was I doing? I can't explain it, but now it's like, yeah, now I get it. Now I understand. And I feel like you know, like you said, Oh, this is a grownup thing. Oh yeah. So I was like adulting hardcore when I learned this. So I think that's great. And now Steph, before we jump off, where can people reach out to you or find you social media if they have questions? Stephanie Weyrauch: So I'm on Facebook. Stephanie Weyrauch. Or you can find me on Instagram or Twitter at theSteph21 and I'm available on any of those platforms. Karen Litzy: Perfect. Well, thank you so much. And everyone, thanks for indulging us, at least here in the Northeast on a very rainy, very rainy Saturday to talk about setting your budget, sticking to your budget and creating more wealth from the money you're already taking in. So Stephanie, thank you so much. And everyone, thanks so much for listening. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!