Pelvic Floor Truths For Athletes, Soldiers, And New Moms

Leaks under a heavy deadlift, pressure during a ruck, or a sudden urge mid-sprint can derail training—and confidence. We go straight at the myths and mechanics behind pelvic floor symptoms in athletes and service members, unpacking how high load, high speed, and high fatigue interact with hormones, recovery, and technique. Christina Prebbitt, pelvic floor physical therapist and researcher, shares a candid journey from national-level weightlifter to clinician advocating for stronger, smarter training through pregnancy and postpartum.

We break down the pelvic floor’s role in continence, sexual function, and trunk stability, then connect it to real-world demands: impact landings, belts and bracing, long days with limited sanitation, heavy kits, and sleep debt. You’ll learn the difference between weakness, poor coordination, and high tone—and why each needs a different plan. Expect clear cues for bracing without bearing down, practical positions to reduce tension, and evidence-backed strategies to raise thresholds without pushing through symptoms. We also confront stigma and silence, outlining simple referral questions and a trauma-informed lens that respects lived experiences across the force.

On pregnancy and postpartum, we replace fear-based rules with individualized progressions. New research on women who kept lifting heavy shows lower complication rates and no “exercise triggers labor” effect, while Canada’s new postpartum guidelines endorse early return to activity based on symptoms and goals. Translation: no more blanket bans—coach mechanics, watch thresholds, and build capacity. If moderate to vigorous training flares leaks or pressure, get a pelvic PT screen; otherwise, movement is medicine for body and mood.

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Transcript

Welcome And Personal Backstory

SPEAKER_00 0:07

Hello everyone and welcome to the Barbell Mamas Podcast. My name is Christina Prebbitt. I'm a public floor physical therapist, researcher in exercise and pregnancy, and a mom of two who has competed in CrossFit, powerlifting, or weightlifting, pregnant, postpartum, or both. In this podcast, we want to talk about the realities of being a mom who loves to exercise. Whether you're a recreational exerciser or an athlete, we want to talk about all of the things that we go through as females going into this motherhood journey. We're gonna talk about fertility, pregnancy, and postpartum topics that are relevant to the active individual. While I am a pelvic floor physical therapist, I am not your pelvic floor physical therapist, and know that this podcast does not substitute medical advice. Alright, come along for this journey with us while we navigate motherhood together, and I can't wait to get started.

Why High-Intensity Training And Pelvic Floors Collide

SPEAKER_00 1:08

One of the things that became a really transitional experience for me was that I was a national level weightlifter before I got pregnant. And I wanted to continue lifting. And at that time, seven or eight years ago, you know, the internet being who the internet is, people were telling me my baby was gonna die and that my organs were gonna fall out of my body. And I remember having a mentor say to me, Christina, if you don't think there is research enough in our geriatric space, you should take a look in pregnancy. And what that has transitioned to is looking at high-intensity movement and its interaction with polyfluorid dysfunction with a specialization around the pre- and postnatal period, right? And I think this relates really closely to military life, right? Because many military um members are doing a lot more physicality in their occupation, right? And similar to other orthopedic injuries, we can see that the pelvic floor being a set of muscles can break down under high speed, high fatigue, and high load, right? And recognizing first and foremost just how common this is, right? The current estimates, and this is generally for people who are thinking that their pelvic floor symptoms are severe enough to be labeled as a problem, is that one in four individuals in the general public, females, experience moderate to severe pelvic floor issues. And that's one in ten for males. When we look at one, this is already a massive number, right? 25%. But for those with pelvic floor symptoms, about 50% of them describe that it is a reason why they either modify or completely stop exercising. It is a very big barrier to maintaining physical activity. And we do not have a movement problem in Canada where our population as a whole is too active and we're trying to slow them down, if we think about it from a population level. Right?

Military Demands And Hidden Barriers

SPEAKER_00 3:28

So we don't want there to be any barriers for individuals being able to participate in exercise that they enjoy. When we kind of think to the military piece, one in three service women have a pelvic floor or genital urinary complaint. New research that has just come out in the last six months is putting some of those estimates even higher, between 37 and 57 percent. And that is because we're starting to expand our definition and have a deeper understanding. And this is US data, but that research that has come out in the last six months is Canadian forces data. And so when we think about this, if you look at your team members, there is probably somebody who is struggling with a pelvic floor complaint. And while I'm gonna be focusing in on the female pelvis today, uh, as I was mentioning before, for my males, this is testicular pain, hemorrhoids, hernias, erectile dysfunction, pain with orgasm, low back and hip pain has influences into the pelvic floor. And therefore, there is a lot of our males who are also struggling with many of these issues. And I treat both sexes. When we look at military life, we know that there is a lot of physical demand on the body. But then, if we're also thinking about recovery variables, when we are outside of home base, sometimes conditions are not ideal for recovery. And even things around sanitation, around menstruation and opportunity or availability of resources that are needed for individuals who have endometriosis or fibroids where their menstrual cycle is extremely painful, their bleeding is extremely heavy, and they don't have access to toilets. And so there's a lot of challenges, and one of the hard things is that many individuals feel like they don't have a safe place to land in order to talk about it. And that's why I'm so thankful that you have had me here multiple times talking about this, because the way for this to be an easier conversation is for us to have that conversation over and over. When I first started talking in pelvic health and I had to ask the person about if sex was painful, I'm pretty sure I was more red in the face than they were, right? And now my husband always jokes because talking about bowel, bladder, sexual activity, sexual preferences like none of that really is something that shocks me. Um and and it's just because those conversations have become uh very normalized in my day-to-day life. So if we think about our demands in military life, while our evidence in the military space is still quite new, and we really are trying to build up a bit more um evidence in that arena, we can extrapolate a lot of our data from the also growing area around sports and performance. And what we know is that our strength, power, and impact athletes,

Normalizing Tough Conversations

SPEAKER_00 6:56

whether they have had kiddos or not, given birth or not, is approaching 50%. So individuals who are lifting heavy, doing CrossFit, functional fitness, these areas of sport and physical activity that are also very popular for military members, um, about 50% of them are leaking, whether that's with heavy deadlifts or with things like jump rope. And again, the reason for this is because that in those domains, we are putting the pelvic floor under high load, high speed, high fatigue, or all of the above. And so at some point we can hit a failure point similar to how other muscles can hit failure, but instead of you failing the squat, you end up having urine going down your leg.

unknown 7:44

Right?

SPEAKER_00 7:44

So a little bit of a different output, but absolutely the same concept. When we start layering in obstetrical history, what we do know is that the rate of pelvic florid dysfunction increases. When we start looking at the amount of impact and intensity in the sport that you choose, same thing where the rate of pelvic florid dysfunction goes up. And then any big transition in hormones across the female lifespan also come in line with an increase or a bump up in pelvic flora dysfunction. That can be transitioned into adolescence and puberty, right? So we see a lot of this in adolescent endurance athletes, for example, pregnancy, both of these are estrogen high transitions. And then our estrogen low transitions are postpartum and menopause. So these can all come with their own blips, uh, increase in pelvic florist function across the lifespan. When we are thinking about the demands and considerations around pelvic florid dysfunction and military service, it can be around readiness with the force test, thinking about considerations or modifications that may be needed for military members who are pregnant, ensuring a hopefully successful and low pelvic floor symptom return to duty in the postpartum period, and then thinking about activities in military life that can increase the demand on the pelvis and make individuals more likely to experience pelvic flora dysfunction. So, for example, with wrecking and weight of equipment,

How The Pelvic Floor Works

SPEAKER_00 9:29

I was telling Lindsay before we started this talk that I got brought into the US Special Ops to do a pelvic floor course, and they were seeing higher rates of pelvic flora dysfunction in paratroopers. So the high amount of force going through the legs also goes through the pelvis. And so we're seeing changes to bachelor range of motion, for example, for our paratroopers, uh, just because of having to withstand that force. So things that are unique, but also things that we can make parallels to from other things like high-impact sport. To begin this conversation, what we first need to recognize is that as a society, we are extremely undereducated about our bodies. And I'll kind of lead with my own vulnerability here. I remember being like 15 years old and being like shocked and surprised when my boyfriend's mom told me that I could pee with a tampon in. I was like, what? They're different holes, right? But like I just had no awareness as an adolescent about my own anatomy, right? And so it's funny because I have a four and a six-year-old at home, and both my kids know that boys have two holes, one that pee comes out, one where poop comes out, and girls have three holes, one where pee comes out, one where a baby can come out, and one where poop comes out. And my daughter decided to share that with her kindergarten class, and everybody got an anatomy lesson. And the teacher was like, she's probably in healthcare doing something. Um, but it's funny how you know my own lived experience and then obviously my professional life has made me um definitely aware of this. And we have evidence about this where we are looking at adolescents between 17 and 18, and many of them can also not identify the amount of holes that they have within their bodies. And so, what we need to do is is start with this orientation to this system and make it something that people can talk about. So there's a pelvis that's about to come up here. So if we look at the external genitalia for the female, um, it is actually called the vulva, not the vagina. The vagina is the canal. When we are looking at the external genitals, what is really important and a lot of people don't understand is that your genitals change as you age and as you live your life, right? So in early pre-puberty life, um, it kind of looks a little bit more like the picture on your right. As estrogen comes into the body, we see a bit

Underrecognized Male Pelvic Health

SPEAKER_00 12:16

more of a differentiation between the outer and inner labia. And we've seen a moving away of talking about it as a labia majora versus menorah, because some people their inner labia is bigger than their outer labia, right? There's a lot of different shapes and sizes to the external genitals, and all of that is a normal variation to the this area of the body. And when we are looking at the genitals, we always say too that sometimes our labia are like neighbors, not twins, or sisters not twins, where one side to the other can look slightly different, and again, that is very normal. As we transition into menopause, because of being in that low estrogen state, we see a somewhat of a fusing of the inner and outer lavia, and we see some atrophy to the outer lavia as well as to the clitoris, which is a very big sexual function area of the external genitals. And so we see these changes that happen, and then we also experience changes to the pelvic floor and the vaginal walls through pregnancy and into postpartum. I always joke that when we think about pregnancy and postpartum, that we expect our chest to change, we expect our bellies to change, but we expect our vaginas to go back to factory settings. And that just isn't the case. Our body has pushed out a human, especially if you deliver vaginally, and that means that there are these changes that happen. And unfortunately, many women are not educated on those changes, and then they feel those changes postpartum, and their world is rocked because they don't know what is normal, what is not normal, what they should be feeling, what they shouldn't be feeling. When we think about our pelvic floor, this is the muscles that are inside of the vulva and around those three holes, pee, poop, baby, right? So this is your pubic bone, and this is your tail bone. So urethral opening, vaginal opening, and anal opening. We have two layers of muscles in our pelvic floor. And males have these layers as well, too. Obviously, the length and orientation

Gaps In Education And Field Realities

SPEAKER_00 14:36

of them are slightly different with a different appendage. But if we look at our superficial layer, we have three muscles: our superior transverse perennium, our ischiocavernosus, and our bulbocavernosus. Really important in sexual function. Individuals who have pain with penetrative activity, whether that is sex, tampons, speculum exams, etc., if it's at the initial penetration, it's oftentimes linked at least in part to these muscles. And then our deep layer, the biggest muscle that I want you to focus on is this levator ani, and that's the keegling or pelvic floor contraction layer. While this seems like a foreign area to the body, what I want you all to be thinking about as I am talking today is that they're gonna respond just like any other muscle. They need to be able to contract, they need to be able to relax, they need to be able to contract at the amount that they need in order for us to successfully do an activity that we desire to do. And they are a really important part of our force transfer system. So our pelvic floor muscles help to maintain continence so that we are peeing and pooping only when we want to be peeing and pooping. They have a role in sexual function where individuals with tension or tightness in these muscles can experience pain with sexual activity, but also they're a really important part of our orgasm response, and there's a strength piece to that orgasm with strength of the pelvic floor. And then they're also a really important part of our force transfer system. When we think about doing anything effortful, lifting objects, moving objects, running really quickly, we have this coordinated co-contraction of the core canister, pelvic floor, abdominal wall, chest wall, and low back muscles. And when they co-contract together, this increases interabdominal pressure, it helps with spinal stiffness, and allows us to accelerate, propulse, or lift. And so with that, it's also really important for function. And I'm a huge proponent for that every person who is in the exercise or rehab space should have at least a working knowledge of the pelvic floor. Because if I had a person with knee pain, I wouldn't say I'm not an adductor therapist, I'm only a quad and hamstring therapist. And so if you have medial knee pain, I'm gonna have to refer you to somebody else. What we see is a huge crosstalk between the pelvic floor and the back and hip, where many individuals that are coming to you with hip and low back pain also have pelvic symptoms if you kind of press and ask these questions, male and female. And sometimes some of these deep hip muscles contribute to pelvic floor dysfunction, and pelvic floor issues contribute. I'm gonna just do this and see if I can just make this up and have this come back on. Um I don't know why that went off. Um, can also contribute to some of these issues. Oh, I got one up all by myself, which great. I don't know. Oh, there it goes. Oh, let's see, I did it. There you go. I just like turned it back on. Um, okay. And so it's really important for us to be thinking about this in a really functional way. Okay, and so as I already alluded to, the pelvic floor has a lot of functions. The only one that I have not mentioned yet is that it is a support for the organs or fetus

The Big Three: Leak, Prolapse, Pain

SPEAKER_00 18:23

above um with respect to pregnancy. Okay. Maybe this isn't gonna work because I'm on this is just uh a penis picture you can't see. Um that is what you are missing out on um in this upload. But um what I I want to mention it, and I really do like to um to highlight this, is that women are more likely to talk about this stuff. My male clients can sometimes have been struggling with this for years or decades, and have never spoken to their friends about having testicular pain or having pain when they orgasm and how it can change libido and sexual health and function, right? Because it's an awkward thing to talk about, there is still a lot of stigma, and so there is a lot of demand for pelvic flor rehab in the male space. If we really started uh diving into these issues. So, if we are thinking about supporting pelvic health, there are a variety of different buckets at which this can be helpful. Number one, even if you are not a pelvic therapist, so this was based off of a cross sectional survey of military members. I'm just gonna try and upload this to see if it'll go with this. So when we looked at the oh yeah, it didn't work. When we looked at the experiences of service women when they are managing. Pelvic flora dysfunction or issues with pelvic health, this was some of the things that they talked about needing more support with. Okay, so the first thing is a lack of education regarding pelvic health. Many of their leadership team didn't really know that there was something that they needed to be asking about or screening for. Or if they did try and bring it up because they didn't have that information, they would freeze and feel really uncomfortable and it would kind of go nowhere because they didn't know what to ask, where to go, and how to manage. A lot of these um issues around earth suppression, hydration, and menstrual cycle management are around deployment when individuals are off base and are in a variety of different areas that may not have the appropriate or the access to things like toilets. And so, you know, being off base for a long period of time and it's not as easy for women at the side of the road to just go to the bathroom as it is for our male colleagues again because of that added appendage. And so urge suppression, um, hydration and toilet access, individuals who are menstruating, particularly some of these heavy um issues that can cause heavy menstruation can be an issue, and then understanding of postpartum fitness and what that can do or what is necessary in order to return to exercise. Um, this was done in a US context, and so postpartum fitness was particularly challenging because their um their maternity leave used to be six to twelve weeks. Now they have a lot more time, they're in the five to six to seven, depending on the unit. Um, but this this was because a lot of a lot of this work and advocacy on that end. So if we're gonna try and understand pelvic floor issues or health, let's kind of speak to some of the bigger buckets of pelvic floor dysfunction that we see. We've oriented you to the pelvic floor, I have oriented you to the pelvic floor group of muscles. And so when we think about all of these issues, it is when these muscles start to go into some dysfunction or start to have some challenges. So the three most common issues that we are seeing in female service members is urinary incontinence, it could be fecal incontinence as well. So um loss, urinary incontinence is involuntary loss of urine in scenarios where we have an increase in interabdominal pressure.

Athletic Incontinence And Daily Triggers

SPEAKER_00 22:41

Um becomes fecal incontinence if you're in the never trust a fart category, where it's like involuntary loss of gas or stool. And then prolapse is a feeling of heaviness or bulging sensation around the opening of the vagina because of an increase in range of motion of one or more of the vaginal walls towards the opening of the vagina. And then pelvic pain is a very complex presentation that has a lot of factors that may be contributing to it, but is also in higher frequency in service members. So when we're looking at urinary incontinence, this increase in leaking with interabdominal pressure is stress urinary incontinence. Interabdominal pressure is increased when we cough, sneeze, laugh, vomit, lift heavy, or work and go fast. Uh sprinting, for example. We have a subgroup of individuals, and this can be very relevant in a military context that have athletic incontinence. So their day-to-day bowel and bladder function is totally fine, but it's when they're at five miles of wrecking or when they're lifting more than 225 pounds. It's this heightened athletic threshold at which they start to become symptomatic. And what I see clinically is that those who start here think that it's okay until they get here, and now it's when they're coughing and sneezing, and then they they transition into coming to see me for care. Um, so I would love to have individuals who who come in earlier before they they've kind of ignored it for a long time. And then that urge suppression piece is um where we can transition into urge urinary incontinence, which is basically when you get the urge to go to the bathroom, you have to go immediately. And if you don't, you feel like you're gonna pee yourself or you have had accidents. Um, and so then the mix is some kind of combination of the two. When we're looking at civilian life and veterans, potentially, the other category that I didn't put up here is also functional incontinence, when a person's mobility or cognitive status makes it hard for them to reach the bathroom. So they can't go on their own to the bathroom or they can't get up from a toilet seat, so they can only go to certain bathrooms that are elevated is one kind of component of functional incontinence. And then the other one is if somebody has different types of dementia where they get the urge to go to the bathroom, but the translation of I have the urge to the bathroom to the motor planning of getting to the bathroom can be mismatched. And so we can see that urinary incontinence is one of the leading causes of institutionalization and need for things like skilled nursing or long-term care. And so we really want to be kind of thinking about that from an aging perspective as well. As I mentioned, pelvic organ prolapse is this increase in vaginal wall range of motion. Really important for you to realize though, is number one, your vagina is not a hollow cartilaginous tube. Okay, I have never done an internal exam and looked and saw a hollow tube straight towards the cervix. Okay, so things touch and things move and they are supposed to move. We see a decrease or a change in your vaginal wall range with age, stage, and time of day. Um, and so there is expected some movement, but as that movement gets larger and we start to see some movement of the vaginal wall towards kind of the outside of the body, um, symptoms can increase. So things for for individuals to think about. And so, as I was mentioning about this paratrooper training, because there's such an increase in demand on the pelvis,

Prolapse, Impact, And Paratrooper Loads

SPEAKER_00 26:28

one of the things that we saw was for niliparous college-aged women who were in paratrooper training, when we looked at their vaginal wall range of motion before their training versus after, there was a noticeable change in that range of motion. And so there is components of military life that may predispose military members to things like pelvic organ prolapse. And so it is important for us to understand this range of motion change and be able to offer resources if somebody does start to become symptomatic. Vaginal pain again, I could do a whole course on this, so I'm I'm really just doing a glancing blow here. But um, pelvic pain is a very big deal in the military space. Um, over the last 10 or 15 years, we've seen a lot of more subtyping and awareness that not all pain around the pelvis is the same. Um, vaginist used to be like pain that was in this area of the body. But now we are starting to break this down where it can be at the clitoris, and you can have clitorodinia externally only, like vulvadinia. Dysprinia is an internal pain around the pelvis that only happens with insertion of something, uh phallus, speculum, finger tampon, whatever. And then vaginis is vaginal tightening that can create a big fear of anything inserting into the vaginal canal. When we look at chronic pelvic pain, it is extremely multifactorial, um, where sleep quality, sweet sleep quantity can be an issue. Estrogen levels, when estrogen is low, pain can be higher because of the change to blood flow and dryness of the tissue. Hypertonicity is a big one where individuals have a lot of tightness and tension. Um, this can happen for people who are wearing like really heavy uh belts or rucking. It can cause that tension. Anxiety, depression, history of sexual trauma, high psychological distress, or impaired well-being is also a very big contributing factor to pelvic pain. And then central sensitization, which is a threat response that the body starts to feel, where we have a lower threshold when we start to feel like I need to protect myself and I have pain. So, what would normally be a non-painful stimulus, our brain becomes sensitized that this what used to be a non-painful stimulus is now a painful one. And so there is a lot that can go on there, and so that awareness is super important, and the management is really critical as well. And so, when we're thinking about the management, I'm gonna make sure I got time here, it's gonna be a combination of zooming in and focusing on the pelvic floor itself, but then zooming out and focusing on the conditioning of the body. And so the way that I kind of want to explain this to you is gonna be around uh coordination, strength, and relaxation.

Pelvic Pain And Nervous System Factors

SPEAKER_00 29:47

I do not expect anyone in this room to be a uh pelvic floor specialist, and so I just kind of put this list on here about when to refer to pelvic. What might be some things that individuals are presenting to you that you may make the recommendation to refer out into the community for pelvic floor specialists, and and they're kind of listed here. What might make you make that referral is to ask a couple of questions, right? Are you regularly menstruating? For some of our active women, underfueling is a big cause of pelvic floor dysfunction and just generally not feeling very well within your own body. It's a condition called relative energy deficiency in sport. Um, and it's when the caloric needs are too low for the demands of the body, and it can cause a whole bunch of issues with orthopedic injuries but also pelvic floor dysfunction. If you are experiencing pelvic symptoms, do you notice some of them are worse at certain parts of the cycle? Do you have a history of UTI or yeast infections? If you are on contraceptives, what was the reason? Are you in menopause? Are you on menopausal hormone therapy, sleep stress, and changes to weight in combination with are you having some of these pelvic symptoms? And so when they are saying that I'm having pelvic symptoms, what activities do you notice them with? If you feel like you're gonna pee, is it an urge? Is it like a drop of uh urine that's in your uh underwear, or is it like a full loss of control of the bladder? Um, are you regularly wearing continence pads? Um, this is sometimes because they're just so worried about leaking, versus or could be because they are actually having to change the mouth multiple times per day. Um making sure that they're not wearing menstrual pads, they are wearing continence pads because menstrual pads are not meant for all day use. Um, how much exposure to an activity before you start to feel symptoms? Is it all the time? And do you notice anything that makes your symptoms worse? Things like caffeine and alcohol can make pelvic floor symptoms worse. Um, what alcohol because of recovery and the amount of like alcohol is a toxin, so it tries to clear through the kidney more. Um, and then caffeine can just kind of create some urgency symptoms. When we think about managing pelvic floor muscle training, so learning to strengthen and relax the muscles of the pelvic floor is the gold standard intervention. We have very strong evidence for the use of pelvic floor muscle training in the management of pelvic floor conditions. What I am aiming for in my research and in my clinical practice, and some of my and in some of my advocacy, is I really want to see an extended definition of pelvic floor muscle training. Right now, all of our literature is focused on the squeeze, but what we're seeing in our high-level athletes is that their squeeze pressure is actually higher if they have incontinence versus if they're continent. What that means is that it's not just about the strength, but the ability to relax and the ability to coordinate the pelvic floor. So making sure that it is doing the right thing at the right time. And

Assess, Refer, And Ask Better Questions

SPEAKER_00 33:15

so, in order to try and differentiate, right, this kind of goes into our next steps. Is it pelvic flora not strong enough syndrome, pelvic floor not coordinated enough syndrome, or pelvic floor too tight syndrome? Those are my scientific names. And this is where there is a lot that we can do from a management perspective. If we think that it's pelvic flora not strong enough syndrome, that is when we would be giving pelvic floor muscle contractions as part of an intervention plan. Um but we don't just want to squeeze at the pelvic floor, can be helpful. We want to isolate there, but we want to think about functional strengthening of the hips, especially the glutes and low back muscles. Um, because if some people will talk about the pelvic floor kind of like a trampoline where it accepts force in order to stop us from peeing. But if the spokes of the trampoline are not strong enough, then it puts a lot more pressure on that pelvic floor muscle. So, what we're seeing in a lot of our athletes is that that glute strength piece is really important, and for our endurance athletes, too, there's a loss of glute strength that we're seeing in our incontinent runners. So, things that we want to think about is that strengthening not just of the pelvic floor. Yes, we do want to isolate the pelvic floor, and then also functional strengthening of the lower extremity. When we're thinking about pelvic floor not coordinated enough syndrome, um, you want to think about your pelvic floor as a reflexive system. It's an anticipatory system, which means that when you're winding up to cough or sneeze, it is before you do the ah-choo that your pelvic floor is already contracted, right? It contracts so that it can withstand that pressure. And so if we're not contracting at the right time or contracting too late, then we'll be giving people what's called a knack, which is to squeeze before they sneeze, and to do that consciously before they're sneezing. And it's the people that are doing this every time they're trying to cough, you know that they're probably trying not to pee. This is this is the position of trying not to pee when you sneeze or cough. That cross-legged. And then for individuals who are experiencing coordination issues with lifting or activity, our brace is a really important thing to make sure that we are teaching any person in our care that is lifting heavy weights. People are told, especially if they use a weightlifting belt, to inhale nice and big and push out against the belt. That is literally the worst thing you can do. My gents get L5 issues, they get TLJ issues, so it's either tear coming into the hip or it's L5S1. And in what world would we try and change our bracing strategy as soon as we hit our heaviest loads? Okay, so when we are thinking about bracing,

Training The Floor: Strength, Timing, Relaxation

SPEAKER_00 36:16

right, what happens as we lift heavier weights is that inspiratory volume goes up, we start taking bigger breaths and we close off our glottis. Like that's gonna happen naturally, whether you are trained or untrained. But then our bracing strategy is that essentially it's like blowing up a balloon and then trying to hug around it. When we are bracing, though, we want to distribute force everywhere around our body equally. Oftentimes, people end up bearing down. And so women who have smaller urethras end up peeing. Our men don't, but they start getting hemorrhoids, and it's not really that fun when you bleed when you're having a bowel movement. Right? So the cue that I give people is to inhale nice and big and then to contract your belly as if somebody was gonna punch you in the stomach, hug your baby if you're pregnant, or as if your kiddo was about to jump on you. If anyone's got little kids at home, they're like kawabunga, and their knees are coming in. You know that if you're lying down, the first thing you do is you put your ribs over your pelvis and you brace for impact, right? And so that is what we want to be doing. This can clean up a lot of low back, hip, and pelvic floor-related issues. This is where the the nuance of this comes in. I am aware of my timing, so I'm not gonna go super deep into this. Um, this is a paper that I published with a colleague of mine that is open access. You can get if you really want to deep dive into this. Um, there was a long time in the pelvic world where bracing and the valsalva maneuver, which is the closing off of our breath when we're lifting something effortful, uh, was really demonized. And again, we've really shifted away from that. Um, our brace is a really important strategy for performance, and we do it naturally, right? The the next time you see a person who's doing a max set of pull-ups, you're gonna see them. As soon as it starts to get really heavy, you're gonna go, right? And it's because they're Val Salving to try and help with performance. Um, it's just a way that you can see it happen very naturally without anybody intentionally doing it. When we think about pelvic floor too tight syndrome, um, this is where individuals um sometimes if they're feeling like they're constantly having to pee or they have the urge and they just have to hold and like they get told you just have to do more Kegels, and then they try and hold their belly in and hold their pelvic floor in all the time, it's exhausting, right? And what I always compare it to is imagine that your resting position for your bicep is chin over the bar for chin-ups. If you're already hanging out here and then you're asking it to do more, your biceps are like, I got nothing left. I'm giving you everything I got, and it's highly fatiguing. I see a lot of pelvic floor too tight syndrome and people who are also having some sort of pain, usually hip or low back. So if they're telling me that they're having some pelvic floor symptoms and they tell me that they have a history of hip or low back pain, I'm usually starting here for them, especially for my active folks. And so the three positions that bias our pelvic floor into a more lengthened or stretched position is happy baby, a deep passive supported squat, and child's pose. And so oftentimes I am working on getting them into these relaxed positions, getting them to do a pelvic floor contraction, but then focusing a lot on this relaxation or spreading and getting that awareness of the pelvic floor. Being able to relax. This is also my type A high stress individuals. Another joke that you're gonna hear if you're a patient of mine is that tight ass is

Bracing, Belts, And Pressure Management

SPEAKER_00 40:12

a reason, there's a reason for that condition, right? And it's because we we hold our sphincters when we're really stressed and we're really anxious. Um, and so that that relaxation can be in positioning, um, but it can also be a lot of like mindfulness and mind work, um, yoga, deep breathing, taking 10 minutes to to stop and take a mindful breath. Um, that can all be really, really important. And so what we see is that uh pain and hypertonicity, I kind of mentioned that they can go really hand in hand. In particular, um, it is highly um prevalent in the military, um, and there is a very strong link between sexual harassment and sexual assault and sexual trauma. And so um what we do see is that if I am working, um I do see quite I do see military members in my practice, I am always taking a trauma-informed lens because there is a strong link to some of those symptoms and sensations. Um, where a lot of people, 64% of victims, did not report their incident to a commanding officer. And so I kind of go in with the assumption of yes until I get told otherwise emphatically. So we just want to make sure that we're being very aware of the way at which we approach these conversations because it is really important that uh we consider the the well-being and mental health of the person that we are talking to. And then when we start thinking about our pelvic floor issue, um, there's so much that we can do in the gym, right? So when we are thinking about pelvic floor issues, a lot of people think that all I do is stay in a room with my finger in somebody's vagina and get them to squeeze around it. That is so far from the truth. It's only about five to ten percent, maybe, of what I do, just to get an orientation of what's going on down there. Um, and so much of it is trying to coach mechanics, make sure that everybody is in their strongest position, and then make them the strongest version of themselves, right? So building their capacity and threshold where we're not gonna be pushing into symptoms because that's like pushing past pain and realizing that long term that's not gonna be the biggest benefit. You might have to do that in the short term, um, but just like for shoulder or back pain, just like grinning and bearing it, just means you start taking a lot of uh over-the-counter pain meds and it doesn't probably get better. Um, the same can be said with palvic floor dysfunction, where we don't want to be blowing past symptoms when there's a lot that we can do from a rehabilitation perspective to help out. All right, last 10 minutes, I want to talk a little bit about this pregnancy and postpartum transition. So when we look at our current best evidence, the really important thing that has shifted from, you know, seven years ago where I was being told my baby was gonna die, is that there's been a very big shift in acceptance of maintaining strength and strength training behaviors in pregnancy. The reason why this was so restricted, and and I just published a systematic review in the British Journal of Sports Medicine, is that when we look at what our current best evidence is was over the last several years, it's changed a lot, but um, it was that women who are pregnant for 16 weeks they were doing yellow fairband exercise. They were only able to lift to a max of three kilos, which made me laugh because the baby they're about to push out of their vagina is probably gonna be more than the max exercise they were allowed to use for the 16 weeks of this RCT. The reason why I bring this up is because, especially in pregnancy, which is such a protected time in a woman's life, um, if we don't know, the answer is no. And so these guidelines of don't lift more than 20 pounds or don't lift more than 40 pounds, it was not because

When Tightness Is The Problem

SPEAKER_00 44:18

we had evidence for harm, it's because we didn't have evidence at all. And so we felt very comfortable under 20 pounds because that was where our evidence was at the time, and thank goodness this is starting to shift. And so the the shift at which we are starting to see these changes and differences is that one moms were saying, This doesn't work for me. I have three other kids at home that are all over 20 pounds. I lift them every day. We had athletes who are saying, I need this for my sport. I can't take 15 weeks off. My athlete window and my fertility window directly overlap. And then the second piece is when we think about strength, what part of your life do you go in and you're like, you know, I really wish I was weaker to handle this really stressful time in my life, it's gonna make it easier for me, right? Being pregnant is hard, but being pregnant deconditioned is significantly harder. And being postpartum is hard, being postpartum deconditioned is harder. And so, what we have really been trying to push in my research team is that these narratives can actually be harmful because yes, they may not cause pregnancy complications if a person is more sedentary, but it is definitely making this motherhood transition a lot more difficult. And so this is where we have really started to see a shift. And so this started in 2022 when my first published study came out with my colleagues that was looking at CrossFit athletes, and basically they were the ones that kind of ignored what their doctor said and said, Well, I'm still gonna keep lifting, it feels really good for me. And we said, Well, can you tell us about what happened so that we can start pushing back on some of these recommendations? And so we got um 679 women who lifted more than 80% of their pre-pregnancy one or at max during pregnancy. Um, and then we asked about their labor delivery, their pelvic floor, et cetera, related outcomes. And what we saw was that rates of cardiovascular complications, so gestational hypertension, pre-eclampsia, etc., were much lower than our current general population national averages. Our rate of cesarean section right now in Canada is between one in three and one in four. Pregnancies end in cesarean, our C-section rates were lower. And then we didn't have some people would say, well, if you lift too heavy, you're gonna go put yourself into labor. And we saw that this was also not true. My world in the pelvic PT world is like you're gonna make your pelvic floor worse. What about your pelvic floor?

Trauma-Informed Care In The Military

SPEAKER_00 47:10

And we actually saw that some of these rates were actually quite low as well. And the shift that I have really started to look at is that when I am helping a person postpartum, in what other injury would I say, don't do anything for six weeks? And if you have any symptoms of pain, discomfort, or anything, then you failed rehab and you're doomed to dysfunction for the rest of your life. But that's what we tell women is like do nothing for six weeks, gradually return. If you return too fast, if you start to feel pelvic symptoms, you're done, you're done. You just cause this on yourself. And so when I'm seeing somebody postpartum, I'm literally trying to get them to run until they feel like they're gonna pee, or I get them to do activity until they start to feel the urge to go to the bathroom because their pelvic floor is recovering, and that's the pelvic floor symptom of capacity that it is giving me. And so this has been a really big, big change. And so when we are working with somebody who is pregnant, instead of saying at this time we are going to see that you're gonna avoid this activity, what we are moving toward as a research team, and we're hoping that this is gonna reflect in the update of the pregnancy guidelines, is that there is no such thing as pregnancy safe versus unsafe exercise. And how far and how fast and how much pregnant uh women are gonna do is gonna be completely dependent on them and their experience, their fitness going into their pregnancy, how they're feeling in their pregnancy, what their home-based activity looks like, and all of that is gonna allow us to make more informed decisions. And some of my new research that is in manuscript and hopefully it will be accepted for publication, is that this awareness has been really helpful because before a lot of people didn't even know what the pelvic floor was. However, what we are seeing is that it can shift from advocacy to hypervigilance, and so we're seeing individuals have a lot of fear of what exercise I do in pregnancy is going to

Gym-Based Solutions And Capacity Building

SPEAKER_00 49:12

dictate if I have pelvic floor dysfunction postpartum. And currently, our evidence just doesn't substantiate that. That it is usually your pregnancy and your labor and delivery story that are gonna be the biggest predicting factors, right? I could not control that my baby's head was in the 95th percentile. There was some stretch that happened there, right? And that was outside of my control. Um, and and so much of that is. So things that we want to think about is ask um how they are feeling and kind of do that check-in every week or a couple of weeks, depending on where they're at. We want to make sure that we're coaching mechanics in our pregnant athletes just like we would in our non-pregnant athletes. We may need to increase like the distance between our feet to make room for a baby belly or shorten the range of motion if the baby belly is starting to get into the in the way of proper movement mechanics. We wanna refer to pelvic floor physical therapy. I often have a lot of success when I get to see people in pregnancy, help them make those modifications, give them all the education they're gonna need about what's gonna happen during labor and delivery and what their body is going to feel like postpartum can be super helpful. And we wanna make sure that we're not leveraging fear-focused messaging, right? So um the messaging is so often like this is just something you have to deal with in pregnancy, just wait till the baby comes out and it'll get better. Um, but that isn't always the case, and there's a lot that we can do, especially in the pelvic girdle pain and some of the pelvic symptoms perspective to make their pregnancy maybe a little bit of a smoother experience. The last thing that I wanted to mention again, I I recognize that I'm getting um close to being off time, but um, in 2025, I got to be like just the tiniest little 1% um influence on these new 2025 Canadian guidelines, and Maggie Davenport, who is my um uh research supervisor, she is just an incredible human, and the entire team did an incredible job with this. Um, this was our first ever postpartum exclusive guideline that came out internationally, and so Canada really is leading the way when it comes to pregnancy and postpartum movement. The last update had been done in 2003 when the postpartum guideline was nestled underneath the pregnancy guideline, was like, oh, postpartum do this. Um, and so this was a big step up. And what this guideline moved to is that one medical screening is not necessary for returning to physical activity, except in the presence of complications, and so it's not the postpartum part that might need screening, it's the complication part. That the time at which individuals return to exercise in the postpartum period is gonna be completely up to them, and that early return to exercise is probably one of the best things that we can do to mitigate the impact of postpartum depression and anxiety, especially if we can get moms early on to 120 minutes of moderate to vigorous physical activity. And um, that shift around language is just absolutely massive. And where the screen can come from from a pelvic floor perspective is that if there is an exacerbation of pelvic floor symptoms with moderate to vigorous physical activity, it is worth being screened by a pelvic floor physical therapist. That language changed because there is a lot of access issues that we still have with pelvic because of the expense. And in um in the US, a lot of individuals are cash pay, and there's just a lot of circumstances at which people would not get access. Um, thankfully, in Canada, many many people do,

Rethinking Pregnancy Strength Guidelines

SPEAKER_00 52:54

but um, we just kind of wanted to be aware of that and not make it like you can't exercise unless you're screened by a pelvic therapist because what we know is that many women will feel better when they start reconditioning their body in the postpartum period. Obviously, I if I have to put up, we're we're doing some new research studies. So if you know somebody who might be interested, um I'm about to also be putting up a study about uh return to exercise after miscarriage, and I think that's a whole other area. So if you guys follow me on social media, um that ethics will soon probably hopefully pass. Um, and I'll be able, we one of the things that we don't have any um research on right now is uh the experience of pregnancy loss and return to physical activity, and that I think is really relevant here in the military too, with um return to work duties.