REWIND // Why Moms Leak When They Run: What Urinary Incontinence Research Gets Right (and Wrong) with — DR. LINDA MCLEAN

If you've ever accepted leaking as the toll you pay to keep running, this one's going to reframe it.

Dr. Linda McLean (@mfm_lab) is one of the foremost researchers on the pelvic floor and urinary incontinence — a professor and Chair in Women's Health Research at the University of Ottawa. In this Summer Rewind, we cut through what the science actually shows about why running-induced urinary incontinence happens… and where popular advice for active moms gets it wrong.

We get into pelvic floor morphology, how running may load and change those structures, and what the evidence says about interventions — including pessaries and other intravaginal support devices for runners who leak. Linda also unpacks the difference between evidence-based and evidence-informed, and how to break down the barriers keeping women from exercise.

Leaking when you run is common… but common doesn't have to mean permanent.

Always work with your own pelvic floor PT and maternity provider — this conversation is education, not individual care.

Time Stamps

1:00 Introduction

3:58 bio feedback in pelvic PT

6:46 morphology paper

16:41 the roll strength plays

21:15 connecting clinical findings to research

32:10 intra-abdominal pressure

34:50 different causes of urinary incontinence

40:20 supportive devices

44:29 elongation of the pelvic floor

CONNECT WITH CARRIE

IG: https://www.instagram.com/carriepagliano/

Website: https://carriepagliano.com

CONNECT WITH LINDA

IG: https://www.instagram.com/mfm_lab/

Website: www.mfmlab.ca

X: @mfmlab

Facebook: @mfmlabuottawa

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Transcript

SPEAKER_00 0:00

Welcome back to the Active Mom Podcast and our Summer Rewind series. This episode is from a couple years ago when I was introduced to Dr. Linda McLean, who I've uh been able to get to know a little bit more, was up at her lab in Ottawa this last year. She is one of the foremost researchers on pelvic flora and urinary continents with her lab MFM in Ottawa. And this conversation is one of the first of many where we kind of cut through what the science actually shows about why leaking happens with running and where popular advice might get it wrong. And since this interview, they've come to do some amazing research and we've chatted with a lot of her researchers on the podcast about learning what the pelvic floor does in running when you have leakage and also when you don't. So if you've ever been told that leaking is just part of being a running mom, this is going to help reframe it. Of all the conversations that I've had in you know four and a half years on the Active Mom podcast, this is one of the most poignant. And with Dr. McLean being both a physio and an engineer background, um, she's probably one of the smartest people I and the most lovely people that I have ever met. So dive into this summer rewind series with Dr. Linda McLean. You're listening to the Active Mom podcast with host Dr. Carrie Pegliano. I'm a mom physical therapist and your go-to guide for staying active with public health issues and pregnancy, postpartum, perimenopause, and beyond. Whether you're a fellow mom, physical therapist, or women's health professional, join me where I'll share expert insights, real life stories, and the latest research to help you approach running, CrossFit, yoga, paletti's kit, or whatever activity you love with confidence and evidence-informed guidance. Let's start the show. All right, you know how we love bringing researchers on the podcast. Um, our next guest, Linda McLean, interesting enough, um, before I started following her uh lab on Instagram, I'd read a few of her papers. And then recently I had taken a course kind of diving into more of the research on stress urinary incontinence. And lo and behold, um, she's on a lot of them. So I'm really super excited. We were already scheduled to chat today. Uh, Linda McLean, thanks for being on the Active Mom postpartum podcast.

SPEAKER_01 2:14

Thanks so much, Carrie, and thanks for the lovely uh endorsement in the introduction. Um, I'm happy to be here. I am a professor in the School of Physiotherapy at University of Ottawa, and I run my own research lab called the Motor Function Measurement Lab. Um, I hold a chair in women's health research, and most of my research career has focused on studying women's pelvic health.

SPEAKER_00 2:40

How on earth did you decide one to go into pelvic health and two to become a researcher? Because you've been at this for a little while.

SPEAKER_01 2:48

I've been at it for a little while. So the story around getting into it is actually quite interesting because I was always um, when I did my physiotherapy degree, I had always tried to decide whether I should be an engineer or a physiotherapist. And I finished the physio degree and absolutely love being a physio. Um, but I also had this curiosity about engineering and mixing the two. So when I went back to do graduate school, uh I decided to do my master's and PhD in biomedical engineering. So I'm a bit of a hybrid. Um and it was there where I learned a lot of my measurements, which is so essential to what I do in my research lab. So I learned a lot of approaches for measuring different things, electromyography being my key area of expertise. And all of my PhD work was actually looking at ergonomics and work-related pain, which kind of has circled back. So what happened was I was happily studying work-related shoulder neck and shoulder pain when a physiotherapist in Halifax, where I was working, contacted me and said, I have this biofeedback machine that I use for pelvic floor muscle training and it's not working. Can no one seems to know what it is or how we could fix it. Can you come and take a look at it? And that was how I started. I spoke with her, I saw the biofeedback system, I recognized that actually it was a horrible system, and so we need to do something about that. Um and that's where I started. It was really to say, wait a minute, what we're doing with biofeedback is totally wrong, and someone needs to step in here.

SPEAKER_00 4:28

But I'm in love, I'm sorry.

SPEAKER_01 4:30

It really enjoys me. And and then it just went from there. So then we started studying pelvic floors, and you know, early on I knew very little about women's pelvic health. I was a you know, a general practitioner as a physiotherapist, and I was an engineer. Um, so I had a fairly steep learning curve. And then uh gradually it's been interesting because that has taken over my research program. So now I'm only studying pelvic health.

SPEAKER_00 5:00

We're we're so happy to have you on the dark side, which is something I got like we lured you over. Um, not to get too off the rails, but go back for one second because biofeedback is one of those things that just won't die. Um, it was what I mean, I started with, you know, 20 some odd years ago. Um, depending on I think where you treat in the world, I think there's some people that that's predominantly um the standard of practice. Still, what did you find about it that you were like, mm-hmm, not so much?

SPEAKER_01 5:29

Well, mostly it was how the system was put together. So the electrode configurations were not specific to the pelvic floor. They would pick up signals from anywhere, right? You could contract your hip and you'd get signal, right? Squeeze your buttocks and you'd get signal and you could misinterpret that as being pelvic floor activation. Um, so that in and of itself really bothered me. Um, the literature on biofeedback then is not very good because if you're using these systems, and almost all of the commercial systems are still that way, right? They still have massively big electrodes that are really widely spaced. So when you use it, it's a very non-specific signal. It can be good in some cases, like a lack of signal tells you the muscles are quiet. So if you're trying to downtrain something and the signal is quiet, then you can be fairly confident that what you're seeing is what you get, right?

SPEAKER_02 6:25

Yeah.

SPEAKER_01 6:25

But if you are trying to use the system to encourage contraction, um, you better watch carefully and make sure that your patient is actually doing the contraction properly because the EMG might not tell you that.

SPEAKER_00 6:39

Um I used, yeah, I used to work at a hospital where um the if the table were plugged into the wall, it would bring out this like low interference tone or something. And I forget, I forget how long it took us to realize that that's what was going on. We're like, oh, if we just unplug it, it goes away.

SPEAKER_01 6:56

We have a high-tone pelvic floor that's dependent on whether or not this outlet is being used. Yeah. I had that problem in my lab early on when we were doing needle EMG recordings because they're more sensitive to noise. And if you had, if it was hot and in the summer we plugged in a fan, we'd be getting some high-level activity going like this isn't real. So we very quickly figured it out. But yeah, you could be easily fooled with EMG for sure.

SPEAKER_00 7:22

Well, and I I think the takeaway, if if you just started listening and that's all you have right now, and you're thinking, oh no, this is awful. Now I can't do my job anymore. I I think you know, Linda's point is is a really important one, is just know what you're getting and what you're not getting. And and that's probably going to be the summary to a lot of what we talk about today is um some things that we used to think that we knew everything about and made assumptions about what we were doing. It's may not actually be the case the more we start to understand um, as I think where we're going today. You let me know. I'll just follow along. We'll just go, right? Exactly. Okay. So um let's let's dive in first um to uh the morphology paper that came out, I guess, a couple months ago. Um primarily I want to dive into that one because it looks at um running, um, which obviously a lot of our listeners, a lot of um the people paying attention today, that's one of the things that they want to understand about most. But I think we're also gonna need to have a side conversation about what we understand about the pelvic floor kind of under normal circumstances. So I'll I'll let you kind of drive the bus on which way you you think is easiest to go first, normal versus uh running versus um symptomatic and so on. I'll I'll let you drive.

SPEAKER_01 8:41

Sure. Sure. So we've been looking at runners now for a few years because it's been uh a real interest of mine to look at the athlete pelvic floor and what's going on because prevalence rates are so high. And and the the papers don't really give us a sense, right? The some rates are up over 80% and others are down around 25%, but that's still a large, large proportion of runners who would leak urine. Um, which then intrigued me because I wondered if leakage that's experienced predominantly or only during running is in some way different from leakage that's experienced during your regular cough, sneeze, laugh position change. Is it the same pathophysiologic mechanism? And so we had done a systematic review looking at what goes on in the pelvis when people have stress urinary incontinence. So when they leak urine, when they cough or sneeze or whatnot. Um, and the literature is still quite uncertain about what is happening in the pelvic floor. And a lot of um a lot of the papers aren't very good or there are problems with the measurement, but it looked like the you know, what we think about pelvic floor dysfunction and urinary incontinence may not be, you know, exactly it's not clean, right? It's a multi-system problem. And any particular person could have, you know, whatever combination of of dysfunctions that leads to incontinence. And that's what it looked like. That's what I thought. That's what it looked like in the systematic review. And I kind of likened it to we do some whitewater paddling. And you know, if you make one mistake and you're in, you know, a tough rapid, you're probably not gonna tip over. But when you compound a second, maybe, and by the time you've got the third, you're flipped over, right? Yeah, and all your stuff soaked, yeah. Um, which makes it a nice nice analogy here, but but it's around this idea of compounding impairment. And it looks like you know, we have evidence that the urethral sphincters have a certain level of dysfunction, and that's probably a fairly important one. Um, urethral mobility. So as you cough or sneeze, you know, things start to move, and if they're moving too much, you're not getting the compression. Like it's like stepping on a garden hose is the analogy everyone likes to use. But if if things are dipping down, you're not getting the support, you can't block off the lumen, and so you might leak there. Um, pelvic floor muscle morphology and functions are really interesting thing because we know we absolutely know that pelvic floor muscle training works, right? So if you have symptoms of stress, urinary incontinence, and you do your pelvic floor muscle training, you're likely going to see some improvement. And about half of women will see a cure with that. So, you know, we kind of dove into that literature and found that the literature itself is not very clear on that. So the studies are small, they're really quite uncertain. Um, and yet we know that training helps. So then your head kind of goes to is this a compensatory mechanism? Do we, you know, is the training compensating for defects elsewhere? Or is it that there's a real problem there? And we still haven't answered that question. But my point in the that review was that we found these multi-system problems, and then we started thinking, well, is that different in athletes? Because a lot of athletes don't necessarily a lot do, but a lot don't leak when they cough or sneeze, but they do leak when they train. And so what's going on there? Um and that's where this paper started. So we said, okay, let's bring in a bunch of runners. Um, half of them will leak, half of them will never have leaked. And the ones who leak, we we picked runners who were for that particular paper fairly um experienced and training at a fairly high level and only experienced urine leakage when they ran. So if they experienced leakage during coughing and sneezing, we didn't want them, which was unfortunate because then it made it really hard to find this thing. But um it let us then see what the differences were between the two groups. And so what we found was um the pelvic floor muscles were actually better at creating force quickly. So if they contracted their pelvic floor muscles, they had more power. Um, and then we also found that if we elongated their pelvic floor muscles, and it's a very non-specific elongation, you have to bear that in mind, but the tissues didn't offer as much resistance to that elongation. So then the question is are is there something about the connective tissues that is really leading to incontinence? And what was really interesting was that our two groups were both high-level runners. And the fact that there were differences between the runners who leaked urine and the runners who didn't leak urine, you know, in and of itself says that not everyone, like running is not going to create this problem in everyone because they had the same exposure.

SPEAKER_02 14:13

Right.

SPEAKER_01 14:13

Um, but the ones who leaked did have more strength and less resistance. And we did a bunch of ultrasound measures to look at pelvic organs support and bladder neck support, and none were significant, but a lot of them trended towards there also being, you know, the tissue sitting lower in the pelvis, the the opening where the the urethra, the vagina, the anus comes through was wider. So our question was does the repetitive strain, I'm gonna say, of running cause this, you know, change in the connective tissues, but always having to bear in mind that we only compared runners who leak to runners who don't leak, not to non-runners. So in fact, we're doing that now. Oh, lovely. Sorry the questions. It was already part of the plan. But so, but but we already then know that not everybody leaks under those situations, right? Not every runner develops leakage. So we are finding, you know, maybe there's something about the connective tissues in individuals who begin to leak that is different. And so we can't blame entirely the the running. And so the next paper that came out looked at this same group of runners, and we had them come in and we had them run on a treadmill for it. For many reasons, it was a 37-minute protocol, which sounds like an awkward time, but we're experimenting.

SPEAKER_00 15:42

That is weird, by the way.

SPEAKER_01 15:45

Most of what we do is weird, so it all fits. But um, but we had them do this running protocol, and we looked at their pelvic floor muscle strength, pelvic floor muscle stiffness, and and pelvic organ support before and after the run. So these are the same people who had, you know, we looked at the differences before they ran, and we found that everybody showed an increase in the opening, the size of the opening where all of these, you know, urethra, vagina, anus pass through. It's called your levator hiatus. And it was wider after the run. It was longer after the run, and where their urethra or their bladder neck, so where your bladder attaches to your urethra um sat lower. And that's the one measure that always intrigues me because it's the one that comes up repeatedly in everything we do as an indicator of success with pelvic floor muscle training, severity of pelvic, you know, of urinary incontinence symptoms. But we found that that happened in both groups, not just in the runners who leaked, but also in the runners who didn't leak. So there is something about the repetitive loading that makes the tissues relax, but that makes complete sense because as physios, we know that it's a great way to stretch tissue is to repetitively, you know, uh, if you repeatedly want to elongate a tissue, it's going to respond and it's going to lengthen. Um, but it isn't necessarily causing incontinence because our our runners who don't leak also had the same change. So we're still we really need to compare to our sedentary group. Um in an ideal world, we also would want to compare to maybe swimmers, right? Who don't have that you know that high impact loading going on. So again, you could compare across sports and activities, right? We have a hundred ideas and not enough time, but I'm gonna add a few more.

SPEAKER_00 17:54

Yeah, yeah. So if we if we backtrack to to the first study that you talked about, you talked about um strength playing a role. Um and and I mean obviously years of pelvic floor muscle training, and and this is where I do think there's at least some, I think, gray area in the literature is um being aware contraction versus relaxation. Because I I think historically it should kind of be both, but sometimes people tend to think pelvic floor muscle training, it's all about contraction, that sort of thing. What can we kind of draw from that initial study um kind of clinically to not only what should we be assessing, but where probably should our treatments be targeting?

SPEAKER_01 18:37

Well, it's really interesting, and bear in mind it wasn't a treatment study, right?

SPEAKER_00 18:42

So, but I gotta ask. I know, and I so if you were a clinician, what would you say?

SPEAKER_01 18:50

Good news is well, well, we've actually done, we just recently we've submitted it and it hasn't come back from peer review yet, but we have a systematic review on interventions for exercise incontinence. Um, so I can speak to that a little bit. Great. Um, what is really interesting though is you're right. I mean, there was no evidence that the pelvic floor muscles were any weaker. Um, in fact, they were stronger. We don't know if that was compensatory or not. Um, you know, maybe. And I've had a lot of people ask me about pelvic floor muscle training and running in particular, because that's what we've been studying.

SPEAKER_02 19:29

Right.

SPEAKER_01 19:29

And I can't get my head around any way that, you know, performing a whole bunch of pelvic floor muscle contractions is going to change the outcome here because strength is not, doesn't seem to be a problem. And it's not like we're consciously contracting our pelvic floor while we're running. Like it's not feasible, it's not functional, right?

SPEAKER_00 19:54

Um there's still people that are telling, I kid you not, there are still people saying, contract your pelvic floor when you run. I literally have clients ask me, should I be doing a kegel when I run? I'm like, Lord, no, please don't. And you were never meant to think that fast. You would never get anywhere. Please don't do that.

SPEAKER_01 20:13

No, let alone trying to coordinate it, right? Um yeah. So it seems to me like that's a little bit uh, you know, kind of ill-founded in terms of training. Yeah. The the studies that have been done on pelvic floor muscle training and athletic incontinence, there's only been, well, there's five now. So in our systematic review, we included four. Um, another one has just been published out of Norway. But the the big picture answer on that is most of the studies are not good. They've got um a lot of bias built in. Um, but there are some randomized control trials that suggest that leakage is reduced. We can get into how you measure that because most use a pad test, which is another whole problem when you're running. Um but leakage is reduced. The problem is if you use a questionnaire, um, they're measuring overall leakage during day-to-day activities. So there is some evidence, particularly the new study out of Norway showed that for urinary incontinence symptoms in athletes, you can reduce the frequency of urine leakage, the severity of urine leakage if you do pelvic floor muscle training. They didn't find any increase in it was a home-based program, but they didn't find any increase in pelvic floor muscle strength, which might be because the pelvic floor muscles were already strong.

SPEAKER_00 21:34

Okay, so now I'm gonna I'm gonna go down a rabbit hole and and and bring clinician mind into the lab and you can make sense of it. Um, because I think a lot of what we find in the clinic, I don't think we're I don't think our explanations are correct. Um there has been a move clinically um to recognize what people perceive as high. Tone pelvic floor or a pelvic floor that's not good at relaxing or coordinating or things like that. We tend to see this anecdotally in a lot of our athletes, a lot of our runners. And more recently, I would say the last like five to eight years, more, I think that's an explanation that's come up a lot in stress urinary continents. More recently, I think addressing more pelvic organ prolapse that we have symptoms, but not so much the physiological prolapse. Um are we completely off base? Where does this play in? What what what might actually be happening that we're just like, that's not really what we're feeling?

SPEAKER_01 22:44

That's that is a huge rabbit hole.

SPEAKER_00 22:46

Yeah. Okay.

SPEAKER_01 22:47

I I I know it. Do the best you can with it. So sorry. We have not seen it in the runners. We have not, you know, we're measuring our passive resistance. It's actually they have less passive resistance when we're asking them to relax, they're more relaxed. We're not seeing when they contract that they don't come down to the baseline that they started at, and their baseline is no different. So we're not seeing it in the runners we've studied. Okay. That doesn't mean that they're not doing it while they're in their functional activities. And we have seen it. So in some of our studies on pain, we've seen that, you know, women are not, it looks like they're not relaxing. The sad part is we haven't used our dynamometer in women with pain because I just can't get my head around how I would do that in a kind way.

unknown 23:40

Right.

SPEAKER_01 23:40

But on ultrasound imaging, we've seen that they're the tissues are shorter, right? So on ultrasound, you can tell that that either the muscles are contracting and not relaxing, or that they are tighter morphologically, like the the tissues themselves are tighter, and teasing that out means EMG. That's where I poo-pooed EMG at the start, but there are ways you can use EMG. Um, but so I know that a lot of clinicians palpate and feel that there is some risk that you know, either something there, right?

SPEAKER_02 24:18

Yeah.

SPEAKER_01 24:18

Um, and to be honest, I don't think anyone has studied whether you can, you know, work at is it motor control? Is it, you know, you need to learn how to relax. It's not going to help you necessarily while you run, but it may help with the control overall, or maybe even mobility overall.

SPEAKER_02 24:37

Yeah.

SPEAKER_01 24:38

And we don't know is the bottom line. Nobody's really, as far as I know, looked at it in any way that I would be able to say, yeah, you need to relax out those tissues.

SPEAKER_00 24:49

Well, and that's where, again, I think this is what it I just we need to clone you and and and have more people to to study this. But like I think a lot of us that got to, I don't know, just treating leakage and running in a different way that was not just pelvic floor muscle contractions. We got to that because we did work in the pelvic pain space where there was this high tone. Um, we saw similarities in our athletes, but maybe they didn't have like the pain with sex or the, you know, the stereotypical signs. Um, maybe they had constipation, maybe they had leakage, maybe I live in the DC metro area. So everybody's very type A and high strung, and we all hold our breath and that kind of stuff. And what we found is if we started to treat our athletes almost in a similar way that we treated our high-tone pelvic pain patients, we were getting an improvement in symptoms while using that in conjunction with impact training and things like that. And so I think this is one of those scenarios where I think we have a treatment that's working. I don't think our explanation is right at all. And it's really hard to, and so we've made up this like oversimplified explanation, which kind of makes sense to the average person, but in our guts, I'm like, that's not it. Um I don't know. Like I and also too, I'm I'm fortunate enough to have real-time ultrasound imaging here in the clinic. And what I feel on palpation versus what I see, I'm also aware that those are completely different pieces of information, too. That I think we've been trying to say that they're somewhat equal, but I don't think they are. Um, so I don't know. I just threw a whole bunch of stuff at you. Make sense of it.

unknown 26:31

All right.

SPEAKER_00 26:32

You're so sorry you sign up to do this now, aren't you? You're like you're trying to answer all the clinicians' problems.

SPEAKER_01 26:38

It's all good. It's all good. I think, you know, I think a lot of what we do, we don't really know why it works, right? And in some respect, does it really matter why it works? If it works. Um, so we've looked, you know, just to give an example of that, is looking at trying to find some relationship between gains in pelvic floor muscle strength and improvements in symptoms. And we haven't seen that relationship come out clearly, right? But that doesn't mean that pelvic floor muscle training doesn't work. It does, right? So maybe we don't fully understand the mechanism, but it's still doing something. And like I said, maybe it's compensatory. And maybe people who leak urine when they run, maybe they have other things they're doing during their day to compensate for the fact that they've lost support somewhere else, right? I would do it if I was leaking urine and I, you know, my body learned that if I did this certain thing that stopped the leakage, I would do it. Right. And so if you do something over and over again, then you are really strengthening the signals that go from your brain to that muscle or that pattern and whatever. And those that becomes very strong, right? It's just like you know, walking with a limp. You're going to reinforce that limp because you're reinforcing the motor patterns.

SPEAKER_02 28:04

Right.

SPEAKER_01 28:04

And so they may not be the right motor patterns. We don't really know what the right motor patterns are with the pelvic. The the literature is really thin in this area, and it's because it's so hard to study. Like it's you know, sticking tools and instruments and then in the vagina and then asking people to act natural, and it just it doesn't work. It's not natural, no? Um, we have actually we built an electrode that makes things a little bit more natural because we it suctions on the vaginal wall and we can't even feel it once it's in place, and we can look at what the activity is, but we just uh we're we're low on human resources to do to answer all the questions that I have. But I mean the bottom line is you know, if you're we're you know, if what you're doing from day to day is creating a guarding response, right, then maybe that is in some way influencing the you know, the the way all the pelvic organs sit, you know, how they're sitting, how they're moving, um, we don't know, but it's you know, there may be a mechanism there. And if you know what I find really interesting, so in my lab, um, I moved to the Ottawa area about 10 years ago, and I used to be in a smaller center, and now I'm in a bigger, big enough area that there are enough pelvic health physios around that we have a bit of a community, and I invite them into the lab as often as I can, which is usually about three or four times a year. We just did it a couple of weeks ago, but you know, I hear this from the clinicians as well, and I the thing is the research is only as good as the information you have. So, you know, I'm really intrigued by this, but we haven't really delved into it in any detail. But, you know, there are ways to look at it, we just need to sort out how. And I think it would have to be electromyography. Um, and I think it would have to be during functional activities, which means most electromyography systems are useless because they're just gonna, as we started, give you everything. Um, but our electrode can actually then give us information just from the pelvic floor muscles without all the interference. Um, so it would be really interesting to look at that um in more detail in the runners, but we haven't done it. And yeah, and I think the but if it's working, like I think the thing is the nice thing about being a clinician is you have some opportunity for trial and error, right? And you know, if something starts working for a series of five, six, seven patients in a row, then to it, yeah, then there's might be something to it. So then it's a matter of, well, how can we study this and and see more of it? But it it's like just because there's no evidence behind it yet doesn't mean it's not effective. And even if we don't understand it, it doesn't mean it's not effective, but it means we should probably delve into that area, yeah.

SPEAKER_00 31:11

And and that's where I I I do make a big distinction between evidence-based and evidence-informed. I think they're different because um, like you said in your systematic reviews, like we didn't do good studies and it's not great science, so it makes it really hard to make these assumptions moving forward. As clinicians, I I always I always love when I see a new study come out, and then I'm always like let down because I'm like, oh, you're just telling me something I already know. But we have to have that foundation. But there's still stuff, again, like basic stress incontinence. Like we used to treat primarily, you know, urethra hypermobility, and now we're paying much more attention to um sphincter deficiencies and that kind of stuff. Like that wasn't what I was taught, you know, in the beginning. So shifting that baseline stuff and then moving to now we have far more women um doing athletic endeavors, participating, talking about dysfunction, you know, operating at a pro level. Um, and then tech has got to get caught up. Um, so we need more women in STEM to make the things to help us study to quantify what we think we're actually studying. And so I think if you're new to this field, it can be incredibly frustrating that we don't have the answers. But to me, I'm like, actually, we've come a really long way in just a short time.

SPEAKER_01 32:28

It's things have really exploded. Um, but it's still a measurement challenge because you know, I find, and when I started in this area, it intrigued me. And now I have to say it's half intrigue and half frustration because it's you know, it's just so hard to measure exactly what you want to measure in a muscle that's inside the body. And you, you know, I I look at my colleagues who do biomechanics research, you know, studying limbs. I look at them and go, oh, if only. Right. And we've tried some, and we're constantly trying new tools to figure out what we can look at. I have a bunch of ideas swirling in my head. Um, but it is challenging. And even, you know, so one of the big things that is always an elephant in the room is intraabdominal pressure as well. Right. Yes, you read a lot of papers where people are talking about intraabdominal pressure and how much it influences um in athletes, urinary incontinence, pelvic dysfunction of one form or another. And the measures we have for intraabdominal pressure are not good, right? You can't measure intraabdominal pressure in isolation, it's highly variable. We've got a study we're about to publish um where we just put a so are different ways to do it. The most accurate way would be to have a sensor right in the stomach, right? Um a colleague in Alberta years ago studied six people where he had them, he was a back pain researcher, but he had them swallow a sensor and then do the study, and then he would wait for them to poop it out and then they would sterilize it, and then they would and you know, in this day, I don't even think that would be allowed in this day because you couldn't. I can't see how you would sterilize it properly, but anyway, um, the measures that people have, because there's been some interesting work coming out on intra abdominal pressure, and we've recently used a sensor, you know, you put it up in the posterior fornix of the vagina, which is way high up for people who are not um physiotherapists, but you know, you put it way high up, and then you think you're measuring the intra abdominal pressure, so that pressure coming from within the abdomen downwards on the pelvic floor. But the problem is when you're bouncing up and down, you're also measuring gravitational loading. Right. So you can't tease those two out. Um, you're gonna measure both. And so we've been doing some work with this sensor in the posterior fornix of the vagina. Um, yes, you can see higher forces when people run faster. So there is this link between accelerations and loading.

SPEAKER_02 35:25

Okay.

SPEAKER_01 35:25

But is it intra-abdominal pressure or is it gravitational loading? Right. Um, it's hard, you can't tease that out. I suppose you could if you put people somewhere in a gravity eliminated.

SPEAKER_00 35:38

I was gonna say, I wonder if you put them in one of those. Um, it's escaping me right now when you you put them in the it's the the treadmill that has a bubble in it. Yeah. Um something like that. Yeah. See, now you're gonna get me down that rabbit hole. Um, I'm gonna pull you back out for a second. Um, so for somebody like that, and and I I love that you kind of highlighted upon it, um, you know, we can have differences when people run faster versus slower, because that can be a symptom complaint. And again, with all of this stuff, I I feel like, you know, there must be different things going on for somebody who has leakage with coughing, sneezing, you know, even jumping versus running. I have some clients totally fine with running, not okay with double unders, or totally fine with regular pace running, but when they go to sprint, they get trouble. Or if they stop at the end of a sprint, they get in trouble. There has to be differences with all of that. Um, knowing that we don't have the data know as far as like what's actually going on, and we don't have papers to speak to interventions, like what what are kind of the best suggestions, thoughts, things that we should be considering as clinicians, knowing what you know about this is all different. I know that was a big question.

SPEAKER_01 36:51

It is a big question, and I think I mean we're still getting our heads around how what this exercise incontinence really looks like.

SPEAKER_00 36:59

Yeah.

SPEAKER_01 36:59

Um, and I feel like I keep saying we've got to study, we've got to study, we've got to study. Um we've been doing that now. We've been developing a questionnaire to even get our our heads around symptoms, right? And I'll tell you, it's a lot of urgency and urgency incontinence experienced by those who are running too. It's not to stress. So we had, you know, years ago when I started saying, hey, let's look at runners, I had this crazy assumption that the leakage that would occur during running was all related to loading the valley floor. Um, but it's not. And then you get this crazy mix where let's just say your upper urethra gets a little bit of urine in it. So maybe your sphincter wasn't keeping it nice and closed. And so maybe that's support at the bladder neck, maybe whatever it is, it's a loss of support somewhere, and you get a little bit of urine that gets into your urethra. Well, does that not trigger a lot of sensory receptors that say, oh, now I've got to go urgently? So we don't even know what we're measuring. Is that urgency incontinence or is that stress incontinence? Because, you know, then it's so anyway, you've got this mix of symptoms, yeah. Right. And so I think you've got to treat what you know, what someone presents with. And if there's urgency, but how do you do a strategy around if it's a little bit of urine leaking into the urethra? That urgency's not going to go away with bladder cleaning or bad bladder scheduling.

SPEAKER_00 38:32

I'm I'm thinking even just subdividing that, you've got the the average runner that knows where all the bathrooms are. And then you have these more hyper niche situations where if you've ever run a race, um, you have your nerves are up and you feel like you have to go to the portabody 17,000 times before the race, or you even did that, and then you know, you're you're half a mile in and you still have to go, and you know if you don't go, you're going to be bothered by that the rest of your race. Like again, there's gotta be different things going on there too.

SPEAKER_01 39:04

Yeah. And I think so. I mean, we've been doing a little bit of looking at biomechanics and you know, is there something about running mechanics? You know, can we change the loading? I someone said asked me the other day if I thought the running shoes would matter. And to be honest, I just can't see it having a big enough effect.

SPEAKER_02 39:24

Yeah.

SPEAKER_01 39:24

Um, we're not seeing anything with whether you're a heel strike pattern or a foot strike pattern, and we don't have enough data to really make definitive, you know, calls on that.

SPEAKER_02 39:35

Yeah.

SPEAKER_01 39:35

But I think, you know, if someone's leaking urine during, particularly during a race or regularly during training, um, you know, maybe intravaginal devices are the way to go. And there's very little literature on those as well. We didn't find one randomized control trial uh on the use of a pestery or an intravaginal device. There's a couple of um randomized, you know, repeated measures designs where someone would come in and they'd run. Um, we're doing one of these right now, you know, they run with no intervention, they run with a regular menstrual tampon, they run with uh an intravaginal insert. And, you know, is it effective? It looks like it might be effective, but there's not a single RCT. We're building one, um, but there isn't an RCT out there that has really looked at that. But if if what we're seeing is a problem with support, right, then maybe what we need to do at least in the short term is provide passive support, or maybe that's a preventive measure too, right? Maybe you know, maybe things get worse and we don't know. This again, too many questions and not enough people in time.

SPEAKER_00 40:49

But I think that's a I mean, that's a conversation I think is shifted here. Um, and I can't remember as far as pestry um uh prescription in in Canada, but um here in the States, physio started doing more fittings probably in the last two years. Um, our academy came out with a, I think a white paper position statement or something like that about two years ago. Um, and I think for a very, very long time, because it would take so long to get to somebody to fit it, it was put in this category of last resort. But now we're looking at, and I know I've been messing around with um with clients using it sooner than later. As soon as those tissues are healthy and can stand something being in their postpartum, what if we provide that support sooner, um, can build a foundation, a strategy around it, and then wean off of it, or use it for specific um times of the month if you're if you're cyclic symptoms or um certain activities or things like that. Just again, it's just been a whole different way of looking at it as um just kind of an addendum support sort of thing, as opposed to okay, this is be all end all. You need to use this all the time. And again, and to your point, like we just we don't have that information. But I think the more providers that are able to um give people access, and again, all the over-the-counter stuff, um, there's so much of that stuff coming out now. I think there's gonna be probably more opportunities to get that information. I hope I think so.

SPEAKER_01 42:15

Yeah, I've been working with a couple of companies that that are interested. We haven't really started any anything in that space. Well, I that's not true. We started a study, we actually um have uh had had trouble getting runners interested in participating in our study on Bessroots. Oh but yeah, uh, but for those, we've had a very few people come through who have been really impressed by it, you know. We get messages, you've changed my life, um, which is awesome. Yeah. So I do think if if it helps and if it keeps people active and symptom free, then I agree with you. And maybe it's uh you use this like you would use a tennis elbow splint or uh whatever, right? You go into an activity that you know causes a problem and you wear it and then you remove it because that's what the tech is coming to now. It gets easier and easier to find one you can insert and remove.

SPEAKER_00 43:16

Yeah.

SPEAKER_01 43:16

Um, fitting is a problem.

SPEAKER_00 43:19

I think I don't know if you saw that there's some company that figured out how to do 3D printing, which would be super cool. I don't know what the price tag is on that. Yes, we're not so good in the states on wanting the paper stuff.

SPEAKER_01 43:33

Yeah. Um, and that that may be good. The the big challenge with it is finding out how you decide what is needed. And right, right, it's still trial and error at this stage, but it is an exciting alternative. Fill all the holes. You can't just do that. I don't think that makes sense. There's some cool designs coming down the pipe. Um, and I don't want to speak to specific companies because I have talked to a couple, um And we are in the works of probably doing a little bit of research, but I think it is an exciting opportunity. And there are designs coming out that will be more acceptable because they're not big and bulky and they can be customized somewhat. And they can be fit at home. So that's the other thing. Like, do you really need a provider if it's something and it doesn't have to be a disposable to be fit at home? And you know, can you wash it and reinsert it just like you'd be wearing a knee splint or a pelvic, you know, a penis elbow splint or whatever. And then the idea of weaning off, maybe like postpartum, it's a really interesting idea, right? Um, yeah, because if you want the tissues to heal, you want to protect them just like you would. I was telling you before we started, you know, I'm I'm becoming an expert in ACL tears and I'm watching the weaning process. And every day I look at my kids' knees and I'm like, you know what? We should be doing this same process for the pelvic floor. And we don't, and yet I'm following all these instructions, you know, two weeks that knee needs to stay in extension, and then you can move to a certain amount of flexion and then a bit more and a bit more. We don't do that postpartum.

SPEAKER_00 45:12

I know, but we could we could as soon as it would be acceptable.

SPEAKER_01 45:17

And you're I think you said, you know, once someone's willing to accept a device in there, because I think you know, right after, probably not.

SPEAKER_00 45:24

But I mean, I I think at that point, I mean, there's there's probably more studies that have to be done as far we're just making a list for you as far as you know why aren't people interested? What are the barriers to you know doing pessaries or you know, thought processes or attitudes or things like that? Exactly. Um, yeah, we're we're just gonna add to your list here. All right. One one more thing I want to circle back to before we wrap up here. Um, you did mention um earlier in in one of the studies talking about elongation um of the pelvic floor, specifically with running. And um I think conceptually, clinicians and even like the average person can kind of get a muscle needs to elongate to a degree. Um can you kind of dive into that a little bit more specifically as far as what that means in the context of kind of just the running mechanics, but then also um with uh those with symptoms versus those without with stress incontinence?

SPEAKER_01 46:21

So when I'm talking elongation, I'm talking about the muscles right inside the pelvis, right? So your pelvic floor muscles attach anteriorly to a they they're nicely fixed to a bone. One of the problems with this muscle group is to a large extent, they're attached to soft tissue. So there's not a really solid anchor. There are some that attach to your coccycx, which is the bone at the base of your of your sacrum, so right at the bottom. Um but if those tissues elongate, you they're more inclined to descend a little bit, right? So they're not offering the same amount of support. Um, what that means in terms of the actual running mechanics, which I think is where your question was going, is I don't think it really changes it. I think it really is focused within the pelvis. There were some early attempts to look at, you know, whether the levator ani or that group of muscles at the base of the pelvis is influenced by, you know, muscles around the hip. There is one. So your obturator muscle actually shares an attachment with your so it is a hip internal rotator. So maybe, but I don't, again, I don't think that it really would impact your your running mechanics or your lumbosacral posture, you know, the the posture you're holding yourself at. I don't see that as having a large effect. I could be wrong, but I don't think it changes the mechanics so much. I just think it changes the pelvic organ support. So if it's elongating, you may have more symptoms, you may leak urine, you may have that vaginal heaviness, right? You may be getting into sort of a lack of support from those pelvic organs. Um, and that's what we look at a lot of ultrasound images, and one thing we're finding in our runners is we always measure them before and after our run. And measuring after the run is always messier, something's going on, right? Things are dropping, and sometimes we see uh prolapses that weren't apparent at the start of our session. And then we're looking afterwards, going, Oh, those organs are actually descending pretty low. And so, you know, at a certain extent, if you're seeing elongation in those tissues, you're also seeing elongation. We're not measuring it, but it's probably there, it's probably everything that's structuring right. So now your pelvic organs aren't as well supported. And then here's where it could go. Now you're feeling vaginal heaviness. Now you might change what you're doing. You might keep guarding with your pelvic floor, you might um, you might change your posture while you're running to try to alleviate that symptom, right? Because if you're feeling it, maybe if I just move my body in this way, oh, I don't feel it as much now because I'm changing where the loading's coming from. So, you know, as much as I say I don't think it would change your running mechanics, I don't think it made indirectly, right? Yeah. And we don't know, I, you know, now we're in an area where no one's even looked at any of these ideas.

SPEAKER_00 49:33

But I want the answers. Well, and then also too, I mean, thinking about, you know, the role of hormones and estrogen. And um, I was talking to um Jenny Lacrosse, who's over at University of Michigan, and she was talking about um like viscoelasticity of tissue and all that kind of stuff, which to me is super cool, understanding genetics. Um, what what I'm kind of thinking also too, clinically, um, I've spent a lot of time in the past probably year and a half playing with different uh running drills with progressively increased vertical impact forces. Not that I know if that's the right thing to play with, but it's just given me some sort of continuum to be like, all right, well, you can't do this. Let's back up a step, start here, and then progress up. And just doing that alone with the right group of patients within just a couple of sessions is addressing symptoms. And so again, I also think too, it's like kind of like you said before, is like you've got the whole situation, you've got to figure out what's relevant for that particular person. And ideally, that's going to inform what the best choices. Do we, you know, do we can we just skip pelvic floor muscle training and go straight to the drills? Are we addressing something retraining that elongation aspect? I have no idea, but I know it's working. And that's tell me what I'm doing, Linda. What am I doing?

SPEAKER_01 50:57

Well, why don't you come here? I will totally come there.

SPEAKER_00 51:02

I will totally come there. You can solve all my problems.

SPEAKER_01 51:05

It's uh it is, I mean, there are so many questions, and so many of them are unanswered. And it's these discussions that create those questions, right? So understanding where I was heading before, which I don't think I finished the thought, was that you know, inviting clinicians into my lab and having discussions, like over the years, you know, I started off. Maybe I thought I was, you know, so smart and I would present all my research to everybody and they would love it because it was really cool. And, you know, I have more to learn from clinicians than they have to learn from me, is the bottom line. And so these conversations and the conversations I have with the clinicians locally here are the ones that really drive change, right? Yeah, because we can only know what we want to look at or what we should look at when a bunch of people are saying the same thing, right? It's like, okay, well, people from different places are all telling me that this is effective, or you know, this person's developed this graded intervention that seems to be effective. Well, you know, what questions can we take? What's important to answer about that? And yeah, is there something is there, and here's the big thing with urinary incontinence in particular that I've come to appreciate over the years is that everybody's different, and the mechanisms involved in this person may be very different from the mechanisms involved in that person. And so it has to be driven by the patterns that we're seeing. And this questionnaire we've been developing, we're kind of in this last stage of testing it, making sure people understand it. Um, but I think it will serve to really help us understand symptoms and when, you know, what the triggers are, what people are doing to mitigate the leakage, and you know, when it occurs, what are the training parameters around when it occurs? Like we're getting it all. Um, because I think there are probably clusters. It's, you know, this group looks this way, you know, they leak at the end of the run and only at the end of the run, and maybe only on, you know, on days we're actually getting, you know, cyclic fluctuations are in there, time of days in there. Um, you know, what are the factors that really are triggering for this group versus maybe this person who starts leaking at the start of the run and then leaks all the way through? That's yeah, total, that's probably, I say it's totally different, it's probably totally different. We haven't looked at it, but but there are so many pieces of information that could be important. Yeah, and we may need to phenotype, right? We may need to say, you follow this pattern, and pelvic floor muscle training may be right for you, you follow that pattern, and maybe we need to be doing something different. Yeah, and so there are so many unknowns, but it's the clinical observations that help start to fill in those pieces. And, you know, I think we have to work together because totally.

SPEAKER_00 54:12

Well, and it's so much more fun, by the way. Um, I think when people are open to saying, I don't know, um, and when I'm like, okay, I I I say this is what's happening, but I'm pretty sure there's something else going on. But I think all of these acknowledgments are incredibly important to um either clinicians that have been kind of stuck in their own biases for a really long time, to stop and re-examine those biases, to new clinicians that um the poor things don't know that it's not a black and white world and they need to get used to the gray. But I think also too, this is incredibly important information to the mom who's looking for answers, that they thought they did the right thing by going to pelvic floor PT and they only got so far, um, and they got the same thing as their friend down the street, but their result wasn't the same to understand that there can be a lot of different reasons, and we need to figure out what the factors are, what the variables are that's important to that person, and then address those in the best way that we can. So if you try it and you don't get better and you thought you would, that doesn't mean that's it and you're stuck with that forever. I think that's, you know, if there's any take home from this, it's like there's a lot we don't know, but that's really good information. That's really encouraging because that means the answer is out there somewhere. Absolutely. At least that's how I look at it.

SPEAKER_01 55:28

So absolutely. And I think um it's not, and I'm I'm glad we've moved away from this idea that you know, everyone does the pelvic floor muscle training. And the problem is the pelvic floor muscles, and therefore, if we treat the pelvic floor muscles, everything will be better. Right. Um, I think, you know, I'm happy to see that we've moved away from that. And then you're absolutely right, is that you know, it is a bit of trial and error. So you may not have the right answer or the right intervention for this person at this time, but that doesn't mean there isn't an intervention that will work for that person, right? And I love that. And we need to tease that out. And um, the longer I'm in research, I mean, research, we were we we love to work on um averages, what the average, you know, you take a big group of people and the average person does this, but we're not all average. And so we need to look at those extremes. And in in research studies now, we tend to get really interested in the responders and non-responders because that's where we need to understand who's responding to be able to say, you know, this kind of symptom presentation may be really, you know, well served with this intervention. Um, and medicine is going that way. I think rehab is going that way. Um, we try to, but it's hard because you need big trials to be able to do that. Um, but this idea of responder and non-responder is the really interesting piece.

SPEAKER_00 57:02

Yeah, and is there something to learn? There's absolutely a lot to learn either way. Well, I don't know about you, but I have hope. One, um, because you're you're you mentioned about a zillion studies that are are coming up, and I'm really excited. I can't wait. And then also um looking at the size of your lab and looking at all of those uh lovely ladies that are um putting papers out and putting information out and stepping up to become researchers gives me a lot of hope. Um, because not that long ago there wasn't. And so um, and I I love conversations like this. Um I I love that you don't have the answers. I it makes me feel better in some ways. I I when I first started as a PT, I was like, well, someone has to have the answer. It's just up to me to find that person. No, we're all still working away at this. So absolutely.

SPEAKER_01 57:48

And I find that that um the longer I I you know take this with a grain of salt, but the longer I'm an academic and a researcher, the less I know, right? You become the same way, yeah. So aware of all the gaps in knowledge, and um, they are many, and it's not unique to this area, yeah, but it's what makes it interesting and challenging and clinically makes it super challenging, but also means that you have to, you know, dig in and really, you know, you're not following a recipe, you are treating what you see in front of you. Yeah.

SPEAKER_00 58:24

And honestly, that's what's I think kept me in this field as long as it has. And and what I think is so amazing about working in pelvic floor physio is that there are you're never gonna get bored. There's always gonna be a question, there's always gonna be something to learn from somebody else, and then pull it back and and apply it here. Um, so we're we're gonna keep you in business with lots of questions for a very, very long time.

SPEAKER_01 58:48

Well, it's been an absolute pleasure to be here. It's nice to chat with you.

SPEAKER_00 58:54

If you if you guys want to learn more about Linda's lab, um they're on Instagram um at MFM underscore lab. Um, and hopefully if you guys uh need participants, keep posting it up there. We'll share it as much as we can because um you guys can't do research unless you have participants. So anything that we can do to kind of help you guys along as well, that would be great. And yes, someday I will take up your invitation and go to Ottawa and I want to see it all. Thanks so much for being on the show.

SPEAKER_01 59:23

Thank you very much, Carrie.

SPEAKER_00 59:25

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. Carrie 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.