Treat the System, Not Just the Symptom

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Transcript

Hello and welcome back to the OTs in Pelvic Health podcast. Today I want to give you an organizing framework that you can use clinically, especially if you're a newer pelvic health therapist and you're in a phase where you're seeing clients with real symptoms and  trying to make good decisions without getting lost in a 100 possible interventions.

Which is so normal and something we see  all the time inside the Level 1 functional pelvic health practitioner program and inside my off social media community  called Pelvic OTPs United.

You're probably not the person being told, just do Kegels. You're the person being asked, should I be doing Kegels? Can you help me get my life back? So the way I'm going to teach this today is the way I'm always thinking about it. Cause I'm holding three things at once. I'm looking at what the evidence generally supports. I'm looking and thinking about my clinical experience,  what I've seen help.

what I've seen not work as well, what patterns I keep seeing in different bodies. And then I'm looking at the client right in front of me, their priorities,  their lived context, their nervous system state, their history, their safety,  and of course, what occupations matter most to them. And in Pelvic Health OT, the last piece is not a footnote. It's the whole thing.

occupations and what matters to them is the whole thing. Clients rarely come to us just wanting less symptoms in a vague way, right? They want very specific things back. They want to get through a work day without thinking about their pelvic floor every five minutes. They want to go to the gym without fear. They want to travel without mapping every bathroom. They want to pick up their kid without feeling heaviness and the spiraling

Did I just make it worse? So today we're gonna talk about prolapse symptoms and urgency and frequency, not in a mechanical way, in a clinical reasoning, biopsychosocial way. I'm gonna walk you through what the pelvic floor is actually doing, why the same symptom can come from very different mechanisms, why the nervous system state and pressure management are so often a missing link. And then we're gonna talk about a case

from my outpatient practice, which consisted of an eval and about five to seven sessions. So you can hear what this sounds like in real life. All right, let's begin with pelvic floor 101, but the version that actually matters in the clinic. When we say pelvic floor, we're talking about a group of muscles and connective tissues that form the base of the pelvis. And it matters for continence, bladder and bowel support.

But in the case study that we're going be talking about later toda.

What matters just as much as support and is pressure management. The pelvic floor is a part of a pressure system, right? It coordinates with the diaphragm, the abdominal wall, the deep back muscles and your hips. It responds to breathing, load, stress, posture, movement strategies. So when I'm assessing pelvic floor function, I'm not just thinking, can you contract? I'm thinking, can you coordinate? Can you contract when you need support?

Can you lengthen and soften when you need to? And can you respond to load without bracing  and bearing down? Can you change state? Can your body be fluid  and responsive to the demands it has? 

A pelvic floor that is strong but stuck isn't functional, right?  And a pelvic floor that can relax but can't support isn't functional either. We're looking for options.

Now let's talk about the clinical trap I see  all the time, especially when people are new to pelvic health.  So you might hear prolapse symptoms, right? I'm talking heaviness, pressure, right? And your brain wants to go straight to strengthening. And yes,  strengthening can be part of the plan. But if you don't understand how that person is managing pressure, you can accidentally train a stronger brace  

And bracing especially breath holding, rib flare, abdominal gripping and bearing down  often increases downward pressure, which is exactly what tends to aggravate heaviness and urgency. So for me, the question isn't do we strengthen? The question is, what are they doing under load  and what does their nervous system do when they feel a symptom? Because urgency and frequency also live at that intersection of mechanics  and threat. 

If your system is always scanning, always guarding, always trying to control, urgency can become less about bladder volume and more about alarm settings  and habit loops.  So we have to think system, not just muscle. So I want to be really clear.  When I say nervous system state, I'm not saying it's all in your head.

I'm saying state changes tone and coordination, right? State changes breathing. State changes muscle recruitment. State changes how we interpret sensation. And in pelvic health, we're often working with a body that has learned some very efficient rules. If a body has learned heaviness means danger, then heaviness tends to produce bracing.

If the body has learned urgency means get to the bathroom immediately, then the alarm gets louder and faster over time. So when we treat pelvic health, we're not just changing tissue capacity, we're changing what the nervous system predicts and what the client believes they can safely do. And that's why our outcomes aren't just  symptoms changing or going down.  Our outcomes are participation going up. 

Okay, let's do the case study. I think that's going to really help a lot of this come together, right?  So my client was 33.  She had a desk job and her primary complaint was prolapse symptoms, heaviness, that dropping feeling along with a lot of urgency and frequency. Right away, I'm holding three clinical reasoning buckets, right?

First, what does evidence generally support for prolapse symptoms and urgency frequency? also, what have I seen clinically that tends to move the needle? And then what is this client doing in her real life, in her real body, under her real stress?  Because with that desk job, I'm thinking about prolonged sitting.

Breath patterns that are kind of like held all day, probably due to a little bit of kyphotic head forward posture, looking at the screen. The abdominals are bracing as a default and a pelvic floor that's probably on guard without the person noticing. So in that eval, I'm watching her move. I'm watching her breathe.  I'm listening for how she talks about her symptoms and I'm hearing a lot of  fear.

avoidance, maybe even some catastrophization, this feeling of I'm pushing through it. I'm listening for the story of what her body has learned. And here's what I observed with this client. I did see breath holding,  not just during the big movements, but during transitions. So going from sit to stand, shifting, anything that really felt effortful for her. I saw a rib flare, a pattern where her breath was living high in her chest.

I saw abdominal gripping, kind of like that abdominal mall was  on as a default. It didn't really have a choice. She didn't learn to grade  anything but being  on. And then I saw bearing down. And this one matters because bearing down can show up as someone trying to engage their core, but it's actually increasing downward pressure. So if a client is doing that all day, right, getting up, lifting, working out, even toileting,

that can absolutely feed heaviness and urgency. I also saw some hip weakness, right?  Which matters because if hips and trunk aren't coordinating well,  people often compensate with bracing strategies that increase pelvic pressure. So I saw signs with this client  that made me wonder about overactivity or guarding of her pelvic floor.

I also had scar mobility findings to address,  and of course the emotional layer was present. That was that fear and avoidance piece, right? She was really worried about making symptoms worse. She was monitoring her body constantly. Certain movements felt dangerous, which meant her nervous system was essentially cuing bracing before we even did the task.  

So, What I'm trying to say here, Is this client is not someone who needs more effort. She already has effort. She has bracing. She has gripping. She has a strategy, but it's not the most optimal strategy. So my plan wasn't strengthened immediately and hope symptoms calm down. My plan was change the strategy. And most importantly,

I did no internal work in this plan of care. We did external work  only. And I'm saying this  because I want you to hear that you can do a lot without internal work when the drivers are very clearly breath, posture, movement strategy, toileting habits, fear and avoidance, scar mobility, and global tone patterns.  I teach four different options to give a client

when they are thinking about the internal exam. And it starts with the one I did with her, which was  all external work. If you want to learn more about the four options,  the only person you're going to learn those options through is the Level 1 Functional Pelvic Health Practitioner Program or OT Pioneers. So with this client, we started with education. Not a giant lecture, but a clear map, right?

 I explained how the pelvic floor, fits into the pressure system, the diaphragm, the ribs, the abs, the pelvic floor, and how breath holding and bearing down can amplify downward pressure. We connected that to her lived experience. So I said, hey, when you feel heaviness, your body braces. When your body braces, pressure increases down. And then you feel more heaviness. It's this loop. 

We also talked about urgency and frequency as not only a bladder story, but a system story. A body that is on high alert tends to send go now signals sooner. And bathroom habits, rushing, hovering, straining, going just in case reinforces these cycles. We did a little bit of manual therapy and external work. Scar mobility was a big piece of that.

We address tissue mobility. We also used it as a way to give her nervous system a different input other than guard. A lot of clients with high tone signs and that kind of that, like that fear avoidance need safe, non-threatening touch and movement experiences that teach  “I can be here without bracing”. 

We definitely did down training, right?

We worked on reducing breath holding, shifting towards a longer exhale, improving a little bit of her rib position so she wasn't living in flare.  And we practiced abdominal wall softening without losing a sense of support. Clients with prolapse symptoms can soften, can actually feel their body softening, and to them it could feel like, I'm dropping everything, right? that doesn't feel good to them. 

And so we built the experience that you can soften unnecessary gripping and still be supported. We added toilet training after that, and this was a major piece for her. We worked on mechanics and pacing, how to empty without bearing down, how to set the body up so it doesn't need to strain, and how to interpret urgency loops in a way that didn't feel like she was white-knuckling through it. And I'm going to tell you, the goal wasn't perfection.

The goal was lowering threat and reducing the behaviors that were driving symptoms. Once she could access  better coordination, we layered in strengthening. And this  was a sequencing piece, Strengthening wasn't brace harder. Strengthening was hip and trunk capacity paired with pressure management. We  practiced exhaling with effort. We trained movement patterns where support came from the hips and trunk not from breath holding and pushing down. 

And then we did graded exposure, right?  Because fear and avoidance wasn't theoretical. It was shaping her choices. There were movements and activities she was avoiding or doing in a protective way, right? Because heaviness and urgency had become danger signals. So we identified those tasks and we reintroduced them progressively.

And the clinical question I was always asking wasn't, did we flare symptoms?  Right? It was, what did the nervous system learn from this exposure? Did the session teach that was awful and I had no control, right? Which just reinforces that threat. Or did it teach I approached it safely? I had choices. I could modify. I could recover. Those questions build tolerance and confidence.

Because the goal in pelvic health isn't to eliminate all sensation forever. In fact, we really  just want to help a client interpret sensation accurately and respond with options instead of fear. 

First changes we saw were awareness and coordination, right? She started noticing breath holding in real time. And I love when a client notices that that's such a turning point. She started catching abdominal gripping earlier. She began moving with less bearing down, pressure management improved and her heaviness, urgency and frequency became less intense and less disruptive. And I want you to hear what really matters clinically. 

We didn't fix  one structure.

We helped her system stop rehearsing a pattern that was driving symptoms all day. That's OT.

So if you're learning pelvic health, here's the takeaway I want you to keep. With prolapse symptoms and urgency and frequency, it's not enough to ask, do they need strengthening?  Ask, what is their pressure strategy? Are they breath holding? Are they bearing down? Is the abdominal wall gripping? Are the hips contributing? Is there guarding? And is there fear and avoidance changing their movement and their relationship to their own body?

Often the faster win is pressure management and coordination, reducing breath holding and bearing down, plus toilet mechanics and graded exposure. Then you layer strength in a way that supports function without recreating the brace. When you see breath holding, rib flare, abdominal gripping and bearing down, especially when that fear and avoidance piece is there,

We should at least consider that overactivity and guarding are in the mix, right? And again, that doesn't mean someone never needs strengthening, right? It means you don't want strengthening to become more bracing. So our clinical targets become, can they exhale with effort? Can they reduce rib flare? Can they move without pushing down? Can they toilet without straining? And can they tolerate sensation with ease and calmness?

Can they return to activity with options? This is where I think OT is uniquely powerful in pelvic health,  right? We treat participation, not just symptoms.  We treat habits,  context, and meaning. We can take something like breath and pressure management  and actually integrate it into real life. Desk work, commuting, workouts,  lifting, and toileting routines.

We're trained in graded exposure and in restoring confidence after avoidance. We're trained to notice nervous system states and work with it, not against it. And we're trained to build plans that people can follow in the context of  real lives. That's why Public Health OT is not just a set of exercises. It's behavior change, motor learning, safety, and function. 

So, As you go into your next evaluation, here's what I want running quietly in the background. Pelvic floor function isn't just tight versus weak. It's options,  it's coordination, it's context. Pick one thing to try this week. Watch for breath holding and bearing down during transitions. Teach exhale with effort in a way that makes sense to that client. Train pressure management inside the tasks they care about.

and treat fear and avoidance like the functional barriers they are, not like a side note. Thank you so much for listening today.  I always appreciate when you take a quick moment to leave a review.  Not only does it help Muratees find this podcast, but it lets me know that you want me to keep producing episodes like this. Thank you all so much for being here.