181: Incontinence in Female Athletes with Mindy English, Orthopedic & Pelvic Health PT

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Brianna Battles  00:01

Welcome to the practice brave Podcast. I'm the host Brianna battles, founder of pregnancy and postpartum athleticism, and CEO of everyday battles. I'm a career strength and conditioning coach, entrepreneur, mom of two wild little boys and a lifelong athlete. I believe that athleticism does not end when motherhood begins, and this podcast is dedicated to coaching you by providing meaningful conversations, insights and interview topics related to fitness, mindset, parenting and of course, all the nuances of pregnancy and postpartum, from expert interviews to engaging conversations and reflections. This podcast is your trustworthy, relatable resource for learning how to practice brave through every season in your life. Everyone. Welcome back to the practice brave podcast today. I'm here with Mindy English, she is a pelvic floor PT, who also has a background in Sports Med and or so PT, so it really helps to have these conversations about coaching and treating the pregnant and postpartum athlete or athlete mom with her, because she really has a scope of pelvic health, but also sports performance. And we live close to each other, so we get to do a lot of different collaboration. And if you missed it earlier, she's been on the podcast quite a few times now, and we are doing a series in 2025 that's all focused on different aspects of Ask a pelvic floor PT, and different topics that Mindy and I can share and collaborate on. So with that, today, we're going to be talking about incontinence for the female athlete, peeing when you lift, peeing when you jump, and different mechanisms to address and also the root of it. Why is that happening? Whether people have had a baby or not, I think a lot of times Mindy, you can correct me, but a lot of times people believe that, Oh, you just have a weak pelvic floor and you need to get stronger. But that is rarely the case with female athletes, and so we want to bring a little bit of nuance and explanation to that topic today. So Mindy. Thanks for being here. Thanks for having me again. Is there any context about your background that I left out that you want to add on for today? Um,

Mindy English  02:21

you know, I think sometimes the when I think about, like, what makes my approach different, I also think about the fact that I've I've been in an athlete's shoes. I've coached also at a college level. I've coached like kindergarten all the way up through college, and then even people beyond that. And so I think when I first came out of PT school, I love you the athletes. I still love you the athletes. But, you know, I always said I have a perspective from an athlete. I have a perspective from a coach, and I have a perspective from a PT so I can kind of see all different sides of it. And I think now, as I move into the public health world, I think I still try and see it from all different sides, like, understand where the athletes coming from, understand where the medical profession is coming from, and then understand those people have coaches, or have performance expectation, or understand where those people are coming from too, to try and just be an advocate in all different ways, and figure out how we get these people performing not the best.

Brianna Battles  03:19

Yeah, and I mean, as you know, like you're kind of a unicorn, because there's so many people that come to both you and I, separately or even collectively, that are like, my coach doesn't know how to help me, or I went to a pelvic floor PT, and like, they don't know what to do with me. And how, I mean, I've sent so many people to you for that same reason my sister included who lived out of state, and her PT straight up, told her, like, I don't know how to help you any further. And I think it's really unfortunate that we're not able to better bridge that gap, because the way women work out now is not suited for the information of the pre and postnatal industry, and the guidance that pelvic floor PTS traditionally give, which might be a lot more clinically based or rehab based, they don't know, oftentimes not everyone, but how to bridge that gap from almost like pelvic floor rehab into Applying it into like, higher performance strategies, higher performance demands. And obviously that's what I try to teach in the certification program that I have. But bridging that gap into the practitioner community proves to be a whole other beast. As as you well know, yeah, I think that's

Mindy English  04:37

the thing I hear the most, is I've been to pelvic floor. PT, I just don't feel like they understood what I was trying to do. And that can be something like for us, who, if you live in kind of a fitness world like double unders, doesn't seem like that far fetched of an idea. But if you don't understand that world, you've never been in that world, double unders sounds like, well, just don't. To do it. But if you do CrossFit competitions, the lenders come up and you can't just say, I'll just do single lenders. I'll just do something different, like it just doesn't work that way. And so, so I think that's where people get frustrated, is just that lack of understanding or lack of curiosity or connection of, let's figure out, let's help you find someone. And I think sometimes in the practitioner world, we get a little territorial, you know, we'll feel like, well, I don't want a trainer telling my person about their pelvic floor, but that trainer understands the demands of the person's activity and so, so I think we have to collaborate. We have to, like, just be good teammates with the each other, to help the athlete in front of us. If you don't understand what they're trying to do, talk, you know, talk to them about them, ask them questions, see if they care, if they you talk to their coach. Like, figure out, we have to figure out how to help them so that they don't just leave the office feeling really frustrated, and I'm feeling really defeated. And then they see stuff online, and if they're somewhere remote, they say, I don't even like they just feel like they got less than and they probably didn't necessarily get less than treatment from like, a pelvic floor perspective. They just didn't get that connection right.

Brianna Battles  06:16

And this is where, like, I'm gonna obviously do a shameless plug here for the certification pregnancy and postpartum athleticism, because that is the bridge that you know, if you feel like you're not quite getting it from your coach or from your PT, your coach or your PT, or even you can learn in the coach certification how to apply a lot of these concepts from the outside in, because not everything to do with your pelvic health symptoms or your diastasis, has to do with, you know, an internal assessment, or things that you have to do, like pelvic floor, PT, specific, related, it can be a lot of coaching strategies, movement strategies, breathing adjustments, pressure distribution, tension adjustments that can be made from the outside in that affect your pelvic health in a really positive way. But those strategies have not been taught to us as female athletes, from the get go, from the get go, it has. We have not been taught how you know, different breathing strategies may influence our pelvic health symptoms. For example, I worked with an Olympic weightlifter a couple weeks ago, and she's a professional level. So she's very high level, great athlete. Obviously, like her form is excellent, you know, but her warm and her breathing and like Valsalva tendencies, were not great for her current symptoms that had started more she was absolutely, like, not just leaking a little bit, but she was like, losing, like, totally peeing her pants on the platform, to the point of having to wear a pad because she couldn't trust her body, even at these meat she's like, Yeah, I would just always wear a pad because I knew after over a certain percent, I'd be peeing all of the platform, even though that was like, very normal there. She didn't want that to be like, her thing, but she's like, I just knew that was going to happen once I reached a certain percent, if I was at my max, max, max, and then it started to kick up even more, even though she's taken a step back from competing a lot, she's noticed that her her strategies, or maybe just getting older, certain things are just still making her pee to the point where she was like, I don't even want to, this is so discouraging. I don't even want to, like, lift or push it to that level anymore. And like, bowing out of our workouts, and that's how we got connected. And again, it's not that she was lifting wrong. It's just like, sometimes your strategies aren't cohesive with what your body needs at different points in time. And that might be, you know, symptoms might flare up a little bit more around the time of your period or population different points, obviously, in pregnancy and postpartum and menopause, and we're going to talk a lot about that today. But it is. It is interesting knowing that, you know, it's not always about a pelvic floor being the problem. It's almost the mechanisms, the sum of all of the variables that then affect the pelvic floor. So I know that wasn't a specific question, but can you riff off of that a little bit with what you've seen?

Mindy English  09:17

Yeah, I mean, I think there's all we always assume that is the pelvic floor. And we assume that, oh, they must just have weakness there, or or they're stretched out, or whatever it is, because they've had babies, and not everyone has had babies and leaks when they lift and do sports. And I think a lot of these athletes, when I see them, and if we do a pelvic floor exam, a lot of them actually do Okay, right? Like, compared to the average person, a lot of them understand how to contract. They might not relax super well, but if you give them the right cues, they can kind of figure it out. But they still pee and it's it's not because. Because they're not necessarily, like, contracting at the right time in a lift. You know what I mean? Like, sometimes there's just, like, other things that are happening at the bottom of a lift. And if you're like, maxing out on a lift, that's a lot of load that you're just trying to put through your whole body. And there is a tendency, like your breath holding, you're grinding it out, like you're just trying to stand up again. And so helping people figure out and kind of looking at and saying, okay, like, how else can we distribute your breath? And like, you were saying, with a Valsalva, there's a time and a place for a Valsalva. And like, you know, sometimes 12 or four therapists are like, no, like, let's not, like, that's a lot of down pressure. And sure it is, but sometimes people need a little bit of that, and they need to distribute the pressure a little bit wider, right? Like we can still get kind of a similar effect with our pressure, distribute a little bit wider. And then we also have to look at what else is happening, what's happening with their hips, what's happening at their ankles, what are all those other muscles doing to help them get up out of if it's, you know, a heavy lift, if it's a deep squat position, how do we help them get up out of that? And no amount of, like, pelvic floor strength is going to help someone get up out of a max snatch or a clean or whatever it is, and not leak. Like, that's not for muscles. They're, they're robust, but they're not. Those aren't your powerhouse muscles that are getting you out of there. And so they're, I view it as it's a it's a sign, and like, no pun intended, there's a leak in the system somewhere, and that's where that, that's where that's showing up. For some people, that could be pain, could be knee pain. For someone else, but for a lot of female athletes, it is leakage, because they've just they they've reached their capacity, and the pelvic floor just can't take any more of it, and something has to give. But it doesn't mean that the pelvic floor is weak, or that, you know, they need to use like, vaginal weights at the bottom of their lift or something like that, like that's not going to fix it?

Brianna Battles  12:03

No, absolutely. And so one thing I tell a lot of my athletes is, like the pelvic floor has to be able to absorb force and produce force, and it does that, not by acting as like a singular contraction, right, but more of a coordinated unit with the rest of that core system. We talked about that in last month's episode of Just like how that core system works together. So if you didn't listen to that episode, that will be really helpful context for this conversation. But pelvic floor has to be able to absorb cellular we're talking about, like the clean for example. It has to be able to absorb that force of the catch at the bottom, absorbing that. And then as you start to grind out of that position, shift the pelvis goes through a different goes through kind of a variety of range of motion. They're really subtle, um, but that's where then it's having to produce that force coming out of the bottom. And that um, that catch of the absorption into the transition into that production of force is a lot of demand on the pelvic floor. So this is a case for really needing to involve the glutes and changing the pelvis position in that range of motion to get the glutes involved more, because the glutes help with that absorption. So it's not just all going down to the pelvic floor in a position like a clean for example, it's kind of easy to go into that tucked under position. Think like a butt loop position, or even if you're dead lifting, and you get to that point right above your knees, and I call it, this is, like a really unedited version of of how I speak on social media, is on the podcast, but like, it's like the dog shit position where, like the back just kind of round that pelvis grounds under, and that's when a lot of female athletes pee, when they're doing dead lifts, and then same thing, if they're catching it, that really a deep squat at the bottom of a clean and then they're transitioning up that pelvis position being even slightly tucked under and that but we position can really put the pelvic floor in position where it cannot absorb and produce that force well, because the glutes are no longer as involved. So if we can make a case for getting the glutes more involved in a lot of these movement patterns and small adjustments to that range of motion into their form, so to speak, that can go a long way, and not every athlete is going to be consciously able to make that positional adjustment in the moment. And that was one thing I noticed with Christy Brewer, who, she's the Olympic lifter that I just worked with, and I have permission to talk about her. For her, it was easier to cue a different breath strategy in certain positions, because that automatically forced her pelvis into a different position automatically. And why? And I'd love for you to elaborate on this, but when I had her, like, exhale, she was transitioning out of that movement, it kind of forced her pelvis into a slightly different position, and she wasn't leaving anymore. So as she would like, catch the clean for example, she'd start to transition up out of the bottom with a little bit of a like a force exhale. And. That fixed her pelvis position and her symptoms without me saying, like, drive your hips back, or get your butt back or anything like that. Didn't really need to do that. The exhale did enough to course correct her pelvis position and her her symptoms in a lot of ways. So why? Well, why does that work? Mindy,

Mindy English  15:20

well, you know, I think our brain loves new things. It loves like different strategies and different tasks, and so when we think of our body and movement, yes, we have, we have our own volitional control over things that we do, but we also have this involuntary control that happens and involuntary movement patterns that happen with the brain. And so sometimes just cueing something different, like gives our brain something different to like think about. And when I think of like, that kind of butt wink position, there's lots of reasons for it, and sometimes it's just a neuro motor pattern that someone's learned. You know, we if we clear hip motion, we clear ankle motion, all those things. Sometimes it's just a learned pattern from years of reps of doing it. That way, you just find that's what worked when you first learned it. And so your brain goes, oh, like, that's successful. I'm gonna keep doing it. And so when we cue something like breath, when we just give a different focus our brain, you know, we're not, like, trying to override a system our brains just like, oh, that's that's kind of different. And so it just kind of forces your your body, to adopt a different movement pattern that you already kind of know, right? Your brain knows all these different movement patterns. It just forces to change the order of activation of muscle patterns. And just, yeah, it can, it can change your position pretty easily, right? And you don't have to sit and think about, you don't have to sit at the bottom of a squat while you're like, grinding out saying, Okay, let me. Let me untuck my

Brianna Battles  17:02

or, like, contract my pelvic floor muscles. Like, that's not gonna work. But I was telling her, like one thing, that when you do that exhale, and I had her, like, do, like kissing lips, or like blowing through a straw, even, like adjusting her lip position there, that that exhale solicits that CO contraction of the pelvic floor. So it's kind of like a little bit of a super boost coming out of the bottom where there's this contraction, even if it's really subtle, through that exhale, that gives you a little bit more support from the bottom of your core up. I mean, it's a muscular base. It all works together with that diaphragm. So again, it's like finding little tweaks to not just like what you're doing, but how you're doing, that can make a really big difference for athletes who pee when they lift.

Mindy English  17:48

Yeah, I mean, and even thinking about how we breathe is going to affect how some of our abdominal muscles activate, and that's going to have some attachments to the pelvis, and so that can alter some things a little bit too, just because you're just getting the free activation of your abdominal muscles again, without telling someone to tighten their core,

Brianna Battles  18:07

yeah, because it automatically just forces again. We're talking about, how do we distribute and help that pelvic floor absorb force and produce force. It's not just the glutes. It's also like the abdominal wall too. That can do so much for our female athletes when they are experiencing incontinence. So when we think about female athletes that are like, you know, I'm I don't know why I'm king, or this just started, or only happens sometimes. What do you tell them?

Mindy English  18:37

So I try and ask lots of questions to see because sometimes it feels like there's not a pattern. And if you ask and if you ask enough questions, there is, yeah, not in that we can find. So you know, there is some, there is some value in saying that people are going to have some more symptoms at certain points in their menstrual cycle. But if you don't ask people those questions, they may not necessarily put that together. And sometimes you need right? Like, I might be seeing something like, I just finished my period, I don't know. And so it might be something that you have to come back to a month later and just see, okay, did you notice the difference here? Certainly different phases of life. So when we're postpartum, when we're perimenopausal, menopausal, those that can be when symptoms start to show up. We're starting to discover those, basically those times where our estrogen is low, that can be a time where the pelvic floor is really just becomes more symptomatic for people, or not just the pelvic floor, but just in general, it become more symptomatic. Sometimes it can be at a certain point in their workout, right? So we have to start thinking about, is there a fatigue factor that's sitting in? Again, if I think about we'll just say, you know, like your CrossFit athlete, because their workouts vary a lot more than maybe some other sports. You know, it's kind of wondering. You start wondering, is. There doesn't matter, like, the sequence of things, like, when something shows up in a workout, like, again, double unders, it's a really common exercise that women leak with. Does it happen if it's at the beginning of the workout, or is it only if it's at the end? Or does it matter, right? Like, and so, you know, I think for me, I think people know, if you work with me, I'm going to ask you to play with your music movement a lot, and I'm going to ask a lot of questions, and I'm going to ask, like, how much, how much variability can we have in the sequencing of things? Just so we can figure out, like, I don't, I don't always know the answer for why you're leaking, and we need to be a detective a little bit to figure out, okay, if we what variables can we alter, right? Can we just alter timing of when this happens in a workout? And if we can, that's great, right? Like, that's an easy thing to fix, at least for right now, right? Like, as we work on some of the other things so that you can be strong at the end of a competition, too. So I think we just have to get really curious and ask lots of questions. If you run, you know, when in your run, is it happening? If you stop and walk a little bit and then you start writing again, do you start leaking again, or does it go away? You know, if you're if you're jumping, when in your jump, does it happen on a Bucha, right? Like, do you notice? Are you leaking when you land? Are you noticing leaking as you start to swing your arm back, arms back to take off? You know, try and talk me through when you think it's happening. If you don't know, then let's next time you do it. Just like, have some little awareness about it. Don't obsess over it, just have a little awareness and then come back and let me know. Because when I think of your needs analysis, I need to understand where it's happening to be able to help you right?

Brianna Battles  21:53

And I think it even happens. I think what I've noticed working with different female athletes is sometimes they're surprised in the movements that happens, and they're like, well, it's not jumping or, you know, it's when I'm catching the barbell, like, after doing the jerk, and like, you're like, re racking it on your shoulders, and it's that movement pattern that against, again, absorbing that force of the barbell with gravity, that that's when they're leaking, or it's toes to bar, and they're like, What? Like, I'm not even, it doesn't seem like my pelvic floor is really involved. But again, it's, it's looking at a lot of different factors, of what range of motion the pelvis is in and how it's having to exert that force, whether it's a really dynamic movement or it's a lot more of like a strength and grind kind of movement, you know, if we're looking at, like heavy lifting, that's more of like a longer duration force and effort on the pelvic floor, where something dynamic is almost like the speed and fatigue factor and like the automaticity, where then fatigue can kick in for other reasons. So, you know, I think it's important to note that it really can happen in a variety of fitness and movement settings. And of course, not just limited to fitness, when you sneeze, cough, maybe laugh, or sometimes just even the urge to go pee and feeling like you cannot make it to the bathroom. And then Amy, maybe not so commonly talked about symptom of incontinence is fecal incontinence, and that can be so humiliating, especially for female athletes who take a lot of pride in, like, not feeling limited by their body, and now they're worried about that, you know? So, I mean, I think that's the really eye opening piece of being a female athlete and now being a lot more, I guess, aware of how your pelvic health influences your performance across your lifespan. And pregnancy and postpartum are often just the seasons that bring more awareness, that highlight it, whether you are actually experiencing symptoms or not you now officially, kind of know what your pelvic floor is, you know, like, okay, it's been through a thing or two. Now, whether it's just the the carrying of the baby through pregnancy, that's a lot of extra force in the man on the pelvic floor. If you have a vaginal birth or C section, either way, you have a lot more awareness of the role of your pelvic floor in your daily life as well as your performance. And I think that's the I think that's the eye opening. Fact is that you now have a lot more consciousness around different things that can happen, even if it's not immediately postpartum, like you were saying earlier. With perimenopause, different hormonal changes can affect your pelvic health across your lifespan. So there's a lot we can do proactively.

Mindy English  24:42

Yeah, and I think, you know, I had someone who was pregnant say to me, like, I was talking to my friend about this, and she said, You need to see a pelvic floor therapist. Just thought that, like I didn't. I thought this only happened postpartum, and, you know, and it's just awareness that it. It can happen even before you've had kids, and it just doesn't get talked about. I mean, I was a volleyball player, and I can tell you now, like we didn't necessarily talk about it when we were, like, playing, but when I talk to volleyball players now, whether it's like teammates or just other volleyball players, interact with they're like, Wait, it's not normal to pee when I

Brianna Battles  25:22

Oh, I know it's so it's so funny because, like, I feel like we've been just yapping for over a decade, of like, there's help, and it doesn't have to be like this. But in every every corner of the fitness industry, there's a way that it's been really normalized for women to pee. Like, I was at a higher rocks competition recently, and it looks like there's this ongoing joke, like, oh my god, I gotta go painting. And, you know, it's because, like, they're like, you know, 40 something minutes into the race, and they're like, Okay, now their body's been through a lot of different a lot of running, a shit ton of running, and then they go into a a different movement, right? Like, whether it's a sled or a row or a wall ball or whatever is now their pelvic floor is having to go through a different demand than just the running and almost like that change up can be really confusing and really hard on the pelvic floor. We see that in the Olympic lifting and power lifting communities of again, kind of that normalization of peeing on the platform, and when you reach a certain level or a certain like load that you're pushing, that it's kind of inevitable that it's going to happen, whether you've had babies or not at triathlon races, for a variety of reasons. Sometimes people are just like shitting down their leg, you know, whether it's because they don't want to stop, or sometimes it's because there's like a loss of control there that happens. And trying to think of other, obviously, CrossFit community and the double unders and the peeing before the workouts and stuff like that. Like, we've just seen this so normalized in a lot of different fitness communities. And while, obviously, we're a proponent of female athletes being in the gym and wanting them to be successful, and not making it like, not making anything taboo or bringing shame there. Because, like, yeah, like, if you pee, then that's like, we don't want to be a limiting factor, and we want, we don't want that to necessarily be like a normalized this is just how it has to be when you work out. Because there's actually things that you can do that doesn't bring you away from the movements you like doing. You can still train in those environments and lift heavy and do the double unders and compete in a high rocks race, and do all these different things that might trigger symptoms, and we can troubleshoot a lot of different things to help improve your overall experience there that doesn't say or doesn't mean like you have to stop doing Those exercises, or stop doing, or stop competing, or stop whatever it's like. No, we just have to, like, reverse engineer this process a little bit change a couple weighings that you're doing. It that might be your form, that might be timing of your breathing, that might be just like, how would noticing where you're holding a ton of tension in your different movement patterns and redistribute that, and that alone can kind of be a quick fix. And I know none of this is actually a quick fix, but we got to give them a little bit of a win. And oftentimes, I don't know about you, but I find that there's at least a win that we can make something that can be corrected easily early on, that's that like, again, it gives them that win of it. It creates a little bit of relief to their symptoms, maybe not permanently, but an improvement for

Mindy English  28:28

sure. Yeah, and I think it's just giving them that awareness of what their tendencies are. So many athletes hold their breath, and I'm guilty of it too. I tell people not to hold their breath all the time, and I get into a really tough workout, let's say with, like, rapid, you know, box step ups, or, you know, whatever it is. And I'm, like, dying after 30 seconds, and I realized, well, yeah, because I just held my breath through the whole stinking thing, right? Like, that's the strategy my body chose to use. And so if you understand that, and then you just remind people, okay, like, breathe during it, that can give them a quick win, especially if they maybe notice that they're leaking or they just have a lot of urge during it. Like, okay, well, let's just breathe during it and see, does that help in it? And I say that not to make it like, so simplistic that it's just breathing, because it's not always just breathing, but, but sometimes it is just a little bit of it's either a slight position change or just a change in your breathing for that quick win. Now, while we also work on these other right, if we're talking if someone needs glute strength, you know, strength things are going to take four to six weeks to even start to become noticeable, right? And if, if I'm training for something, four to six weeks is a long time to feel like nothing is really changing, if the only thing I have to rely on is I just need to get stronger, right? There's some hope in that. But also, can I make some some changes in my position, in my form and my breathing and my timing, to give it a temporary fix while I still train? Yeah,

Brianna Battles  29:58

I. Absolutely agree. I think there's so much that can be done with just like, a little like, reassessment of, like, how you do things, and we can go through aspects of the P and P principle. Again, I teach this, like, extensively in the coaching certification so that you understand, like, this is essentially an assessment for any female athlete. And again, we just tend to see the need for it a lot more during pregnancy and postpartum, because that is where there are more vulnerabilities introduced. You are not fragile and you're not invincible. This strategy helps you learn to be a little bit more adaptable, and helps coaches have, like, I guess, like, really practical ways of troubleshooting, right? Because I think we've always been told, Well, just listen to your body do what you've always done. Or, like, well, if it feels good, you can keep doing it. Or if you're peeing, okay, stop. Or if you're coding, you don't want to do that anymore. Like, yes and like, there are some some things that we can work through as coaches to provide some suggestions and like, understand what we're actually looking for and what we're working with. So the first one is breathing, and then we also look at pressure, pressure distribution. Then we look at tension and how that's also being distributed throughout the body. Then we look at position, so that can be, like, position of the pelvis, or form or posture, and then we look at movement, how all of those different strategies are being applied to the movement at hand, whether that's double unders or lifting or re racking the barbell, whatever it might be like. What is the movement that we're trying to apply all of these different considerations for? And those are the things that you're really trying to assess, and if you're making an adjustment to the breathing, to the pressure, to the tension, to the position, then you should have a win with your athlete. If you're the athlete, you should have a win if you're making one or two small adjustments to any of those variables listed, because that little adjustment can make a big difference from the outside in. And that doesn't involve having to, like, Okay, I'm going to actively recruit my pelvic floor right now. Like, that's not going to work. That's not practical for athletic movements. And I think that's a the bridge that has to be connected between your world and pelvic floor. PT, and my world in, like, sports and performance, where, you know, there's not that disconnect of, like, wait, what do I do with my pelvic floor at this point in the movement? Or am I recruiting here or doing that? No, no, no. Like, we're retraining that brain, and we're kind of looking at more outside in tactics that really improve the position and the overall function of the pelvic floor,

Mindy English  32:37

yeah. And I think even, like, thinking about, okay, like, I've tried all these different things, I'm still not getting a win. Okay, what's the regression? What's like one step back from this? Like, if I decrease the load, does that change anything? Does that change your strategy? Does that change your symptoms? If I do a buck squat instead of a full range squat, do I have the same symptoms, like, what do I need to train in the regression to help someone be successful? I mean, I think sometimes we don't, I think in the public health world, we don't always think about that. It's like, it's like an all or nothing. And I feel like, when you run, then just don't run. Well, what about like, a run, walk or, what about a jog, you know, what? If we're just not going as fast, can we go the same distance and not have symptoms if we just, like, regress them a little bit? And I think, you know, for athletes, sometimes the regression feels like punishment for them, like I had someone the other day, she said, I have to do box squats. And I was like, that's great. Like, if you can still squat and just decrease your range of motion and not have symptoms, that's a great place to be right now. It doesn't take you out of the movement. You're still training the movement pattern. We just need to figure out how to get you past that, but you can still do it, and that's you know, you just have to help people understand it's not forever. Like, everything there's a spectrum. Everything is a spectrum. And right now we might be here because this is what your body needs for movement. We're going to get you back here, but we just need to take a step back while we work on all these other strategies to try and help your body be functional again. And I think sometimes we miss that, like, just take a step back

Brianna Battles  34:21

hard. Because, like, we're always, we're literally programmed to think forward, like, progressive overload, or, well, like trying to get back. Especially our postpartum athletes are like, Well, I just want to, like, be able to do this again or that again, or I used to be able to do X, Y and Z. And so they're constantly thinking of moving forward. But sometimes, I mean, as an athlete in general, regardless of where you are, like, you have to take a couple steps back in order to make progress forward. That is the nature of being an athlete across your lifespan, because it was not linear ever. It's not it's linear for a particular season, and then there's a regression, maybe there's an injury, maybe there's just, like. A Life variable. Or maybe you're like, Okay, I gotta introduce a new skill or a new task that I work on so you're gonna be more of a beginner state again. Or just, you know, like, maybe you're burned out and you're wanting to work something differently. There's so many different reasons for taking a step back that we can justify in some seasons of life, but it does seem that when it's on behalf of like your vagina, people are like, No, I can't do anything. I'm willing. I cannot do anything differently, because in the end, it feels taboo or like, I think there's the overall thought of like. I don't want to feel less than like, you know, if we're as female athletes, like we've we've worked hard to be in positions where we've normalized competing and lifting and being really fit and feeling really strong in our bodies, and now to have, like, a vagina be a limiting factor that just feels so wrong and vulnerable. And I don't know, I think that it's just like that is the mental piece of this for a lot of female athletes. And so I think we just have to normalize the fact that, like, if you are willing to take a couple steps back, it's not just that your pelvic floor function will improve. You will actually be a better athlete. You will perform better period like that is the missing piece. We just have not been taught how to coach female athletes with their anatomy in mind. El Salvador was not created with female anatomy in mind. It just wasn't. So again, it's not that Valsalva is bad, it's just there's a different way to generate pressure for the female body, especially if that female body is symptomatic, like there just is. And so we have to take a good look at a lot of sports performance strategies and recommendations, and a lot of our evidence isn't through the scope and lens of the female athlete body. Nevertheless, the female athlete body through pregnancy and postpartum and perimenopause like those are three substantial variables, so it really is just re examining, like what we've been taught and what we know isn't necessarily appropriate for a female athlete across her lifespan, we so we just got to get creative with it. And that's, I mean, that's certainly the work that you and I are doing day in and day out,

Mindy English  37:12

yeah. And I think that's the key, is you just have to get creative and kind of figure out, okay, like I may not have all the research to support this, I can extrapolate different pieces of research, of what I know and and I know there's people doing some great research right now, like, I think, from different podcasts I listen to and different people I follow. I know there's some great research that's supposed to hopefully come out in 2025 to help support our female athletes, which is awesome. It's a super exciting time for all of that. But until I have, until I have the resource that says, Yes, this is like, how we do it. This is what we know. I have to take pieces of what I know from an orthopedic standpoint. I have to take what I know from what pelvic floor studies have been done, and kind of mesh that together to try and get people their best outcomes. And then also what we see clinically with things, right? Like, you just, you try some things clinically, you get a win for someone, and then, so then, as a clinician, you kind of say, Oh, that's interesting. Like, I wonder if I would work with this person, right?

Brianna Battles  38:13

And that's like, I think that's the the fun thing is, you know, we get to notice patterns because we're actually coaching or treating people all the time, all the time. This isn't just like us spouting off a theory that we learned in school 10 years ago, 15 years ago, 20 years ago. And I think that's a huge problem in both of our industries. Is either a like not coaching women, not knowing anything about that, not having any updated information, or in your world, like not bridging into the fitness space at all, and solely operating through the space of like pelvic floor work alone. If I you know, I think that there's just, there's so much we can do, because we see it day in and day out. We're not being dependent on research, like we can be evidence informed evidence we do have. But ultimately, when coaching is creative, it's not always attached to some scientific methodology. It's like getting creative with a person in the body that you have in front of you, and there's so many people on social media, there's so many people teaching and selling and this is, like, you know, a hill I'll die on that. I'm like, they're not actually coaching this population. They're trying to tell you how to coach this population and certify you to coach this population, but they're not coaching this population. They're they're telling people in their clinics, we'll do this, do this, do that, but they're not actually coaching them through that progression. They're just saying, well, like, try this and do that, and that's like, the end of it. And then they don't see them again because that person doesn't come back because they're discouraged. So it's like, you got to stay in the game with your athletes to see that process all the way through. And then not just one athlete. Do. With a multitude of athletes of all different sport backgrounds. Because what might work with your Olympic weightlifter is not going to work with your jiu jitsu athlete, two different sports, two different demands on the body. And you gotta be creative in how you're working with that population. Of course, that's what I try to like teach, teach the different P and P A coaches that go through the curriculum, because there's no one size fits all strategy. But in the pre and postnatal industry, a one size fits all strategy is the scope in which exercise is taught and and same with pelvic floor PT, like it is taught through a very particular scope, not a very creative one, not a really dynamic scope. And so it's kind of on us as the individual coaches, practitioners, and frankly, even the individual female athlete to say, like, I there's more to this, and I'm willing to learn what that is.

Mindy English  40:48

Yeah, I think where pelvic floor PT misses is not doing like that needs analysis, which gets really honed into you, and you're doing that all the time when you're in an ortho and sports PT, world, and even, like in a sports performance world, you you're kind of, you're always doing needs analysis, like, what does this person need to be able to perform this task? And I think sometimes in pelvic floor. PT, whether it's because of time or education or whatever it is, sometimes that it just gets missed, right? Like, when we posted reels of like, what a pelvic floor visit looks like for me, some of the comments from clinicians is, wow. That must have taken two hours. There's no way you can get that all done. And you can, if you prioritize it, and you listen to your athlete, you understand what they want to get out of that session that day. Like, you

Brianna Battles  41:38

know what you're actually looking for? Like, if they're leaking in the again, the catching position, then, like, simulate that in your session. Like you don't have to go through, like, the whole whatever prior to that necessarily, like, maybe a few steps reversing from there, but there's so much you can do to just sort of, like, cut to the chase. Like, where's the problem at? Okay, it's not here. It's not when she's flat on her back, it's when she's standing up, and not just when she's standing up, it's when we're now adding, like, load and force absorption, like, we can get really practical and really crafty if we actually listen to them, and not just our own, like, preconceived ways of doing things.

Mindy English  42:18

Yeah, and if you just, like ask them, you know, what's the most important thing that you get out of today? Yeah, right. And so if I have someone who has pain and they're also leaking, if it's the pain that's stopping them from moving, I have to figure out what the pain is first, like the leaking. Yes, that's important, but I don't need to understand always why that leaking has happened on day one, if they can't participate in their activity because they have pain, right? To, like, figure that piece out first, and then figure out why they're leaking. But, like, sometimes it's like, oh, I have to figure out why you're leaking today. And they're like, Well, I mean, maybe, but that's like, not the thing that's

Brianna Battles  42:55

stopping me, right? Like, what's their priority? Versus, like, what's your almost assumed priority for them, yeah, and then again, there's just, there's so much that we can really do to hone in on making small adjustments from the outside in. And it's, I think some people automatically assume, like, well, the only way I can stop peeing is if I get surgery or but we know that that's like, I mean, that's not usually the case, like there's again, so much more to this, like neuromuscular connection and so many different pieces that we can look at to improve symptoms, both in like their daily life of coughing or laughing and sneezing to then having that be transferable to the movement that they're in. So why? Why would surgery, like not be the the next right thing for them in most cases? Because I know that is a common thought of like, well, clearly my pelvic floor is just broken or weak. Let's fix it.

Mindy English  43:54

Yeah. I mean, I think there's a place for surgery, and sometimes people do need it, but it's not, I think if you haven't tried some conservative things first, it's, it shouldn't be your automatic thought. I mean, I guess if you're looking for hope, like what you think might be a quick fix, but that's a pretty substantial quick fix, right? Like, you have to think of like it's a surgery. There's a lot that goes into it, and people can have surgery and still weak and still have symptoms, and then they feel like, Oh, my surgery failed, right? And then we get down the multiple surgery Trail, which I think is a slippery slope, and it's

Brianna Battles  44:33

like, more common than than not, for there to be those multiple surgeries, and most of the time, surgery on the pelvic floor is like more related to prolapse and the degree of prolapse, and then if there's a the byproduct of maybe improving incontinence. But again, it's not a certainly, not a guarantee.

Mindy English  44:55

Yeah, yeah. And I see people after prolapse surgery because. Are leaking. Like, there's just, it's not, it's not as simple as it's made to seem. And, you know, I'm fortunate to work with some great urologists in the area who are big proponents of pelvic floor PT, and say, Let's like, start here like, and have that really nice teamwork approach of like, this is what I can offer you, and this is what pelvic floor PT can offer you. And then if that's not working, then let's reconvene and figure out if we go back to like, some of the options that the urologists can offer absolutely and we'll

Brianna Battles  45:30

be talking about prolapse and surgery and and that scope of conversation at in another episode, we really wanted to keep this focused around the nuances of incontinence and just leaking when lifting or jumping and stuff like that. So we aren't going to really get too much into prolapse land just yet, but we will, because, again, it's a common experience for female athletes that can show up across the lifespan, not just pregnancy, not just postpartum, but later on in life. So that's why we have to have some proactive strategies early on, be proactive in your pregnancy, even if, like, I think this is how I want to wrap up this episode. But like, even if you don't have pelvic health symptoms, like, I, for example, have never had any pelvic health symptoms. I just had a really significant diastasis. Like we all there's there's no Get Out of Jail Free card, right? At least, there's something that affects somebody to some degree, but like it's being conscious of the fact that this is a consideration for all female athletes of all ages, because of our unique anatomy and the and the demands that we're putting on our anatomy. It is a it is in consideration. It is something that we are predisposed to as women. Therefore, we should have awareness around our pelvic floor health as early as possible. This is things that we can like, teach our daughters, you know, just to be a little bit more conscious of their pelvic floor. Notice some of their tendencies early on. When people talk to me about trying to conceive, it's like there's a few things that I'm like, let's start adjusting your exercise patterns in X, Y and Z ways, or your breathing strategies here. So we're just kind of building new pathways and new options for them to work with, so that through pregnancy, as there's more weight on their body as the position of the pelvic floor gets altered by the baby that they're making, kind of like these proactive adjustments to their training on behalf of their pelvic floor health, so that when they go into birth, regardless of how the baby comes out, they've sort of set themselves up In the best way possible for that postpartum rehab and your birth experience can create a lot of different pelvic health variables to recover from, whether you tear depending on how long you pushed for, or you could have had the easiest, quickest birth, whatever, and still have a prolapse or still pee like again. There's no Get Out of Jail Free card here with anything pregnancy and postpartum related, and that's not too scary. That's just to say, like, there's something that affects everyone at some point in time, just something, it doesn't even have to be in core public health related. There's just something, like, we all have a variable that trolls us a little bit at some point in time. And so then there's a lot you can do proactively postpartum again, even if you're not symptomatic, you can do it knowing, okay, my pelvic floor is really vulnerable right now. Like, I could create a problem if I do too much too soon, if I'm if I'm not addressing these things, like, I don't want to be symptomatic, so I'm going to be really conscious of rehabbing and progressing my exercise Well, of making some of those adjustments that I did during pregnancy and letting that transfer over. Transfer over into postpartum. And then, again, like me, I haven't had pelvic health symptoms, but I know that. Again, nobody is immune to this throughout their lifespan. So as I get older, I still want to be really aware of of my pelvic floor health and know that, you know, I don't want to have leaking, and if that's something I can control, then I'm going to be training in a way where I'm preserving my body as much as possible. Again, the variables not everything is in our control, but we can have more awareness, so then we can make more informed choices about our training and our progression, what to do and what not to do.

Mindy English  49:18

Yeah, it's just optimizing. It's optimizing our body and optimizing it in all realms. And like we talked about the last podcast, a lot of people just don't realize that there's muscles in the floor like that. That's a group of muscles and and so we do have to consider it, you know, especially with certain activities, we have to, we have to think about what's happening there. And like you said, make the most informed decisions. Because I think when you make when you have the education, not the shame, but if you have the education, and you're making your best informed decisions, then you're not left feeling like, I wish I would have known, right. And 1015, years ago, I think that was a much bigger trend of I wish I would have known. I think more people know now there's no necessarily know what to do. With it. And so if we can just continue to help people make those really informed decisions, because sometimes we just don't know. We don't know when, when that symptoms going to come up. We don't know when something's going to be a problem. Might not be right after you have baby, might not be immediately postpartum. It might be like five years down the line. And so we just have to help people make the best decisions for their body that they can't and that just comes through education and helping them understand that there are strategies, there are resources, there are considerations. Yeah,

Brianna Battles  50:29

because again, like so much of what, so much of our exercise science, so much of our sports performance, was not created through the lens of the female body and I we need, and that's not to say that we need, like, some special treatment. No, it's just we need options, and not limited ways of Val salva or of like landing position or catching whatever it might be like literally anything. Within the extra science, strength and conditioning, sports performance realm, there's not one right way. And we know that as fundamentally we know that as coaches, and I feel that that gets very lost in translation when coaching female athletes, because they keep trying to hammer in the same way, and it's like, well, clearly that's not working, or maybe it worked prior, but now she's had three kids, and like that coach that like breathing strategy, that pressure management strategy, it just doesn't work anymore. Okay? So like, let's keep her lifting. Let's just change a few things, change how she's doing it. And that's really where we start to see those wins, where we're not trying to do the same stuff over and over and over, we get creative in doing the same things through the same movements, keeping her in the game, but just playing it a little bit different. Mindy. Thank you for being here. I know, if there's questions that stem from this conversation, send them to us, and we will address them on our next episode. What we realized after the first episode is that people want the opportunity to, like, ask me or ask Mindy, and have us, kind of like, troubleshoot their situations. And we want to do that, kind of like, poll the audience and see if there's questions unique to your situation that you feel like you can't get a straightforward answer on. And we'd love to bring those to this series that we're doing on this podcast with Mindy as our like go to ask a pelvic floor PT, or ask me, and together our brains, we can probably come up with some helpful suggestions that may be hard to get elsewhere. So if you have questions that stem from this episode, if there's something we've missed, we'll be happy to include that info in future episodes. We're aiming to do this series one time a month, where Mindy comes on the podcast and we just troubleshoot and talk all the pelvic health for female athletes. So thank you so much for listening Mindy. Thanks for being here. Thank you so much for listening to this episode of the practice brave podcast. If you enjoyed the show, please leave a review and help us spread the work we are doing to improve the overall information and messaging in the fitness industry and beyond. Now, if you are pregnant and you are looking for a trustworthy exercise program to follow, I have you covered. The pregnant athlete training program is a well rounded program for pregnancy with workouts for each week that are appropriate for your changing body. That's 36 weeks of workouts, three to four workouts each week, and tons of guidance on exercise strategy. We also have an at home version of that program if you are postpartum and you're looking for an exercise program to follow. The eight week postpartum athlete training program would be a really great way to help bridge the gap between rehab and the fitness you actually want to do. From there, we have the practice brave fitness program, which is an ongoing strength conditioning program where you get new workouts each week and have a lot of guidance for myself and my co coach, Heather Osby. This is the only way that I'm really offering ongoing coaching at this point in time. If you have ever considered becoming a certified pregnancy and postpartum athleticism coach, I would love to have you join us. Pregnancy and postpartum athleticism is a self paced online certification course that will up level your coaching skills and help connect the dots between pelvic health and long term athletic performance, especially during pregnancy and postpartum, become who you needed and become who your online and local community needs by becoming a certified pregnancy and postpartum athleticism Coach, thank you again for listening to the practice brave podcast. I appreciate you, and please help me continue spreading this messaging, this information and this work.