Jessica Drummond:
Hey everybody. It’s Jessica Drummond here with the Integrative Women’s Health Institute, and I have a very special guest for us today, Dr. Amanda Olson. She is a Physical Therapist who specializes in pelvic pain, and she originally graduated from Pacific University in 2005 and got her Doctorate in Physical Therapy in 2008 from Regis University, graduating as a member of the Jesuit National Honor Society.
Jessica Drummond:
She has been focused on pelvic pain for many years, and has a Certificate of Achievement in pelvic floor physical therapy through VA PTA, pelvic floor Practitioner Certification through Herman and Wallace Pelvic Institute. She’s also a Pilates instructor and running coach, which comes in handy because we know the pelvis is not isolated. It’s a part of the whole body.
Jessica Drummond:
She’s written several physical therapy continuing education courses, newspaper and magazine articles on women’s health, pelvic floor dysfunction and running. She’s the President and CEO of Intimate Rose where she develops pelvic health products and education, and she’s the author of the book Restoring the Pelvic Floor for Women. So, welcome Amanda.
Dr. Amanda Olson:
Thank you so much. It’s so great to be here.
Jessica Drummond:
Thank you. So, I love your products mostly because I think you’re very thoughtful about the materials and the shape and the ease of use. And today we are, let’s kind of set the stage here. We’re recording this video in the midst of a global pandemic, and so most nonessential or whatever are termed non-essential outpatient healthcare systems are really closed.
Jessica Drummond:
There’s not a lot of options for outpatient, hands-on manual therapy, because we’re trying to contain a pretty contagious virus. And there are occasional places where someone could access hands on manual therapy if you’re in acute pain. We do want to keep people out of emergency rooms as much as possible. But what we’re going to talk about today is how we can use a lot of your tools for two main concerns that we often deal with in pelvic physical therapy.
Jessica Drummond:
And the first is that many people with chronic pelvic pain have unregulated tight pelvic floor muscles and not just in the pelvic floor, but globally around in and around the pelvis. And then the strengthening of the pelvic floor muscles once the pelvic floor muscles are able to completely relax. When we can’t do it under the eyes and hands of a skilled public Physical Therapist, sometimes some of these tools can be really useful for biofeedback because great thing is, is a lot of the Physical Therapists who practice and tell about public health are doing tele-health. So, combined with kind of skilled instruction and then physical feedback from some of the tools that you’ve created, people can make sure they’re doing their pelvic health, pelvic floor strengthening and stabilizing exercises correctly.
Dr. Amanda Olson:
Yeah.
Jessica Drummond:
So, tell us where you would begin right now with doing pelvic floor down training in general, and then some of the tools you have to support that.
Dr. Amanda Olson:
Sure. From a telehealth perspective, if I couldn’t be there providing tactile cues, using my fancy imaging system and all those other things, I would start with getting the patient doing different forms of breathing and getting in tune with their breath and how that breath relates to the pressure in the trunk. Making sure that they can expand through the rib cage in all dimensions, not just up and out like we tend to think, but also down in through the back part of the ribcage and into the sides as well, and then being able to correlate that with a lifted drop of their pelvic floor. So then bringing the attention to their pelvic floor and getting them to recognize where it is. Certainly a towel roll could be used in the seated position, so if we roll that towel roll up and sit on it like a horse saddle, we could practice dropping into that horse saddle because that towel roll provides that nice little boost into the perineum.
Dr. Amanda Olson:
From there, we could certainly look at using dilators or the wand, even depending on what our relationship was prior with this patient and what we know to be true at their pelvic floor. The dilators are really nice. Please just start, because they come in a wide variety of shapes. So looking here at the smallest one, which is roughly the size of my pinky, the patient can start even at a very small level of being able to feel the opening of the vagina opening around the dilator. They can be doing some gentle compression with the breathing coupled with that breathing to feel themselves opening around the base before they start into full dilator training.
Jessica Drummond:
One thing we did, used to do too, is take two thick markers. And so if someone’s sitting on a harder surface, like a chair, maybe not a super hard chair, but a chair with a little bit of give to it, put those markers in parallel. Sort of like you were saying, sitting on the saddle of the towel roll right inside the sitting bones. So, that’s another sort of ability to have external feedback to the muscles of the pelvic floor. So you know, we’re sitting here, the sitting bones, then you’ve got a thickness of pelvic floor muscle. And if you’ve got two Sharpies or thick dry erase markers sitting right here, or having that full towel roll to sit on and relax the pelvic floor. And then, once the muscles are more globally relaxed as you’re saying, insert the smallest or the medium or the larger dilator depending on where the person was in their progression to be consciously kind of opening the vaginal opening and the smaller muscles that are more superficial.
Jessica Drummond:
So, that’s a great place to start. And then how would you progress or use the wand? Once there’s kind of that feedback of, okay, I know where my pelvic floor is. If I give it a little bit of compression with a towel roll or some thicker round markers and then you can put something vaginally, then how can the wand help us as well?
Dr. Amanda Olson:
So, the nice thing is the wand has curved edges that are designed to go into even the most deep nooks and crannies of the pelvic floor. With the first curvature here, I specifically need to be able to come in and hook puborectalis here in the very front and the longer flat side designed to come in and hook into Obturator Internus on the lateral walls and then into the deep posterior.
Dr. Amanda Olson:
So, once that person has the ability to drop in relaxed and superficial pelvic floor muscles, they could use the wand to come in, provide a little bit of feedback, just like we would be doing manually with our finger and practice dropping and relaxing gently into the wand. You know, with the wand, I always say, I know people have heard me say this a lot, “We never push any harder on tissue than we would use to check a tomato for ripeness.” But for this intents and purposes, I would recommend being really light with it and cuing that patient to be fine, pushing their body gently with that drop and [inaudible 00:07:58] into the wand, wherever it may be.
Jessica Drummond:
Ah, that’s a good tip. So pushing kind of moving the pelvic floor muscles, contracting, gentle relaxation, shifting. So actually pelvis, pelvic floor muscles into the wand versus the wand, kind of poking at the pelvic floor muscles. Do you have any other good cues? We’ve used kind of warm knife and butter. Any other visualizations that you find work well for people?
Dr. Amanda Olson:
Bubblegum … like in terms of palpating into the pelvic floor? I like bubblegum and you’re gently going to touch that bubble of bubblegum but you don’t want to pop that bubble gum, so you would come in just ever so gingerly to that bubble gum. And I like envisioning when we’re talking about drop and relax to the public floor as that bubble because it kind of gives that spaciousness, that three dimensions of coming down and out so finger into bubblegum.
Jessica Drummond:
That’s nice. And similarly that opening, you were talking about the breath work around the rib cage, thinking of kind of opening an umbrella, but you could also think of almost an upside down umbrella or a flower petal opening of the public floor. I think that idea of remembering that the pelvis is three dimensional and not, you’re not just squeezing it, releasing it, you’re lifting it, opening it. Those kinds of visuals are nice as well.
Dr. Amanda Olson:
Yeah.
Jessica Drummond:
Anything else on down training, muscle relaxation that you want to share?
Dr. Amanda Olson:
I just really, especially in this time when people tend to be a little bit more unregulated because of the circumstances that we’re under, and it could be this way for a while as we’re kind of defined and coming back into what was life before. It’s just trying to find a place in the home that they’ve probably been spending a lot of time with that feels just very safe and very comfortable and maybe even a little bit novel to them so that, sometimes in the bedroom, especially if they have pain, especially if they have pain associated with sex, there can be some feelings and emotions tied with that place. And so trying to find a place that just feels like you can just really practice and find that mindset. So it may not be the bedroom, I mean the bed is the obvious comfy place to think about doing this, but maybe it’s not. Maybe it is the living room, or maybe it is a bathroom with a yoga mat down or something. But trying to be creative in their space, especially in this time.
Jessica Drummond:
Yeah, that’s a great idea. What about, are these tools waterproof? Could you, is there any reason why you couldn’t get in a warm bath and bring this with you?
Dr. Amanda Olson:
Yes. You totally can. Absolutely. Yeah, yeah, that’s, yeah. Nice warm bath.
(**Note: Avoid submerging the vibrating pelvic wand.)
Jessica Drummond:
Okay, great. And then what about strengthening? So we have a number of patients who are struggling with pain up regulation, but then we have other patients who are dealing with prolapse, pelvic floor muscle weakness, lack of coordination. How can they help use some of these tools as feedback for strengthening and stability during this time?
Dr. Amanda Olson:
Absolutely. So, the most obvious tool would be the weights. The vaginal weights come in six different weights. They’re all the same size. The white is 25 grams. As the color purple gets darker, the weight gets heavier to 125 grams. But even in theory, very underactive low tone person with really poor proprioception, can get into a position where they’re not directly against gravity and have the weight. So we’re talking here, and we put them into say quadrant head position.
Jessica Drummond:
[inaudible 00:12:13].
Dr. Amanda Olson:
Yeah. And the weight is dropped down into the anterior pelvic floor, they can feel that sensation. It doesn’t even have to be white. If they’re against gravity, we could bump them up a little bit and give them something a little bit more middle of the road and have them activate against it. It would be the same thing as if we put our finger on that tissue inside right here. I wanted to contract right here.
Dr. Amanda Olson:
So we can put them into a hands and knees position here with it dropping into the anterior pelvic floor. We can put them into sideline position, supported, have it drop into one side and activate on that side. Certainly we want to even them out and have them do it on the other side there. We can also have them put it in and sit again on that towel roll or just on a firm surface. And then they’ve got support in the perineum and they’re able to be then directly against gravity and they’re practicing pulling it into their body.
Dr. Amanda Olson:
So, there’s just a lot of variation. And from there, once they’re able to sense it, once we get them out of that lower tone state to a place where they can feel the contraction happening, they are confident that they’re doing it right. We can then start tailoring that to more functional activities based on what their goals are. So, that’s the weights.
Jessica Drummond:
Yeah. And so you can use it even starting antigravity like with a wedge or bridging position or something just to kind of get a sensation of it. I like the sideline options and then using, being able to hold, lift and hold the weight, and then stand up or walk or squat or rotate. You know, I think those functional movements with the feedback of where is it, and not letting it sort of just hang out in a space in the pelvic floor because I think sometimes that’s the challenge with weights. They can sort of get lost.
Dr. Amanda Olson:
Right.
Jessica Drummond:
But be actively feeling the muscle tensing gently around the weights, yeah. I love that.
Dr. Amanda Olson:
Yeah. I have an arsenal of kitchen sink exercises that I love to use along those lines where I have them do a set of 10 in standing position and then I’ll have them weight shift roll up to it, a heel rise, like as if they were just doing that simple heel rise. So they’re getting that weight shift forward. And then lateral kicks up out to the side on each side and then a squat and then a sit to stand. So it kind of gets all the 360 degree view of the pelvis, very strengthening and stability, with the weight. And so they have that proprioceptive cue.
Jessica Drummond:
Nice. You know, one thing I’ve been thinking of, I used to work on a lung floor a long time ago, was kind of collaborating with, it was only because it was near the high risk pregnancy unit, but it’s all coming in handy now. And of course one of the reasons they often would call me, and this was a floor where there was a lot of patients with cystic fibrosis and lung transplant. And so we did a lot of chest PT and that sort of thing. But now one of the key symptoms of coronavirus, Covis and Covid infection. SARS Covid infection is lots of coughing. So, hopefully we don’t have too many patients who are actively infected with Covid, But I think it’s important that we consider that even though we’re doing this work of flattening the curve and staying apart, it doesn’t mean fewer people get infected necessarily.
Jessica Drummond:
It just means more people get infected over a longer period of time, when hopefully we have better therapeutics and hopefully we have maybe even a vaccine or antiviral or medications or a better medication therapy. But there are a lot of people right now who, and over the next few months who will be infected who don’t have the most severe cases needing hospitalization, but do have a lot of coughing.
Jessica Drummond:
So it could be a good idea for our patients who are kind of vulnerable, like postpartum moms or women who are runners or gymnasts or trampolinists who have that risk of having prolapse, pelvic floor muscle weakness, stress incontinence, that we can expect that some percentage of them will be infected with this infection that one of the key symptoms is heavy coughing, that we can start to build up all of our patients more preventatively to coordinate the coughing with the pelvic floor strength. Anything that you suggest around that?
Dr. Amanda Olson:
Yes, absolutely. So you know, the old, I don’t like this word for some reason, the knack, teaching them to contract prior to a thrust movement, whether it’s a cough, a sneeze or a lift. So training that coordination and then training it fast. [inaudible 00:17:06] to kick in so fast, especially with these big coughs and especially with a big sneeze. So training, the speed, the timing and the coordination of it especially, you know when they get that tickle. And I think it’s a really valid point that you made that the pelvic floor implications of this illness are great. Not in a good way, but they are significant. So, being ready to be seeing that clinically, and it’s even in the [inaudible 00:17:35], the women that have had no children, I get a lot of those questions on social media. “I’ve never had children, but I think I have prolapsed, my doctor told me I’m crazy.” I mean we just, we have to be ready for these, and to be able to take them on, and to let them know that we’re here for them.
Jessica Drummond:
Yeah. And I think there’s an important role in pelvic health, rehab, and rehab in general and restoring energy, the fatigue that can come along with this. And even people who maybe are not infected, but have been really kind of just sitting around in their house for weeks and weeks, 10 days. I think it’s, no, it’s three days. The original studies were done on healthy collegiate men. Putting them in bed for three days was very significant. Just deconditioning. So, people hopefully are doing some degree of home workouts and daily walks outside as much as they can depending on where they live. But I do think we have to, as rehab professionals, be prepared for a general level of deconditioning in our clients who, we’ve been on official lockdown for, this is our almost our fifth week. So, and we have a couple of weeks to go before the peak here in Connecticut and the rest of the country’s a little bit behind.
Jessica Drummond:
So I think that we have to be thinking ahead to how are we going to be supporting the population a little bit differently when we get back to it. So those exercises are so key.
Dr. Amanda Olson:
Yeah.
Jessica Drummond:
All right. Well thank you so much Amanda. Anything else you want to add that you think can help people during this time, or in general in terms of utilizing the tools that you have? One thing I do want to ask you about real quickly is you mentioned the dilators. So the dilators are really valuable for stretching, but I saw when we last were in person not too long ago that you now have a handle. Tell me about that.
Dr. Amanda Olson:
Yeah. Yes, absolutely. I’m really proud of this. So this is our handle here and each handle comes with bands that accommodate every single dilator. So with the handle comes three different silicone bands. What the patient will do … so this is for our patients that need either A. a little bit of help with reach for, perhaps they have shoulder problems or back problems or wrist problems where the general angle of trying to get a dilator into their vaginal canal is challenging. So this is designed to have a curve. They can come in through the front, they can come in through the back, they can come in on the side. So it gives them some variability.
Dr. Amanda Olson:
Another population to consider is people that are just not ready to touch themselves. They’re just not quite ready to touch their body. They need that space. They need that distance as they’re beginning this process. So, the patient will load the dilator into the band and from there, they will load the band onto the dilator and then they have that extra dexterity that they can use to help with their dilator training.
Jessica Drummond:
Excellent. I think that’s a great tool because I think we have to be really adaptable and accessible for all populations who are struggling. Well, thank you so much, Amanda. These are really valuable tools. I use them all the time in my practice. Recommend them highly. I think the materials that you’ve chosen and the thoughtfulness around how we can use these very clinically, but comfortably and safely and adaptively is it really kind of bubbles to the top when we make the choice to use these products. So, thank you.
Dr. Amanda Olson:
Thank you so much. I appreciate that.
Jessica Drummond:
All right, thanks everyone. Hopefully that gives you a few more ideas for how to support your patients and clients while you are doing much more tele-health and in person health. And then you can bring this back to the clinic when we all eventually open back up. Thank you. Have a great day everybody.
Dr. Amanda Olson:
Thank you.
Jessica Drummond:
Bye, bye.
