4 Pelvic Rehab Cases That Teach Resilience

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Transcript

Welcome back to the OTs and Pelvic Health podcast. I am always so happy when you are here.

If you've been enjoying the podcast, can you take a super quick second, head over to wherever you listen to my podcast and very quickly rate this podcast. It would mean the world to me and it would help so many more OTs find the incredible specialty that is pelvic health. Okay, today we're talking about one of my favorite topics, resilience.

But not resilience as a trait and not resilience as just be tougher. I mean resilience as something we can actually treat and train in pelvic health. The skills that help a nervous system stop living in constant threat mode.

I am using a conversation as my launching point between Dr. Dominic Sportelli, a psychiatrist, talking about stress physiology, the autonomic nervous system, thought patterns, and what actually changes people's outcomes over time. And I'm going to translate it into pelvic health OT language. Urgency, pain, dyspnea, bowel dysfunction, pelvic tensions, and especially for the clients who say, I don't know why my body won't calm down.

Because if you're a pelvic health OT, you already know this. You can have the best manual skills in the world. And if client system is living in threat, their symptoms can stay loud.

So today is practical, kind, nervous system forward and full of case studies. 

( Intro )

Let's start with what stress really looks like in pelvic health. In our world, stress isn't just I've had a hard week. Stress is urgency that spikes when you're behind on work, constipation that shows up the week before a big event, pelvic pain that flares after conflict, poor sleep, or feeling unsafe, dyspnea that worsens when someone feels pressure, performance anxiety, or resentment, or clients who can do diaphragmatic breathing beautifully in our clinics, but then can't access it at home when their symptoms hit.

This is why I think pelvic health OT is one of the clearest windows into nervous system physiology. We see it in real time. We see a person's pelvic floor tone, breath patterns, GI symptoms, bladder habits, and threat response all on the same day.

So when psychiatry talks about fight or flight, I want you to imagine my bladder is on edge. My gut is reactive. My pelvic floor is bracing or I can't exhale.

One of the most useful things from this interview that I read is that reminder that our bodies evolved for short term threats. Back in the day, right? Threat meant you are in danger now. You need energy and focus right now.

Your body shifts blood flow. It changes digestion, increases alertness. It basically gets you ready to act.

But now threat can be a deadline, a text message, doom scrolling, chronic uncertainty, and the body doesn't always differentiate. It responds to just perceived threat. And here's the OT translation.

When a client says, I know I'm safe, but my body doesn't believe it. I take them seriously. Because many pelvic symptoms are the body's version of I'm not safe.

Pelvic floor guarding, bladder urgency, gut changing motility, pain sensitivity increases, sleep gets lighter, and appetite changes. So asking the question, what does your nervous system think is happening? When our clients notice these changes is a beautiful way to start. All right.

Let me tell you about a recent client of mine. Her name is Maya. She's 34, high achieving professional, no major medical history.

And she came to me for urinary frequency and urgency, no infection. And in fact, the person who referred her to me said, Hey, it's probably stress, but go see the functional pelvis and we'll get to the bottom of this. She really hates being told it's just stress because in her mind, stress means she's weak.

In the eval, she's pleasant, she's organized. And she says the classic line to me, I'm not anxious. I'm just busy.

She pees just in case constantly. She does her best to avoid long meetings, which is even more stressful to her because her, her colleagues pick up on that. She knows every bathroom when she's out traveling, taking her kids to sports events, etc.

And she's also a shallow breather. She breathes with her upper chest. Exhale is short and her abdomen barely moves.

So here's the key moment. I asked her, when did this start? She said it just started after a job change, right? She had more responsibility, more pressure, but she said, I don't feel stressed. She feels normal.

She's glad she got the job. But here's the first teaching point. Chronic stress can become someone's baseline.

The nervous system can live in sympathetic tone without the person labeling it as anxiety. So my plan with Maya wasn't just to relax more. It was skills-based.

We framed urgency as a signal, not an emergency. We taught a very simple cue, lengthen the exhale. We paired urge suppression with a body behavior she could actually do at work.

So she really liked this one we ended up coming up with, which is feet on the ground, the full foot on the ground, jaw on clench, slow inhale, longer exhale. And she loved that. We also addressed the habit loop just in case voiding and how it trains the bladder to demand smaller volumes.

And I think I followed it up with something like, look, your bladder learned to be hypervigilant. We're going to teach it a different pattern. Over time, her frequency reduced.

But what really changed the outcome was that she stopped treating urgency as danger. And that right there is resilience in pelvic rehab. Another concept that I want to share is this idea that brain filters information and pays attention to what feels emotionally significant.

And this is often threats. In practice, this looks like clients remember every flare, every bad day, every time sex hurt, every time urgency embarrassed them. But they'll often downplay the wins, you know, and then they'll say something to you like, I'm not better.

But you, as the pelvic OT, look at the data and realize they've actually had five good days this week. That matters. So here's a huge OT intervention, helping clients track improvement in a way that their brain can register.

And I'm not talking obsessive symptom tracking. I mean, things like how many hours did you go between voids today? How intense was the pain at its peak this week compared to last week? How quickly did you come down after a flare? Or did you recover by bedtime instead of carrying it into tomorrow? Resilience isn't no symptoms. Resilience is I can come back.

Okay, let's look at another case together. I want to talk about dyspnea and perfectionism now. And this is where thought patterns kind of become the pelvic driver.

So I'm going to use my former client, Elena, not her real name, 29, painful intercourse. She definitely had overactivity in her pelvic floor, constipation and bloating. She's seen another practitioner in the past where she was told to do a bunch of stretches, do dilators.

She's very good at homework, but the symptoms persist, which is why she found me. In the session, she says, if I don't do everything perfectly, I fail. And that's not just a personality trait.

That's physiology fuel. Perfectionism keeps threats high. So here's what we did.

We treated the pelvic floor. Of course we did. We did graded exposure, positioning, pacing.

We also treated the meaning she was attaching to pain because Elena had a belief. Pain means damage. And if sex hurts, my partner will leave.

That belief created pressure. Pressure created guarding, guarding created pain and the pain proved the belief. The loop is what CBT calls thought emotion behavior loop.

And my OT language was, I said, I'm not asking you to pretend it doesn't hurt. I'm asking you to stop treating pain as proof that you're unsafe or failing. Let's collect the new evidence.

So we created evidence assignments, OT style. And it looked like this. Two minutes of non-demand intimacy with a clear stop signal.

Pelvic floor drop and exhale practice before touch, not during pain. A post intimacy debrief, what went well, what felt neutral, what felt hard and a constipation routine support because gut flares were pouring gasoline on her pelvic floor. Over time, her success wasn't just less pain.

It was less fear of the pain. She could recover faster and avoid the three-day spiral. That my friends is resilience.

Okay. Let's get a little concrete here. If I had to choose one, let's call it like a gateway skill for nervous system regulation and pelvic health.

It's definitely breathing because it's one of the only autonomic functions you can voluntarily influence, but I don't teach take deep breaths. I teach it as mechanics. So a simple option you can teach your clients is box breathing or any breathing or the exhale is longer than the inhale.

And if your client hates breathing exercises, I validate that a lot of people do. And some people even feel worse at first, they feel dizzy or it increases awareness. So in those cases, I say something like, let's start with the smallest version that works for you.

We're not going to perfect breathing. We're just going for a longer exhale, even if it's one second extension. And then I pair it with something physical, feet grounded, soften jaw, shoulders drop or tongue off the roof of the mouth because pelvic floor tone is not separate from jaw and shoulder tone.

They're often in the same orchestra. Okay. Let's do another case study this time with constipation and pelvic pain and then avoidance.

So I'm going to use a client, Tara, 41. She did have constipation, pelvic pain, and a history of painful medical exams. She avoids them, avoids intimacy, avoids exercise, and even avoids leaving the house when her gut feels off.

But here's the key. Her avoidance makes sense. It's protective.

It's her nervous system trying to prevent danger, but avoidance is also a symptom maintainer. And in Tara's case, the constipation created pressure and pain. The pain created fear.

The fear created avoidance of movement and even hydration routines, and that all worsened the constipation. The loop tightened. So I approached it gently.

We created a minimal viable plan for the days she felt unsafe. This consisted of a short walk to the mailbox, a consistent morning routine without straining, a supported squat position, breath out on the exhale and no forced pushing, pelvic floor down training after bowel movements. And we measured success like this.

Do you do the plan even when you're scared? Because that's the definition of building capacity. So there's a long running Harvard study that emphasizes that relationship quality is strongly linked with well-being and longevity. And here's what that means in pelvic health.

Pain and pelvic dysfunction are not only body problems. They're relational stressors. Pain changes how people communicate.

It changes touch. It changes expectation and it changes identity. So part of resilience work is helping clients move from secrecy and shame into support.

OTs can do this. And we can ask things like who in your life knows what you're dealing with? Do you feel pressure to push through? What would supportive intimacy look like for you? And do you want language to explain this to a partner? Sometimes a client needs scripts more than they need another stretch. Okay.

Another case study for you. This one is postpartum pelvic symptoms and doom scrolling stress loop. Okay.

Imagine Nina. She's 32 postpartum. She is having pelvic heaviness, urinary urgency, sleep deprivation, and anxiety.

She starts every morning on her phone. She's not doing it because she loves news. She's doing it because her nervous system is searching for certainty.

When we talk about doom scrolling, she says to me, I can't stop Lindsay. It's like my brain needs to know what's happening. We worked on pelvic rehab.

Yes. But the biggest lever was routine design. We designed a two minute before phone routine.

Water, one longer exhale sequence, one supportive thought, and then the phone. Not no phone, just not first. And she noticed that her morning urgency decreased.

Her pelvic floor felt less clenched by midday. This was small shifts, but a big payoff. All right.

Resilience and pelvic health OT isn't a pep talk. It's not just be positive. Resilience is being able to downshift your body state being able to interpret sensations with less threat, being able to recover from flares faster, being able to communicate needs without shame, and being able to take tiny actions, even when fear is present.

And your role as a public OT is huge because you're often the first person who makes the connection between physiology and lived experience. And that is huge. Thank you so much for listening to today's episode.

If you could take a quick second and grade this podcast, wherever you listen to podcasts, I would appreciate it so very much because it does help other OTs find the incredible specialty that is pelvic health. As always, if you have a topic you want me to cover, DM me, email me.

I love your suggestions.