#7 - What You Didn't Learn in Grad School: Unlocking the Pelvic Floor with Dr. Kelsy DeMelo, Part 1

Factor, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents, serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare in a short format that is easy to digest with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. In today's episode, we are kicking off a brand new training with Dr. Kelsey DeMello titled What You Didn't Learn in Grad School: Unlocking the Pelvic Floor. Dr. Kelsey DeMello is a chiropractor and exercise physiologist. She's a graduate of Texas Chiropractic College where she excelled as a teaching assistant in the Department of Anatomical Sciences. Prior to chiropractic school, Dr. Kelsey graduated from Simmons College in Boston, Massachusetts with a bachelor's degree in exercise physiology and nutrition. After completing her undergrad program, she worked at New York University in cardiovascular research and as a health and fitness coach at Equinox, providing group and individual fitness training to a wide spectrum of clientele. Dr. DeMello aspires to continue her specialization in the fields of pre- and postnatal women's health, nutrition, and pelvic floor rehabilitation. She is currently working towards the Herman and Wallace pelvic floor therapy certification and is offering both virtual and home care services. In her spare time, Dr. Kelsey is also a nationally qualified figure and bikini competitor with the National Physique Committee. Her previous passions were marathon running and classical ballet. So really, she genuinely is one of those incredible people that really does it all. In part 1 of this 2-episode training, Dr. DeMello is going to discuss the connection between pelvic floor health, core stability, and proper breathing mechanics. We will also take a deep dive into the anatomy and biomechanics of the pelvic floor and its action versus function and simple assessments that you can do with your patients. As always, if you have questions as you're listening to today's training, you can submit your questions in the Q&A link in our show notes. We will have our instructor back on for a future special Q&A episode so that we can cover all of your burning questions. With all of that being said, let's get started with today's training. Welcome everybody. Thanks for joining us. We're going to get started here in just a minute with Dr. Kelsey DeMillo. We are excited to have her presenting for us today on a topic that from what we've heard from many practitioners was not something that was covered very in-depth in chiropractic school and even in many physiotherapy and physical therapy schools. So we're excited to have her here. Thank you, Jessica. school curriculums, but it's something that I know a lot of you guys are encountering in practice on a regular basis, and something that is definitely a hot-button topic with many of your patients that I'm sure they want to know more about how to fix some of these issues that they might be having. So with that being said, we'll go ahead and get started here. My name is Jessica Riddle with Southeast Sports Seminars. Once again, thanks everyone for joining us today. We're excited to have you all. Today's topic is going to be on pelvic And we're very privileged to have Dr. DeMello joining us today and covering this topic. All that being said, I will give the floor now to Dr. DeMello to go ahead and begin the presentation.

Hi everyone, thanks for logging in. I'm Dr. Kelsey DeMello. I'm just, I'm super excited and grateful to be giving this presentation today, and I'm really excited about this. It's a topic I'm really passionate about. So I want to kick off with a question here is how many people actually remember learning about the pelvic floor in graduate school, because I'll admit I remember some professors mentioning it, but no one ever really dug deeply enough to understand the pelvic floor. And I think a lot of times people put the pelvic floor on this pedestal because it houses a lot of really sensitive organs, both male and female, and its function has a lot to do with topics that nobody likes to talk about, right? Urination, defecation, intercourse. Menstruation, things like that, and pelvic floor problems are more traditionally thought of as an issue exclusive to pre- and postnatal women. So again, if this is an issue where you have always thought that pelvic floor problems were male or female, right? Because that's something, again, before I personally started to develop pelvic floor issues, I never really thought of this as being an issue that could be something outside of someone who was pregnant dealing with it. So again, I used to think this, and before I really started to go down the pelvic floor rabbit hole, if you will, I didn't really know any better either. So again, I'm just really excited about this and excited to deliver you guys some information that will help you in your practice regardless of the population that you treat. All right, so as I mentioned, my goal for today is to provide you with at least one valuable takeaway about the pelvic floor and its function and how you can apply it to your practice. Okay, regardless of who you treat. So we're going to be reviewing not only the anatomy and the function, but also how to evaluate and treat the pelvic floor without even touching it. So keep in mind that traditional pelvic floor therapy is very invasive, and it's basically a musculoskeletal OB-GYN appointment, and not everyone wants to go through that. So by adding this knowledge, you're absolutely able to provide care to so many more people without the added stress of traditional pelvic floor Therapy experiences. And, you know, I was chatting with a friend the other day that I used to work with when I lived in New York at Equinox, and she's a personal trainer, and we were talking about all this pelvic floor stuff. And she had mentioned she has a client who, every time she asks that client to go to a certain depth in a lunge or in a squat, the client just doesn't do it. And she finally called her out and said, well, why don't you do this? And she said, well, every time I get down to that depth, I urinate. I essentially, I lose control of my pelvic floor and I urinate. And she's like, I've been working with you for 6 years, why didn't you tell me this? And a lot of this is stuff that people are embarrassed to talk about, so having those experiences in a one-on-one setting is really valuable, and getting your patient or client to really open up about that stuff is really important, and you can have a really big impact on their quality of life and what they're able to perform. All right, so again, if you feel like there's a lot of sensitivity around this topic, if you feel some kind of mental block, whether it's emotionally or just some kind of block about talking about pelvic functions and it makes you uncomfortable, just say like, yeah, this makes me uncomfortable, and that's okay. Everyone has different experiences and concerns discussing these bodily functions, so we're definitely going to be talking on that today as well. And here, just some information on me. My name's obviously Dr. Kelsey DeMello. I came into chiropractic school with a background in exercise science and nutrition, and it was actually a very personal experience that sparked my interest in In pelvic floor rehab, in pelvic floor therapy. So I definitely view the pelvic floor a little differently than most pelvic floor practitioners, and I think that translates well with patient communication and easing some of the concerns about discussing these issues. And I hope that's, that's something you can see as a strength, as well being a group of sports medicine practitioners, because I think you guys have a really different outlook on human movement in the human body. So definitely take that into consideration that you do have a different outlook than most people, and I think that the pelvic floor is something. You either specialize in or don't talk about at all. So hope that this presentation can kind of start to bridge that gap in your practices. So here, just regarding pelvic floor anatomy really quickly here, I want to start by addressing the image on the far left of the screen when you're looking at it. So you can see the aerial shot of the pelvis, right? And you can see the type of the kind of sling that is created by the pelvic floor, and it behaves as kind of a trampoline to house the pelvic organs, and obviously during pregnancy houses the fetus. Okay, and you can see that really well. Depicted in that far left photo on your screen. Now, when I say it behaves like a trampoline, an analogy here I like to use with patients is that when you have an issue in this trampoline, I want you to imagine you're jumping on it, right? And there's a spring that's loose, or there's one side of the trampoline that the spring is loose, right? What's going to happen? You're not going to get the depth you want on the trampoline, right? When you jump, you might go sideways a little bit, right? So that spring effect, that trampoline, and the quality of the springs is really important to produce the quality of movement that you want. So a really important form and function relationship there when we're talking about the pelvic floor. And you can also see between the first photo on the left and that middle photo here, that second one, the attachment points of the psoas major. And that actually shares an attachment with the diaphragm, which you can see really well depicted in that second photo there. So we're going to be talking about respiration quite a bit and the pelvic floor's role in respiration. Those attachment points are going to become really important later on. So just really keep that in mind as we kind of go out throughout the presentation here. We look at the photo on the far right, you're going to see the relationship between the transverse abdominis or the TA and the pelvic floor and how it kind of creates this abdominal canister with the diaphragm above, the pelvic floor below, and then that TA kind of wrapping around the middle and the relationship between these 3 muscles in addition to obviously the oblique and the paraspinals and the rectus and the other abdominal muscles, the relationship between these muscles in this abdominal canister allows us to have a big impact on the pelvic floor without even touching it. Okay? So without having to do, again, that more traditional pelvic floor therapy type work that is extremely invasive. And the other thing I want to point out while we're still on this slide is that the pelvic floor has 3 different muscle layers So the issue with having those 3 different muscle layers, there's really no photo to depict that very well. A lot of people will remember their cue to Kegel as to hold the flow of urine. Okay, so a lot of women, you'll hear that, we're going to talk about that later on as well. You'll hear like, yes, I know how to Kegel, I can stop the flow of urine. And when you're stopping the flow of urine, you're actually only involving the first layer. of the pelvic floor. So that's really not the best cue and not a complete picture. So we're going to be diving into that technique a little bit later on as well. All right, so pelvic floor dynamics. Before we really dive into this, I want to discuss some just definitions as we go throughout the presentation and about the dynamics and their importance. So when I say expansion, when I use the term expansion, what I'm referring to is the descending of the diaphragm And the pelvic floor, and then when I'm talking about retraction, I'm talking about the ascending of the diaphragm and the pelvic floor during breath. And again, I use the phrases spasm and trigger point somewhat interchangeably throughout the presentation. And just note that when I'm referring to these terms, I'm referring to tightness. Okay, I realize that spasms and trigger points are very different, but for the purposes of this presentation, just kind of consider it as a underneath the tightness umbrella. Okay, when we're talking about balance in the pelvic floor, the core, and the rest of.

Today's episode is brought to you by Southeast Professional Education Group, formerly known as Southeast Sports Seminars. For over a decade now, we've been pushing the envelope to raise the bar on professional continuing education within the healthcare space. If you like what you hear in this episode, I highly encourage you to continue your learning with Dr. DeMello's 8-hour pelvic floor rehabilitation and movement course. This virtual curriculum equips practitioners to treat dysfunctions of the pelvic floor in a variety of patient populations and covers the fundamental anatomy and physiology of the pelvic floor, along with biomechanics, assessments, and myofascial release techniques. Continuing education credit is available for chiropractors and physical therapists in a variety of states. Visit online.sports-seminars.com for details Or visit the sponsor link in our show notes.

So let's dive in a little bit talking about the action of the pelvic floor versus the function, because that's where things start to get a little dicey. And there are certain movement patterns we can program through rehabilitation and neuromuscular education, like Kegeling, right? Like twisting movements and incorporating breath into those movement patterns. But ultimately, a lot of these functions with these muscles are supportive and involuntary. Okay, so holding urine, digestion, defecation, orgasm, intercourse, menstruation— those involuntary functions will also complicate the healing of these muscles. So we'll be discussing the healing barriers later on as well. So one way to attack the pelvic floor is by addressing the function of its antagonists. So looking at the antagonists of the pelvic floor, As the diaphragm, the TA, the obliques, the glutes. And the cool thing about it is that it really does have multiple antagonists. And I've even seen some articles that look at the thoracolumbar fascia as playing an antagonistic role to the pelvic floor, which is really interesting and really cool. And it makes sense because it attaches way down at that dorsal surface of the sacrum opposite of the pelvic floor. So there is a lot of potential here to have an effect on the pelvic floor without the invasive nature we discussed earlier. So the best way to illustrate this when we're talking about antagonists is I like to pick on the bicep because it's just an easy muscle we can all visualize and say antagonistic relationship. The patient has bicep pain, and during our exam we find a ton of trigger points and dysfunctional issues with the tricep. Being holistic practitioners that look at the whole body, are we going to start addressing those dysfunctional issues?

Absolutely, right?

And that's the same concept here. We're going to start looking at those antagonistic muscles So again, the diaphragm, the TA, the obliques, the glutes, the thoracolumbar fascia, and seeing what impact we can have on those muscles to positively impact the pelvic floor. So one of the easiest ways to address a pelvic floor concern is with breathing. And right from where you are, I want everyone to put one hand on your lower abdomen and take a big breath in. So when you take that big breath in, focus on forcing air down into the lower abdomen, and you should feel that hand start to bulge out a little bit. And that's because, as we all know, during the inhale, the diaphragm descends, the TA relaxes, and the pelvic floor bulges. And that's not to say that every patient is going to be able to do that and that you're not going to have to work with them a little bit on that, but that's the normal pattern. That's how it should work, right? During the inhale, the diaphragm descends, TA relaxes, and the pelvic floor bulges. Now the exhale is more of a recoil type situation. So during exhale, the diaphragm will ascend. That's a given. The TA and the pelvic floor will contract only if expiration is forced. So I'll say that one more time. The diaphragm will ascend during exhale no matter what. The TA and the pelvic floor will retract if exhalation is forced. So that's really great for you guys to know in practice because Forced exhalation is a really good way to get your patient to cue their TA and pelvic floor without that prior knowledge of how to contract. So you might be sitting there forever trying to get someone to contract these muscles that their brain isn't connected to, but through their breath you can connect them. So that's a really powerful tool and a really great way to start getting these muscles to fire. And you're going to see on the slide here some information about Pregnancy and breathing patterns and also being overweight and central obesity. So I want you to think about the diaphragm again. So we're talking about breathing patterns. If your diaphragm is sitting right below the rib cage and its job is to ascend and descend with breath, if you're pregnant, right, and or if you have just a lot of central abdominal fat, what's going to happen when you breathe, right? The diaphragm is not going to fully expand as it should normally. So these patients end up recruiting their scalenes, their levators, their traps, and those other muscles in order to breathe, and the diaphragm therefore can't do its job. So if the diaphragm can't do its job to ascend and descend with breath, what else can? The pelvic floor, right? So in a situation where a person is carrying extra abdominal weight, whether that's because of pregnancy or obesity or the extra weight that they're carrying around, not only is the pelvic floor very stressed from hanging on to that load, which we're going to circle back to right here in a little bit, but the pelvic floor also isn't getting its normal motion that it would because it's being blocked by all of this extra weight in their midsection. So weight control is actually a really important component of pelvic floor health as well. And again, that's going to be applicable to pregnancy, which is one reason they're a lot more prone to pelvic floor issues, and also your overweight population. And again, circling back with this overweight stress Again, I'm going to pick on the bicep again, just for example purposes. If you were to take a dumbbell and hold it in your hand and flex your elbow to 90 degrees, right? And you just held it there, would your bicep get stronger? And the answer is no. And the reason for that is because you need that eccentric and in turn concentric motion in order to develop these muscles. And in a situation where we've got either pregnancy or a patient being very overweight or a lot of central abdominal obesity, the pelvic floor is just holding on for dear life. Right? It can't get that normal motion because the diaphragm is also restricted, and so you've got it supporting all of this weight here. So as the pelvic floor is supporting this weight, it really can't get stronger because it's not able to move. So again, relating that back to the body and the motions that we're already very familiar with, you can't hold a dumbbell in your hand at 90 degrees and expect the bicep to get stronger. So why would we expect that of the pelvic floor? And the answer is we can't. So just circling back, your breathing mechanics to allow for that normal motion and controlling weight are going to be very important in letting the pelvic floor really do its job and allow it to support adequately. And more pelvic floor dynamics here. When in doubt, blame the glutes. And I think a lot of us, you know, fall into that treatment mindset. For sure, the glutes are a big culprit for a lot of things, but patients that have pelvic floor tightness, there are a lot of patients that have pelvic floor tightness because their glutes don't kick in properly. So when we have that sleepy glute syndrome that a lot of patients suffer with, the pelvic floor tends to kick in and pick up the slack and creates a lot of tension to compensate for that functional deficit. So we're going to tie back into the hip flexors here for a second. So that sleepy glute syndrome involves tight hip flexors. So remember that picture we started with? The hip flexors and the diaphragm actually share an attachment point. So now that we know that, and now that we understand that, we can deduce that allowing for full expansion of the diaphragm— because it attaches from above and the hip flexor is below— when that diaphragm fully expands, that actually allows the hip flexors to release because it's applying force from above, right? It's pushing down on that hip flexor. So when we can allow for that diaphragm to really descend, the hip flexor can let go. And then what happens when the hip flexor can let go? The glutes can perform better. So if getting a patient to deep breathe can help the psoas loosen its death grip, we're going to improve glute function, and then we can allow the pelvic floor to do its job of supporting instead of compensating for the sleepy glutes. And you'll actually also notice when you start to dive into this stuff a little deeper with your patients, A lot of different compensation patterns during deep breathing, TA contractions, and Kegel contractions. So a lot of patients will actually start to try to recruit the hip flexors or clench the glutes or clench the adductors during these exercises, which is obviously something that we don't want, right? We want them to be able to deep breathe, contract their TA, perform a Kegel without these compensation patterns and without this muscle recruitment. So when I perform these movements with patients, I like to have them palpate them on themselves, their hip flexors, their adductors, and their glutes in order to enhance that mind-body connection and allow the patient to have their own aha moment in order to let go of the hip flexor or the glute or the adductor or whatever other muscle they're recruiting underneath their hand during their breath or their TA contraction or their Kegel. It's very important to ask patients about training habits. So many people, and I hope that you can start to see now the whole relationship between breathing and how that would affect some of your patients that are athletes or how they're in the gym, because there are so many people that get under a bar and really don't consider how to brace or engage their core properly, which now in turn, you hopefully understand the load that that places on the pelvic floor and how that can really potentially cause some issues. So, but further than that, not only is that bracing issue really important, but also what does their core training look like? And I'm going to go out on a limb here and say that the Average weekend warrior going to LA Fitness is probably doing a lot of crunches and a lot of planks, and they've got sacral instability or pelvic pain or sciatica that isn't letting up. The root of that might actually be a pelvic floor issue, and maybe the patient needs to discontinue these movements because they can actually be weakening the pelvic floor in turn and causing more harm than good. So asking about these routines and what they look like are very important in setting your patient up for success in the long run here. And I like to see balanced core training routine that will help engage and strengthen the pelvic floor include TA contractions, twisting patterns that incorporate breath. And the reason for that is when you're doing the twisting pattern incorporating the breath, again, with that forced exhalation, you're forcing the pelvic floor and the TA to contract. And when you're twisting, you're allowing for a unilateral contraction of the pelvic floor, which is pretty difficult to do when you're just performing a normal TA or a Kegel or something like that. So the twisting motions can be really valuable to get patients to engage. And again, because I have an exercise science background and I come at this, I think, from a little bit different approach, I do like to see patients incorporating a lot of this work into their fitness routine. So the clients and patients that I work with have daily work in terms of Kegels, breathing, and soft tissue release, in addition to their fitness program to start incorporating these movements into their routines. And that has been huge for success rates because I think many women postpartum have issues returning back to the gym after baby's born because the pelvic floor issues, that's a big hindrance to their success. So where our kind of zone of genius comes in with a background in sports, if you can add this pelvic floor knowledge, you're really able to service those patients and those clients a lot better. And of course, even if the patient in front of you is not pregnant, Hopefully now you're starting to see why that integration of fitness and rehab is something that's very important to patient healing in the long term, because these pelvic floor issues are very applicable to your athletes and your weekend warriors. So now you can see that dysfunction in the upper, lower, and the central kinetic chains will absolutely have an effect on the pelvic floor here, right?

All right, guys, that is it for today's episode. Be sure to tune in for part 2 of this training in episode 8, where we will dive a little bit deeper into how pelvic floor instability can affect the lower kinetic chain in both male and female patients. We'll also discuss how assisting your athletes and active patients with correct breathing and bracing of the pelvic floor can make a huge difference In regards to their performance in the gym and on the field. Dr. DeMello will also discuss some simple treatment protocols that can be easily performed in your office, as well as some exercises you can have your patients do at home. You won't want to miss it. Episode 8 drops in 2 weeks, or 1 for our Patreon subscribers. Now you can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a five-star rating and help us grow the show. Every little bit helps. Also, be sure to look out for our Patreon link in the show notes to access additional bonus content, early release episodes, and an ad-free listening experience, along with bonus content and special offers. We're constantly adding more benefits for our patrons, so be sure to get in early for maximum value. And finally, last but not least. Please remember to visit the show notes for that link to download the PDF of today's full presentation. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online options. Offerings, as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.