Everyone's calling it a 'tight pelvic floor'… but can we actually feel it? — with Gosia Starzec-Proserpio, PhD

You've heard it. Maybe you've said it. "Your pelvic floor is too tight." It's everywhere right now — on the socials, in the clinic, out of the mouths of people who've never assessed a pelvic floor in their life. But here's the question almost nobody stopped to ask: can we actually feel the thing we keep confidently naming?

Researcher Gosia Starzec-Proserpio, PT, PhD, just did the work to find out — across 528 women. And her answer is more interesting (and more freeing) than either side of the internet fight wants it to be.

I got to sit down with Gosia — 12 weeks postpartum, "just coming out of the darkness into the light," her words — to talk about the study that went a little viral, and what it actually means for the person on your table.

🔹 What "tone" even means (and why it meant nothing to her as a new clinician) 🔹 The single biggest mistake we make: treating "pain" and "tight" as the same word 

🔹 Palpation vs. ultrasound vs. dynamometry — three tools, three answers, and why that's a feature, not a flaw 

🔹 Where our fingers are genuinely good — and where they quietly aren't 

🔹 Why you can't get "fixed on the number," even when we love a good number 🔹 The pregnancy nobody warns you about being harder than postpartum

This one's for the clinicians who want to sharpen how they assess and explain tone — and for anyone who's been handed a label they've been carrying ever since. 

Come nerd out with us.

Education, not individualized medical advice — loop in your own pelvic floor PT for what's true for your body.

Time Stamps

0:00 introduction

3:56 quick fire questions

9:43 troubles breastfeeding

18:55 muscle tone explained

21:54 explaining the research

25:35 communicating with patients

33:51 comparing different measurement modalities

45:53 addressing personal biases

49:11 changes in clinical practice

CONNECT WITH CARRIE

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

Website: https://carriepagliano.com

Course waitlist: https://course.carriepagliano.com/RSAWL

CONNECT WITH GOSIA:

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

Linked In: www.linkedin.com/in/mstarzec

Research: https://www.researchgate.net/profile/Malgorzata-Starzec-Proserpio?ev=hdr_xprf 

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Transcript

SPEAKER_01 0:00

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 in pregnancy, postpartum, perimetopause, 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, Pilates hit, or whatever activity you love with confidence and evidence-informed guidance. Let's start the show. Hey guys, Dr. Carey here. If you are thinking about getting back to running and you have no idea where to start, I don't care if you're newly postpartum, a couple years postpartum, maybe you're diving headfirst into Perry Menopause and never got started. A great place to start is your return to run readiness screen where you check out your tolerance to impact, check out your strength, check out your balance, and see if you've got some gaps that might need filling in before you get started on that walk run program. There's a link for the free screen and the show notes. Check it out and enjoy the show. Welcome back to the Active Mom podcast. I'm your host, Dr. Carrie Pagliano, and I am incredibly excited for our next guest for two reasons. One, um, it's not often I get to meet a researcher and then we get to talk about their works. And I got to meet our next guest um back in October in Vancouver at PFD Week. Um, so we'll chat a little bit about that. And then we also have a new mom. So we're gonna talk a little bit about new mom life as a researcher in the public floor space. Um, I'm gonna let her say her last name because I cannot do it. Um she goes by Gosha and we'll let her say her last name, Gosha. Welcome to the podcast.

SPEAKER_00 1:35

Thank you so much for the invitation, Kari, and I'm so happy that we get to meet again after October. Yes. Now online, but but I've got the great pleasure to meet you in person, which is which is amazing. Um, my name is Gosha Stazec Proserpio, although sometimes I can hear Prosperio, which I don't mind at all. I like that. Or once I heard proseko, which I don't mind either.

SPEAKER_01 1:57

That's even but that's good though. Like I can I can get behind that. And by background, you are from Poland but researching in uh Quebec but currently living in Toronto. Um tell us a little bit about how that came to be, and then we'll we'll dive into a few things about you.

SPEAKER_00 2:16

So I am uh originally from Poland, and this is where I was trained as a physiotherapist and women's health physiotherapist, and I was working there for many years. But throughout my education and uh working experience, I was uh changing a bit the places I was living. So I used to study uh for some for a year in Czech Republic, then um work in uh Spain in Tenerife, then uh in Norway in Oslo, and came back to Poland again and then for my um PhD. I was visiting here in Canada um two times um to do some PhD fellowships, and I came back here for my postdoctoral fellowship. So right now I'm currently between Poland and Canada, um, doing my postdoctoral fellowship uh here at the University of Sherbrooke in Quebec under the supervision of great Melanie Moron. Um again, um by accident, my uh postdoctoral fellowship was supposed to be in Australia, but before, because of COVID, um everything was transferred. I was so happy I could come back to Melanie because it is with her that I did my um PhD fellowship as well. And uh and I can learn from her for over all these years every time something new, which is amazing.

SPEAKER_01 3:35

That's fantastic. Um yeah, I got to meet her as well for the first time in Vancouver, and um I I I'm really enjoying hanging out with the Canadian researchers, I'm not gonna lie. We're we're a little uh low on research in the US these days. Um, so it's nice to hang out with with um the Canadian researchers for sure. Let's get to know you just a little bit. Um lately, obviously, you're doing mom things, but before your your little son was born, what was your favorite thing to do outside the lab when you weren't researching?

SPEAKER_00 4:11

So uh I uh it's a difficult question what I was doing when I was not researching, right? Because uh we love our work so much that sometimes we do our work also after our work.

SPEAKER_01 4:25

For fun, yeah.

SPEAKER_00 4:26

Because we for fun like to listen to great podcasts like yours, for example, or read some interesting books that are again uh from our field. So this is what I was doing a lot, and I still do, but outside of that, I I love traveling, so wherever we have occasion with my husband, we we love to travel in different places or do some kind of like workation that I can now do um working in research. Uh I can let's say work uh remotely from different places from time to time, and then uh what I also love to do it's uh some form of physical activity. I never was training something like very seriously in the recent years, especially. But uh just staying outside, going for a run, doing a regular gym, like this were these were the things that were uh very ingrained in my daily routine. Now they are not. I'm trying that they will be again, and we will probably talk about this more later, but uh but this is what I was uh what I was doing as well.

SPEAKER_01 5:30

Yes, and you're so good to join me. You're 12 weeks postpartum. So we were just talking before we pressed record that you're just coming out of the darkness into the light, trying to find some some normalcy in your day because this is how things go now. Um, what is your go-to either snack that you have while you're working, or now your your go-to mom snack?

SPEAKER_00 5:54

So I am I'm calling them uh bowls or of power, which is okay, which are kind of like a snack that I prepare myself and I like it a lot. Um is it it has dates, uh, a bit of protein powder, um, a bit of cashews, a bit of coconut. Um how do we call this coconut coconut? Shredded coconut. You mix everything, you create like little balls, and then you have this kind of like um a snack um that is sweet and with not so much guilt.

SPEAKER_01 6:28

I like that. With little protein in there, we've got the carbs. I was like, it's probably pretty similar mom fuel versus you know research fuel too.

SPEAKER_00 6:36

So and now I'm doing all this kind of you know, snacks with uh brewers yes all over the top.

SPEAKER_01 6:44

The lactation balls, yeah. All all the all the lactation things, yes. Yeah, it's everywhere right now. Yes, yeah. Um are you reading or listening to any podcasts or anything right now, or are you just reading up on you know breastfeeding and sleep training and all of that?

SPEAKER_00 7:05

So yeah, I'm I'm reading uh a book about the baby's sleep, that's for sure. But um I also like to detach sometimes. So I have this, let's say, me time once per day when I go out for a walk with my son. He sleeps, so I call it me time, and I can do some power walk with the stroller, and this is usually where I would listen to a podcast, and this is the time when I would hit the podcast that it's not related to my profession. So I I have like one podcast, like a one polished podcast that I like to listen, that it's saying about different stuff happening in the world, but sometimes not the really the stuff that we would not really hear in the news. Um so this is what I find interesting because it helps you detach a bit from all the best stuff in the world because you just listen to something else. And so this is it. And the other one, currently I'm listening to some mom podcasts, yeah, navigating parenthood and things like this.

SPEAKER_01 8:01

Oh, yeah. I mean, I don't know that that ever ends. We were talking about that too, with you know, obviously, my kids are are much older and I'm still drinking from the fire hose. I've I've managed to keep them alive this long now. We just gotta get through puberty and all that other stuff. So, yep. All right. Um, anybody mom inspiration right now? Like, are there uh moms that you're looking up to either in your field or online or anything like that?

SPEAKER_00 8:27

So I think I have to mention one mom that is actually um is also known in our field, which is my uh pregnancy body, and now I'm my postspartum body, which is uh Marina Pate Rodriguez from Lindas Maquinas. We have a hotline all the time. I love this, and I think like uh I never thought about the pregnancy body and the postpartum body because I have a lot of friends who are moms or um to be moms and all this kind of stuff, but to have someone that is more or less at the same period as you, it's a whole different thing because probably you know it yourself, you forget all the bad stuff later on. But to have someone that is going through similar issues, similar problems, and we are actually sharing a lot of similar problems recently uh with Marina. I think like this is uh this is really a person I look up to right now and I listen. I I listen because we we exchange loads of voice messages.

SPEAKER_01 9:25

Yes, I love the voice. No, I love it.

SPEAKER_00 9:29

So it's all the like pumping talks, like uh when we pump it, let's say at night or things like this, so we record messages to each other. So I would highly recommend it to every mom who was who is afraid of this dark period to find a pregnancy body and postpartum body. That's definitely the thing. And then, of course, like I mean, we have a space, like I have the impression that in our space we have so many amazing women that I still don't know how they are holding things like you, Gronia, Christina Preves, my own supervisor, um Melanie More, who has also teenagers uh grown-ups, but still like I'm a mom too. Uh, and all these um different researchers in our field that are doing amazing jobs that requires enormous amount of effort, and yet they are also moms, they are showing up uh every day for this different kind of like work that they have at home. So these are all the people that I really, really look up to, and and and I'm happy to be part of the club. I hope I will be playing the level of the club.

SPEAKER_01 10:34

It I have to tell you, it is nice to have some moms a little bit ahead of you, and it's nice to have some that are a little bit behind you because you're learning, but then you're also kind of paying it forward to those moms coming behind and saying, gosh, I I could have done this better or whatnot. So it is I I love you have run speed tiles. That's fantastic. What's maybe one thing before we get to your paper here, what's maybe one thing that has surprised you the most? Um, either about kind of pregnancy, being in this initial postpartum time period, or even just being a mom?

SPEAKER_00 11:12

So I think I have two things that were most striking to me and that I was really not uh not being aware of, is that you and because we don't really hear about this, that you may feel much worse during pregnancy than postpartum because I was always hearing like how the postpartum times uh is difficult and and how dark it is. But for me, let's say I really have to say, although I was it was a planned pregnancy and I was very happy to be pregnant, I was really, really struggling for my pregnancy, both physically and emotionally, and uh and I was having a whole sort of various expectations what I will do while pregnant, uh you know, like all these uh different things like I will run, I will do this until the end, till the last day. I was feeling so awful. I was feeling so awful. That's uh that didn't happen either. I mean, I I was active anyway, I was traveling really a lot, but but other than that, I mean it was a very, very difficult time for me. So actually, the the early postpartum times uh were really the time I was really the happiest in my life. So that's the one thing. And the second thing that was not I was really not aware, or maybe it's because I'm I'm in my pelvic health bubble and I don't really see about the lactation bubble, but uh I was always hearing like what an amazing experience that one is, and I was not even aware how difficult it is. It's it's a rocket science. Like, I mean, to me, breastfeeding is a rocket science, and I was shocked because I'm living I'm passing, let's say, my postpartum period at the center of Toronto, being surrounded by the best specialists, having lactation consultants just let's say uh next to me basically, and having their help once per week, having phone calls, having visits, and having all of that. I am I was and I am struggling so much. So then I'm thinking like I really look up to all the heroes, moms, who are not having this and are making making this because it's so so difficult, and and I was really not aware of that. And then maybe I will add the third thing to this. I I was working as a physiotherapist, uh, pelvic health physiotherapist, and over the last years, um my um um the majority of my population was uh pain population, so it was like sexual pain disorders, vulvodinia. And you know, you hear from these patients that uh no one believes me, that I'm I'm uh all the time having the feeling of being invalidated, like people are not treating me seriously. And I'm like, Yeah, but I mean uh we are now speaking more about this. Like, I mean, no one is doing this intentionally. Like, I mean, how come other people can make this woman feel like this? And then I'm finding myself with excruciating breastfeeding pain, saying it hurts, and everyone's not having to shadow pains. Everything is fine, and then I'm feeling like this crazy patient who was told it's all in their head, and I'm like, I am living the worst nightmark. I am leaving all the histories of my patients right now.

SPEAKER_01 14:43

I yeah, my my oldest, I think he did okay, and then my second one, we she had a um a tongue tie that we caught pretty early, but like she would come towards me, and I would just feel my like that first latch was just so I you cannot describe that pain, like, but when you're talking about it, I'm literally having like phantom boob pain right now. But you in in hamburger nipples, if I say that to some people, they don't know what I'm talking about, but you know what I'm talking about. I'm I'm very lucky. I have a dear friend of mine. Um she's been on the podcast a couple of times. She goes by the balanced boob online. And we were neighbors back before either one of us uh had even got married, had babies. Um, she's hysterical, but really, really smart. And so she was a uh labor and delivery nurse, um, also has a uh pediatric cancer history. So when COVID happened, she really leaned into her uh IBCLC um training as a you know international uh breastfeeding uh consultant and does a lot of resources and stuff online. And so um the good news is there's so many more people in the world doing this education. But for for those of you that are listening, you don't have one in your area. Um, the balance boob, Kelly Kendall, um, she's wonderful and amazing. And but yes, I am right there with you. But she's my person that I have a client, they can't figure it out. I'm like, go talk to Kelly, like she fixed it. But yes, oh I am with you. I am with you.

SPEAKER_00 16:17

The biggest lesson that I that I get from this as a as a physiotherapist, like taking this kind of looking it from the professional lens, is how communication is important because I mean no one really was mean to me, never, right? But sometimes the words are are hitting in a in a very particular uh way. And of course, we cannot be always responsible and take full responsibility for how someone will understand what we are talking about, and and and that's that's also the the the important thing to say here. But really, like as a professional working with women with pain and uh during pregnancy postpartum, we really need to upskill ourselves in the communication skills because now I mean I was always thinking it's very important, but now being on the other side, hearing what is being taught to me, uh feeling it very, very deeply sometimes because of all the hormones and all the difficulties and challenges. I really think that we we should invest in the skills. We always invest in various courses, manual therapy, new ultrasound course, things like this. But we really, really have to, the soft skills are are really essential, and and sometimes they can make uh a bigger job than all the best skill set, techniques, uh, and devices we will have in the office.

SPEAKER_01 17:44

Yeah, I I will tell you, I I think you hit on the one thing that um well actually there's two things. One is the the the communication piece that I got from being a mom that wasn't ever taught to me. The other is the um kind of meeting people where they are, helping them organize like you know, before I had kids, if I gave somebody a bunch of exercises and they didn't do them, I'd be like, oh, well, you're just gonna have to take this more seriously. Or I would tell them, well, if this hurts on this side, well, just hold your baby on the other side. That doesn't work. Um but just you know, if you're not able to get to exercises, let me know. I've given you too many. Let's sit down and figure out exactly where this goes. You're gonna get up, you're gonna go pee, you're gonna go to this mat, you're gonna do these three exercises. If the baby wakes up, your husband's gonna go get them, then you're gonna finish your exercises, and then you can go get the baby. Like we will go through it that specifically because once you're in it, you know how much that mental load is. That's all skills I think that make moms so much better at our job, but then also in the workforce period. But we could have a whole podcast on that. But I I love that you talked about communication and kind of how we talk to people because that's a nice segue into kind of this paper that just came out. Um, because one of the things you're talking about is muscle tone. And tone means a lot of things to a lot of people, especially in pelvic floor land, when a physical therapist says to you, whether you have pelvic pain or pregnancy postpartum, you have high tone, which is the very cool thing to say now all over the socials. Um, and your study was looking at how we can kind of understand this through palpation and other mechanisms. Um, can we start with just what tone actually is? And so that we're starting kind of with with this foundation.

SPEAKER_00 19:37

So tone, um tone of the pelvic from muscle relates to that change in force per unit length change. So, like that that's the whole kind of like proper definition. And I mean, to me as a clinician, it always means nothing, meant nothing. Yeah, I mean it includes uh active and passive contribution, so the active uh muscle activation, and the passive contribution, which can be the various structures like the viscoelastic component, which can include things like scars, like connective tissues, the actin myosin cross bridges, all that kind of stuff. But this is very uh, I would say, proper things like what the tone is. To me, as a at-heart clinician, the tone was always something what I could feel during my um pelvic flower assessment that I was conducting, which was basically the resistance um that we feel uh over the pressure, the resistance for the passive stretch that we would do. So that's the that's what I would say it, and that's what it would always means to me. Like the resistance for a passive stretch uh once we are assessing pelvic flower muscles. So it's a thing that it's very difficult to measure. And what we are trying to do in research is to trying to measure this thing that is basically or very difficult to measure, uh, as we do many times in uh in research. And uh and I would say, as you say, um tone can be can mean many different things to many different people because it can be measured in many different ways. For example, uh we have our tone uh queens, which is my supervisor, Melanie Moran, and uh Rachel Warman from US, who did also a great job regarding this, looking at all the different tools that we have to measure the tone. And actually, like although all of them measure the tone, each of them measures something differently. And this is also what what I probably think happened in our uh in our study too.

SPEAKER_01 21:42

So, what made you want to kind of look at this? It looks like you you pulled some information from a couple of of other trials to pull this together.

SPEAKER_00 21:51

So I have uh an amazing opportunity to to work with my supervisor, uh, who was ahead, Melanie Moran, who was ahead of Great lab when they have a massive amount of data from various RCTs they conducted. So to me, professionally, uh as a clinician and researcher now, uh, it's a great opportunity because I get to uh learn many various things from the various data that they have collected, and I also have a great opportunity because I can kind of um use the data that were already collected by a ton of people because it takes a village to get the data that were included in this study to do it. And that it was actually my supervisor's idea that she said, like, we listen, we have this data, we were trying to look at them some time ago, but we only look partially at Vulvodinya data, but now we have another RCT, which was the um avulsion study, and then we have a whole set of data from women with uh urinary incontinence, mixed or stressed urinary incontinence. What about looking at this and trying to discern this um this research question? And this is where I step in. So so I am I am standing in the arms of the giants here, uh, of the people who already conducted the job and uh and got the idea, and I was the one who did the job looking really at the data and trying to order them and see what they are saying to us.

SPEAKER_01 23:20

Yeah, as a clinician, it's not often you see those kind of two patient populations in the same study, where you have these, you know, stereotypically higher tone vulvadinia patients, and then we're not quite sure what we're gonna get with the urinary incontinence. Um as with your clinician hat on, you know, how did how did you feel kind of being able to kind of work with these two data sets? And it was like 527 individuals, it's pretty big for a pelvic floor study.

SPEAKER_00 23:53

Yes, so uh so the thing is that what sets this study apart is that for the first time we were able to combine the two population, as you say, is because sometimes we have, for example, only healthy people, but we don't see so many healthy people in the clinic when we really assess them. Sometimes you would only see, and that was what previous um research has been done, we only see, for example, a high-tone population, which is, for example, provoked by stibulodenia, or only the uh urinary incontinence, which many people would say they are maybe more prone to a lower tone than higher tone, although as we know it is not always the case. Um, so that's what sets this study apart: that having those two uh different randomized controlled trials and having the data from those two randomized controlled trials, we couldn't we could combine them all together to really have the impression how it is. We got also another study, which was by our friend Melissa Davidson, and then it was also a very nice study, but then again, they were having a special kind of tool, so it was not like very clinical conditions, which was a perfect prerequisite before our research was made, because we kind of built on top of uh on top of that. And um what is very interesting for me is to look at the subpopulation to see how good we are in detecting the decrystone and increasine and what are the differences here, and that I think was uh was the most interesting part for me.

SPEAKER_01 25:26

Yeah. As a clinician, when you have that patient in front of you, how do you explain to them, maybe if they've never heard what internal palpation is and what you're looking for, what does that explanation look like when you have a patient in front of you? What's your typical thing that you say?

SPEAKER_00 25:45

So I think I'm trying to uh firstly be very objective in front of myself because sometimes what is very tricky, we get a patient that comes comes to us, and for example, they say, I'm coming with sexual pain disorder, or this kind of issues, and we already can have some uh predetermined uh thoughts, what we might find there, and that's what is very tricky, and that's what I was always reminding to myself when the patient was coming before even speaking to this patient, not to kind of suggest some stuff to myself as well that probably maybe it's an increased tone. Because again, we know it may be increased tone, but it doesn't have to be. So that was the first thing, always for me, try not to make an idea before assessing this patient, and then for the patients, once we were assessing when I was explaining um what are the structures that we are assessing, I was trying usually again not to pathologize too much.

SPEAKER_01 26:43

Yeah, no, I it it's funny when you were talking about um when you have the diagnosis, you kind of have that preconceived notion of what might be. Um I I will go in lots of times, you know, with my subjective informing, you know, these are the things that I want to look at. But I think the longer I've been at this too, I'll go in expecting one thing, but be open to what I might find. And and I think again, that's made me think, you know, more than once about gosh, I feel like this should be worse or more high tone than I'm what I'm feeling, and I'm not feeling that. And so then that makes me wonder okay, is there something else? Or it just it makes it it does, it makes you question yourself. But I I don't know, you know, if if that's just we've done it for a long time and we allow ourselves the space to consider other possibilities. Um, or you know, it would that be different if we were just out of school for a couple of years, which is I one of the things that I I thought was really interesting of the the experience range of the clinicians that you use, but the average ended up being three and a half years of experience, even though it was like a pretty wide.

SPEAKER_00 27:54

It was very wide, it was from less than one year until 30 plus years of experience. And that was also what I think sets the study apart because of course, at the review process, some people would say that was not very standardized. But I said, like, we didn't want this to be standardized because we wanted it to reflect a real clinical conditions when we may have someone assessing pelvic floor who was right after school, or we can have someone very experienced, and it was not our question, research question to see whether the experience helps us doing this. Our question was to see if we get a group of pelvic physios, how good they are in assessing pelvic fluor muscle tone.

SPEAKER_01 28:36

Yeah, the the one other thing, and I and again I think it kind of came more with the different groups was one, um, it was the the vestibular group that was all nullaparis, right? So no, and then the other had varying degrees of parity. Again, that's very much what we see on a regular basis. And I I you know, I mean, that obviously does change things, but it's really cool to see these things kind of um compared, especially because um again, I feel like the word high tone is like super popular or like tight pelvic floor, all this stuff is super popular in social media right now. Like trainers and coaches and and non-medical professionals are really latching onto it. And I don't know that they actually know what they're saying. Does that make any sense?

SPEAKER_00 29:26

I think the biggest mistake we do in um in our communication, both in social media and in the clinic, and in our, let's say, professional uh conversations, is that we are linking very tightly pain and increased tone. So when someone says they have pain, we already always say that's for sure the increased tone, and because of increased tone, there is the pain. But we know it's not that simple, and we can have someone who, in our subjective uh assessment, may have an increased tone, but have no symptoms whatsoever. And we may have a person who will suffer from a lot of pain in the perineal area or pelvic pain, and we will not be really sure that this tone is increased there. So, um, so I think like that's a very important thing for us clinicians not to marry these two concepts because they are two separate concepts, and that's also what is very important in terms of a scale that we um that was used in the studies that then feed into our recent study, is that we use the raising scale, which is not marrying the pain and uh the tone. But we know that out there there are also the scales to assess palvicular muscle tone that includes um that include pain component. And I think like that's uh that's a problem because it's usually it there is an assumption that the higher the pain, the higher the pelvicular muscle tone, which again um maybe in some cases, but in some cases maybe totally not related.

SPEAKER_01 31:03

Yeah, and I I think you could say the same thing um with more the the postpartum diagnoses with your neural incontinence and and even to some degree with with the prolapse diagnoses, too, is I think you know, 25 years ago we were taught to think, oh, this is just low tone or you know, just weak muscles or things like that. And and I think now being open to gosh, there's a whole bunch of other things, you know, having diag, you know, conversations about avulsions and things like that, um, partial evulsions, all of these conversations are just opening us up to there's a lot of variability here. And we don't necessarily have that all figured out yet.

SPEAKER_00 31:40

And then how it's changing, like I mean, even now when I'm talking with you, I am concentrated, maybe I am stressed a bit. I I may have some elevated palvicular muscle tone, but for example, when I am I will be relaxed in a moment playing with my son, it will not be increased anymore, right? So, like, there is also this part of the inherent in-person variability, not only between person variability. So it's so dynamic and it changes so much. And I always say it when I'm also teaching uh physiotherapies during various courses or webinars. Like I always say to the say to them, don't really stick so tightly to this first exam. Because if you have a person who sees you for the first time, maybe it's their first physiotherapy assessment, of course, they may have some tension there, and of course, there it may be uncomfortable because imagine someone sticking you a finger in various holes of your body that you are not used to having fingers in, and of course, there may be some of the um tone increase of the tone, but it doesn't really mean that it's the reason for all of the problems because this tone may vary across the different situations, and this is again what I think the palpation can be very useful for because we can kind of during the talk, during various exercises, in vivo without very specific tools, we can try to see how it is changing because we can give some extra cues to our patient to see whether this increased tone that we are maybe feeling initially upon starting our examination, maybe it can change when we get the person to relax. Maybe we can use some different um calming uh strategies, maybe some breathing, and then we can see it's changing life. So uh that's why I think palpation is a very important part of our clinical practice, and that's why I was so eager to jump in in this data. Um, and I really was happy that Melanie shared this data with me. Um, because uh I think that was a very important thing to do.

SPEAKER_01 33:46

Yeah. So in in this study, you were specifically comparing palpation to two other um kind of measuring modalities. Tell us a little bit about each.

SPEAKER_00 33:57

So the thing that we uh what that we did it was comparing palpation, which is very subjective, and although it is a basic um assessment, not only in palvic or physiotherapy, but in physiotherapy in general, we use a lot of palpation. Uh, we wanted to compare it to a bit more objective measurement tools, ultrasound, not fully objective because there is some element of um of assessor who needs to measure some stuff, and then the direct uh assessment of pelvic through muscle tone, which is dynamometry, which is a direct assessment because it measures the forces. Whereas um in pelvic fluor ultrasound, based on morphometry, we imply or we suspect what kind of let's say um tone situation may be there, but it's indirect measure. Then we have also dynamometry dynamometry, which is so-called direct measure or of pelvic through muscle tone, because it can measure forces directly that are elicited upon uh the stretch and relax cycles that we are doing within the assessment. So the thing was to compare it to these two um measurements because so far we didn't got a proper validation study of palpation. So we are using the tool a lot in our practice. We were having some reliability studies, but there was not a proper validation study. And a validation study is where we compare this our palpation tool to something which is a direct measure of palvictor muscle tone, for example, like dynamometry. Um, so that's one thing. Uh, a second thing, why we combined both dynamometry and ultrasound, is because they, although they are both intended to infer some information regarding pelvictor muscle tone, they measure it in a bit different way, and we may suspect that they are giving us a bit different information about pelvic through muscle tone. So, uh, what we could see in our data, and what I find particularly interesting, is that we're having three different measures that were intended to measure the exact same thing, but in fact, they are measuring the exact same thing, which is the concept of tone, in a very different way. Because we may have an ultrasound probe and we use the external technique which is the transparineal ultrasound, when the probe is basically placed on the perineum, and then we are measuring the levator heatus um anteroposterior diameter or the um or the levator heatus area, so that's one thing. Then we have palpation when we elicit minor um when we elicit a small passive stretch over the structures to see what kind of resistance to stretch we feel, and then we have dynamometry, which basically creates several stretch-relax cycles between uh very small opening to maximal tolerated opening. So you can see the conditions in which we are measuring the same thing are very different. So the difference that we could see between all of these different tools is very important because it's not necessarily says that one is better than another, it's just that they are measuring the same concepts but from a different perspective. So each of them are giving us some unique information about the state of the tissues.

SPEAKER_01 37:33

Yeah, and I think clinically, I mean, obviously, we've been doing palpation, you know, our our whole careers if we've started there. Um, I'm seeing more clinicians, myself included, doing the transparineal measurements. So we we feasibly have you know two ways that the everyday clinician may be looking at this information. So so what did you find?

SPEAKER_00 37:56

So it's interesting because now when when the study got a bit viral and and people were really, let's say, like sharing it a lot, I can see that uh people are looking at the study in many various ways in various ways. So generally, what what what was the result of the study is that with the palpation we were able to distinguish between different levels of um of the rising scale. And the rising scale that we used, I will maybe um introduce the scale for those who are not aware of the scale. The rising scale that we used is a seven-point scale from minus three through zero to plus three, so from a very low tone to a very high, very increased pelvic from muscle tone. And what we wanted to do is to look whether the various levels of the rising scale can be distinguished when we compare the palpation against ultrasound measurements or dynamometry measurements. And what we could see first is that palpation uh assessment correlated with both dynamometry and ultrasound measures, all of them. And the second thing that we could see is that the palpation scale that we use and the palpation technique that we used was able to distinguish between various levels of tone. So when we trying, we're trying to see if there are some statistically significant differences between those various levels of palpation scale, then we could see that there were these differences when we compared to both ultrasound and dynamometry. So we then dove farther into the analysis and we wanted to see, okay, there are differences, but between which particular level, uh, between one and two, two and three. So we did some post hoc analysis and post hoc tests, so-called, when we kind of tried to look between which exact levels uh we see these differences and whether we as a physiotherapist are able to distinguish between, let's say, normal tone and slightly increased tone. And that's uh when it uh when it became very interesting because we could see that depending on which tool we used, we could see more or less of these differences. So definitely we could see that uh when the palpation was compared to ultrasound, then we could see more differences between various scale levels than when it was compared to dynamometry. And then the second thing that we could see, if we looked at the various scale levels, there were more differences between adjacent scale levels on the increased portion. And that kind of showed me that maybe we are kind of a bit better in this increased tone, but when we have to rate the decreased tone, and whether this is minus one or minus two, whether it is little decreased tone or a bit more decreased tone, then we are not that good. And when you think about this, it makes sense because in general physiotherapy, we are also searching mostly for the increased tone, like when we search for trigger points, some increased tension with various parts of our body, we are usually trained to detect the increased tone portion, right, throughout our studies, throughout our education. And we are not really that skilled, probably in detecting between various levels of decreased uh tone. So that was um a thing. Another thing that we could see in our data is although we could see the statistically significant differences, we could see a big overlap between the various scale levels. And there are nice uh appendices to our work when you when you can see how um how the different um scale raising scale levels or the palpation scale levels were um were which kind of data were there inside from uh ultrasound and from dynamometry. And you can see that there's a lot of overlap, which told us also that we can get a general idea about pelvic from muscle tone through palpation, but we are not very precise, we are not very accurate, which tells me again that palpation is a good tool when I want to get a general sense of pelvic from muscle tone. But if I would like to precisely monitor the effects of therapy or how my therapy influenced the pelvic through muscle tone in a given individual, or if I would like to use it for research purposes, this is not the tool to go. And when I look at how the study is being uh used, I see that some people are saying, Yeah, hooray! We have finally the data to say we are good in palpation because there were some differences. Then I would say, see some other voices saying, Yeah, this study shows that we are actually really bad in palpation. And my take is that this study was not supposed to really tell us whether we are good in palpation, we should use it, or whether the palpation is useless and we should ditch it. I think this study, what it really says to us, it gives us finally a proper data about the most popular and the most basic tool we are using in everyday practice. So it kind of validates finally the primary tool we are using. But it also tells us what we can do with this tool. So again, we can use it for like a to have a general sense, but it also tells us what we can't really do with this tool, uh, which is we can't be very precise, and it can't be that me between probably various visits, I will be able to find very specific changes that are maybe probably because of my miraculous therapy that I did. Like, probably this is not where we are. In terms of this tool. And I really believe it's important because although we have amazing tools right now, not only in research, but many of them are becoming more and more popular within clinical practice like ultrasound. We have to be aware first that not everyone has and have to have ultrasound in their clinic. And second thing is that it's very expensive, very costly. So again, it's not very sustainable to demand from physiotherapists to have it. And another thing is that we are measuring a bit different things through ultrasound than we are measuring through palpation. So it's not about saying we will now use ultrasound instead of palpation. It's about saying I will use my palpation for the things that I need to assess with the palpation and for the things I can assess with the palpation. And then probably after my basic assessment, which is the palpation, I will then choose a different tool, like I don't know, EMG or ultrasound to complement my assessment with some extra information.

SPEAKER_01 45:12

Yeah, I I love that. I I started doing trans abdominal ultrasound maybe 15 years ago and then transperineal, maybe three. And that was one of the things that I think I've truly come to appreciate as it's it's just a different facet that you're able to see to pull this whole picture together. Um I find it so interesting that you can have one study online, and like you said, when it went viral when you were you're posting it, I I love that we can have this conversation after it's done that. Um, that you have people, they kind of pull their biases and and just kind of cherry pick out what they want from it. What was what was one of the ones where you looked at it and you're like, no, mm-mm, that's not at all what this says. Anything that sticks out to you?

SPEAKER_00 46:03

I think like so far it's it's it's this uh really uh polarized way of looking at it. Or it's good or it's bad. And it's one people using it as an argument that we should use it, and other people using it as an argument we should not use it. And I think this is uh there's a bit more nuance into this uh results, and it's not about whether we should or should not use it, it's about really to inform us what we can and what we cannot infer from this uh technique. And I think it's a very important thing because honestly, I believe this is um the basic tool we have also using different tools in clinical practice, although it may inform our assessment, it may add some objectivity and all of this kind of stuff. I also think like we have so limited time with our patients within in the clinic, right? And then their time is limited, our time is limited, and now being in the postpartum uh period and seeing what different challenges are coming, and sometimes we really need to spend time explaining things, educating our patients, like being there for them, not really focusing on their tissues only and measuring I don't know how many different parameters. So that's what I love palpation for because it's not only quick, readily evaluable, but it also adds us this extra space that we can be really present with our patients. Because when you do ultrasound, for example, when you do EMG, you are very focused on the equipment and on the device. And with the palpation, usually, at least as I was doing it, I was always like being on the side of my patient, looking at her face, discussing with her, speaking with her, being very present with her. And I think like this is this extra clinical beat that for me was always very important. That this is not the device that mattered the most. It's the person that is in front of me, and this is what I like the palpation for. Um, and that's why I was very happy to do this study, to show what it really can uh do, and that it is useful in clinical practice. We can't say it's not, but it has its own limitation, like every method that we use.

SPEAKER_01 48:14

Yeah, no, I I think it's it's one of the things that's always differentiated us, if that you know makes sense. That um, and I see this in a lot of you know patient-facing, you know, Facebook groups and things like that now, where um, you know, patients are really they want that exam, or if they've not gotten it, people are telling them, well, you've never really, you've not had a full exam. Um, at least here in the States, there's a lot of um therapists that are saying, gosh, I I do pelvic floor, but don't do internal. And and you know, that's a whole aside conversation. I think there's a lot to get from external, I think there's a lot to get from internal, but I think that's the one thing that you know we've really truly held from the you know, from the onset of our practice is assessing internally, having that connection, like you said, you know, you've just met somebody and within a couple of minutes we're up in there checking things out. Um, for you, is there anything, you know, once which you kind of seen these results, um, is there anything that you've changed your mind about or confirmed in how you practice clinically? You mentioned, you know, this is this is a nice connecting point for you. Um, do you feel that you'll change anything kind of moving forward um with what you've learned?

SPEAKER_00 49:29

I think for me, a very important thing is that although there were differences between various scale levels, is that there also was some overlap. And it tells me that when I, for example, um write um a result of the examination and I put the raising scale in my documentation, and I used to work in obstetric gynecological hospital back in Warsaw when we were doing this exam to postpartum women, uh upon their um discharge from hospital. So oftentimes, then with the discharge paper, they were going to some other physio in Warsaw who was seeing my exam, and then they were starting from from there. And then it could tell me that sometimes I can feel something, but then this the other person, since there is a big overlap, they can feel something totally different. So we can't really get fixed on these numbers, which sometimes we also like. We like numbers, we like some values, and we can't really get fixed on them because firstly the tone is very dynamic thing. Uh, it's a dynamic concept. So we were talking previously that it can change from one moment to another, it's a one thing, but also, even if it would be um stable thing, a stable measure, again, one person can measure it totally different than the other person. That's the other thing that was very important for me, that there is this overlap. And I was actually surprised because I was always expecting that we are good in assessing tone over the continuum of the tone. So I was not really thinking that it would come up that we are better in feeling the increased tone than the decreased tone. So that was a big surprise to me, and my take on that for the clinic is that I will be very curious assessing the low tone, and maybe this is exactly when I will probably use some other measurement tools to add some extra bits of information in terms of uh what's happening there at the level of the pelvic floor.

SPEAKER_01 51:37

Yeah, I I think the one thing we could all use more of too is just access to norms, if that makes any sense. I don't know about you, but I love it every once in a while where I just have a you know, somebody with no symptoms, they come in because you know they want to do preventative stuff with pregnancy or whatnot. And even then there's changes. I'm like, huh, so this is what this feels like. It's kind of nice.

SPEAKER_00 51:59

And that's interesting because when you look at our although we selected people with presumable pelvic for dysfunction, which was the provoked vestipulenia or stress and mixed urinary incontinence, you could see that the scale levels that we got were were all over the place. So it was not only decreased or increased on, but we also got from some zeros, which are called the normal value, right? So interesting thing would be probably like to build again on results of this study is to add uh some healthy controls with no pelvic flower dysfunctions. Uh and I'm pretty sure that what we would notice there as well, again, a whole range of various tone levels. Because again, I think tone is just one element of all the things we are assessing, and it it can be that someone is perfectly healthy with no pelvic flower dysfunction, and we will measure with subjective and objective tools some increased tone, and and we can see that probably more um in younger patients or like highly active patients. Sometimes I would have the uh some some athletes some people engage in sports, which you could feel that there are there's more firmness in the structures.

SPEAKER_01 53:20

Right.

SPEAKER_00 53:20

But for example, they would say I have no problems, no pain, no incontinence, no anything like this. So uh so and then there are the genetic predispositions. Some of us just have a bit more uh higher or lower tone in our structures. So I think if we would add um the healthy populations, the distribution of the tone would be probably very, very similar. And um that was actually one of the limitations of our study that we didn't got the healthy population. But I'm just wondering whether that would change the results or not.

SPEAKER_01 53:53

So, does that mean what's next for you? Looking ahead, what's on your research plate?

SPEAKER_00 53:59

Looking ahead of what's my in my research plate, that's uh that's a very interesting thing because again, uh what I love about working with my supervisor is that I get to dive in many different topics and in many different study designs to really, let's say, learn a lot and not be bored with one topic only. So, what we are currently working on, we are expanding some um some more um our knowledge on some more stuff related to tone. So, we are using some more advanced techniques to measure pelvic for muscle tone, including uh shear wave elastography, so the ultrasound-based techniques that are using various shear forces, and these are all the other topics that I would need the engineers who are working with us to explain them because they are very, very difficult concepts. But the essentially the concepts that are allowing us to measure stiffness, but not from the whole pelvic floor, what like we do, for example, in dynamometry, but from a specific structure like transversus muscle or pubo rectalis muscle. So, this is what we are trying to do right now. We develop like two methods uh to use this ultrasound-based elastography techniques to measure this stuff. So we are diving into this data right now, and again, no tool is perfect. And with shear wave elastography, we also see loads of many different challenges, and and one could say maybe it's better from palpation. One could say maybe it's not, because again, we have a lot of different things that we need to uh sort while doing these assessments and many different artifacts and things like this. So that's one thing, and the second thing, I'm I'm saying that I'm at heart clinician and I started working fully clinically, and then I slowly, slowly dove into research gradually, to the extent that right now I'm fully in research at this point, not practicing clinically, and I'm thinking like maybe there's something going farther, and maybe it's my mental health that is being shifted because of being in research, and I'm kind of getting crazy because I started to get very, very interested in methodological concepts. Because I really believe if we want to want to improve women's health, we not we don't only have to have research in woman's health, but we need to have a good research, and that's where is my second interest, which is the research methodology, and we are now um working on a really big project regarding to how we should correctly interpret data from randomized controlled trials, which is the what the work that we just submitted, and uh from systematic reviews, but because we have loads and loads of studies right now, but we can see that we have also more and more systematic reviews and various knowledge synthesis, but if they are not done properly, then the information we are getting is being lost. So we have the information, but it's not being synthesized in the correct methodologically speaking, um, in the correct way. So um I don't know if it's my crazy postpartum project, but I'm now uh also on this on this methodological project and and and I enjoy it a lot.

SPEAKER_01 57:07

I I'm I'm glad you do because that would be a nightmare for my brain. My brain does not work that way. But if if I'm thinking back on, you know, research, you know, my career, I've I've been at this 26 years. If I'm if if if I'm thinking back on um kind of the studies over the years and things like that, I think that's been one of the hardest things is is everybody was measuring things or doing things a little bit differently. And so it was hard to make, you know, big collective, you know, comprehensive statements from it. Um and it's it's so it again, the longer I'm at this, the the longer I'm like, well, what about this? And how about this? And how do we measure things? And how what about the words that we've been using for the last you know 40 some odd years? Is that actually what we say it is? And then you bring in engineering and you're like, no, that's not what that is at all.

SPEAKER_00 57:57

I recently received a comment from the engineer, it's ridiculous. I felt like it doesn't mean this and this. I said, No, it's ridiculous.

SPEAKER_01 58:07

Oh my and and I I love that because it's like it makes you rethink everything. And the last couple of years, I am rethinking everything. And I I have you know, these these things that I usually say to my patients, and I'm catching myself before I'm saying it. I'm like, well, that's not actually 100% accurate. But what else am I gonna say? Because I can't explain to them that the engineers didn't agree, because that doesn't matter. So it again, like to be at something this long and still be learning is insanely frustrating, but also really cool. Yeah. So I want to thank you for having a brain and a desire to to to do and answer these questions and kind of go after this, even even after going through postpartum these first couple months and being like, nope, this is still what I want to do. I love that. Thank you. I appreciate that.

SPEAKER_00 58:58

It's a pleasure and and then the nice, let's say, brain teaser, something to keep me alert. Yeah. Uh so thank you. Thank you so much for the invitation. It's it's a big honor. Uh it's a dream come true to be here. So uh so thank you so much. And hope to see you around on some other conference in a time soon.

SPEAKER_01 59:14

I do hope to see it for those of you that are, and I will put this in the show notes. Um, the study that just came out. Um, oh gosh, it probably was it, I can't find it here, but it was um probably March or April 2026. Can we rely on palpation to assess pelvic floor muscle tone, a validity study comparing palpation with ultrasound and dynamometry? Um, and it was in the American Congress of Rehabilitation Medicine, the archives of physical medicine and rehabilitation. Um, so you guys definitely check that out. Message her. We'll also post your Instagram in the show notes, give her some time to respond because she is still in post-mom life. But Gosha, it's such a great time to be able to talk with you. Um, not only in this you know, postpartum phase, but um, it's it's really cool to have new research out. Um, it it's been great to chat with you and um thanks for sharing your morning with us.

SPEAKER_00 1:00:06

Thank you so much, and see you again soon.

SPEAKER_01 1:00:08

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.