All right, let's do this.
All right, welcome to Orthostatic,
a product of the Academy of
Orthopedic Physical Therapy.
I'm your host today, physical therapist,
Jimmy McKay.
Today,
we focus on a critical and often
under-discussed area of physical therapy,
the treatment of pelvic
floor dysfunction and related conditions.
Our guest,
a highly skilled physical
therapist at UW Health,
specializing in the spine
physical therapy,
as well as pelvic floor
disorders and women's health.
She treats a wide range of issues,
including musculoskeletal
and joint problems,
but also things that focus
on the topic at hand.
Please welcome Keri Schwerer.
Keri, welcome to the show.
Thanks for having me, Jimmy.
And before we hit record,
you were live on the radio
doing just this thing.
We love when we see physical
therapists out in the real world, right?
When we talk to people in
the community that can
benefit from our insight,
we like to say like the
knowledge from our neck up,
the things that we can do
value-wise from our neck up.
So thanks for doing that.
And thanks for talking with us today.
Absolutely.
Thanks for having me.
And also, before we hit record, you said,
hey, listen,
I could talk about this all day.
And if someone looked at the
topic and said, yeah,
this is something I want to listen to,
this is something I want to learn about,
you are our expert.
So how does women's health,
which might be a different academy, right,
a different component of APTA,
how does women's health
intersect with orthopedic
physical therapy?
When posed with that big picture question,
where does your mind go?
Well,
I think we oftentimes get really siloed,
but we need to get some
bridges between silos.
So when it comes to women's health,
we really have a lot of things going on.
The basis is the bony skeleton.
So bone health issues are such a big deal.
And that's also core to
orthopedic physical therapy.
But if I'm not considering
age of my patient,
where they are through their growth cycle,
those are things that need
to be considered,
especially as people age
and go toward menopause, women that is.
So that's one way it overlaps.
Then if I think about pelvic
health specifically,
all of those muscles have
synergies with the orthopedic,
what we think of as the
traditional orthopedic system.
You need the pelvic floor to
work with the diaphragm and
the hip muscles and the low
back and everything to get
meaningful movement.
So I'm not really ever just
treating the pelvic floor,
but I'm looking at the
balance among those systems.
And if you think about it,
it's suspended right off
the bottom of the pelvis,
which we all think of as
being orthopedic in nature.
And then if we take it
another step further,
in terms of pregnancy,
there's lots of changes all
over the body in terms of
how loose ligaments may get
during pregnancy.
And if there's pre-existing conditions,
there can be lots of pain
that happens in that regard,
but you're also dealing
with a changing center of mass.
So
something to be kept in mind there.
And then finally,
I think about our oncology patients.
So breast cancer is very
prevalent in society and
urogynecological cancers
also are in society as well.
And oftentimes the fields
that they do radiation with
can impact the shoulder or
the hip to a large extent.
And even with some of our myeloma patients,
they may have radiation
done over their sternum,
which is going to impact
how the ribs move as well
as the spine itself.
So
There's a lot of overlap that can happen.
And of course,
myeloma is not a women's
health issue specifically,
but it does tie together.
So we have these silos of
maybe we have the Academy
of Pelvic Health and we
have the Academy of
Orthopedics and we have the
Academy of Oncology,
but there's so much
crisscrossing that happens
and all of that needs to be
taken into account.
Yeah.
So you're a physical
therapist first and you're
taking the person in front
of you into consideration,
whatever that means.
Absolutely.
And what their goals are,
what they want to get out of it,
because maybe they just
want to be able to do everyday things.
But, you know,
we may have someone who
wants to continue on with their sport.
So we need to meet them where they're at.
So let's get specific.
Right.
That sounds like you set the
table and you set the tone.
Good context.
But what are some common
orthopedic issues that
might primarily affect women?
So osteoporosis with
menopause is one that's a big deal.
And I actually with my
orthopedic resident do menopause.
a clinic once a month where
we see people who've had fractures,
they are primarily women.
and it is primarily postmenopausal women.
So you really need to know
how bone health changes
over the course of the lifetime,
and that there's that
susceptibility immediately before, during,
and after menopause.
And there's an education
component there to be sure.
And I think we as PTs have
the opportunity to come up
with more classes and
public health options.
Since we know there may be a
health shortage,
we need to be a little more creative.
So that's something I'm
hoping to move toward
in the future in my clinic.
So there's your bone health
piece of things.
Then if we look at pregnancy,
like that is one big old ball of wax.
So there is a lot of neck, low back,
and pelvic girdle pain in
pregnancy because there's
so many changes happening.
If we think about the fact
that the center of mass is
at approximately S2 in pregnancy,
that center of mass moves anterior
and superior.
So there's always this changing,
how are my muscles pulling on my joints?
And for someone who maybe
doesn't have coping skills,
that can be challenging,
or if they have previous
low back pain or anything of that nature.
When you come up to the neck,
the diaphragm really gets pushed up, up,
up, up, up by that growing baby.
So you can't get the
expansion of the ribs.
And now patients will start
using their SCM and
and all of those accessory muscles,
and that can develop into
neck pain and headaches.
I see a fair amount of that as well.
And really it's something that, you know,
I do as a women's health professional,
but orthopedic,
orthopedic PTs can do that as well.
It just takes some
creativity for how am I
going to position them?
I've got the basketball shape in the way,
but we have a critical role
there and it doesn't stop
with just the joint pain.
We have increased fluid
that's required during
pregnancy to really take
care of keeping a pregnancy going.
keeping that baby safe.
And unfortunately,
it's not just in the belly
that that happens.
It can happen in the neck
and manifest this thoracic
outlet syndrome.
It can happen in the arms.
So you may wind up with any
of the peripheral nerves
being a little bit impinged,
thigh numbness and tingling.
Thankfully,
the lateral femoral cutaneous
nerve doesn't have a motor component,
but you also can get a foot
with the tarsal tunnel.
You can get some changes there.
So all things that both
women's health therapists
as well as orthopedic
therapists can all address
those sorts of things.
And then when you get to the flip side,
baby's been delivered.
You know,
those abdominal muscles have stretched,
stretched, stretched, stretched,
stretched over nine months.
So they're not working optimally.
So there's opportunities for
neuromuscular reeducation there.
particularly if there's a
diastasis rectus abdominis present,
which is a splitting of the
heads of the rectus abdominis muscle.
And that just sort of leads
to lessening of being able
to generate force.
And there's a lot of
thoughts out there about
how you best identify it,
but it is one of the things
that individuals come in with.
And then that can bridge
over to some of our
incontinence issues and pain issues,
which wouldn't be more...
more continuing education to
get really well versed in
that area of things.
So those would be, we have our menopause,
we have our prenatal, postpartum.
And I go back to the cancer
population again,
because some of the
specific things we see is
with breast cancers, axillary syndrome,
axillary cording can be one
thing that comes out and it
really limits shoulder range of motion.
So it's on our differential
diagnosis list.
Is this from the cancer or
is this patient in
you know,
age group and has comorbidities
that this might be a frozen shoulder.
We need to work through
those things and meet their goals there.
And certainly if there's
been any sort of pelvic radiation,
it can decrease the range
of motion of the hip,
which the pain might not be at the hip.
It might be at the lumbar spine,
or it might be in a
different angle or a different area.
And there's always the
challenges with cancer of
some of the chemo brains,
that fogginess and the fatigue.
But with all of these populations,
even though it sounds like, oh,
these are special,
what do we do from a
cardiovascular perspective?
It all comes back to the
American Heart
Association's 40 minutes of
moderate activity most days of the week.
We just mix it up a little
bit and maybe spread it out
for moms who are close to
that delivering mark.
They might be a little short of breath.
We do that.
We do the same thing with
our oncology patients.
And then we modify and use a
rating of perceived exertion
to be able to better manage
where they're at with their symptoms.
But I would say those are
the biggest things I see.
And I am not a lymphedema therapist,
but if we talk about the cancer,
there is also that piece of things.
I have great colleagues that
I refer to out for that,
but sometimes there's still
that orthopedic piece that
needs to be done.
Yeah.
So it sounds as if this is
paying attention to the
patient population,
the person you're sitting in front of,
understanding what things
could commonly and do
commonly happen to those
types of people and understanding
what you as a physical
therapist need to
understand to get the most
out of them in terms of
education or intervention.
So it sounds like it's
really understanding is where it starts.
Understanding is where it starts,
and I think a healthy dose
of humility in all of us to say,
this is what I know,
and this is what I don't know,
and if I'm not the person to help you,
I will get you to the
person that's more qualified.
With my patients who've had
gynecological cancers, yes,
I can do the pelvic health rehab,
but if they also have a
lower extremity lymphedema,
I'm very clear to say that
is not in my wheelhouse.
But I have fantastic
colleagues who are going to
take care of you and we're
going to coordinate and
make sure everything
happens the way it's supposed to.
So I do think we all want to
help our patients,
but we also need to be
humble enough to say you're
going to get better
outcomes with someone else
on this particular aspect.
You had touched on physical therapy,
being able to address
issues related to pregnancy
and postpartum care.
I feel like this is a good
trend is we're seeing more
and more people be very,
very vocal in our
profession and outside of
this being a need and not a want.
This is not a nice to have.
This should be a need to have.
It absolutely should be a need to have.
If you think about that
change in center of mass
that occurs over nine months,
and then the muscles that
get stretched in different ways,
it's not like you deliver a
baby and everything is this
really perfect rubber band
that goes back to normal.
There are things that change.
The ribs are not going to
come back down after the
diaphragm's been pushed up forever.
And in terms of pelvic health dysfunction,
Yes.
Maybe it's okay for the
first four to six weeks.
If you had a vaginal
delivery and muscles got really stretched,
maybe some incontinence is normal there,
but it should not go on for
a prolonged period.
And the sad part of it is,
is most of the time the baby has,
you know, X day follow-up,
two week follow-up, one month,
and they have these check-in points.
You know,
the person who delivered
generally gets a six week
follow-up and it's mostly, uh,
our tissues healed enough to, um,
participate in sexual activity again?
And are you experiencing any
symptoms of postpartum depression?
And from my perspective,
postpartum depression isn't
always identified that early on.
It can come on quite a bit later.
And, you know,
they're not even necessarily
screening for
urinary symptoms.
And I'm not saying everybody
because I'm sure there are
physicians out there who are,
but there are these needs.
And the American Congress of
Obstetrics and Gynecology
actually published a
position paper that they
called the fourth trimester,
which speaks to some of
these things as they should
be more mandatory.
and not a nice to have anymore.
And we are way behind other
countries in terms of our
maternal care following delivery.
Scandinavian countries, France,
they have much better and
more structured ways of doing this.
So I would like to see in my
lifetime a big switch to
that being a standard screening.
I mean, what's the harm in it?
If everything's going well,
you've at least had a check-in point,
you have a baseline.
But if something's not going well,
you may be able to identify
it soon versus it turning
into this chronic low back
pain that becomes more
debilitating over the
course of your kids growing up.
And now you can't keep up with them.
You can't do the activities
with them that you'd like to.
So if we could catch it early,
it would be so much easier
to treat versus letting it
become a chronic condition.
Now,
when we get our physical therapy license,
we can treat almost anybody.
But what specialized
training do you think
should be focused on the
physical therapist working
in women's health?
Well,
I do think the physical therapist
that's working in women's health,
it sort of depends upon
which niche they decide to go to.
You know,
I started out my career thinking
I was only going to do
prenatal postpartum.
And my first boss out of school said, well,
you can do that if you also
do incontinence.
And I was like, well, postpartum women,
they have that issue some of the time.
So great.
You know, I'm going to do that.
And then it turned into this other niche.
And then once you start
seeing pelvic health,
it's sort of like drinking
from the fire hose.
If you're on the front end of it,
they're like, oh,
we have someone who treats incontinence.
And now you're getting men
and you're getting, okay,
you're incontinent,
but you've had oncology.
things going on.
So, you know, we've developed over time,
but if you're going to go more oncology,
you would want coursework in that regard.
Anybody who wants to work
with women who are pregnant or postpartum,
I think going to courses
for that are really critical.
And this is where we talk
about the Cross Academy.
I know the Academy of Public
Health has a certification
program for that, but you know,
the Academy of Orthopedics
has also had independent
study courses for that
And that was actually the
first independent study
course I took out of school
was a women's health issue
one that I think was six monographs.
But it addressed the osteoporosis,
the adolescent development pieces.
And that helped guide me to
branch out into some of
those other areas as well.
So it's really figuring out,
do you want to do an
overarching theme or do you
want to go in one area?
one specific direction and
that can guide it.
But a solid basis of
orthopedics is absolutely
crucial because I, you know,
said I was going to do
women's health and I was like, okay,
I'm doing this,
but I need to be better at
the spine and the hips.
So I actually came back and
did an orthopedic residency
and I still practice my
orthopedic skills every day.
It's like you said earlier,
I look at the person in
front of me and say, okay,
These are your concerns.
This is what I'm seeing.
How do we get to your goals?
So I haven't buried any of
those skills in any way,
but it gives me an
overarching ability to to
have that those nuanced conversations.
Yeah.
When you're talking about all these things,
right.
Statistics are great.
We can throw statistics left and right.
There's lots of them
mentioned position paper.
I'm sure it's full of statistics,
but I want a story or two.
an example of a success
story or something that you
came across that related to, hey,
being able to combine these skills,
really it's combining your
profession as a physical therapist,
but being able to combine
these skills in terms of
women's health or pelvic
health and orthopedics to get a really,
really great outcome for a person.
When I say that, what comes to mind?
I guess there's a number of
women that I've seen over the years.
I collaborate with my sports
colleagues downstairs and
they have a running clinic
where they'll look at.
So sports ortho,
those things go together right away,
but they'll actually do a
running assessment and they
are trained in screening
for pelvic health dysfunction.
So they may say, okay.
we don't think your hip pain
is coming from your low
back because you've had
lots of PT for that and it
hasn't gotten better.
So let's have you do a
pelvic health consult.
So I've had a number of
people who were having pain
with running or having
leaking during running or
both that actually were
able to complete marathons
without having any leaking
and without having the back pain.
Um,
And like I said,
that's more than one patient.
I know if you ask for a specific example,
but that's more than one patient.
Another patient that comes
to mind is a patient who
had quite a bit of low back pain,
which wound up being SI
joint dysfunction when I
did all the clusters of testing.
And she was a yoga instructor,
pregnant with twins and a
high risk pregnancy.
So we had to be a little
careful with how we went
along and we got her low
back pain under control before delivery.
Usually when I'm seeing someone prenatally,
I'm proactive and I reach
out to the referring
provider because they're
not real thrilled about
direct access when there's
another human on board.
And I'll say,
I would like to see this
patient six weeks after delivery.
Will you sign off on that?
And they usually do.
And I schedule them for,
as we talked about earlier,
more of that proactive piece of things.
So
She came back in, we really,
and she had to have a
C-section because of twins.
So we got her C-section scar
taken care of and she was
back to instructing yoga by
10 weeks postpartum.
And she didn't think that
that was anything she would
be able to do just based on how quickly
With the pregnancy,
she wasn't able to do that.
So she was just ecstatic to
be able to do that in and of itself.
And then this last example
happened quite a long time ago,
but it sticks with me
because it was a little embarrassing.
I was treating a patient who
had had pelvic floor pain
since she delivered her son
25 years earlier.
So she had not had sex in 25
years and we got her to the
point that she was able to do that.
And it wasn't just her pelvic floor,
it's her hips had gotten
stiff and she wasn't mobile
in her lumbar spine.
So we got her a good
exercise program besides
the pelvic floor things and
discharged her.
Six months later, I see her.
in the Overture Center,
which is our symphony building.
And she comes running up to
me and she's like, thank you.
I've been able to have sex again,
very loud.
So there's all these people
around that are staring at us like,
oh my gosh, what does that woman do?
And I was taken aback and I'm like, well,
that's fantastic.
I'm so happy that you've had
those outcomes.
And then my husband who's beat red is like,
we need to find our seats.
So-
That one sticks with me
because he and I have a system.
Now,
if I see a patient or a past patient
coming up, you know,
I kind of tug on my hair
and he he splits so that
that doesn't happen again,
because I think he was more
embarrassed than I was.
Yeah,
I think that's just a testament to
the impact that something
like that could have.
I mean, 25 years, 25 years.
That's that's not a small deal.
It's not,
but a lot of women are told this
is normal after pregnancy.
So, you know, just deal with it.
But that is not the case.
And I'm glad over, you know,
the 20 or so years of my
career that that message is
changing because initially it was always,
well, you just have to deal with it.
Wetting your pants after you have a baby,
completely normal.
Organs falling out, completely normal.
Your back pain will go away
within four to six weeks after,
and it's 10 years down the line.
And they're like,
I can't deal with this pain anymore.
And I just say, well, when did it start?
Well, during my second or third pregnancy.
So that story is changing gratefully.
And there's not as much
stigma attached to these
things anymore either.
I think we as a profession
are doing a better job of saying,
you know.
This is not normal.
Like when the CrossFit video
went viral that said,
I lifted so much weight, I wet my pants.
My colleagues in the Pelvic
Health Academy were quick
to respond to that and be like,
that is not normal.
That is not something we want happening.
So I think we as a
profession have taken
bigger stances and more
assertive stances on what
is and is not normal.
And I think we found these
other venues like what you
do with your podcast that
resonate with people that
we didn't have 20 years ago
when it was mostly, you know,
the print sorts of things.
So we have more vehicles by
which to deliver our messages as well.
Yeah.
Uh,
speaking about vehicles to deliver
messages,
you said one of the first
resources that you, uh, used, um,
was an Academy of
orthopedic physical therapy resource.
There's, you know,
just looking on their website,
ortho pt.org and the
independent study course section,
the female athlete through the lifespan.
That's a course right there.
32.2.
What are some other
resources you might recommend?
Cause if someone's still
listening 20 minutes in, they're saying,
okay,
She's got me.
I call it on the end of the diving board.
She's got me on the end of
the diving board.
I'm ready to jump in.
What are some things that
you've found useful?
Well,
I have found the Academy of Pelvic
Health's courses for
prenatal postpartum as well
as pelvic health to be extremely,
extremely beneficial.
They do have certification programs,
which when I went through,
they weren't a thing.
And I did not do the
remedial work to get those
certifications just because
life happened with kids.
But they are both excellent resources.
Not to continue to stay
completely with the APTA,
Herman and Wallace also
have an incredible...
And very similar certification program.
And then both of those resources,
I consider them to be very,
very reputable resources.
They have more niche topics too.
Once you get past there,
like there's some oncology
and then there's male and
you can dive deeper into
those sorts of things.
I also think any course on
menopause and how the
hormones change and what it
does to bone health.
I think any therapist would
benefit from that because
if you're not in women's health,
you're probably still seeing
the 50 plus subset.
And it might be important to know,
you know, what you're dealing with,
what changes may be happening there.
So those are all incredible things.
I love going to CSM and like
picking off the menu, the buffet,
so to speak,
all sorts of different things,
because that helps to drive
me into specific areas as well.
But as you get into some of
these niche areas, you can also, you know,
go into more oncology things.
So I know sometimes my
Oncology colleagues will be like, okay,
this association is doing
this and PT registration is
less than a physician's.
Might you be interested?
The ISHWISH,
which is the Sexual Health Society,
I've done some programming
through there because when
you get into pelvic health,
you have that.
Really solid basis of lumbar
and sacral spine.
Crucial if you're going to
be seeing prenatal, postpartum,
and just getting some of
the creativity involved.
of treatments in there.
So there are so many options
that are out there.
I would just say if you are
an in-person learner,
you're going to have those options.
I'm a kinesthetic learner,
so I really like those in-person things.
But if you feel like you can
get it from webinars,
there's tons of those.
There's melded learning.
Again, 20 years ago,
it was mostly you go in person or you do
a read independent study,
but now we have that melded version,
which can help with defraying, you know,
cost of needing a hotel
room for X number of nights,
those sorts of things.
But there are a lot of
really smart PTs out there
before I could out there
that I've learned from.
I couldn't even begin to
name all of them because I
would inadvertently leave
some of them off the list.
But, you know,
connect with somebody who's interested,
shadow them if you have that opportunity,
and, you know,
get together a really
robust group of people that
want to talk about the same thing.
We have journal clubs here
for our public health team.
And in our orthopedic team,
we also will discuss new
articles and things like that.
So
It doesn't always have to be
the really formal.
I think some formality is necessary,
but if you get in there and
you love it and you don't
know where to go,
just connect with people
who are like-minded and are
going to help you get those
resources and help you when
you get to a stuck point.
Because even when we know the stuff,
there might be a little
twist on the patient that
you haven't seen before.
And those are your best
resources in those instances.
Yeah.
Great advice.
All right.
Last thing we do on
orthostatic here is called
words of wisdom.
So what words of wisdom
would you want to leave
with the audience today?
It can be a personal mantra,
soapbox statement.
What would you want to wrap up with?
I would just say the day you
want to stop learning is
the day you should hang up
being a physical therapist
because things are always changing.
That's the great thing about
science and research and us
learning more.
So
If you no longer have a
desire to keep learning and
pushing yourself to be the
best you can be,
it might be time to
consider hanging up the hat.
That might sound harsh.
That's a great way to look at it,
but challenges you to be a
lifelong learner,
which is a phrase we love
to use in this profession.
Carrie, appreciate your time.
Thanks for coming on
Orthostatic and sharing your knowledge.
Oh, thank you for having me, Jimmy.
This has been fun.