#8 - What You Didn't Learn in Grad School: Unlocking the Pelvic Floor with Dr. Kelsy DeMelo, Part 2

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 continue our 2-part training titled What You Didn't Learn in Grad School. Unlocking the Pelvic Floor with Dr. Kelsey DeMello. Dr. 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. Kelsey 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, she also is a nationally qualified figure and bikini competitor with the National Physique Committee. Now, if you have not listened to episode 7, which is part 1 of this series, I highly encourage you to hit the pause button, go back and listen to episode 7 first before diving into today's episode. That being said, we're very excited about what we're featuring on today's episode. We're going to be digging deeper into how pelvic floor instability can affect the lower kinetic chain in both male and female patients. We'll also be discussing 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 exercises you can have your patients do at home. As always, if you have questions as you're listening to today's training, you can simply 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. Let's get started.

So for example, from the upper kinetic chain, if a patient is experiencing just classic upper cross syndrome and the smaller muscles of the cervical region are overfiring— and we did touch on this a little bit earlier talking about pregnancy and central obesity, but that can happen in the average person as well, right? They don't need to be carrying around extra weight in their abdomen in order to be experiencing that. So if the smaller muscles in the cervical region are overfiring, this in turn causes breathing dysfunction, which you guys know, and won't allow for full expansion of the diaphragm, leading to stagnancy and movement of the pelvic floor. And so I want you to think about this just on a greater scale. How many people in the United States or all over the world have anterior head carriage? And that's pretty much everyone, right? That's almost everyone we see in practice. And so we should absolutely be asking relevant questions and digging deeper to figure out if the pelvic floor is part of that bigger picture and why is this happening. And that's actually one of the things I love about our profession and why I decided to get into chiropractic is because we really do look at the body as a whole and how is it functioning altogether as one. So I think that that's extremely important in addressing these issues and part of the reason I got into this profession in the first place. So this is the stuff that really gets me excited and I'm really excited to be able to teach you guys. So I hope that you can take something away there for sure. And of course, I think it's a little more obvious when we're talking about the lower kinetic chain how that can affect the pelvic floor, right? So just again, quick example, if a patient is an overpronator at the subtalar joint, that's going to lead to genu valgum, decreased firing of the glutes, and triggering overfiring of the pelvic floor to help stabilize and compensate where the glutes cannot. And If the pelvic floor is contracting in order to stabilize the pelvis, then it can't do its normal job, which is retaining urine and bowel function and intercourse and menstruation and all these other type of functions that it has to support those functions, right? It's got to— if it's got to work to make up for the glutes, then it's not going to be working where it needs to be. So we're going to run into a whole lot of issues. So again, with this slide reiterating a Several different things you might see in practice that could be stemming from a pelvic floor issue and when to start to look outside of the box and incorporate some of these strategies we're about to review in just a couple slides here. With the pelvic floor, I think this is kind of where the wheels really start turning for me because you start to question, well, was it the chicken or the egg? Did the patient become constipated because of a GI irritant that generated a pelvic floor spasm and now sciatica symptoms are kicking in? Or was it that we had sciatica symptoms triggering spasm of the pelvic floor and now the patient's also constipated? So sometimes we'll never know the answer to that question, and I don't know about you guys, but I definitely don't want to be treating constipation for a living, but just something to think about and something to consider again when we start touching on some of the history questions that are relevant and sort of that, that uncomfortability that the pelvic floor generates for us when we're talking to patients. And something else you'll notice on this slide here is that I have sciatica in quotation marks because I think it's a term that's very loosely thrown around for a variety of different symptoms. And from what I've seen in practice, that whole sciatica-type presentation is extremely sensitive to functions in the pelvic floor. And I mean, I have— I even had a patient a couple weeks ago that has just been having the worst sciatica symptoms, also constipated, Ended up having a massive bowel movement and her symptoms are gone. So I think the whole sciatica presentation, if you really want to dig deeper with your patients, it's definitely worth it and talking to them about what other symptoms they're experiencing because the pelvic floor has a big role in that. And again, if we've got a pelvic floor spasm, regardless of the chicken or egg situation, it is an issue that can throw off the entire kinetic chain, both above or below the pelvic floor and in the sagittal, coronal, and transverse planes because That pelvis is a bowl, right? So that bowl's got a twisting motion, it's got that tilting motion, so you can throw the body off in any kind of way, shape, or form by affecting the pelvic floor. So it's extremely important in a lot of the different conditions you'll see here. And again, if you do have patients with any of these chronic issues, start to look at the not obvious. So it might seem kind of weird to talk to a chronic rib patient about constipation or incontinence or hip tightness or sexual dysfunction, but I hope you're starting to see the way that this dysfunction can travel up the kinetic chain, and that if there is an issue with one of those functions, that the pelvic floor experiencing dysfunction or spasm or trigger point will then trigger the diaphragm and then possibly cause a rib restriction or a rib issue as we're traveling up the kinetic chain here. So again, if you do have a patient with one of these issues, whether it's a rib or sciatica or pelvic imbalances or SI joint dysfunction, any of these issues, step number 1 would be walk them through a breathing assessment. So just like we did earlier, putting one hand on the lower abdomen, one hand on the side of the rib cage, and allowing them to really breathe and assess where their breath is going when they take those deep breaths. And then once you determine where the breath is going, have them palpate their glutes during breath, palpate their hip flexors, See if they're recruiting those muscles to perform this very simple motion, and if they are, especially in the glutes, I see this a lot more commonly in the glutes than in the hip flexors. But in the glutes, if they're clenching during breath, is one side firing more than the other? Because that will indicate where the pelvic floor spasm is and start to give you insight on how to address it. So, for example, if the patient is noticing that the glutes are clenching and it's more so on their right side. Side, we can then say that the right pelvic floor is probably not doing its job, right? So if the glute is here, the pelvic floor is here, and that right glute is clenching, that pelvic floor probably isn't working very well. So we know then that we've got weakness or laxity or something going on on that right side and/or spasm and tightness and trigger points and something on the left. And then we can choose how to address that with strengthening and making sure that that right side is intact and addressing those concerns with that weakness and providing some soft tissue techniques, whether that's an at-home release or something you do in the office for the left side of the pelvis. All right, so hopefully this is triggering some brainstorming for you guys as to what populations might be in need of help with their pelvic floor. And I think for most different types of patients that you can look through a lot of this stuff and it Makes sense. And again, are you going to have a patient walk into a chiropractic office with erectile dysfunction, just something on this list, or interstitial cystitis? Probably not, right? They'll be coming to you with chronic SI pain or some other symptom, and you following up with these history questions might lead you a little closer to getting to the root of the problem and finding a solution rather than throwing the kitchen sink at it. So one thing I would really like to point out here is the last bullet point of assault victims. And as I stated, the pelvic floor issues can be really sensitive to discuss. And if someone is a victim of sexual abuse, this can trigger a lot of psychological dysfunction in the pelvic floor. And I'm not saying that we need to be asking every patient with a chronic issue this question, because obviously it's a very invasive question. But it is something to keep in mind that this population of people, your assault victims, are at very high risk for pelvic floor issues because of the psychological component involved in their trauma. So again, I really like to take the pelvic floor, to look at the pelvic floor from a scientific approach and take it off of the pedestal, right? Just because it's responsible for a lot of these sensitive bodily functions. So one way I like to explain the healing complications, which you guys can start to take a look at here, when I explain this to patients, I like to say treating the pelvic floor is similar to treating a 12-year-old boy who's a pitcher with tiger parents That are gunning for a scholarship. And the reason I say this is because this kid ends up in your office, say he's got a labral issue, and you tell him and the parents no more pitching for, let's say, 6 months or however months you decide, right, that this patient needs to heal. Now, aside from the child services issue at hand here, right, say that kid goes out and pitches 7 innings anyway. Is that labrum ever going to heal? And the answer is no, probably not. And the reason is, is that labrum, that shoulder needs to rest. And the patient isn't providing it with rest. And in the case of the pelvic floor, the patient's pelvic floor is involuntarily pitching 7 innings. This is happening daily in the form of holding urination, the form of defecation, monthly in the form of menstrual cycles, and depending on the level of sexual activity, another daily, weekly, or monthly component affecting the healing process. So off of that, And I've explained this to many patients and even many other kind of male practitioners that I've talked to about these issues, is that menstrual cramps that interfere with daily life or are unilateral in nature or are not relieved by over-the-counter medications are not normal. So asking questions about the quality of menstrual cramps that a woman has can prevent us from digging into someone's piriformis for 3 months trying to alleviate SI joint pain or a sciatica-type issue That's actually stemming from the pelvic floor. And to be clear, menstrual cramps of this nature can be indicative of a bigger problem, like ovarian cysts, endometriosis, fibroids, pelvic inflammatory disease. So if you are asking those questions in office, make sure you're informing the patient of this and that they are following up with their OB to make sure there's not something more serious going on. And of course, here on our complication list, we see the psychological component involved in the trauma and sexual assault. So that's again another big barrier to healing is the psychological component. And so here for your assessment, start by asking those history questions. Okay, does the patient have a history of respiratory disease? Are they a smoker? And so I have a patient that I'm treating now whose son is 7 years old and she still is dealing with urinary incontinence. And not only did she have a very difficult labor, but she had bronchitis when she was pregnant. So Allowing us to set her up for success in her treatment protocol is— education is a big part of that. So informing the patient of these different things that contribute to their healing is huge, and asking those history questions is really important. So here we've got the, again, the breathing assessment, which we've already touched on, and addressing is the patient a chest breather, right? And again, putting them into the position where they're breathing from not only their belly but into their Into their side as well. So allowing for that kind of little teapot hand on the side to really expand with their breath. Okay. And creating that what we call kind of 360 pattern of breathing is very important to get air back into the rib cage and into the mid and low back as well. And again, this ties back into in the posterior chain, the diaphragm and psoas, that relationship, right? That's why that 360 breathing is so important. So hand on the rib cage, hand on the lower belly, even a hand in the mid back. If you feel like the patient's very restricted in the mid-back, and tying in chiropractic in here is really important, maybe they have a thoracic spine restriction that needs to be adjusted, and once you do that, they're able to get air into the mid-back, which is really important. So again, addressing postural concerns. If the patient has a forward head carriage, is the pelvis balanced and level? Is there a functional or a structural scoliosis, and how does that affect their pelvic floor? That's going to cause an issue in the line of pull in the muscles of the pelvic floor. So again, start to look at these issues from a holistic perspective and really zoom out from what your patient is dealing with to really be able to assess the pelvic floor effectively. Now, again, just to kind of tie in here how to assess the Kegel, you're going to have the patient be sitting on your hand in a tented position, which is as depicted here in the photo, right? And when the patient performs a Kegel, you want to be testing endurance. Because again, these muscles function in support. So when you're testing endurance, you're going to want to pay attention to how long are they holding that contraction? When do they start to fatigue? Are they recruiting other muscle groups for support? How long in that contraction are they starting to recruit those other muscle groups? So paying attention to those slight, slight changes during their Kegel is really important, and you're going to be wanting to feel their Kegel from both the distal portion of your hand, which will be more closer towards their rectum, and the proximal portion of your hand. Okay, and when you're feeling that Kegel from the entire dorsal surface of your hand, that indicates that the patient is actually pulling up from all 3 layers, which is what we want, right? We don't want them thinking that holding urine is the way that we produce a Kegel, because that can again lead to UTIs, that can lead to all kinds of issues. And it's only one layer of the pelvic floor, so it's really not the complete picture. And again here, just kind of tying everything together, addressing postural deficiencies, trigger points in the antagonistic muscles, and starting the patient on a pelvic floor and core-based rehab program, which we touched on earlier. I think of this just like surgery. If we have a patient walk into our office with a disc herniation, we want to manage that conservatively in the office and with adjustments and rehab and weight management prior to sending them for an invasive surgery. So I kind of view this as the same thing with pelvic floor issues is that I'd much rather see the patient address this in our offices than have them going into a pelvic floor rehab setting where they're exposed to these really invasive techniques here. And again, teaching proper Kegel techniques is very important because I think a lot of women, and especially women over the age of about 45, I've found think that Kegels should be performed as many as possible and as quickly as possible, Almost like they describe it like a ballistic stretching type pattern. So as we discussed, muscles do need concentric and eccentric action, and we do want to be holding these muscles for a length of time since their function is support. So asking patients what they already know about Kegels can give you a really good indication of where to go with it. And again, as we touched earlier, the Kegel technique is something we really want to make sure that patients aren't actually holding the flow of urine when they're trying to Kegel, because that can lead to UTIs down the road if done too frequently. It's a great cue to get someone to initiate the contraction, but it's not something we want to be doing long-term for sure. And I actually do offer a free monthly Kegel class. I do like it to have women only just for comfort purposes, but if there are men interested, maybe I can get some women to allow a record so we can share it with some of the men that are interested in this. But I would love to have people join if that was something that they're interested in. And again, that's one Once a month, and it's happening this Monday, so feel free to reach out to me if that's something you guys are interested in. It's a lot of fun, and I do talk in more of a patient-centered dialogue, so I share a lot of these techniques on that platform as well. And again, when to refer out. So I like to have a 2 to 4 week period of trial care, and if the patient symptoms do not improve or if they worsen, referring them to a pelvic floor PT for that inner pelvic work. It is a lot more invasive, but if that's what the patient needs at the end of the day, then that's what they need. And I do like to. Set the patient up with that expectation from the very beginning. And thank you guys, you're ready for questions.

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. The first one we had was from a bit earlier on. Someone was asking about the musculature. They were saying that if the pelvic floor can kind of hold together the hips, why is it that it has such a hard time holding in things like urine?

That's a great question. So again, that's going to boil down to 2 different things. Either the pelvic floor is so tight That adding the pressure of, say it's some— the patient, they leak when they're jumping, right, or when they're laughing, right? The pelvic floor is so tight that when you add that pressure, it caves. It's the straw that broke the camel's back. So that's going to be one potential issue there to holding urine, and then the other potential issue is weakness. So either the pelvic floor is so tight that it can't handle that extra load, and that's when you see leakage, Or the pelvic floor is just too weak to actually hold it in the first place.

The next question we have here, if a patient is not comfortable with Kegel assessment, how do you proceed?

Yeah, and that's something that I've actually personally never experienced. I think most patients, when you take the time to explain these things to them and educate them properly, they are very open to it. Kegel assessment is clothed, so I do encourage patients to wear yoga pants or shorts or something where you can feel the movement. But if they're not comfortable, then I would focus on the TA and the diaphragm and give them different cues and different releases for the pelvic floor. But if you can't assess it, that does make your job very difficult. So if you are sensing resistance from a patient with that assessment, I would A, go back to education, and B, say if you're still not getting anywhere with them, say we're going to practice the breathing techniques and we're releasing your diaphragm and working on the TA for say 2 weeks, and in 2 weeks we'll revisit it. If you feel more comfortable, we'll proceed, and if not, that's okay too. And again, that touches way back on the sensitivity around this issue, and I'm a very kind of straight-to-the-point person. I, in a lot of ways, I call out the sensitivity on these issues, and I think patients appreciate that, when you address it just objectively, I think it goes a long way for the patient in seeing that these are just muscles, and the more you treat it like that, your patients will respond.

Another one here, you often heard that when patients have a hard time doing any type of like core bracing exercises and breathing at the same time, that that can be possibly indicative of pelvic floor issues. Someone was asking if you could kind of repeat how breathing and pelvic floor muscles are related.

Yeah, so again, we've got the— back to that anatomy slide, you've got the diaphragm and the pelvic floor. So I think you guys can still see me here. The diaphragm and the pelvic floor, right? And then you've got the TA that wraps around. So when you take deep breath in, the diaphragm pushes down. When the diaphragm pushes down, the pelvic floor should expand. And then when you force your exhale, the diaphragm should retract And when, again, forced exhalation, the pelvic floor should also retract. Now, again, with looking at the pelvic floor from the lens of we want to induce concentric and eccentric motion, that's one of the ways that you induce concentric and eccentric motion in the pelvic floor is through breath because of that dynamic. So I hope that answers the question and that makes a little more sense.

Someone else asked, it's a 2-part question. Do you have any comments or thoughts on reverse Kegels and how is pelvic floor related to hemorrhoids?

Yeah, so the reverse Kegel, I'm assuming that we're talking about a bulge and there are some patients that do experience a lot of pelvic floor tightness and you therefore have to look at the bulge. I would say that that's probably not the norm. But it is something worth assessing and worth looking at. And again, through that tented hand, that assessment, you can feel a bulge, right? You can feel that as well. So asking your patient to kind of push down through the pelvic floor without using their breath, if that makes sense. It's very actually difficult to do. But if you can get the patient to do that, then you're assessing again both the kind of concentric and eccentric action of the pelvic floor. floor for sure. And yeah, that's definitely a whole nother topic. I could go on for another hour about that. So I'll save you guys that.

And in regards to pelvic floor being related to hemorrhoids?

Oh yeah, of course. So hemorrhoids, you're going to get obviously a lot of pain with those hemorrhoids. And so again, just like any other muscle, if you've got pain in the bicep, is that going to affect the ability to contract the bicep? Probably, right? And is it that the pain— the patient can't contract because of pain, or is the neurology actually affected? And that's something we have to really look at and again, zoom out from and assess with hemorrhoids, as it's more likely to be just a pain situation causing the patient kind of a mental block and be able to access those muscles appropriately.

The next question here is, how often do you find yourself prescribing breathing exercises And do you have any tips on kind of a generalized protocol that you start patients with in that regard?

Yeah. So basically everyone gets breathing exercises, especially if you're working with general population, because again, as we talked about the kind of anterior head carriage, right? If you think about in your practice, how many of your patients have anterior head carriage? Probably all of them, right? Probably everyone on this webinar has it, right? So if we're not addressing breathing, that's really not setting your patient up for success. And so I prescribe breathing to everyone and just like any other exercise, I start from the ground up. So, I start them lying on their backs, face up, knees bent, assessing their own breathing with one hand on the abdomen, one hand on the rib cage, maybe on the lower back if they need that biomechanical feedback there for that expansion and retraction. So, starting them there and then from there getting them to sit up with a back support. And now, with the back support, let's focus on that breathing. And maybe when you change positions, you notice that they're recruiting hip flexors, recruiting glutes, Recruiting other muscles and working with them through that. And then from that position, take away the back support and just progress them through that movement naturally like you would with any other exercise.

Wonderful. Another question is in regards to what you were saying about the 3 different layers of muscle in the pelvic floor. How do you assess the 3 different layers, or can you?

Yeah, so again, when we're cueing a patient to Kegel, The holding urine is only assessing the first layer, and so if a patient is sitting on your hand, and you can see my hand here, you can imagine their vaginal area would be here and their rectal area would be here. If they're only using the first layer, you're going to feel that kind of up-pull from that proximal portion of your hand. When you know they're using all 3 layers, they're going to be recruiting more muscles, you're going to be feeling that from the distal portion of your hand, so you're going to feel kind of both that pulling up sensation from both layers, from both sides of your hand when you're assessing that Kegel.

And that kind of leads into the next question. Someone was asking for you to explain the tenting technique for the Kegel assessment. So it sounds like your hand is tented and they're sitting on top of the top of your hand, correct?

Exactly. Yep. So just like this, and that was in the photo here, so you can definitely see that. But yeah, Hand is tented and patient is literally just sitting right on top of the hand there. Absolutely.

Another question here was, if Kegel exercise only contracts the first and second layers of the pelvic floor, which exercises do you recommend for getting to the deeper layer?

So again, teaching the patient holding urine is the first layer, and then once you get them to start recruiting the second and third layer, That's going to be more of like— and this is kind of a strange cue here, but when you tell the patient, I want you to pretend you're wearing really tight pants and you have to hold in passing gas. So you can't clench your glutes because you don't want anyone to see you're about to pass gas, but you need to focus on not passing gas without clenching your glutes. And that will take care of the second and the third layer as well. And you'll feel that again in that distal portion of your hand when you're doing the assessment.

Next here we have, for patients with scoliosis or any permanent structural imbalance, how do we gauge the progress of pelvic floor improvement?

Yeah, and that's a great question, and when I was actually coming up with this presentation, I had wrote scoliosis on one of the slides, and going through it, I realized I needed to address both functional and a structural scoliosis, and the answer is, is that a structural scoliosis, you may not be able to make a big effect, right? Because that's going to affect the line of pull of the muscles. So again, focusing on what you can change and what you can't with a structural scoliosis, there's not a lot that we have an effect on, right? So we do the best we can, but you're going to use the same assessment protocols with a structural scoliosis as you would with any other patient in terms of pelvic floor health.

Another question we have here is, are there any variations in the types of pelvic floor training that you would do with a male versus a female patient?

Yeah, so I actually use very similar and the same type of cues for men and women, and I review this a lot in the pelvic floor, the class that I teach that is women only, but I do a lot of those cues. So for women, a lot of it is imagining that you're like suctioning something up off the floor with your muscles of the pelvic floor, right, that you're using a bunch of those muscles to suction upwards, and men kind of, I think, have a hard time conceptualizing that because of the way their parts are, right? So it does change the way that you cue them a little differently, but ultimately, and I tell men, because obviously as chiropractors, we're not asking people to disrobe during these appointments. So I tell men what we want to be looking for when they're Kegeling at home, and you are going to want to be seeing kind of the scrotum lifting as part of the Kegel. And that's something I encourage them to just look for in the mirror when they're at home.

Another question here involves breathing again. Does breathing through the mouth in any way benefit in targeting the pelvic floor, such as in cases where patients have respiratory issues or for women that are in labor or are in late stages of pregnancy?

That's a good question, and I think that would be very individual. I've never really seen anything on that, to be honest. I'm not sure that really mouth breathing or nasal breathing would make a difference. I can imagine that if someone had septum defect or something going on in their nasal passage where they were restricted from breathing, that the mouth would obviously be much more efficient. But I've never actually seen anything on that. That's a really good question. I'm gonna write that down.

Another question here is regarding kind of how you cue patients. So you had mentioned earlier that sometimes you're trying to stop patients from doing the glute clenching or straining in areas that they shouldn't be. How do you explain to them in a way that makes sense what you want them to do so that they're not clenching the glutes or straining different areas that they shouldn't be so that they can start using those pelvic floor muscles better?

That's the reason I have them palpate with their hands. So I will literally have a patient, if they're lying face up on their back and the knees are bent, I have them put their hands underneath them so they can feel their glutes, right? Or if it's the hip flexors, their hands are on the hip flexors, the adductors, the core, whatever the kind of problem area is. And I say, okay, you feel that that's tight, And as long as they can feel with their hand that that's tight, because their brain might not be able to recognize that it's tight, right? So if they can feel it with their hand, I say, okay, let it go, and tell them to just let it go on their next exhale. And then I say, okay, next time you breathe, if you feel that clench again, let it go. Do the same thing you just did. And it might take a while. It might take an entire session of getting that patient to let go. But using their own hands and their own ability of what they can feel with their hands does help improve that mind-muscle connection.

Another question that we had here regards patients that have had incontinence issues while doing exercise. As you mentioned earlier, you have had a patient that urinated every time they went into a certain level of a squat or what have you. What tips do you give these patients so that they're not afraid Afraid to exercise again? Like, do you recommend yoga? Do you recommend specific types of movements to be avoided while they're trying to train their pelvic floor?

Yeah, and I think that specific example was a patient who— it was a certain depth she couldn't get to in like a squat or a lunge. So for her, it's just a matter of, okay, well, we're not going to go to that depth. And I think a lot of times we want kind of a Shiny, glittery answer to that question, but if it's a certain depth that the patient can't handle in that movement, then just don't go to that depth while they're still healing it, right? And maybe every 2 weeks or so, if they are doing their daily breathing and their Kegel work and things like that, and you know they're diligent about it, after 2 weeks of breathing work, test it. See if they can, after 2 weeks of work, actually perform a squat to that depth or the lunge to that depth and see what happens. Just Really keep them challenged while trying to fix that issue. But I, I would say push them to what they can do without reproducing the problem.

And if you would like more information from Dr. DeMello on some of the trainings that she mentioned regarding the Kegel classes and things like that, we can include some information in that email on ways that you can get in touch with her or ways that you can find out more about other trainings that she offers as well. Alrighty guys, well, if there are no other questions, thank you so much, Dr. DeMello. We really appreciate you taking the time today.

This has been incredibly informative. Yeah, thank you guys for having me.

Thanks everybody. That's it for today's episode. Be sure to tune in for episode 9 for a new training with Dr. Dino Pappas on the differential diagnosis of heel pain. We will be discussing the most accurate ways to diagnose and treat heel pain, along with the best exercises to prescribe your patients so that they can return to sport or daily activities as quickly as possible. You won't want to miss it. Episode 9 drops in 2 weeks, or 1 week if you're one of our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, Or the podcast app that works best for you. Give us a 5-star rating to help us grow the show. Every little bit helps. Be sure to also look out for our Patreon link in the show notes to access additional bonus content, early release episodes, exclusive discount offers, and an ad-free listening experience. We are constantly adding more benefits for our patrons, so be sure to get in early for maximum value. And last but certainly not least, Please be sure to visit the show notes for a 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 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.