Taking the Pressure off Pressure Management

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Transcript

New and seasoned OTs are finding their calling in pelvic health. After all, what's more ADL than sex, peeing, and poop? But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasoned and everything in between? Those are the questions, and this podcast will give you the answers.

 We are inspired OTs. We are out of the box OTs. We are Pelvic Health OTs.

 I'm your host, Lindsay Vestal, and welcome to the OTs in Pelvic Health podcast.

 Lindsey:
 Audra, thank you so much for being a guest on the OTs for Pelvic Health podcast. It is such a pleasure to have this conversation with you today.

Audra:
I'm so excited to be here, Lindsay. Thank you so much for having me here.

Lindsey:
Yeah, we're talking about something that I think as pelvic health professionals, we just can't get enough of, and that is really the foundational topics of breathing, pressure management, interabdominal pressure. There's so much about pelvic health with these topics that we can geek out about, so I'm really excited about this topic and also really excited because you're going to be one of our speakers at the fourth annual OTs in Pelvic Health Summit happening this September 2025, and your topic, I love your title, your topic is taking the pressure off of pressure management. Will you tell us a little bit about why you're so passionate about this topic?

Audra:
So I'm just super passionate about this because I feel that, like, if I go back to, like, how I interpreted and understood pressure management to what I know now, because I started in the world of pelvic health, what, over four years ago now? And I look back and I'm like, wow, I have learned so much over the past four years, and a lot that's helped me better understand my clients' needs and also to better help them and just the community in general. And so one of the reasons why I'm super passionate about this is because I feel like in the world of pelvic health, I feel like people only know, like, almost like the tip of the iceberg of, like, pressure management and, like, what does that really mean? And as someone who is also a weightlifter, I love strength training in the gym, I love lifting the heavy weights. There's a lot of, like, myths and also just, you know, certain comments I hear about people, like, oh, if you, like, strength train or if you're someone that's doing, like, CrossFit or powerlifting, like, that's bad for your pelvic floor because those activities cause too much pressure down there. And for a while, I, like, kind of believed that. And then over time, I was like, well, wait a minute, like, why are we saying these things when it's not even true? And so that's one of the reasons why I'm passionate about it is because I want to be able to encourage people that, like, pressure's not a bad thing. Like, I think we hear it out to be. And in fact, like, pressure is actually really important. So I really want to talk about that today. So that way, anyone who's listening to this is not afraid of utilizing pressure, but also just, like, understanding it is important and it serves its purpose.

Lindsey:
I love that. You've already, like, dropped so many nuggets there that I'm like, oh, I want to know more. And so actually, let's, like, start with one of the ones that I'm so curious about, which is this idea that the basic idea of what we as pelvic floor therapists know regarding the breath and pressure management is just the tip of the iceberg. What do you mean by that? 

Audra:
What I mean by that is I feel like in, you know, different, like, introductory courses or just kind of like the general rule of thumb is I think everybody always believes, like, there's one way to breathe. Like, oh, if you're going to do a heavy task, like lift up a heavy box or a weight that you always need to exhale on the effort and always keep core engaged and always, always, is that you got to make sure your TA, aka that transverse abdominus, is engaged. And that's not to say it's not important. Like, that is important and that might be a helpful strategy for some people. But what if that's just not helpful for everybody? But it's also just not, like, a realistic thing that people are going to do every single time they go lift a heavy object. So I think it's just the concept that, one, a lot of people assume that we have to really overly focus on strengthening the transverse abdominus and that if we're doing something effortful, we should always exhale on it. Which, again, why I'm on here to talk about this is to have people understand those are great things, but there's way more things we can do and we don't have to just, like, focus solely on that, you know?

Lindsey:
So, you know, I think as pelvic floor therapists, like, we're definitely really familiar with customization, really making a bespoke plan for the client in front of us. So, I mean, this is exciting, like, hearing you say that there's not just one way. Could you give us an example of another way? Maybe it was from, I know you have a private practice, like, it could be from a recent client you've had. What's an example of another way besides blow before you go or exhale with exertion that could work for another client?

Audra:
I'm going to say this and it's probably going to make some people go, what? But it's actually performing the Valsalva maneuver is actually a really key critical skill that we could be teaching our clients. 

Lindsey:
So tell me, tell me more about that and maybe like a client you've used it with that it did make a positive impact on.

Audra:
Yes. So the Valsalva maneuver, just in case people don't know what this means. So this is when you go and you are basically taking that initial breath in and you're basically exhaling on a closed glottis. So think about glottis, your throat, right? So when you see, for example, those people who are like heavy weightlifting in the gym, you see that they keep their mouths closed. They kind of take that three-dimensional expansion out and then kind of pull it back in. You're basically using that technique to help distribute pressure in the trunk, which we'll talk a little bit more about that later. But this is a technique I've used with a lot of like my athletes. And I've even used it on like my postpartum moms, which I know some people are like, what do you mean? Like, why would you use it with them? But yeah, I can actually think of a specific example of a mom who is a weightlifter. She does CrossFit and we were talking about how, yes, you can use the Valsalva maneuver and it is actually going to be something that's going to be helpful for you. So we were going over those techniques in terms of helping her feel stronger while she returns to CrossFit, but it was also just helping her better prepare for her day-to-day activities of taking care of her three kids. So, you know, she's got kids that were like different age groups. She's got like a two-year-old and up to a six-year-old. So, you know, she's got like the car seat. She's got the bags of all the snacks and stuff. She's got a lot of stuff to carry. So, you know, trying to get her to do things like, oh, let's just exhale as you're lifting all the stuff in the car, but then kind of realizing she's like, oh, that's just not normal. Like that just doesn't make sense. And I'm thinking to myself, she's going to be picking up each of her kids that weigh different weights, all the stuff she's got to bring with her everywhere. So we kind of practice that maneuver of using a Valsalva. And she's like, yeah, that actually feels good. That feels great. Like I'm not having any issues in my pelvic floor. Um, so there's a lot of clients that I taught them how to use it. But she's just one that stood out to me because she's both the crossfitter, but she's also the mom, which I think in the pelvic floor world, everyone's kind of nervous to try like Valsalva with their postpartum clients.

Lindsey:
Do you ever, so you had said like, she felt good doing it, right? Like, like no, it didn't evoke any symptoms in her pelvic floor. Sounds like she had pretty decent interoception. So it could kind of also give you that feedback that it felt good. Do you ever like take it a step further and do an internal exam or even an external exam while they're doing that Valsalva just to make sure? Because I guess most concerns would be this could lead to prolapse, right? Maybe, maybe they have prolapse. Maybe they don't, but that doing the Valsalva, what we hear often is, okay, what's next? They're going to probably now develop into a prolapse. Do you ever check to kind of like make absolutely sure?

Audra:
Absolutely. As long as it's with like the right client. So I, you know, I perform pelvic floor assessments and always like how you talk about, right? How we can do the internal assessment, like where we're using our finger to assess intravaginally, interactively, or if for some reason, maybe the client's not comfortable with it or, you know, just, they might be not really feeling that for that day. I'll have them assess themselves, like putting pressure up against like the perineum or even just trying to sit on something to get an idea. So there's different ways of assessing, but I do love doing the internal assessment when we can, because it does give a lot of feedback. Like I can feel what's happening. And then usually the client can feel what's happening using that internal input. And I do it a lot. Like I will assess things internally again, not just with somebody laying down, but like during the actual activity. So maybe someone's trying to like work on an activity that requires them to like put something up overhead or picking something off the floor, you know, and so we'll go in and assess to see, okay, are we truly doing this true Valsalva maneuver or are we just like bearing down or something else happens? Because believe it or not, Valsalva and bearing down are not the same thing, which is another reason why I'm on here talking about this. Cause I think a lot of people think they're the same thing, but they're not, they're two separate things. Which I don't blame people for thinking that because even in some of like the literature we read, they interchange it. I'm like, no, no, it's not, it's not the same thing. Like you could attempt to do a Valsalva and end up bearing down, but we know that that's not a true authentic Valsalva. So,

Lindsey:
so you had said, when I first asked you about like your passion for this topic, you had said there was a lot of myths out there. Is this one of those myths that come to mind for you?

Audra:  
Yes. Yeah, absolutely. It's, it's, it's really common. Um, and like I said, I don't know exactly where it's all come from. I do know, again, I've seen it in the literature where it's interchanged, where it shouldn't be. Um, but yeah, I do see it a lot amongst, you know, clinicians and clients. Um, and again, someone might be trying to do Valsalva and they end up bearing down, but that's when I say to them, well, we just haven't practiced this strategy enough, or you're just trying it out for the first time. So when it comes to like training Valsalva, it's just like trying to, you know, train for like a 5k. It takes practice. It takes effort, right? So you may not get it the first time and that's okay. And that's why I encourage people to work on it with their clients because it can be really beneficial for them.

Lindsey:
Are there any other myths like that that come to mind for you that you would love to kind of shout about from the rooftops?

Audra:  
That Valsalva is not harmful for pregnant or postpartum people. Like, again, this is a technique that can be used for anybody, regardless of your gender, regardless if you're pregnant or postpartum, like it can be a really helpful tool. Um, which again, I think another reason why people steer away from it is because they're like, Oh, like you already have so much load in the pelvic floor during pregnancy or your postpartum, like your pelvic floor is still healing, but it's like, it's everyone's so different, you know? I mean, obviously I'm not going to go and say like, Hey, you just had a baby two seconds ago. Let's practice Valsalva today. Right? Like we're going to meet everybody where they're at, but again, like we shouldn't be afraid to teach people different breathing strategies, like Valsalva, whether they're pregnant or postpartum because again, everyone's so different and they might, they might perform better than you think they'll perform.

Lindsey:
So, and so if the Valsalva isn't going down in that typical bear down pressure, can you tell us a little bit about where you want to see that pressure dispersing to?

Audra:  
Yes. When we're thinking about a Valsalva maneuver, I like to have people, which is why I liked thinking about like taking the pressure off of pressure management is understanding that maybe it's not even so much pressure management. I like to think of it as like pressure distribution and I'll say why in a second. So when you think about Valsalva and where the pressure is going, AKA distributing, we're really having more of that 3d dimensional expansion, right? So think about how we emphasize the 360 ribcage breathing. That's one of the reasons why that is so great because it teaches people that three dimensional expansion. So when we're doing Valsalva, what we're working on is trying to make sure that yes, that pressure that sits in our abdominal cavity, doesn't just go all the way down to the pelvic floor. So what we try to do is get it to expand elsewhere. So thinking about expanding all around the trunk. So front ribs, lateral ribs, the back of the ribs, right? There's expansion there. We're going to see expansion right in like the, probably a little bit of the lower belly area into the back. You might see a little bit like in the neck and chest, which again, it's not like a big deal, but it's really just thinking about the pressure, just kind of moving around somewhere else. Which is why, again, pelvic floor is a whole body approach, right? Pelvic floor is not going to work well just by itself. This is why we look at the whole person and the whole body.

Lindsey:
Amazing. So you had said earlier that pressure in the trunk is really important. Tell us more about that and kind of how you integrate that in with your clients.

Audra:  
Yes. So I always talk to people about, like, I like to give different examples about pressure and what that means. So I like to use different analogies, like the soda can analogy, or even like the chip bag analogy, right? I feel like the chip bag one to me just kind of makes a lot of sense because a lot of people eat chips. So I explain to people that we always have pressure in our trunk, like in the abdominal cavity, and pressure is going to change based off of two main factors. One, breathing mechanics, and then also the tension in the abdominal wall, or kind of the whole trunk if you think about it, but especially that abdominal wall, since it's got a little bit more expansive patterns than we see in the back. So when we think about it, right, that pressure just has to go somewhere. So if there isn't enough space in the trunk for that pressure to sit, it is going to find its way somewhere, which usually it's probably going to go down south to the pelvic floor, right? So if you imagine something like a bag of chips, right, we all know you open up a bag of chips and it's kind of disappointing because you're like, I paid all this money and why is only a third or a quarter of the bag full of chips? Now, besides inflation, there's a reason why there's not a lot of chips in the bag. The pressure that sits in the bag when it's closed is there so that when you're moving that bag around, that pressure that sits in there is going to protect the chips. If you kind of move it around, put it in the shopping cart, your chips are going to be less crumbled. Well, what happens if you take out that pressure, right? Maybe there was a little hole in the bag you didn't see, and then all of a sudden you kind of squeeze it or something slams on top of it, right? Now all your chips are crumbled and now you're just left with crumbs. But then what happens if you have too much pressure, right? Maybe you're just kind of playing around, you squeeze the bag and then pop, it opens up, right? That's the example of like too much pressure. So yeah, I am totally team of like, let's not have too much pressure just hanging around anywhere, but let's understand that pressure serves a purpose. It creates stability. It promotes strength. That's why you want to see when you open up a can of soda, because that's another common analogy. You get that nice sound, right? It's that pressure being released. It's the carbonation. So the pressure serves the purpose to keep the formation of the can and give you that nice carbonation, deliciousness. And, you know, if you go to open it up and it's just blah, like there's no sound, it's all flat. You're going to be like, oh, you know, so pressure serves a purpose. Pressure in your trunk gives your spine stability. So when you go to do your day-to-day activities, right, you have support around your spine. So you're less likely to throw your back out or injure it, right? But it also can help promote strength because since it's stable, you're pretty locked in there. So if you go to lift up a heavy object or move something around, right, you're also increasing your power to do that activity. So basically my point is pressure is important.

Lindsey:
I love that. I love those real world examples because I think that's stuff that we can find ourselves sharing with our clients to really emphasize why we're spending so much time, maybe trying different breathing patterns, recognizing we have these different tools in our toolboxes that at different times, maybe we're super fatigued at the end of the day and a different way of breathing is easier or even taking it to the gym. It sounds like you work with a lot of CrossFitters. So having that kind of conversation and breaking it down with everyday analogies, I always think is super helpful.

Audra:  
Yeah.

Lindsey:
I have a question regarding like your support with CrossFitters because a lot of times when we have clients that come in to see us for public floor issues, like they think about yoga when they think about the breath, right? Like it's just sort of this idea of, oh yes, everybody, you know, maybe they've heard of box breathing or a few things like that. Whereas CrossFitters, you know, I think that they've come across it at some portion of their career as a weightlifter because they recognize that it is a way to manufacture more power and to, and to feel connected. I'd love to hear a little bit about like what, when you're working with that clientele, where do you end up focusing some of your thoughts? Like what, what are the myths for that population versus maybe like a general population that you could share a little bit with us?

Audra:  
Yes. A lot of the myths that I have to like kind of bust with people is that they think that the heavy training is what's like, quote unquote, like ruining their pelvic floor is like what people say. They're like, I was told this, I was told that I shouldn't like do CrossFit anymore because that's the reason why I have like diastasis recti or why we pee or why I have prolapse. So I always have to explain to them, like, it's not the activity itself. Like you did not cause this, right? Things like this can happen for any reason. Like we know there's multiple reasons as to why someone may develop like stress incontinence or why they develop a prolapse or diastasis recti. And so it's being able to clear the air of like, this is not your fault. You didn't do anything wrong. It's like the activity is demanding, but that doesn't mean like we can't not do the activity. Like we absolutely should. And we can absolutely enjoy doing activities like CrossFit and still keep our pelvic floor happy and healthy. And in fact, doing things like the activities that involve in CrossFit, right? The heavyweight training, right? The really quick act, like quick, what is it called? Quick acting, fast movements, right? The cardio, like all that stuff is good for your health and it is good for your pelvic floor, right? So I think that's one of the biggest things I have to explain to people is that there's nothing wrong with doing those activities, right? I mean, any activity you do, if you think about it, there's a risk to it. Like we know having a baby, there's risks to that. And that doesn't mean people should stop having babies, right? We there's risk when we go out and drive. Does that mean we should just stop driving? No, like any activity has a risk, right? That's why my big thing I share with people is nothing is 100% preventable. We can work on having things not occur. But again, our role as pelvic floor clinicians is we are also rehabilitators. So if something happens, you come to us and we're going to help you so that you can go back to the activities you want to do and need to do with confidence and not being afraid if an injury was to occur or reoccur again.

Lindsey:
That's, I love that. I think that is a different message than we heard maybe even a decade ago. And even in terms of diastasis, particularly, you know, there was a lot of fear mongering associated with protecting that. And I think, you know, these messages need to be spelled out. And it's so in line with occupational therapy, because we always want to help our clients get back to what's meaningful and relevant and brings them joy. And so to come to you as a practitioner must be so refreshing just to hear. OK, so you're not going to take this away like this isn't something I have to stop doing, like such a message of hope and resilience. And I and I just love that. On the flip side, though, we have some maybe maybe some CrossFitters who there was messaging also over a decade ago where you would see people doing like double unders or something like this where they would just be peeing. Right. And so there was also a little bit of normalization or maybe maybe even a little bit of like, oh, man, I really worked hard today. I peed my pants. What is your message or even like your desire to myth bust maybe a client like that who thinks it's a badge of honor or even maybe just a necessity in order to do CrossFit?

Audra:  
Yeah, that's a really great point is that I think in especially in the world of like CrossFit or power lifting, strength training, even running, we see this too, like our runners that they just have been somewhere down the line. It's been normalized that if you like we pee during these exercises like it's normal or whatever and you kind of just have to accept it. And so I always tell people like, listen, if you don't want to pee your pants, you don't have to pee your pants like we can work on that for sure. And just teaching people that like also with the foundation of the pelvic floor, it's not just about it. Are your muscles strong? Are they weak? Because that's that's a huge debate we see, too, in the world of pelvic floor. Right. It's like, why does somebody leak pee with an activity? Is it muscles are weak? Muscles are tight. Muscles are this or that. So it's also explained to people like the pelvic floor is really complex. And so if we're leaking pee during these activities, there could be a lot of things happening. So, yeah, without a doubt, you are working hard and you are doing incredible work, but that doesn't mean that you should be like having to deal with leaking pee along the way. And so I like to encourage people like what is considered like, I guess I don't use the word normal, but like teaching people that like leaking pee is not a normal thing. It's a common thing, but we don't have to live with it. And just helping them understand there's a lot of things we can do to maximize that. Right. And that if you are leaking pee during those activities, it is a sign that your pelvic floor is trying to give you a call for help with something.

Lindsey:
Fantastic. That's so fantastic. And I also hope that like within your community, the more you work with these type of athletes, like also word spreads. Right. And they're like, you've got to go see Audra. Like you're going to be able to keep doing all the activities you want to do and your pants will be dry. So that's a bonus.

Audra:  
Exactly. It is really nice because I do have like a local like CrossFit gym that they've actually sent a few different people to me and they always like encourage people come to see me. And so it's nice that like my name does get out. And it is kind of nice where, you know, you have a client who comes in. It's like, yeah, we talk about you at our trainings. And I'm like, it's all good things. Right. They're like, absolutely. I'm like, okay, good.

Lindsey:
That's fantastic. Audra, is there anything else that comes to mind for you on this topic that it's so clear you're so passionate and so knowledgeable about? Is there anything else that you want to make sure our community is aware of when they're thinking about taking the pressure off pressure management?

Audra:  
Yes. And that is to, especially when it comes to anybody who is pregnant or like postpartum, anybody, even like post abdominal surgeries, like let's not forget about the importance of overall core strengthening. Right. So I do want to emphasize, yes, strengthening things like your transverse abdominus is important, but remember what's the abdominal wall that's really important. Right. It's that rectus abdominus. Right. I want people to like not be afraid to train some of these kind of different muscle groups. I mean, when you technically train like the whole core, you know, you're like thinking of abdominal muscles, back muscles, pelvic floor, um, diaphragm. Right. So, yeah, we're training all that stuff, but I want people to not be afraid of training things like rectus abdominus. Cause we see that a lot in things like prolapse or diastasis recti, but I'm like, remember guys, what is being split down the middle during diastasis recti? It's your rectus abdominus. Right. So like, why are we not training that muscle more and to not also be afraid if you happen to see somebody might have some like coning in their abdominal wall, when they're doing something like cloning, it's not necessarily a bad thing. Right. During the end of pregnancy, every single person, if they work out or sit up from the bed, they're going to call it because there's just like, there's no room for, you know, all that pressure to move and sit. So it's going to, it's going to come out into the abdomen a bit. And that's okay. Which is something else that I like to teach people. So not be fearful of that, because that's a huge thing. We see on like social media and you know, all these different places is like, if you're coning, like that's bad. Like that means you're going to have diastasis recti or you have it. And I'm like, that's not necessarily the case. Right. Um, I like to think of coning and this is something that actually, um, Anthony Lowe, if you know his content, he's amazing for anybody wants to check it out. He was even suggesting that sometimes maybe people cone in the abdomen. If you think of like a pyramid, it's almost like it's the body's way of distributing pressure. So it's not all going into the pelvic floor. And there's different things we can do to check. Is this coning a concern or not a concern? Right. With stuff. So I want people to like, not be fearful. They see it in their clients, but also not instill that fear in their clients in the community. We've got to train our cores because core deconditioning is a thing, right? Um, so I want people to just not be so afraid of that either.

Lindsey:
I love that. Such powerful messages and ones that also, I think help us take the pressure off ourself to always being, you know, so rigorous or even like the ability you're really giving us permission to kind of like ask if there's another way, you know, and I know deep inside our OT hearts, like we know that, right. But I think this conversation has been really refreshing because it really demonstrated it in two, two very specific ways, um, you know, prolapse as well as coning and DR that like, actually there is another way to look at it and there's another way to work with it. And I think that's really also the longer we're in public health. I think we're going to start to see more and more of those myths turns on upside down on their head because we're getting more data points. We're learning more about the body and that is also really refreshing. So Audra, I can't thank you enough for coming on the podcast today and sharing this with us, giving us a chance to, to reexamine things that perhaps are definitely time to reexamine.

Audra:  
Of course. Absolutely. I love talking about these topics and I love learning about it. Like it's been really refreshing on my end over the past few years to really expand my mind and my skills as a clinician and just to better understand things. And it's funny because the literature is telling us things, but then just like anecdotally, I've been noticing really awesome positive changes when I haven't been so kind of rigorous of like, we have to always engage the TA and we have to make sure we close the gap in DR and no coning. Right. And I think it's, again, it's just taking that pressure off of pressure management as us as clinicians, but also our clients. And I think that just helps us be able to help them at a deeper level. And just also reassuring them that things don't have to just look and be one way.

Lindsey:
Amazing. Thank you so much.

Audra:  
Thank you.

Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group, OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to IG, Facebook, wherever you post your stuff. And be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health podcast.