Running While Postpartum (and Perimenopausal!) with Dr. Carrie Pagliano

Dr. Jessica Drummond 00:00:03 Hi and welcome to the Integrative Women’s Health Podcast. I’m your host, Doctor Jessica Drummond, and I am so thrilled to have you here as we dive into today’s episode. As always, innovating and integrating in the world of women’s health. And just as a reminder, the content in this podcast episode is no substitute for medical advice, diagnosis, or treatment from your medical or licensed health care team. While myself and many of my guests are licensed healthcare professionals, we are not your licensed health care professionals, so you want to get advice on your unique circumstances. Diagnostic recommendations treatment recommendations from your home medical team. Enjoy the episode. Let’s innovate and integrate together. Welcome back. Hi there. It’s Jessica Drummond here. Founder and CEO of the Integrative Women’s Health Institute. Today I have the honor and the privilege to interview my friend and colleague, Doctor Kerry Pagliaro. Doctor Kerry has been a practicing physical therapist for more than 20 years. She received her master’s in physical therapy from the University of the Sciences in Philadelphia in 1999, and her doctorate in physical therapy from the University of Saint Augustine for Health Sciences in 2007.

Dr. Jessica Drummond 00:01:36 She’s a double board certified clinical specialist in both orthopedics and women’s health, and holds manual therapy certification from the University of Saint Augustine for the Health Sciences. What I love about our interview today is Kerry really combines her deep knowledge of orthopedics and sports medicine, specifically in running and CrossFit strength training. With her deep knowledge and care for women in the perinatal and postpartum period, and increasingly in the perimenopausal period. And look, if you are a postpartum and perimenopausal, you’ve got to listen to this, especially if you love to work out. And even more, especially if you love running. This conversation is so important because we’re going to be talking about the intersection between all of these deep subspecialties, and why helping keep women active despite the intense pressures on them. To juggle it all, do it all. Do everything perfectly. Have a laundry list of more things to do, more workouts, and more physical therapy exercises, right? That we need to learn a different way to really help these women. And we’re also going to have a really important conversation about how if you are a generalist health and wellness professional, even generalist in orthopedics, or generalist in sports medicine or generalist in women’s and pelvic health, you need to start to meet and get to know the deep specialists in certain little micro niche areas, or become one yourself if you’re interested in that.

Dr. Jessica Drummond 00:03:20 And then finally, you’re going to learn why you have got to become a health coach. Absolutely. Every health or wellness professional needs to deepen their skill set of health coaching. Listen to what Kerri says about that and enjoy. And I will see you on the other side with a few nuggets that you can integrate into your life and your practice this week. Hi and welcome. It’s Jessica Drummond here from the Integrative Women’s Health Institute. And I am here with Doctor Carrie Pagliaro. She is a physical therapist that is specialized in working with postpartum moms, getting them back to fitness and in particular running. So, Kari, welcome, welcome. And let’s dive into why you started focusing your practice in this population.

Dr. Carrie Pagliano 00:04:15 Yeah. Thanks for having me, Jess. It wasn’t the plan, let’s put it that way. I’ve always been a runner my entire life. Back to, like, seventh grade. And we all go into physical therapy because we want to help people. And I got really lucky being put in the right place at the right time going into pelvic health.

Dr. Carrie Pagliano 00:04:31 At the same time, I was also doing a lot of orthopedics, and this is 20 some odd years ago where they were very separate. And lo and behold, years later we mashed them up together. We get a lot further, and we also have a lot more women and moms being active, including myself, after having kids. And so I think that personal interest and that professional need happened to collide at the same time. And then now more recently in the last, I would say 5 to 7 years, we’ve got a lot more research focused on that. So it’s a really, really fun time to be in that space. And it’s always fun to study and learn about things that you do yourself. So I got super lucky in that respect.

Dr. Jessica Drummond 00:05:11 So tell us a little bit more about your story, or any client patient stories that really deepened your perspective or changed how you were thinking about these two issues of running and being postpartum?

Dr. Carrie Pagliano 00:05:26 I mean, you kind of have to look back and understand not only how we used to look at these issues as professionals, but also as moms trying to navigate what was going on.

Dr. Carrie Pagliano 00:05:37 So backtrack. 15, 20 years ago, we would just say, well, just run and see how it goes. We didn’t really have a lot of guidance or ways to screen out injuries, and even if we did, we didn’t really have a good understanding of why somebody had leakage versus another patient, or why somebody was experiencing prolapse symptoms, but they didn’t necessarily have any topical prolapse. And so we didn’t understand as much as we understand now and then. Same thing with running, to be honest. So we had these two kind of parallel paths. And alongside we’ve got a third path where we have women starting to be more active. And so myself, I ran recreationally through college, after school, that sort of thing. I had actually hip surgery in, oh gosh, I think it was 2007 for femoral acetabular impingement and a labral tear, which that was really new back then, and then went on to have my oldest son. He is oh my gosh, he’s almost 14, which is insane.

Dr. Carrie Pagliano 00:06:38 So he was born in 2011. So really that period of time I was trying to get back to running after hip surgery didn’t really get that far because again, we didn’t have great rehab and then trying to get back after having a baby because you’re supposed to bounce back. I mean, that was still the thing back then. And the problem that I found is there really wasn’t any guidance on how to do that. And here I was, this person that supposedly had this background in orthopedics and this person that had this background in pelvic health. And if I didn’t know what to do, how was anybody else going to figure it out? And so that’s around the same time that kind of this mashup of looking at the whole body, really, I think, started to become real and to understand the role of the whole body beyond just the pelvic floor in leakage with activity and impact, with prolapse symptoms. And ironically, after my second in 2013, I had stress urinary incontinence, I had prolapse symptoms and was navigating abdominal separation or diagnosis recti.

Dr. Carrie Pagliano 00:07:42 And again, like if this is what’s going on with me and I’m supposed to know all this stuff, what’s the path forward? And I kind of had two choices. It was either give up what I loved to do because that’s all the information we had, or look for a new path and see if I can figure it out. And I wasn’t interested in giving up running. When there’s a will, there’s a way. And so fortunately, I wasn’t the only one kind of looking at this path and kind of looking at that mash up. And so fast forward to now, we have so much more women in research that are looking to answer the questions of like, what actually happens in women with their pelvic floor, and then what changes during pregnancy, what changes in postpartum, but then also this parallel path in the orthopedics of how does our body mechanics change when we run in pregnancy? How does that carry over into postpartum? How should that guide what we do as far as getting people back to activity? And how does that give us some insight in how to navigate some of these pelvic floor issues that keep women from being active? So it was one of those things where I wasn’t willing to accept? No.

Dr. Carrie Pagliano 00:08:50 I’m not good at that. So.

Dr. Jessica Drummond 00:08:53 Yeah. Yeah. So now say a client comes to you. They’re past the really acute phase, but maybe five months postpartum wanting to get back to, I would say, like, strong recreational running. Like, she wants to be able to run in road races in her town. And she has, you know, a five month old. She’s given birth relatively recently, and she is noticing a little bit of leakage. And she might have even had it pre-pregnancy, but sort of ignored it then. But now it’s becoming difficult to ignore. Where do you begin?

Dr. Carrie Pagliano 00:09:32 With everybody, I like to kind of lay things out across the lifespan, because I think that assumption that all this stuff happened because you gave birth isn’t necessarily accurate. And so the example you gave, you know, maybe she had a little leakage before she was pregnant. That to me, you know. I want to know what sports people did growing up. I want to know, you know, did they have any issues with constipation or hemorrhoids or leakage, like you mentioned? Because then we’re looking back and saying, are there any genetic predispositions or are we concerned about hypermobility, Ehlers-Danlos.

Dr. Carrie Pagliano 00:10:03 Like, it gives me an understanding of what their muscle strategy was and activity prior to even the increase in hormones that comes with pregnancy. I want to understand how the pregnancy was where there were any musculoskeletal issues, you know, with back pain, see pubic bone pain, were they able to maintain activity? And just a piece of it is that delivery and what happened there? I mean personally I with my oldest, it was a three day induction that unfortunately ended in a C-section that was unplanned. But you can still have pelvic floor issues with C-sections. That’s the other thing people don’t realize either. And so we’re taking all these pieces. And then what did that early postpartum look like? Were you able to get out walking? You know, were you able to get sleep? What did your nutrition look like? What did stress look like? Is your baby having feeding issues? Any issues with postpartum depression? We know all this stuff plays a role in our ability to be consistent with activity, and you can’t tell what tolerance is until you’re consistent.

Dr. Carrie Pagliano 00:11:07 And then from there, did you have any help? Did you see a pelvic floor physical therapist within the first couple weeks afterwards, or did you just DIY start running at six weeks? You’re not doing any strengthening, that sort of thing. So I’m trying to get initially, what are we walking into and where might be the quickest opportunities for change? Because as you know, as a mom, the goal is how little do we need to do so? No one dies and we need to like I need quick wins. Yeah, yeah yeah yeah. Because I think if we have barriers up of these very dramatic over detailed sort of processes that require too much time. It’s not an actionable path forward. So where is the likely problem? Is it a pelvic floor issue? I talk about it kind of like a recipe for a soup. Like what are all the ingredients? And how much of what? And what are the ones that we kind of have to pay attention to the most? And what are the easiest wins? And if we start to kind of go about it in that very intentional way with the goal that if you are going to go back to running, we need to have a regular strength program.

Dr. Carrie Pagliano 00:12:18 And a lot of runners don’t because they just want to run. But it’s imperative. And then we need to have an impact program too, which again, everybody dropped back in high school when they stopped doing their, you know, their drills and things like that. We need to get back into that. And the good news with all of this is if we get all that set in place and we get on top of symptoms, we address any hormone issues if they’re lactating. All this stuff that we learn in postpartum. We’re going to take that forward into perimenopause when we need to be concerned about bone health and tendon health and changing estrogen. Again, I kind of present it in a way that we’re not just learning it for this moment. You’re understanding how you got to this point, but we’re going to carry this forward to allow you to be active in very, very long term.

Dr. Jessica Drummond 00:13:03 So ideally, when would you see any active postpartum woman like pre-pregnancy. You know, because I think one of the things that happens in our categorized or divided health system is that any active woman who is going to be pregnant and postpartum is going to have these hormonal changes, just like every woman, if they live long enough, are going to go through perimenopause.

Dr. Jessica Drummond 00:13:30 Every woman who is pregnant or postpartum is going to have these hormonal changes. And, you know, assuming we want women to stay active and exercising and strength training and running, if they enjoy it and all of these things. What is how are you sort of reaching this population as much as possible?

Dr. Carrie Pagliano 00:13:50 I mean, the earlier the better to have these conversations, for better or worse. I live in the DC metro area and we pride ourselves on being overeducated about everything, which is good news, bad news when it comes to kids, because they’re unpredictable and you can’t plan for everything. But I have moms that even reach out when they’re considering conception because there’s things, again, that we can do. And again, if we know in advance there’s issues with high tone or non relaxing pelvic floor, we know that there’s issues with painful sex or things like that. We can start having those conversations on how to lay this process out. Now if somebody is pregnant usually we’ll see them after we know that that pregnancy is viable.

Dr. Carrie Pagliano 00:14:30 Obviously we can see them before, you know, for any musculoskeletal issues like see pain or things like that, that can happen with hormone flux. But we start having those conversations as early as possible, even if they’re not having issues just to educate them. Because as many of us have seen, we see them in postpartum for the first time and they’re like, oh, well, I couldn’t be as active because I had symphysis pubis pain or pubic bone pain, or I stopped running because of sacroiliac or back pain. Those sorts of things. And those things are really easily addressable during pregnancy. And some of the things that we’re trying to look at is if we address those issues, is there an impact on potentially reducing likelihood for birth injuries? Is there an influence there on high tone or non relaxing pelvic floor? Can we teach down training better. You know can we have an impact on the front end and not be reactive. So to your point I think historically we’ve always been known as the fixers. And it would be really, really nice if we could do more prevention and education on the front end and be very, very proactive.

Dr. Carrie Pagliano 00:15:39 And again, we can’t control everything. But can we highlight where there’s potential risks or things that we might want to pull in. A post-partum or pregnancy doula or something like that for more support. I love doing that because again, like it’s a lot easier to navigate those pieces and there’s a lot less trauma involved than when you’re trying to heal injuries. You’re trying to figure out how to be a parent for the first time. You know, sleepless nights, those sorts of things. That’s just hard. So if we can do it on the front end, when people are a little bit more of sound mind and body, it’s a lot easier for everybody.

Dr. Jessica Drummond 00:16:14 Yeah. And what you said earlier about hypermobility, I think is so important and really under addressed. And I don’t know if I’m seeing this more or I’m more aware of it, but I think a lot of people think if you are hypermobile, let’s say you grew up as you were kind of naturally drawn to things like dance and maybe even swimming, maybe even running because of like the tall, thin billed as going to be the most successful high school runner.

Dr. Jessica Drummond 00:16:41 Let’s say there’s a myth that your muscles aren’t going to be tight, that everything is just loose. So talk a little bit about the interrelationship between hypermobility and myofascial tension.

Dr. Carrie Pagliano 00:16:54 I think this is one of the concepts that has evolved and allowed me to look at how we treat athletes in a much better way. Back in the days, you remember, the way we looked at the pelvic floor was typically postpartum issues, was always a weak pelvic floor, and pain with sex was usually a high tone or a tight pelvic floor. There was no overlap. And what we’re kind of understanding a lot more now is a lot of postpartum injuries, stress, urinary incontinence, even pelvic organ prolapse symptoms. We’re noticing that it actually is a little bit more high tone. And so when we go back, like you said, this is a question I asked. I’m like what sports did you do. Did you know, were you figure skater. Were you a dancer, gymnast? All those sorts of things because you’re going to gravitate to where that skill set shines.

Dr. Carrie Pagliano 00:17:43 That was not me. And my theory is, during that time that you were doing those sports and active, you’re so active that you are maintaining stability strategies and strength strategies through that movement spectrum, sometimes in a very, I think, efficient way and sometimes not. I do think when there’s more aesthetics to the activity, say ballet or gymnastics or things like that, where we’re taught to suck things in and hold it in more for aesthetics as opposed to movement efficiency. I think there’s another layer to that. And then my thought is that as we get older and we’re not participating in those sports anymore, your brain’s looking for a replacement there. And if we’re not staying active, your brain’s like, all right, well, how do I maintain that stability if I do have this genetic Hypermobility. And the thought is that the brain’s like, all right, well, let’s just hold here. Or these movement strategies that you learned in ballet class, you know, when you were three, 4 or 5 years old, have carried on through in diet culture, all that other stuff where you’re supposed to suck things in and hold it in.

Dr. Carrie Pagliano 00:18:50 These things have been reinforced because they’ve been taught at such an early age. So the thought is that now you’re an adult, you have these adapted strategies that you don’t think anything of because you’ve been that way your whole life. But does that set you up for other issues? And sometimes I think it’s obvious painful sex. Obviously it’s pretty obvious, but I think there’s other things that are less obvious that people don’t necessarily put together, like urgency, frequency, constipation, hemorrhoids, those sorts of things that are a little bit more normalized. And so again, these are the questions that when somebody is pregnant, it’s really easy to kind of pull that story together and be like, hey you. You may not be having symptoms that made you come see me in the first place, but I do think you’re at risk for this. I’m not going to necessarily change your genetics. I’m not. Between now and when you give birth. But what can we do to take the edge off? What strategies can we use to make that strategy that your brain’s adopted more accommodating for? What’s to come and be supportive of it? And then on the other side of it.

Dr. Carrie Pagliano 00:19:52 And this goes kind of full circle to where I started. There was a long time where a lot of physicians who worked with patients with pelvic pain or like, don’t do strengthening. Strengthening makes your muscles tight, which I think everybody adopted that for a really long time. Unless you’re in that space. And I started doing CrossFit probably about 7 or 8 years ago and started to realize because I would have clients that would come in, like, if we’re going to try and relax those muscles, we need to give the brain an alternative, because if it’s this inefficient holding and we don’t give it an option, you get those muscles to relax. It’s going to go right back to what it did before. So what’s the alternative? And the alternative is to actually provide some good strengthening throughout that range of motion. And so this idea that people with type pelvic floors shouldn’t be doing strengthening, I think that’s completely untrue. We need to give them some efficiency. We need to get that movement back that they had when they were kids and get that strength back because they were using it.

Dr. Carrie Pagliano 00:20:51 We just don’t look at it that way. Going to dance class as an adult, it’s very different than doing dance class as a kid. But how can we find ways to move that allow support for that genetic hypermobility?

Dr. Jessica Drummond 00:21:04 You know, we do have a fairly strong audience of women’s health and wellness professionals. So speaking a little bit extra nerdy here for a second. So I think a couple things happened. You talked about you work with women through the lifespan. Right. So you have girls who are going to ballet, going to gymnastics, their strength training almost naturally by body weight, by movement patterns, by skills, whatever, whether they’re doing it competitively or they’re doing it for fun. It’s still that full system like stability, just because their brain is learning about holding their body in space before they even have so much estrogen, then they have the added estrogen, but it’s inconsistent initially in puberty. Then we have pregnancy where you have both changes in estrogen and dramatic changes in progesterone, and your whole body is changed.

Dr. Jessica Drummond 00:22:04 You’ve gained weight, you’ve moved your center of gravity, you know, and it happens sort of slowly and then sort of quickly at the end. And I think the other thing that happens when you think about lifespan, so then you get to postpartum and physiologically you lose that estrogen support. You’re in that kind of mini perimenopause if you will. You’re in a low estrogen state. You have other hormonal changes. You’ve also lost the stability of having something sort of pressing into your abdominal wall. But I think the other main thing that happens between post-partum and perimenopause is then you also have kids.

Dr. Carrie Pagliano 00:22:42 It’s just a small detour.

Dr. Jessica Drummond 00:22:46 It’s a small detour, but I think it’s like we always kind of forget about that. Like even though you might have even in pregnancy, even in, you know, even in your 20s and 30s or whatever, done strength training, gone to adult ballet classes, went to Pilates like you might have done, all these things that sort of accidentally kept you stable. You don’t now and then you sort of maybe pick one thing running because other moms are running and pushing strollers, or it’s easy to go out and put your shoes on and be out for half an hour.

Dr. Jessica Drummond 00:23:18 And it’s funny because I was never a runner when I was young in PT school, I picked it up because of course everyone’s competitively doing triathlons and whatever. So And then I met my husband in a running club. He’s a huge runner.

Dr. Carrie Pagliano 00:23:32 I saw that.

Dr. Jessica Drummond 00:23:33 Yeah, he still loves running and he’s been doing it same as you like since he was a kid. Little kid. I never loved it, but it was like very social for me and it was fine. I would do the five K’s and the ten K’s, and then after I had my kid, my oldest daughter, I started running five K’s and ten K’s because it was the only time I was alone. I was like, I needed 30 to 60 minutes. I was happy, I was slow because I’d be like.

Dr. Carrie Pagliano 00:24:00 It takes longer.

Dr. Jessica Drummond 00:24:03 You know? I was by myself for like an hour and especially the races. I was like, I’d be out there, there’s no kids allowed. Like you’re not allowed to bring the stroller.

Dr. Jessica Drummond 00:24:14 So I think one of the things that’s a really important piece of this puzzle here is what you’re saying about people then shift to because especially if they are natural runners like my husband, to get them to strength train is pulling teeth, but he still races at like under a seven minute pace. He’s, you know, 65 years old. He loves that. But you can tell it’s starting to be not really good for him, right. Like he’s a man so he has a little more flexibility. He’s not hypermobile like all these things. But even now he’s like, oh my knee, oh my hip. You know, I was like, well, if you drink train. But I think for moms, one of the big important things is I think letting them know that while there is not as much time to do all the different kinds of training that you wanted to do efficiently, adding in a few things makes a huge difference to your long term viability in any of these sports.

Dr. Carrie Pagliano 00:25:13 Again, I think this is a parallel that we now understand in just running period.

Dr. Carrie Pagliano 00:25:20 If you look at the generation of moms that are ahead of us, that it was revolutionary for them just to run as moms. Strength training was not part of their training in their 20s. It was definitely not something that was the focus. And a lot of them now in their late 50s, early 60s, are not running anymore. They’re switching over to other things like gravel biking because they just can’t anymore. They’re burnout and they’re injured. And I think we’re going to see a shift. And I think you and I are kind of this middle. It’s kind of like typing and writing like we do a little bit of both, right. You know. Right. Right, right. So we’re that generation that we understand the benefit of strength training now later on. And then as we’re going into perimenopause, menopause and strength meaning like lifting weights but picking up heavy things and putting them down. What we also understand now in the running literature is you’re going to have better performance if you do resistance training, and there was a recent paper out looking at resistance training versus plyometric training and five K time trial time.

Dr. Carrie Pagliano 00:26:30 You’re going to be faster with resistance training even over plyometrics. And so now that we kind of have that parallel data, granted a lot of it is male, but we’re extrapolating. I think you have more runners that are running in their 20s. There’s a popularization of strength training and running. And so again, I think the sooner we can get generations like our kids to understand the benefits of strength training and normalize it, because I don’t think it was normal for us to go to Gold’s Gym and like, you know, lift heavy in the corner with the dudes and their tiny little tank tops and they’re Arnold Schwarzenegger. Muscles. Like, that was just the generation we grew up in. But if we normalize women picking up barbells and it’s normal, and that if you are going to have longevity in running, which now it’s more socially acceptable that we should be able to try and do this. We need to do these other things as well. And so that’s why I kind of preach. But again, it can be incredibly overwhelming as a mom to be like, oh my God, that’s one more thing.

Dr. Carrie Pagliano 00:27:30 So understanding, okay, what does that mean to do strength training? I’m like, that means I maybe give you 3 or 4 exercises that if you can get to twice a week, great. Or if you’re like me, I have a class that I go to twice a week that it’s a CrossFit style class. I get my Olympic lifting in, and then there’s a conditioner. I go and I bang it out before the kids get up and it’s done. And I have a couple, you know, running specific things that I do aside of that, like it’s about efficiency. You don’t have to do all the things all the time. But if you check a little bit on each box, what we understand now is if you strength train and kind of replace one of those extra runs with a strength session, that’s going to mean your faster. That’s going to mean less likelihood of injury, improve bone health, tendon health, all sorts of things. And so when you look at it that way and you make it really simple, I think it makes it more actionable for moms.

Dr. Carrie Pagliano 00:28:23 But again, it’s about getting that messaging and normalizing strength training. Even before the idea of becoming a mom crosses their mind. So my daughter, who’s 11, she understands picking up heavy things. That’s what moms do. I would love her to do that when she’s ready. It’s these changes in societal expectations and then also changes in our understanding on what supports a runner’s health and longevity.

Dr. Jessica Drummond 00:28:51 And I think this is where in postpartum and kind of the space between postpartum and perimenopause, we also want to be checking cortisol levels, stress hormone. Because I think the problem is, is modern motherhood.

Dr. Carrie Pagliano 00:29:07 Is you could just put a period right there. The problem is modern motherhood and motherhood.

Dr. Jessica Drummond 00:29:13 Honestly. Yes. And so if we look at that and I think what you said about replacing one of the runs with a string train is really important. Like the problem is, is that women are burned out, but it starts when they’re like nine, ten, 11. And so we really have to look at cortisol before we even kind of adjust their training program, because we have to think about how physiologically burned out their systems are so that they’re not actually creating things like cardiovascular disease in a relatively low estrogen state when they’re doing this exercise, sometimes to be healthy.

Dr. Jessica Drummond 00:29:56 So I think that’s another conversation that is really important in this phase.

Dr. Carrie Pagliano 00:30:01 You know, it’s kind of deja vu in the perimenopause space right now. I’ve been in it personally for about a year, and it feels like everybody’s throwing expectations from every different direction. I’m like, this is what you should be eating, and this is how much you should be sleeping and this is how much you should exercise. And again, like just that list increases stress, you know. And so again, it’s taking a step back and being like all right what’s the cost benefit ratio here. Like what are the easiest things for me to do. Because you don’t want management of this phase in life to be an additional stressor. Like you said, it’s funny. You know, we all do the comparison game, remembering our mothers at our own age and what they had to navigate and manage. And they’re just very, very different expectations. I blame the oh, what was that book? Sheryl Sandberg wrote it. Oh, Lena.

Dr. Carrie Pagliano 00:30:52 Lena. I was like, that was a setup.

Dr. Jessica Drummond 00:30:55 Well, you know, and I think it’s. Yes, you can.

Dr. Carrie Pagliano 00:30:58 Have it all. Yes. However.

Dr. Jessica Drummond 00:31:02 Yeah, that was a core problem, but I think it’s actually deeper than that.

Dr. Carrie Pagliano 00:31:07 And I’m sure that.

Dr. Jessica Drummond 00:31:09 You know, one of the things I’ve been focusing a lot on with my clients, because I have a lot of clients now with chronic illness who are Perimenopausal. And they’re trying to figure out, like, is it long Covid? Is it perimenopause? Is it.

Dr. Carrie Pagliano 00:31:23 That’s a differential diagnosis, right?

Dr. Jessica Drummond 00:31:26 You know, is it danlos. Is it MCAS. Is it dysautonomia.

Dr. Carrie Pagliano 00:31:31 Is it all the same presentation. And all are like similar things of postpartum too. So it literally just blurs one into the other.

Dr. Jessica Drummond 00:31:39 Right. So I think we’re now meeting women in their 30s who are sick. And I think it’s important that we really stated that way because they’re being so gaslit and they’re like, run harder, lift more, eat more protein.

Dr. Jessica Drummond 00:31:56 And like the tricky part is that’s also true. But here’s the thing that I’ve been spending a whole lot of time in, in my practice is teaching women how to really rest.

Dr. Carrie Pagliano 00:32:13 Well, and again, like, what do they think rest is? What are their thoughts around rest? What did they grow up like? That was not in my household. Growing up, that was not part of my upbringing. You know, and again, I think if you look at generations and how are we teaching our kids about the benefits of it? And we’re not even talking sleep here like we’re talking just rest in general. And I think the average person doesn’t necessarily truly understand what that looks like. And also understand that you need to dose that as well. That’s a conversation I have frequently in the context of when moms are returning to activity, always the rest is minimal, and then they just try and do more with the activities, which I think is a very symbolic representation of kind of what we’re talking about.

Dr. Carrie Pagliano 00:33:04 And I’m like, you can get further with really efficient work and also be cognizant of intentional rest. But again, I don’t know that people understand what that truly means and how to truly implement that intentional rest. I’m going to ask you. I mean, like, how do you navigate that with people, what it means to them and, and what maybe it should mean for them?

Dr. Jessica Drummond 00:33:29 Well, I start with that acknowledgement that you just said that, like we literally were not trained in this. And then we start with, what are you doing now? What do you think and feel? Rest is this is one of the reasons why I actually am really committed to using things like heart rate variability, measurements, and like that wearable data that we have, I think is so valuable. Or my continuous glucose monitor we’ve got I’ve got some stories on that, but we don’t really know this now. I’m lucky. So I’m 50 now. My mom is in her late 70s and so I had a stay at home mom, but I had like a busy stay at home mom.

Dr. Jessica Drummond 00:34:09 Like your stay at home mom who was volunteering at school, and she had three kids and my dad used to travel full time, but my mom always was a napper and wow. And she also is a person who naturally or by design, I don’t know. But she under reacts those two values that I kind of picked up by osmosis, I think are the most important tools because I’ve read hundreds of meditation books and pain brain remodeling strategies and all this stuff, and it really boils down to be present and under react. And so there’s a couple things that we do. One is we get really clear on the woman’s vision because it matters what she actually wants to do versus what she’s doing. Because you’re supposed to.

Dr. Carrie Pagliano 00:35:04 Write, she thinks she should do. Yep.

Dr. Jessica Drummond 00:35:06 And that, I think, is a really wake up call in and of itself is like, what the heck am I doing? You know, I’ve had clients literally, like, quit their jobs, move, sell all their stuff. Like, people really can dramatically change when you ask them that question.

Dr. Jessica Drummond 00:35:22 But then the second piece is, okay, let’s say they generally like their life and they don’t want to like, throw it all in and move to a cabin. Right? Most people are like that and that’s fine. So that’s where we start with that question you asked. What are you doing now for rest? And usually the answer is watching TV or scrolling. And the problem is, is that that’s not actually neurologic rest. So one of my favorite examples is, I don’t know, two years ago or something, I watched this documentary about a bunch of NFL quarterbacks. So they get hit every weekend like multiple car accidents, whatever. And then but they have a very slow get back into the week. And it starts with things like literally hyperbaric and sleep. Like lots of sleep and very little strength. A lot of mobility, stuff like that. And so ideally you’re not going to do this every single week. But it’s the same kind of pattern. You know, you’re not going to like destroy your body every single week and then try to heal it.

Dr. Jessica Drummond 00:36:31 Here’s where women struggle. And I think the thing that’s the most important thing. What is absolutely relaxing? Fun. Resting your brain. That’s what they don’t know how to do. And so we discover things like literally just sitting outside, things like watercolor or coloring, like things that they’re not good at. It’s just messy. Sometimes journaling can be that kind of rest. Meditation, which is hard at first. But when people become even a little bit more skillful, it can be real. Brain rest. So I think you have to actually train it, because we’ve learned it even less than we’ve learned. Strength training and get out and exercise. It feels weird at a root level because we are, and certainly our kids are, and accelerating products of intense late stage capitalism. Right. So we were literally trained to be very, very productive.

Dr. Carrie Pagliano 00:37:43 Yeah. It’s funny as you’re talking, I’m thinking a lot of those examples. I mean, should rest be for the privileged. And I think about growing up, both my parents were teachers.

Dr. Carrie Pagliano 00:37:53 My mom didn’t go back to work until I was 7 or 8 or something after my little brother was born. I’m not going to lie, at the beginning was little House on the Prairie like my parents built my house. We went into our woods and we cut down the trees, and that’s what heated our house. We had a huge garden for a long time. This is all. Before they decided to hit the road in the summer and we traveled in our RV every summer when I was a kid after that. But I think about all of the things that needed doing, and one of the things that was a constant concern and worry for my parents was once it was spring, we had to make sure that there was enough wood in the shed so it could dry over. And this is like cords and cords of wood, like a lot of wood over the summer, so that it could dry in season so that we had it to get through the winters. And then back then in Western New York, you could have very cold, snowy winters.

Dr. Carrie Pagliano 00:38:42 And I remember these are like days where you’re going out and you’re doing repetitive tasks. And as a kid you don’t want to be doing that. You’d rather be doing a lot of things. And I do very much remember now, like you go out and be all pissed off and be like, oh, I’ll be here. You know, typical teenager.

Dr. Jessica Drummond 00:39:01 Any ten year old, any 12 year old. Yeah.

Dr. Carrie Pagliano 00:39:05 I’ve been thinking about this lately because I have a 13, soon to be 14 year old son. And so it’s like, how did I navigate this stage? And I would start that way. But like the repetitiveness and we would be out there with each other outside. And the idea my dad would cut a tree down, he would say he’d buck it up with a chainsaw and, you know, chop it up. And then we put everything in the, in the this big trailer. He’d take the tractor back down to the house. We’d have to take everything back out, stack it again like it’s not.

Dr. Carrie Pagliano 00:39:33 Other than the chainsaw. You want to be very intentional when you’re using a chainsaw. which, of course, which I didn’t. My dad cut himself once in the ankle, and that was not good. no. But this very repetitive task in which you’re surrounded by family, it was necessary to do it, was physical labor. But I remember without fail, by the time we all went back in the house to get showered up and cleaned up, and there was a sense of contentment and satisfaction for a lot of different reasons. And that, to me is something that when you are in a position where you don’t necessarily have the ability to do watercolors or this or that or whatever, the time or resources, opportunities to be present in repetitive, kind of thoughtless sort of things, to be around people. Because, again, I remember being very upset, but by the end, my mindset had shifted, which I think speaks a lot to do. We have repetitive things in our day that could become restful, and there’s certain things I obviously don’t stack wood anymore, but in Arlington, Virginia.

Dr. Carrie Pagliano 00:40:38 But I definitely do the dishes and load the dishwasher and just changing that mindset on, you know, the kids not putting their dishes in the dishwasher. And even last winter, our dishwasher was broken and couldn’t be replaced for a month. And having to wash dishes. Just can you be intentional with those sorts of things? Is there an opportunity for quote rest within that is just a different way of looking at it. It doesn’t necessarily have to be this thing that requires so much privilege I guess.

Dr. Jessica Drummond 00:41:05 I agree, and I think this is where it gets complicated and it has to be interjected into whatever the current client’s life is. It’s also very similar, though, to how we would add strength training or change our running program in the sense that, you know, literally in like the Buddhist culture, it’s like chop wood, carry water is, you know, is meditation, right? So I think you’re exactly right that what I think most modern mothers need, who are in kind of like a fast paced, they have a job, they’re in front of a computer, they’re in front of a phone, whatever.

Dr. Jessica Drummond 00:41:45 And they’re juggling children and all the mental load. They actually need more neurologic rest. So it’s not even so much physical rest because physical movements can be meditative. So I think you’re exactly right. It could be washing dishes. It could be cleaning. It could be walking the dog. It’s like, could you do some of those things? Where we start often is, can we just do some of those things without our phone?

Dr. Carrie Pagliano 00:42:13 Yeah. The other place that I find is such a great opportunity to just be aware of the impact of breathing patterns and tension patterns and things like that, our transitions in our day. If you are in a very car based society, the nice thing about turning on a car is if your external cue is okay, I’m going to just take a minute and sit here and breathe before I turn the car on. Let’s say you forgot that and turn the car on. Okay, here’s here’s opportunity number two after you turn the car on. So you’ve got two chances to get it.

Dr. Carrie Pagliano 00:42:45 And I those transitions. I know for me, when my kids were little going from work and then walking to go pick them up in that five minute walk from our house to school, I’d take the dog with me. Like that was an opportunity for me to just switch hats, clear the air. Because as you know, when you pick up kids from school, activities, daycare, whatever. It’s kind of like a live grenade. You don’t know if it’s going to go off. And even now, with teenagers, like they have their buffer time, but I don’t know what’s coming home and holding space so that you can transition. You can kind of put that hat aside from work or whatever that may be, so that you can have that space for yourself for a second and then be able to prepare and receive whatever’s coming next. I think allowing and expecting the need to have that space like you mentioned, like mentally, neurologically, I think that allows you to kind of keep that down during the day.

Dr. Carrie Pagliano 00:43:45 So you’re not trying to fix everything at the end of the day. And again, it’s that multitasking thing that we’re taught to be productive, like you mentioned earlier. I am a mom. If I’m trying to do work stuff and deal with kids stuff at the same time, and I’m not a great provider when I’m trying to navigate kid stuff too. And fortunately, I work mostly with moms so they understand. It’s nice when you work with an understanding group of people. But again, like, we’re more efficient when we’re kind of giving our brains space to do those sorts of things. So having those spaces in between can be incredibly helpful.

Dr. Jessica Drummond 00:44:19 Yeah. So, you know, boundaries, boundaries of time, boundaries of saying yes to things, all of that. So wrapping up our conversation about getting these active moms back to their goals, sport. Talk about some of the things that some parties who maybe dabble in this space but are haven’t fully specialized in it might be missing, as there are other health providers as they’re helping women get back, and really not only decreasing the risk of things like leaking and prolapse, but actually recovering while they’re also able to run.

Dr. Carrie Pagliano 00:44:57 I feel like the first thing is to. I was guilty of this when I was a younger therapist before I had kids is if a mom didn’t get to all the things that I gave her to do that I’m like, well, you know, you can’t get better until you just do this. And that’s just not true. And it’s also actually adding to the problem. Part of I think how I kind of deliver services makes me unique is that I very much am aware that if at all possible, moms want to, they want to get better. And so if somebody comes in and they says, okay, well, you know, I wasn’t able to get to this stuff, instead of just saying, that’s okay. Next time. I’m like, all right, well, tell me why. What were the barriers this week? And this is where I turned James clear Atomic Habits into a parenting book where it’s like, I basically I’m like, okay, do you have a place so that we make this super brainless for you? Because, again, like moms want to do these things, they want to feel better.

Dr. Carrie Pagliano 00:45:57 They want to do the right stuff. How can we set up the environment to be incredibly supportive of that? And we literally will go to, okay, what do you do the second you wake up? And 99% of the time you know what the answer is? They roll over and they grab their phone because their alarm is on their phone. And literally one of the first things I’m like, okay, so why is your phone not downstairs in a different room? Like just get an alarm clock. Like again, it goes back to kind of what you said earlier. Like if our first thing is our phones and again, there’s lovely things about them, I enjoy them. However, if that’s our first go to, you’re already reactionary and I feel like being a mom is so reactionary. Anyway, so I was like, can you put yourself first? Go pee? Because that needs to happen first and then immediately go from there. If somebody’s not awake yet, go to that mat that you set up.

Dr. Carrie Pagliano 00:46:52 You’re going to do these three exercises that are so stupid simple that you don’t even need to look up the video. And then you also have a conversation with your partner the night before that. If kid number one, two, or three, whatever wakes up during that period of time, that is your time. They’re going to go get them until you are finished. Or if that kid’s a little bit older, that kid knows that, hey, you can come on over and do stuff with me, or you can grab your iPad or whatever that is, but I’m going to finish this and then immediately go get your coffee or go get the kids or like you’re checking your box first. And so it’s those logistics that you would think are very inherent to parenting. And they’re not at all what we need to do. I forget what author said. This is like the night before. Pretend you’re your own assistant. Set yourself up to do the things that tomorrow you will thank you for. And that’s where those like, you know, I make fun of my father in law because he eats the same lunch every day, reducing those decisions.

Dr. Carrie Pagliano 00:47:50 Again, if I get up and I do this automatically and it’s not even anything I have to think about, like consistency is 99% of the battle. And so to go back to providers, are you setting up a supportive environment or are you setting up an environment that’s adding additional barriers to add to my mom guilt? And trust me, I’m doing a good job of that on my own. So like, it sounds so ridiculous. I never learned that in any PT school, any class, whatever that like that’s mom knowledge right there. So that’s the first part. What can I do to support that consistency.

Dr. Jessica Drummond 00:48:24 And that’s health coaching literally. That’s the skill set of health coaching. Yeah yeah it’s a it’s a communication and barrier to change a skill set. Like why can’t they do it.

Dr. Carrie Pagliano 00:48:36 Exactly. But we don’t realize that is health providers is like we’re inadvertently we think you know I will dictate you will do as I say. I’m like, no, it has to be that collaboration. Same thing with the exercises that we give people.

Dr. Carrie Pagliano 00:48:50 The biggest complaint that I get, and I do a lot of second, third opinions all the time is they go see somebody and they have this great motivation. And then that therapist gives them a set of exercises, and then they add to it, and then they add to it and they add to it. And eventually it’s like the length of a CVS receipts.

Dr. Jessica Drummond 00:49:06 Yes.

Dr. Carrie Pagliano 00:49:06 As soon as I say that I was like, oh yeah, yeah. And they laughed. But they know it’s true. And I’m like, no, no, no. If I give you a couple of things with exercises, if I give you something that either doesn’t make sense to you, you don’t get to it or you don’t like it because you’re not feeling any benefit from it. You need to tell me and we’ll change it. And then once I give you a new one, assume the old one’s gone. Like I’m not going to give you any more than 2 to 3 at a time. And then we progress.

Dr. Carrie Pagliano 00:49:35 And I think that’s where we lose our patience is when again, like, that list gets bigger and bigger and it’s again, it’s another reason for mom guilt. So be intentional about what you give. And that’s probably, you know, the fault of of our health system that’s incredibly broken and not having time to actually sit down and process and, you know, passing off exercises to text and things like that that are not educated in this. Be very intentional, but show the path forward. We don’t do that. Like, I don’t want you to be my patient forever, love. You don’t want to do that. Like this is what I imagined for each session. But there’s going to come a point where I want you to be able to go to the class that you like, that you went to before you had a kid, because that’s where your community is. I need you to to do that. I want you to be able to go out for a run and not think twice about it, or run across a playground and not think twice about your symptoms.

Dr. Carrie Pagliano 00:50:27 You know how to do your basic triage in case something comes up. But I’m here to back you up to progress. You know, the support of exercises, those sorts of things. But we work together as a team. I don’t want you relying on me for everything. I want to give you ownership of this problem moving forward. So it’s not this thing that only I can fix. It’s the stuff that we do together. And I think, again, that mindset of how we navigate these problems. It’s not the mindset that we were taught as early professionals. I think that’s something that some people kind of grasp Ahold of and figure out. And again, maybe that’s overlay into health coaching as well.

Dr. Jessica Drummond 00:51:02 Yeah. No. Absolutely. I think honestly, it’s the number one skill that every health provider needs. That’s why all the providers at the VA hospital are being required to become trained as health coaches and other more progressive integrated systems. It’s interesting, in our country, the most progressive and integrative systems are actually the military and the VA, and they’re all leading with health coaching because exactly what you said, like, we’ve started to realize the limitations of what humans can actually execute.

Dr. Jessica Drummond 00:51:34 I mean, that’s why we’re going to be getting AI. We have it actually, why we have AI is because we’ve hit the upper limit of what people can do. And so we now have to revisit the idea of that collaboration that you said of what they actually want, and then be really focused on helping them get it through habit change and overcoming barriers to change. And almost like the closet cleaning, you know, analogy of if you’re going to add an exercise, take something else out.

Dr. Carrie Pagliano 00:52:07 No, totally. Totally. But I think the challenges you mentioned, I, I think the challenges that we have with our, some of our younger health professionals that don’t realize they’re coming into working with women, pelvic health, those sorts of things at a time where we’re doing so much more and we have so many more research opportunities and more information all the time, is this isn’t an algorithm. I think what we’ve lost is the ability to critically think. And that’s again, when I see those second, third opinions, these well-meaning therapists very excited to help all that kind of stuff.

Dr. Carrie Pagliano 00:52:39 They kind of run through their list. And when that list is done and that patient is not better, they don’t know what to do and they just keep doing it instead of saying, hey, something’s amiss here. I’m not understanding this or looking at this correctly. They’re just like, oh, well, I guess that’s just what you get. This is all physical therapy is.

Dr. Jessica Drummond 00:52:57 Yeah, I think that’s a huge problem in general in the health system, in the sense that there’s so much to learn, which is actually why one of the reasons why we teach, we teach our students to focus on niche areas. And it’s not just because of marketing, although that is somewhat important. Just because of everything is algorithmically driven now and will be increasingly so. But I actually also think it’s important because of the skill set you begin to develop if you stay niche focused. So you’re very niche focused and essentially runners postpartum, perimenopause, you know, little deviation to different fitness things, but that can help you deepen such a unique skill set.

Dr. Jessica Drummond 00:53:44 And this is where I think in the current state that we are now, I think we could have a whole other podcast about I, which we will, we will someday. But where we are today, in late 2024, this is where I totally agree with you. This is where our gynecologists, our generalist physical therapists, so many providers should be referring to these deep subspecialists. And that’s where the role could be amazing. I mean, I have 100 stories about this, so I’m not going to get into it, but I think the bottom line is exactly right. If you’re listening to this as a relatively new or generalist provider, you’re probably amazing at certain things. And yet, if you have a woman who’s a runner who only leaks when she heels, strikes or only leaks after vacation and she has changed her diet or something like this is where people like Carrie are so important to refer to because they have that deep specialist knowledge.

Dr. Carrie Pagliano 00:54:47 Yeah. An example I was thinking of as you were talking was I do a lot of virtual consults in telehealth now, and I feel like that’s the most underrated aspect of healthcare right now is, is virtual medicine.

Dr. Carrie Pagliano 00:55:00 I was doing it before the pandemic. It just I think it made me a better therapist because I’ll have clients that they’ve seen 3 or 4 therapists in person. We have that time where I just listen to their story and I’m looking for gaps, and the problem might be I have leakage on downhills or I leak after mile eight. Well, how are you going to reproduce that in clinic? Downhills is a lot easier, but like how are you going to reproduce that. And it’s just like with the weight lifting clients. One of my very, very first powerlifting clients was a 20 something who she’s like, well, you know, my one rep max sumo deadlift is 330. I start looking at 270, and I was working at a hospital based outpatient clinic. I’m like, how do I reproduce this? The good thing was, she had a lot of videos that she sent to her out-of-town coach. So we were able to look at a lot of that stuff and play and whatnot. But again, it’s not my hands that fixed those scenarios and that one in particular with the runner who was leaking after mile eight, she just finished the women’s marathon in Savannah completely league free, was able to do the whole thing.

Dr. Carrie Pagliano 00:56:00 No problem. She’s done some stroller, run five K’s with her kids, and I think we had two sessions. That’s again understanding not only the pelvic floor aspects of things, but understanding what happens and running. And it’s not as simple as oh, change your form like it doesn’t work like that. There’s not this magic switch that you flip that’s in an algorithm. It’s like, let me take a look at this whole picture. Let me see what the biggest likelihood is like. What’s my hypothesis? Why do I think this is happening. And then we experiment and see what works in that scenario. And that is rewarding as I’ll get out because, you know, because that person’s gone to see 3 or 4 therapists in person, that they’re at the end of their rope and they’re really still trying, and they still have hope that that answer is out there. And to your point, earlier, like, I think we need to have a lot of generalists. I’m totally fine with that. But also know when to refer out and have those resources.

Dr. Carrie Pagliano 00:56:56 And again, that’s what I always tell pelvic health therapists that maybe didn’t have orthopedic background. Don’t try and become a running expert. Please don’t. Because you’re going to oversimplify it. You’re going to screw stuff up like don’t but have somebody in your back pocket that you can refer to that you can collaborate with, and then you guys can get so much further if you don’t have the time or the interest in kind of establishing that skill set further, like there’s a way to do it, but you don’t have to be everything to all people all the time. You just have to surround yourself with the resources and the people to help you accomplish that.

Dr. Jessica Drummond 00:57:27 Well, and even someone who is a skillful generalist would know, like we’ve ruled out this and this and this. Here’s what I’ve looked at. And they can essentially be handing the baton off to you with the client. I feel like that is such a collaborative model that is being used a little bit more now that we have better access to telehealth, but I think amplifying that would really start to bridge some of these really frustrating gaps for both practitioners and patients alike.

Dr. Carrie Pagliano 00:58:00 And I mean, you know, social determinants of health, you know, the primary is your zip code that can be displayed in a lot of different ways. And again, if there’s somebody that’s better at handling that, we shouldn’t necessarily be limited by geography. Exactly, exactly.

Dr. Jessica Drummond 00:58:17 Yeah. Well, thank you so much, Carrie. This has been so valuable for me, for our audience, for any woman who wants to still run and go to CrossFit and do all the things that maybe someone along her path has been like, you know, you’re a mom now. Maybe you could just stop doing that. Don’t know.

Dr. Carrie Pagliano 00:58:39 Don’t you can always start. I didn’t start doing CrossFit until my youngest was three, so it’s never too late.

Dr. Jessica Drummond 00:58:44 Absolutely right. Thank you so much. And where can people find you if they do want to refer clients or work directly with you?

Dr. Carrie Pagliano 00:58:52 Our website is Kerri Pagliaro. Com and we make it simple so on Instagram and YouTube Kerri Pagliaro.

Dr. Jessica Drummond 00:59:01 Thank you. And we’ll put all those links in the show notes so you can easily find her.

Dr. Jessica Drummond 00:59:06 Thank you so much.

Dr. Carrie Pagliano 00:59:07 Thanks for having me.

Dr. Jessica Drummond 00:59:12 I hope you enjoyed meeting Doctor Kerri Pagliaro as much as I loved speaking with her. That was so much fun. I mean, we could talk for days, but the most important nuggets I want you to take out of that conversation are one. Collaborating with your clients about their goals is so important, particularly in the mom years. In the mom years, the Babies, young childhood teenagers even more so from a nervous system and mental load perspective. Modern motherhood means women are crazy busy and we can change that. We can focus that, but one woman at a time. Take a moment and get clear. What are her actual goals? What does she really want? Then you can really skillfully refine her recommendations down to the most efficient and necessary things. And if you are stuck, find those subspecialists in your area. Telehealth is widely available. Consultation is widely available for you and your clients. Don’t get stuck. Don’t guess like. Just keep helping your clients navigate this absolutely horrible situation.

Dr. Jessica Drummond 01:00:36 Our health care situation, our health care system. It’s not your fault. But being an insider, you have an opportunity to help people get better care by helping them navigate to really deeply skilled subspecialists. People like Carey exist in all areas of niche subspecialty, and you have the tools to help people better navigate the system and look, if something very niche subspecialty is very interesting to you, not just from a marketing perspective, but from a clinical coaching wellness perspective. Go for it. We also need these deep subspecialists because we don’t yet have broadly available tools for the most complicated health situations. We just don’t. And we want to bring together your client’s unique vision and goals with the team that she needs to help her reach them most efficiently because she’s burnt out. She’s busy, she’s overwhelmed, she’s got a lot going on, and she wants to feel well and she wants to feel like herself. You get to be a part of making that happen no matter where you are on her team. Thanks so much for listening.

Dr. Jessica Drummond 01:01:58 I’ll see you next week. Thank you so much for joining me today for this episode of the Integrative Women’s Health Podcast. Please share this episode with a colleague and if you loved it, hit that subscribe or follow button on your favorite podcast streaming service so that we can do even more to make this podcast better for you and your clients. Let’s innovate and integrate in the world of women’s health.