Prolapse, Levator Avulsions & Pessaries: What’s Actually Happening (Part 2) — with MELISSA DAVIDSON, PT

In Part 2 of this conversation, I’m joined again by Melissa Davidson, specialist pelvic health physiotherapist, clinical educator, and PhD, to go deeper into the clinical realities of pelvic organ prolapse, levator ani avulsions, and pessary use.

This episode moves beyond definitions and into what actually matters in practice: clinical decision-making, patient education, and navigating an evolving pelvic health landscape where access is expanding—but not always with the training to support it.

We talk about how to explain complex diagnoses in a way patients can actually understand, why accurate assessment matters, and how clinicians can balance symptom management with long-term capacity building.

We also unpack the growing conversation around pessaries—including types, fitting considerations, complications, and the rise of over-the-counter options—and what that means for both patients and providers.

This is a nuanced conversation about where pelvic health care is right now… and where it still needs to go.

In this episode, we discuss:

•  Different types of pessaries and how they’re used 
•  What levator avulsions are (and why they matter) 
•  Clinical decision-making in prolapse care 
•  Potential complications and limitations of pessary use 
•  The importance of provider training and ongoing education 
•  What “high tone” actually means (and why it’s often misunderstood) 
•  The role of mental health and psychological support in pelvic floor conditions

Time Stamps

1:00 avulsions explained

7:05 proper diagnoses of pelvic floor issues

14:00 over-the-counter pessaries

20:55 cutting through the marketing

29:33 expanding access while preserving quality care

33:33 what we don’t know

40:26 how the research changes clinical practice

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Website: https://www.drmelissadavidson.com/

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Transcript

SPEAKER_01 0:00

A quick note about today's episode. If you have not already listened to part one of Dr. Melissa Davidson, a physio from New Zealand, you're going to want to start there. This is part two of our conversation. Part one, we were talking a bit more about pelvic organ prolapse, elevator AI, Avulsion, and we're going to be continuing that conversation to talk a bit more about Pessaries and her work with creating a Volva model, uh, both for education and providers. So without further ado, here's part two of Dr. Melissa Davidson. Yeah. Now we can have other tearing as well. You mentioned avulsion, which is a complete tear. That that's kind of a something that's deeper that I don't think anybody knows about as an average woman delivering until something happens to them and then it's horrifying.

unknown 0:48

Yeah.

SPEAKER_00 0:49

So an avulsion, so you've got your I'll use two models here. So you've got your this is the levator anal muscle. So normally we're standing up like this, okay, and there's our levator ani muscle, and it it's like a crater or a hammock underneath. It sits three and a half centimeters into the vagina. You can't see it. The only way we can feel it is with a palpation or on 3D transpirineal ultrasound. So 3D transpirinal ultrasound is the um I'll just use my phone. This is the ultrasound head sits like that, and they do um you know angles of this, and they can see from your pubic bone to your tailbone, and you can see really lovely images of the levator ani. So this one is intact, so you can see it inserts into the pubic bone, and like I said before, this part of the levator ani during childbirth stretches over 300%. Inserts into the tailbone at the back, and if it's not working well and it's not nice and strong, and it's a bit floppy, then it's wider. If you've got your pelvic floor muscles working beautifully, they contract when they need to, they relax when they need to, and you've got you can see how it narrows so that your prolapse is more supported. So when your therapist says, do your pelvic floor exercises, this is why we want this muscle working really well. And for pessaries, we need that muscle working well as well. For a lot of the pessaries require it, like the most commonly used pestery in the world is a ring pestery, and this is just one example. You can also get a ring with a membrane, okay? So that's what the membrane of support and ring without, um, and that's the most commonly used one. A lot of uh healthcare professionals they only know how to insert these, that's it, and yet let me just pick up something. We have a heap, okay. We have lots of different sizes and shapes as she drops them over the floor. Now, an evolsion is where that muscle on one side or both sides rips off that pubic bone and it sits there and it sits out of the way and it just hangs, okay. Um, so it's attached on that side, not attached on that side. Now, if you think about it, where's our support gone uh for the prolapse? So if you've got an avulsion, you've got about a 50% chance of it. A prolapse, normally it's the anterior vaginal wall and apical. Um, they can't fix this at the moment. Unfortunately, it is not fixable. They've done a few trials and they haven't been particularly successful. Um, and uh in New Zealand we call that area a fanny. I know you call it a the bumbag is what you call a fanny pack, but in New Zealand and Australia, and I think the UK, a fanny is the vagina. And I tell you what, if I had an avulsion, uh, I'm not volunteering my fanny anytime soon because I don't know what they're doing yet. Okay. Uh so it cannot be fixed. It's happened, it's happened. Um, and that's okay. Well, it's not great, but you've got the rest of the muscles, you've got that other side, or you've got the bottom of those. It's not the end of the world. Okay, now you can get it happening more often unilateral on the right, can happen on the left, and it can be bilateral. Now, obviously, with bilateral, you've got less muscle right at the front, but you've got all the rest of your pelvic floor. We can manage things like your bladder, your bowel, making sure your stools are, you know, you're emptying correctly, you've got good fiber, you've got good probiotics in your gut, you've got fermented foods you're eating, all helps that area really well. And we modify things for you so that you can still go running and you can do that. But if you have an avulsion and they pop a ring in, it's gonna fall out. Yeah, because the muscles are not there to support it. Um, where uh, for example, a cube can it sucks onto the walls. I don't know if you can see that, but it's it it sucks onto the walls, so it's much better for people with avulsion because it sits there, sucks up. You've got to remove this every night. I have seen things happening online where they're putting them in and saying, I'll leave them for three months. No, no, no, no, no, no. They are sucking to the wall, they have to be removed every night. Okay, uh, do not leave them in. These can be left in um quite a while. Um, and the latest research shows if you remove them monthly, uh, you're less complications. Uh so it's great. Do not, you must have if you've got a pessary, you must be on a recall system with your healthcare professional. So they need to be checking. You don't whack these in and leave them forevermore because the the highest risk with pessaries, and I'll put it out there, is death, septic, all related to the neglected pessary because they've forgotten it's in there and they've left it in there and it's got infected and eroded through the tissues. Most of the time, these are highly safe, like super, super safe. Um, and these are made out of inert silicon, these ones, but you can also get them out of other products as well. Um, and if you want to go full natural, sponge, um, a sea sponge. Um, they used to uh soak pomegranates in wine and whack them up there. They used to do cork, they used to do um metal. Um they used to do cow dung uh as well. I don't know why. It um yeah.

SPEAKER_01 6:36

Uh so we I think we have, at least here in the States, we definitely have women that are more educated earlier, or at least where where I live in the DC metro area. And um, I think women are less afraid of having conversations about pesteries and they are more proactive about seeing a provider early. Um, I think I mentioned to you before we we we hopped on here, we have providers that are diagnosing um prolapse and evolsion and things like that less than three months after delivery, and then you have patients that are spiraling. Um tell us a little bit about what we do actually understand about timing in the research, and then also if if it's maybe a partial tear, how soon can we start having a conversation about pesteries and what might the benefits be?

SPEAKER_00 7:32

So we cannot diagnose uh levator an I evulsion correctly until at least six months, more likely 12 months. And that's what the research shows because what may present is a full avulsion at one month or at six weeks, and um somebody takes some images, somebody takes some MRI study, or they palpate and they go, Oh, can't feel anything. Oh, it's an avulsion. One, that's a devastating uh conversation to have, and they just dump that on you and go, Oh, what does that mean? Um, the other thing is they're incorrect because um somebody will probably shoot me from over there, but um uh that's not very PC either. Uh sorry, it's a Kiwi thing. Um, they can heal, a partial avulsion can heal. Um, and a large proportion of women who are diagnosed early are told incorrectly that um they've got an avulsion when in fact it's a partial and it's healing. So, how do we support that healing? We listen to our bodies, we don't go back full on out and go do CrossFit and lift tractor tiles and feel our prolapses coming down. Instead, we go, okay, let's do CrossFit in a different way or go and do something else that doesn't give us the symptoms of prolapse. Let's figure out if, for example, a cup or a gall horn, for example, um, all the different types of pessaries, um, will that support above that healing tissue? We do not have good evidence to say that a prolapse will assist an avulsion healing. We just don't have the research yet. Um, but if we can control your symptoms, that's what's mattered. Um, and then the tissue healing will happen on its own. Now, there's there's some uh folks out there saying, Oh, don't do pelvic floor exercises um in the first year because there might be an avulsion and it's pulling on that muscle. And it's like, well, we can't make a diagnosis in the first 12 months, an accurate diagnosis. We know that a lot of symptoms of pelvic floor dysfunction are happening in that first 12 months. So we're going to put women through a whole pile of dysfunction just because we may have uh a thought that that might happen. No, we get you working your pelvic floor as soon as you are comfortable. Um, and the tissues will get more blood, they will get reduced swelling, all aiding tissues. Um, and if you have a partial tear elsewhere in the body, we still work that muscle.

SPEAKER_01 10:12

Yeah.

SPEAKER_00 10:13

Uh, you know, and if it's a full avulsion, it's gone. Working those muscles is not going to make it full. Uh, you know, it's gone, it's gone. You're not gonna make it worse. Um, it's not something that you did. It wasn't lifting your baby in and out of the car seat that made your avulsion. It's a well-known, it is only happens during vaginal delivery. There is a 1% chance of happening during a cesarean section, and that's because you've had either von tous or forcips before the C-section. Um, von Tuss or the suction, the vacuum, um, is around about 32% chance in Caucasian woman. A lot of these studies are done in Caucasian white women, they're not done in uh Maria Pacifica or African-American woman or Asian woman. Um, so we know that your risk is lower if you are from the Pacific Islands um area, it is higher if you're from Asia and India areas. Um, and we know that if there's forceps involved, you've got a 52% chance of an avulsion. So forceps is a biggie. There are countries that do not use forceps, and the outcomes of the mum and the outcomes of the baby are just as good or better than some countries that use force. Unfortunately, New Zealand is still using forceps for certain things, but we're trying to get them to shift away.

SPEAKER_01 11:43

I think it's geographical here, depending on where you are in the States, um, which is unfortunate.

SPEAKER_00 11:48

Yeah, yeah, yeah. But I think women need a right to know that hang on, let's think about this. If on the UR choice, for example, you're tracking as a higher risk and you've been pushing for more than two hours, that puts you at a higher risk straight away of an avulsion. And then afterwards, if you do tear and it's a third or fourth degree tear, we know that that can be associated along with vaginal tears, which is tears inside the vagina. Um, we know that that's associated with an avulsion. So we keep an eye out for that, you know. You know, we might we might assess you at two months or six weeks and go, look, I can't feel the right side. Um, let's work those muscles, let's get them stronger. They've gone through a big stretch. Let's allow healing to happen, let's allow our natural physiology. If you're breastfeeding, we don't want you to stop breastfeeding because it might have an effect on your pelvic floor. We want you to breastfeed for what time you want and your baby wants. Um, and um, you know, do it wherever you like. I'm very much of a just put the boob out there, that's what it's for. If the guys can't cope with it, it's their problem. They're there for feeding. Um, and you can perfect it if you want, but good luck. Um uh so yeah, I I had a gentleman give me the evil eye once when I was feeding my kids. Um, and I just gave them the evil eye back and said feeding station, mate. Uh yeah. Just because you like to fondle them, not mine, you're not, but um this is what they're designed for. It's a natural, natural thing. You you get I'm and I'm getting worse as I get older. Um, you know, if the filter is gone. The filter was pretty thin to start with. And it's I know. Yeah, it's now it's not so much uh a um, you know, uh sifter for when you make fli you sift flour. It's not so much that sifter now, it's more the wide pasta co colander. Um you know, if if it's still there. I like that most of the time it's gone.

SPEAKER_01 14:02

I'm gonna bring you back to to over-the-counter passeries, of which I have many. Um that's a booming industry. Um I'm actually in the middle of a project now where I'm I'm talking and actually for the podcast where um I'm talking with representatives from the company so they can explain what some of these things are because I I think the more we understand with it, not every device is gonna work for everybody. You brought up some great points about you know, risk for you know, you need to take care of it. It's not just something that you, you know, it's not like a toy. Um, what are your thoughts about some of these devices? Where have you seen some of them work really well as opposed to uh a fitted, formally fitted Passery? Just kind of share a little bit about your experience with some of the ones that are out there.

SPEAKER_00 14:53

Yeah. So I belong to quite a few groups like you, and I I monitor things, and I see really, really scary stuff out there where people have bought it on whatever platform they've bought it from, and they're just whacking it in, they're estimating the sizes, they go, Oh, well, this worked for my cousin, therefore this will work for me. But the cousin's birth experience is very different, or the cousin is 30 versus your 70. Um, you know, like I said before, the cube has to come out every night. Um, now I run courses for health professionals, whether it's a GP, guy, physio, whoever, and the amount of lack of training in pessary, some of them are already fitting like a ring pessary or cube because they've had some online training on that, um, and which is fine, not a problem, but they don't have the background, they don't have all the self-management information that you need to have, they don't have the recall systems, they don't understand the complications and the indications, and the the complications can be vast. Um, you know, what happens when you get an infection and all that sort of stuff. Um so I think, and a lot of the manufacturers are not clinicians, they are a tech person in the lab. Yeah, and all I can think about is the mesh. All I keep thinking about is mesh. Um, as and as in we didn't do the research in mesh before we started inserting into woman, and uh vaginas were experimented on. How many of these manufacturers are actually doing it for the benefit of the woman versus the benefit of their bank account? And what are the long-term consequences? If you can buy, for example, a gal horn, this is a gal horn, so it's got a plate at the top that goes up against the cervix, and this sits at the it on the back wall of the vagina, like that. Okay, brilliant for posterior vaginal wall prolapses. If you've got a longer vagina and you use a shorter stem galhorn, you can have intercourse. If you've got a shorter vagina um and you've got a long stem gall horn, intercourse with a penetration is difficult because that's sitting in the way. Um, but really good for posterior walls. But if it sits in there and you can't take it out because you haven't been taught how to self-manage it, or you don't have the dexterity to do it, and it sits against that wall and it's been in there for six months, and you start getting some spotting or pain, or you start to get a yellow discharge, you've got to get that thing out there. You've probably got erosion, which is like an abrasion on the vaginal wall, and you've probably got an infection. Um, we know that people are popping these in and out all the time without having that knowledge, and that's partly why I'm I've got this course that I'm gonna be putting. I haven't filmed it yet, it's coming, it's it's coming in the next week, sort of two. Um, just got to work it around travel, where I'm gonna be putting a lot of this information together for patients, and it's based on my health clinician's course, but it's for patients wherever you are to be able to go, okay, this is research-based, this is evidence-based, this is how we can do stuff. Because I'm just scared when I'm watching all this stuff, going, they're not they're they're googling and they're listening to their mates, they're not listening to health professionals. Or as somebody just um, we've got a course running, advanced pessary course in Perth next week, and um I've asked them to I make them work around courses, you know, um, including my online ones where you have to actually put competencies together around pessaries, and you have to do case studies and you have to present them online and this sort of stuff, or at least put them in the message boards and stuff. Um, and one of the case studies arrived yesterday where the gynecologist has inserted this, which is a donut pessary, into the woman and said, Oh, I'll see you in six months. And that's it. There's no self-management, no information on complications, no information on if things go wrong, how to get it out. She came to the physio over there, and she's um the physio's taken out, she's already got some erosion, so it's not gonna go back in. Um, and the patient was not empowered with that knowledge. So um, yeah, I haven't come up with a really cool sexy title. Prolapse and pesteries is not that sexy, but it's what its course is going to be about. So, you know, it's gonna end up prolapse and pesteries, probably uh looking for a sexy title in the title, unless you come up with one in the next week for me.

SPEAKER_01 19:49

Um that's what chat GPT is for.

SPEAKER_00 19:54

You see, I'm so slow on that. Hubby's there, he's the tech. Um, and and she's got she's now got a pestery stuck on a finger. Um uh he he's the tech guy, and he keeps saying, put it into chat PD. I was like, oh, okay. Where I'm old school.

SPEAKER_01 20:10

You gotta put good if you put good and you'll get good out. If you put trash in, you get trash out. So and I'm not and and always, always, always edit because sometimes it it makes shit up, quite honestly.

SPEAKER_00 20:20

Um Yeah, oh yeah, it does. It's like Google. You Google some things and you go, wow, it's bad. Please tell me nobody is is following that advice.

SPEAKER_01 20:30

Tell me tell me this. Um is is your community in New Zealand, Australia, are are your women getting bombarded with ads for these devices? Like the second they look something up and they're getting bombarded with it and told this is the answer. Um if if you I mean, this this one right now is is going crazy because one of the major over-the-counter options that we had here in the United States, the poison press, has been discontinued. That's something that we've had for a long time. And so now all these other devices are like, oh, well, that's gone. We can fix anything. And we can fix, you know, you can run ultra marathons, you can do this, you can do that. And it just and to your point, like a lot of uh the it's all marketing language. And it's really and and this is where I think these conversations are so important because um you know, we're gonna have something like this, you know, which is the the review versus um this is a new one, Soma. I think um that they're completely different things. And I I think that people are gonna look at this and the promises look the same and um the explanations look the same, the marketing is the same. You're like, what in God's name is going on here? And I I don't think that you can answer that without knowing what's going on with yourself. And that's where that empowerment and understanding of what what's going on with your body comes from.

SPEAKER_00 22:00

It's marketing to those people who have a what's called a pain point. They've they've got symptoms. They're not been listened to. They might be in rural, um, I don't know what the in the middle of rural acronym is in the US over here. We call it in the boondocks. Um, you know, yeah, it's way out where they don't have a health provider who knows how to do pessary training or haven't done any. So this is why we travel around the world to do pessary training. It's like, let's get more health providers out there so that we can get the right information out to people so that they're trained properly. They have all the systems in place to protect the patient. Um what concerns me is like we've got a variety of different ones here, and they're designed by them, they're designed by uh the bioengineers or whatever, and they're putting them in the market and they don't have research. So a lot of the pessaries, when you try and find the most research pessary, is the ring pessary, and that's what most of the research is on. There is more research coming out on the Gullhorn and the Cube. Um, but as for you know, the Hodge, the Renner, the Dish, the Cup, the Gallhorn, uh, Gerhorn, there's not the research out there. So the manufacturers are leading the charge, and they've got really good marketing people. They know how to, you know, do Mc McDonald's or KFC or uh whatever, Whole Foods, they know those marketers are paid a lot more than physios uh to market to those people who are looking for it. But what they haven't done, they haven't examined the vagina and looked at it in a biomechanical way. So you've got to, with a pessary, the choice of pessary is very much based on what your body is doing. And as a patient, you can't tell that, unfortunately. You might be able to put some information together, you might be able to do some self-assessment, and you know, it would teach you how to do that. Um, and then you might be able to go, okay, uh, this is what I'll what I'll guess might work. Um, but you need to know all the side effects and the complications of those pesteries, you need to know when you should be taking it in, when you should be taking it out, and how to do that. You need to know that if you've got an avulsion, the ring's probably not going to work and it will keep falling out. You know, you need to know, and instead of spending hundreds of dollars on, you know, 10 pisseries, and then getting more depressed and more anxious and more down, um, go and spend that money on seeing somebody who knows how to fit a pissery, can biomechanically assess in a 3D part of the brain, and you're going, okay, when I assess that it's wide there, it's narrow there, it's okay, we've got an avulsion. What bit will fit in? And that's why I'm doing the advanced courses for the health professionals. So we've got an intro course and an advanced course, then going live, hopefully in the next week online fully, where we basically you can't attend them in person. You get somebody like Lily at home in your clinic, and then you can practice putting in all the different pissaries. And I want to see videos of you doing that correctly in order to get the certificate to put on your wall. Because uh, frankly, I don't trust everybody.

SPEAKER_01 25:44

Well, I think I think it's that old rule when when we've started into pelvic health, you don't realize you're gonna work on you know other people. And so the the first time you go in and you want to be on the other side of the room of your friend because you don't want to be touching your friend in that way, but then you learn that you actually want to work on your friend because you trust your friend and your friend's gonna do the right thing and it's not gonna hurt.

SPEAKER_00 26:07

So, for those of you who don't know what we're talking about, it's called peer-to-peer learning. So, physiotherapists and physical therapists around the world, we practice on each other, and that's whether we're working on somebody's elbow or their neck or their vagina. Uh so, but uh other health professionals think we're absolutely weird as. Uh, so models. They practice on models or they've then practice on patients. So, ideally, I love it when I get a doctor and nurse on the courses, and we've got the last course I taught for pessaries in New Zealand was half doctors and nurses and half physios. The physios are all into peer review, peer learning, and the doctors are all going, yeah nah. Um, again, that Kiwi thing. Um, and we'll use the models, which is fine. I've got the models there ready to go, um, and I've got pessaries ready to go. By the end of the weekend, I could barely get the doctors and nurses off the bed. I had to kick them out of the room because they were all into peer-to-peer learning because they learned so much. But we don't have that opportunity in some places. And if you're in the boondocks in the middle of um Minnesota, it's minus 40 degrees, you've, you know, you need to see patients for pessaries, then you do the online stuff and you do it with a model and you practice with models. Um, and you, you know, if you're doing my intro course, for example, you have to do competencies, you have to send in information that you've done five speculums and what you found, and you've done five pessary fittings and a peer review and uh uh um a case study and all that sort of stuff. And so, you know, if you've got a certificate saying you've had training from me, I want you to know that you've done it properly. Yeah. Um, and I think for our public, it's like, okay, we want you to have that information to empower yourself to go, actually, I do know what I'm doing. If I've if I've pop my fingers up in the vagina and I can open them that wide, um, and I'm sticking in a ring and it's falling out all the time, or I when I contract my pelvic floor, I feel no contraction coming in.

unknown 28:19

Right.

SPEAKER_00 28:20

You need to learn how to work your pelvic floor muscles first. Or if you look at your history and you go, I had my baby was um uh 12-pound, I've had four 12-pounders, um, I push for six hours each time. There were four sips involved three times, and the last baby flew out. Yeah, you may have avulsions. You know, the classic is difficult labor for the first one, second baby flew out. And at which point I'm going, do we have an avulsion? Yeah.

SPEAKER_01 28:53

You know, it's it's so interesting to hear you talk about your training there. Um, our history with pessaries here in the US has is is quite recent. It's mostly um we used it to be more of a last resort because it was physicians that were doing the fitting. And the last, I would say three years, we've had more uh companies, and even even our national association would do just a very short, you know, one-day course. Um we've got some virtual courses that are doing online training and then coming here for quick labs, things like that. But the longer I do it, the more complicated I feel like it is. And it's a juxtaposition of on one hand, can we get easier access to patients to get support? So it's not a barrier to movement. But on the other hand, it's do we have people doing this that don't exactly know what's going on? And even with these um over-the-counter options, you know, do we have enough education for women to be okay shoving something up there and you know, navigating whether it works or it doesn't?

SPEAKER_00 30:03

Yeah. And I think that's where you start off. You most of the courses start with a ring in the cube. Um, but when we looked at um putting our courses together, my concern was, and I I put the New Zealand uh PC management recommendations for New Zealand physical therapists together because we didn't have anything. And it was like very lots, lots of cowgirls and cowboys just whack a ring in. Oh, yeah, they've got it in there. We haven't assessed anything. We haven't done a uh pathology check, we haven't got screening from I'm very much you need to have a pelvic pathology check first. Yeah, um, buy a medical doctor to confirm that that prolapse is not cancer. Yeah, it is rare and it's unusual, and don't freak out. It's very rare, but I won't fit a piss three unless they've had a medical clearance. Yeah, um and the the doctors all know that in my local area, in further affair, and I send them a letter for screening and they go, Yep, Mr. I've screened them, they're good to go. Um train them well. You train them well. Uh, and it's just and that's on my courses, I that's what I train. It's up to the healthcare professional if they follow that recommendation. But when I put the recommendation document together, I talk to physios, doctors, gynecologists, nurses, and said, you know, what is the practice currently? What do the guidelines say from international guidelines? And the UK guidelines were quite good for that, but they weren't very specific and they're very much for the UK healthcare system. So um, you know, there's you know, when does recall happen? When what does self-management look like? What does um uh should you be talking to the doctors about stuff? You know, what information does the patient get? I have a five-page booklet for my patients. The only reason it's five pages and not eight pages is because I made the font smaller.

SPEAKER_01 32:03

You're enough thorough.

SPEAKER_00 32:06

Yeah, uh, you know, so that they've got all that information. It's their body, it's their right to know what what's going on and why they've gone and it's failed. And then they think, oh, the only option is surgery. No, it's not the only option. We have other options, and really important to make sure that your pelvic floor muscles are working as well as they can, because that is the number one evidence. Level 1A can't beat it. There's huge studies about the effectiveness of that, and this is what annoys me about people saying, or don't work your pelvic floor because you might have an avulsion, or don't work your pelvic floor because somebody thinks you've got uh increased tone in your pelvic floor, um, and yet we have yeah, the evidence in that is not there. Um, so um, and that's my thing. And if you listen to Michelle Lions, you'll hear me rant about that. That's my little rant, uh, because that's what I did with my master's and my PhD. I thought we were good at it, and we're useless at it.

SPEAKER_01 33:10

I I had a great conversation um a couple of years ago with Linda McLean um in Ottawa about this. And it was one of those things she's like, well, this may not be what you think you're feeling. And it just and and it made sense to me. And I'm like, okay, great. But does that mean that you know we don't do anything in the meantime? She's like, Well, if your interventions work, great, you can be working on that while we figure out what this other thing is and what you're measuring and feeling and and whatnot. And that made me feel better because I'm like, but what are we doing? She's like, you don't have to throw the baby out with the bathwater. So she made me feel a lot better.

SPEAKER_00 33:47

Yeah, yeah. Linda was one of my examiners for my PhD. Oh, I love her. And then yeah, and then last year or the year before I presented with her uh in Australia, I got invited to uh to do a workshop over there, and she was one of the uh presenters alongside me. I'm thinking, oh god, she uh so we had a good giggle about that. Um but yeah, I think I think where we go wrong with that is people are told you've got high tone because I've assessed you, even though we don't have a valid and reliable palpation scale for assessment, and there is more research out in the last six months around that. Um, the fact that, yeah, no, we don't, um, and it's in our head if we think we do. Um, but if what's working, what bit of it is working, is it the fact that you're interacting in the therapist effect is working really well because they're listened to and they're empowered, and that's what the and we know placebo works in about 30% of cases. So um I'm pretty sure I have a really good therapist effect on my patients. Sometimes, you know, I think, yeah, definitely biomechanically, this is gonna work for you, or this is the area we definitely want to work in. Other times I might I see very complex patients as a specialist, and I I normally see them after they've seen lots of other people, and so they come and and I think, oh great, with everybody's tried this, this, this, and this. I'm thinking, ugh. Um, and then sometimes it's going back to the basics, you know. It's like, okay, actually saw a lady the other day, and um her coccyck is moving about 30 degrees, flexion and extension, and she gets pain with sitting. And it's like, well, okay, no, it's not you pretend on neuralgia, it's everybody's worked on your glutes, everybody's strengthening your glutes. Oh no, it's not gonna work. Your glutes are in proportion to the rest of your body, and they're contracting and relaxing, and people have been releasing her glutes and her pain's been massively increasing. It's like, no, let's stop that. So, um, yeah, it's just going. I I see patients and I go back to the basics, and I think that's where people sometimes go down tangents and they think, oh, this is the latest shiny thing, like a magpie. Or they do what a sheep, like in New Zealand, like in Ireland, there's a lot of sheep, you know. I think we've got we're down from about 70 million sheep to about 40 million sheep. Um we have five million people in New Zealand, um, but we have a lot of sheep. And the saying is we and what that you watch this, you go on video and you watch one sheep will move in this direction and the rest will follow. And I think that's what we have a tendency to do is we get on the bandwagon and um one sheep heads off in this, or one person has an idea, and everybody goes, Oh, that's new and shiny. Let's go that direction as well. Even though the research is not supporting it, let's all head that direction. I think that's where we've gone. And I think I think we are dreaming if we think some things are working when we've got no evidence of that, and repeated no evidence, and repeated actually you're dreaming. Um when when will we listen to that?

SPEAKER_01 37:04

Um let me ask you one last question because it's it's a a little bit of a a line that I've have felt lately being being in this space for as long as I have, and things that I have uh said and clinically before I know not to be validated now. And then when you're trying to explain things to a patient, and like I almost feel like a deer in headlights sometimes because I had these these narratives that I would say and things that I held on to, and I I find that I can't do that anymore, but I'm also trying to explain it to somebody, but uh we don't know yet. Also doesn't come across with much confidence. Where uh how do you how do you is that something that you've navigated and and it's so oh yeah, help me out here.

SPEAKER_00 37:49

Yeah, pain space. You know, what I learned about pain back in 1990 is very different from today. Yeah. What we know about, I mean, we didn't know about avulsions. Right. You know, 35 years ago, if there wasn't any research on avulsions. Right. Now we're getting it because our imaging is getting better, our technology is getting better, all of that, and our skill set is getting big, better. And we're do following the research. I I am very evidence informed. If the research I did believe that we were really good at palpating muscle tone, I knew what I was doing, you know. I thought, yeah, my PhD was all about assessing the changes during pregnancy with muscle tension, tone stiffness. Um, and I went into it going, yeah. My supervisors were bioengineers and an ex-midwife who's more bioengineering now. And the bioengineer said, Okay, we can bring in some of these clinical measures. And then when I explained how well it was palpating muscle tone, they said, Pardon. And I said, Well, this is what we do, and they said, Well, that's just what you do, isn't it? And I go, No, no, no, it's it's what we do. Uh, and they said, just in New Zealand, and I said, No, no, no, no, worldwide. And they go, Well, what training do you have in it? I said, uh, none. Um, what validated and reliable palpation scales do you use? Uh, let me go find some. Uh, and then I went hunting and it's in my thesis, and it's like, okay, I went deep diving and I chose one scale that was the least offensive, so to speak, um, and it wasn't perfect. Uh, it wasn't, you know, it didn't have a wording associated, so we added some wording to it. We added bits and pieces, and we went okay. And then we took it out to the clinicians with an objective measuring device to say, right, let's measure your ability to use the scale. And we were useless, absolutely useless. I couldn't put that in my thesis. I said to my supervisors at the time, I, you know, we're useless. And they said, you can't put that in the paper. Uh, you can't put that in academic writing. It's like, well, we are useless. Um, so that's what I just verbally say. Um, but we're very inconsistent, and you know, if you see a patient and you see lots of patients in pain cohort, um, you know, you get a lot of pain patients in, then you were the pay the therapists were measuring increased tone all the time on this objective device, even though I gave them multiple different um randomized uh stiffness measures, they only detected it as increased tone, and that is bringing a huge bias into it. Um, now I at that time I was seeing a lot of women who are postpartum, and my bias was towards softer, a less tone because they have less tone and they're a little bit more loosey-goosey in the vagina area. So I think clinicians have to step back and go, right, what is our own biases coming in? What validated, reliable palpation scale are we using for this? What training have we received in it? Uh, and accept the fact that it may not be perfect, and you've got to step outside your beliefs and look at the research and look at the wider person, you know. If she's coming in and she's got pelvic pain with sex, is there abuse history? Does she is she aware of that abuse history? Is there trauma involved with um toileting? Um, you know, had a young lady in who um can't empty her bladder. She doesn't have a tight pelvic floor. She can contract and she can relax, but as soon as she thinks about toileting, she subconsciously tightens her pelvic floor. Now, a wand is not going to do anything, a dilator is not going to do anything in that situation. Psychological support is gonna do stuff in that support space. So I think we need to get that psych support. That's why I've gone down the health coaching route to be able to add in that mental health side of coaching into the therapy. Um, so I think we need to step back. And I think if you're a patient listening to this and you've been told you've got increased tone, increased tone, and that's all about why your pain is there. We actually have no correlation studies between pain and pelvic tone. In fact, we've got the opposite now coming through. So I think we need to acknowledge the fact that research changes as we find out, as we do better research. Um, and we've got good research in public health, um, and it's getting better as the technology improves. And so, what I would have trained people, you know, 30 years ago in pain, I won't go there now. You know, it's not that way. We know that this bit is working well, it's not just in biomedical, you've got you know, you've got a cut, that's what's causing your pain. We know that if you are tired, if you see a red light, if you um if you are warm versus cold, if you uh have had a stressful morning, your pain will increase. Well, the scar is the same, the bio is the same, the psych is different. So we need to we we need to look beyond the box. So I think that's where um we need to, you know, if you've been told certain things, question it. Um, and then go have uh a good um uh talk with somebody that you can trust, whether it's online, whether it's in person, if you're in the boom docs, it's probably gonna have to be online initially, but that's okay. Let's get you the right information. Yeah, as we know it now. So at the moment, if I'm going, you know, to patients, um, and I say to them, I'm not a hundred percent certain, but this is what this is lining up to look like. This is the latest research on this, and it seems to be working. Let's go there, you know. You know, avulsions, yes, there's a little bit of there's why I think one paper around, don't do exercises because there might be an avulsion, it's like, well, let's have more than one paper. Um, so I I go with the fact that avulsions will heal if they're not full, and we need to work those symptoms because if the woman commits suicide because she's got postpartum anxiety and depression because of her pelvic flaw, then um we've got a problem. We've got a huge problem.

SPEAKER_01 44:34

Yeah. All right, Melissa, I think the universe is telling us with tech that uh that our time is up. Um I think are a little hiccupy back and forth. Um, I'm gonna pop up where uh where people can find you over on Instagram and your your website is there as well, Dr. Melissa Pelvic Physio. Um, this this was fantastic. I cannot thank you enough. I could probably listen to you for another couple hours, but again, the universe and the tech gods are I don't think I'm glad they let us talk as long as we could. So um thank you so much for for joining me. And um, and we're excited to see Lily come out into the universe and excited to see.

SPEAKER_00 45:14

Oh yeah, if there's a discount on Lily. Um DR Melissa Davidson 10. So DR Melissa Davidson.

SPEAKER_01 45:25

And you're Melissa with one L.

SPEAKER_00 45:28

One L, yeah. Got it.

SPEAKER_01 45:29

Yeah, so okay.

SPEAKER_00 45:30

DR Melissa Davidson uh 10, get your 10% discount on the Granville Biomet Medical website. Yeah.

SPEAKER_01 45:38

Beautiful. Thank you. All right, thanks so much for joining me, and hopefully we'll we'll see each other in person one of these days. Yeah.

SPEAKER_00 45:45

And again, yeah, definitely.

SPEAKER_01 45:47

Thanks. If you're navigating pregnancy, postpartum or perimenopause, whether personally or professionally, check out all our free resources and upcoming courses at carypagliano.com. This podcast reflects the opinions of Dr. Cary Pagliano and her guests, and it is for entertainment purposes only and should not be considered medical advice. Always consult your healthcare provider with any medical questions. If you enjoyed the episode, please take a moment to leave us a five star review on your favorite podcast platform. And thanks for listening.