Pelvic Floor Secrets for Hypermobility with Dr. Emily Bohan

[00:36] Dr. Linda Bluestein: Welcome back, every bendy body, to the Bendy Bodies Podcast with your host and founder, Dr. Linda Bluestein, the Hypermobility MD. Today we're going to be chatting with my physical therapist, Emily Bohan. Emily has gotten me out of pain multiple times, so I'm really excited for her to share her insights. Dr. Emily Bohan brings a decade of experience in the personal training and health and wellness industry, as well as years of experience as a physical therapist specializing in orthopedic and pelvic health for men and women. Since 2016, Emily has been a certified 200-hour yoga teacher and is also a certified nutrition coach through the Nutrition Coaching Institute. A passionate athlete, she has competed in powerlifting, horseback riding, and dance. In the past year, she has opened her own business, Bohan PT and Training, to help individuals resolve their pain and optimize their health. With a comprehensive approach to health and fitness, Dr. Bohan is dedicated to empowering clients through physical therapy, fitness, and holistic wellness strategies.
[01:49] As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Be sure to stick around until the very end so you don't miss any of our special hypermobility hacks. Here we go.
[02:05] Okay, Emily, I'm so excited to chat with you. Can you tell us a little bit about your background and training? Because I know you have kind of a different path that landed you where you are right now.

[02:16] Dr. Emily Bohan: Yeah, absolutely. So I was an athlete in high school, and then when I got to college I ended up getting an injury that took me down the route of getting into yoga, personal training, and also weightlifting. That made me want to become a physical therapist so that I could share some of my expertise with the people around me. When I got into my doctorate program, that's where I learned about pelvic floor physical therapy. I felt like it was this area of the body that was so untalked about but so relevant to so many people's dysfunction. And so I really took a deep dive when I was doing my doctorate degree, doing some specialized pelvic health courses so I could learn more about the pelvic floor and its interaction with the body and then also specific pelvic floor diagnoses.
[03:08] One of the moments that made me really want to become a pelvic floor PT was at one of my weightlifting competitions, when I actually missed two of my lifts because of a little bit of urinary leakage. And one of the guys who was helping coach me was like, "Oh, that's normal — that's what that mop in the corner over there is for." And I was like, we should not have this much dysfunction in our pelvis. So after experiencing it myself, I thought, all right, we can make some good changes in the athletic community, but then also in the general population too. We don't have to live with issues like that.

[03:47] Dr. Linda Bluestein: That's really interesting. I saw a study about rhythmic gymnasts and incontinence, which is really fascinating because rhythmic gymnasts — I mean, they're the bendiest of any athlete as far as I'm concerned. Ballet, elite ballet dancers of course are super crazy bendy, but rhythmic gymnasts, you're talking actual competitive rhythmic gymnasts — they are crazy, crazy flexible. And I remember coming across a study that said that a lot of them have urinary incontinence, which I thought was really interesting. I don't know if you're aware of that study or not.

[04:16] Dr. Emily Bohan: Yeah, there are quite a few studies out there that show that athletic populations — even in high schoolers, so think 15 to 18-year-olds — urinary incontinence happens in over 50% of athletes. So it's really, really common, especially in the female athlete population. We have a long ways to go with education with those folks.

[04:37] Dr. Linda Bluestein: Super interesting, but that's potentially treatable.

[04:40] Dr. Emily Bohan: Yes, it absolutely is treatable.

[04:42] Dr. Linda Bluestein: So you are trained as a physical therapist, but you specialize actually in pelvic floor physical therapy, correct?

[04:43] Dr. Emily Bohan: Yes.

[04:50] Dr. Linda Bluestein: Okay. So can you tell us what that is and why it's important for Bendy Bodies?

[04:55] Dr. Emily Bohan: Yeah, absolutely. So pelvic floor physical therapy focuses on any sort of diagnosis that has to do with the pelvic region. That includes urinary incontinence, fecal incontinence, pain with intercourse, pain with tampon insertion. It can even include other generalized pain in the pelvis too. So if you have a lot of pain with sitting, for example, or painful periods, those are all diagnoses that pelvic floor PT can help with.
[05:26] Where that is helpful for bendy bodies is that a lot of the individuals I have worked with who have hypermobility — their body likes to create stability somehow, and that stability doesn't necessarily come from ligaments and joints like it does in other folks who don't have these hypermobility conditions. And so sometimes those muscles end up compensating for what ligaments aren't doing, which can then lead to dysfunction in the pelvis.

[05:54] Dr. Linda Bluestein: So I'm going to hold the microphone for Emily while she shows us what the pelvic floor is. And if you are listening right now on a podcast player, you may want to check out this portion on YouTube so you can actually see what the video is like. I believe we now have the video up on Spotify and some of the other podcast players as well. But if you are listening and not watching, you may want to check out the video portion of this so you can see what we're actually talking about.

[06:18] Dr. Emily Bohan: So here's the pelvic floor. To orient you to the pelvis first — here we have the spine, or the back. The front and the abdomen would be here, and then on either side we have our hip bones. We have a more external superficial layer of pelvic floor that is here. This is a female model, where the labia would run right over the top of the muscles here. All of the pink here is pelvic floor muscle. These muscles help with control of urine as well as the control of stool. Sometimes if these muscles get really tight, it could also create closure of some of these openings, including the vaginal opening.
[07:03] Then we have our deeper pelvic floor muscles that really help a lot with the support of the pelvic organs. So if my fist here represents our pelvic organs — that's going to be our bladder, our uterus, our rectum — it sits right here in the bowl of the pelvis. And these deep pelvic floor muscles really help with support of those pelvic organs.

[07:26] Dr. Linda Bluestein: And I may need a little therapy after holding that microphone. It's not very heavy, but holding something away from your body like that — of course, you've been working on my shoulders and neck for years now — it was harder than I thought it was going to be. Very interesting.
[07:50] So that's really fascinating. I think most people don't — at least I didn't realize, until I had pelvic floor physical therapy myself a few years ago, that there were actually muscles in that part of the body. I think a lot of people don't really realize that there are actual muscles down there.

[08:14] Dr. Emily Bohan: Yeah, it's kind of like this black hole with a question mark for most people. As long as things are functioning kind of okay, most people don't really think about what's happening in their pelvic floor. Society doesn't really have conversations around pelvic floor and normal pelvic floor function. And so I think that's why pelvic floor can be this overlooked piece when it comes to even things like low back pain or hip pain.

[08:40] Dr. Linda Bluestein: That's so interesting. And I feel like even surgeons who operate in that part of the body are probably not super knowledgeable, to put it mildly, about the pelvic floor and how it could possibly impact other conditions. Would you say that's fair?

[08:57] Dr. Emily Bohan: Yeah, definitely. In my time as a pelvic floor PT, I've even treated a few OB-GYNs. They are incredible at what they do, but I wouldn't say muscle function in that region is a very well-known train of thought.

[09:14] Dr. Linda Bluestein: So it's kind of in the region where OB-GYNs are going to work, but it's more a musculoskeletal type of issue. Obviously it can affect the function of the bladder and the bowels — and we're going to talk about that too — but yeah, it's quite an interesting black hole for sure. Who would be a good candidate for pelvic floor physical therapy?

[09:38] Dr. Emily Bohan: Yeah, so I mentioned before some of the things people could be experiencing, like urinary incontinence. If you have urgency — you feel like you have to rush to get to the bathroom — even cases of constipation could be a candidate for pelvic floor physical therapy, because the muscles do control what's happening with everything that comes to the bladder and the bowels down there.
[10:04] I also think for anyone potentially experiencing other things like hip pain and low back pain — especially if you've been in physical therapy for a while and things aren't improving very well — pelvic floor PT can definitely end up being the missing piece there.

[10:23] Dr. Linda Bluestein: And we read your bio at the beginning, and you explained a bit about all the different types of training you've had. But you do both musculoskeletal physical therapy and pelvic floor physical therapy, right?

[10:37] Dr. Emily Bohan: Yes. So I treat both orthopedics and pelvic floor PT. The way pelvic floor PTs like to think about it is: musculoskeletal PT is this big group, and pelvic PT is a small specialized portion within that. But the pelvic floor interacts with so many other areas of the body — it doesn't function completely on its own. And so that's why it's really important to kind of take a whole-system look and see how everything is coordinating.

[11:08] Dr. Linda Bluestein: Yeah, that makes sense. And I know from the patients that I treat that constipation in this population — whether they have EDS, HSD, Ehlers-Danlos syndromes, or hypermobility spectrum disorders, or if they have mast cell activation syndrome or postural orthostatic tachycardia syndrome, a form of dysautonomia — all of which can influence function of the gut and can lead to constipation. So for any of those people, would pelvic floor physical therapy be a reasonable thing to try?

[11:39] Dr. Emily Bohan: Yeah, absolutely. Constipation can happen for multiple reasons, including a little bit of what you just touched on. But in a lot of my people with hypermobility, the pelvic floor tends to compensate and get really, really tight. And if your pelvic floor is tight, one of our pelvic floor muscles — it's called the puborectalis — it almost acts like a sling around the rectum. So if that muscle is really tight, it can create outlet constipation, where it's a lot harder to actually get the stool out because that muscle isn't fully relaxing.

[12:11] Dr. Linda Bluestein: Interesting. Outlet constipation. Okay, that's interesting. And if you have connective tissue that's weak and other parts of your body are stretchy, your bowels could be more stretchy too — so you can have that combination where the muscles are overcompensating and are super tight, plus the bowels are more stretchy. You can see where that could turn into a big problem pretty quickly.

[12:13] Dr. Emily Bohan: Yeah.

[12:38] Dr. Linda Bluestein: But what I love about pelvic floor physical therapy is it's not surgery, so you're not having the potential complications from surgery, and you're hopefully dealing with the problem at one of its root causes. So hopefully you'll have more lasting effects.

[12:54] Dr. Emily Bohan: Yeah, absolutely. It's an area of the body we never get trained in how to use correctly. And so when I ask people to activate their pelvic floor and also be able to fully relax their pelvic floor — if anyone watching right now wants to try, it's a little bit of a lifting sensation in the pelvis, like you're holding back urine or gas. And see if you can also feel it relax afterwards. Often one of those movements is kind of a big question mark on what's actually happening.
[13:25] Regaining that full function back can be really, really useful for both constipation and even in cases of urinary urgency or any sort of leakage. I think most of society assumes that the pelvic floor is getting weak and that's what leads to leakage and issues. But actually, sometimes the pelvic floor is so tight that — I like to say — it leads to functional weakness, because you can't contract an already contracted muscle. So we actually have to work on getting that full range of motion back in order to get proper function of the pelvic floor.

[14:01] Dr. Linda Bluestein: Okay, that makes sense. And I think too, a lot of people — when they even know about pelvic floor physical therapy — when they think about it, they might think of Kegels, for example. Could you explain what Kegels are? And pelvic floor physical therapy is way more than just Kegels, right?

[14:21] Dr. Emily Bohan: Oh, absolutely. So Kegels are that feeling I just described — that feeling of holding back urine and gas at the same time. It's almost like a lifting sensation from within the pelvis. However, if you are one of the people who tends to hold extra tension in your pelvic floor, if you're constantly working on Kegels, we're potentially going to make that tension worse, which can actually lead to your symptoms feeling worse.
[14:49] I always like to tell people: do you hold stress in your neck? I think most of us can relate to that feeling. But a lot of people don't realize they also hold stress in their pelvis. I would say around 80% of the people I work with have some increased resting tone in their pelvic floor that we need to work on first before we work on Kegeling for strength. A lot of those folks, when we get things to fully relax, we get that functional strength back and we don't really need to work that much on strengthening and doing Kegels. It's actually that full range of motion — that relax, and then the ability to contract — that's really important.

[15:31] Dr. Linda Bluestein: Interesting. And are you saying that if somebody has urinary symptoms, they might actually get better with relaxing the pelvic floor — that Kegels may not be the secret to improving their incontinence, for example?

[15:56] Dr. Emily Bohan: Yeah, absolutely. Around 80% of the time, if not more, Kegels are not the answer in the beginning. It's actually getting that full relaxation so that we can get that full contraction. So when you have that moment of "am I going to leak?" or "I have to get to the restroom," we can actually use those muscles to their full capability because they're coming from a more relaxed position rather than this constant clench.

[16:22] Dr. Linda Bluestein: And what about people who have urinary frequency — they need to go to the bathroom really frequently — or urinary urgency, where they feel like they have to go and they better get there fast?

[16:37] Dr. Emily Bohan: Absolutely. Both urgency and frequency I often see, again, in people who are holding excess tension in their pelvic floor. We can also train our bladder — our bladder tends to have habits. There's a stretch reflex within our bladder wall, and usually when we get our first call to go, it's when the bladder has stretched to about halfway full. If we ignore that urge, it'll fill up a little bit more and then we'll get that call to go again. In some people, that stretch reflex has gotten really sensitive, and that's what causes this extreme urgency.
Sometimes we call it "key and door" — there are triggers that make us feel like we really have to get to the bathroom quickly. Whether you're walking into your house from being out somewhere, or you're about to go to bed, those could be triggers for you as well. We can actually train our bladder out of those habits by working on some delay techniques and then working on pelvic floor function too.

[17:41] Dr. Linda Bluestein: Mm-hmm, interesting. And I know there's such a prevalence of urinary symptoms in the hypermobile population, whether they have joint hypermobility, symptomatic joint hypermobility, or maybe they have dysautonomia, MCAS — all of these things can cause bladder problems and bowel problems. Another one we see is incomplete emptying, or a sensation of incomplete emptying. Of course, if you feel like after you go to the bathroom you didn't empty all the way — same thing for the bowels, I'm sure — it might be that the sensation is accurate, but it's also possible that it's not. Can pelvic floor physical therapy help with the sensation of incomplete emptying of the bladder?

[18:26] Dr. Emily Bohan: Yes, it can. The sensation of incomplete emptying can also come from the pelvic floor not fully relaxing when you're urinating — you're feeling like you have to push or strain to get that last little bit of urine out. First of all, we never want to push or strain when we're urinating.

[18:44] Dr. Linda Bluestein: That's very important.

[18:46] Dr. Emily Bohan: Very important, yes. Getting that pelvic floor to fully relax is key. And if we need to use a little bit of gentle intra-abdominal pressure, especially for bowel movements, that's fine — but it should never feel like a big push or a strain.
In the hypermobile population, sometimes working on positioning can really help too. For example, leaning forward when you're urinating can help get the bladder into a more optimal position. I also often see in people who work fast-paced jobs — my nurses, my teachers, my dancers — they like to "power pee" and rush going to the bathroom. Making sure you actually give yourself time to sit down and relax on the toilet, take a breath into your belly, do some diaphragmatic breathing to make sure that pelvic floor relaxes — that can really help with that sensation of incomplete emptying as well.

[19:46] Dr. Linda Bluestein: Okay, I feel like what you just said is so incredibly important, because I feel like I was guilty of this when I used to work in the operating room — it was like, okay, you have five minutes to eat your lunch, go to the bathroom, and get to your next case. So if I'm hearing you correctly, in order to urinate and properly empty our bladder, we're supposed to be relaxing our pelvic floor — it should just be happening rather than us pushing, power peeing as you called it. That's really important, especially since a lot of people have pelvic organ prolapse, and especially in people with symptomatic joint hypermobility, we know we're at increased risk of pelvic organ prolapse. So we don't want to be pushing and potentially causing more dysfunction down there.

[20:31] Dr. Emily Bohan: Yeah — long-term pressure constantly going downwards, including pushing when we urinate, pushing when we have bowel movements, breath holding instead of engaging our core correctly. All of that can put pressure downwards on the pelvic floor. I'm not going to say 100% for sure, but it can contribute to pelvic organ prolapse.

[20:52] Dr. Linda Bluestein: What about sexual dysfunction? Are there things that pelvic floor physical therapy can help with in that regard?

[20:59] Dr. Emily Bohan: Yes, absolutely. There are a few different diagnoses that can happen within sexual dysfunction. One of those is where it's really painful to have something inserted vaginally — whether that's a finger, a penis, a toy, or even a speculum at the gynecology office. The muscles can actually create this big guarding response where they don't want to allow anything in. We call that vaginismus. That is definitely something that pelvic floor PT can help with by helping to relax those muscles and desensitize that area so it's not causing so much pain.
We can also have pain with deeper penetration. If you think about a muscle knot anywhere else in your body — a lot of us have a muscle knot somewhere up in our trap, for example, and it hurts a little bit when you press on it — the pelvic floor can have similar trigger points too. So if you think about a trigger point being deep in the pelvis and then putting pressure of something against it, such as a penis or a toy, that can also create pain during intercourse. Doing some hands-on manual therapy, doing some deep breathing, doing certain stretches can all help alleviate some of those trigger points in the pelvis.

[22:18] Dr. Linda Bluestein: And I'm also thinking about sexual function and dysfunction in terms of joint instability, potentially in the hips or otherwise in the musculoskeletal part of the pelvis. I take it that could be a factor as well.

[22:36] Dr. Emily Bohan: Yes, absolutely. The hip muscles, the hips, the abdominals, the low back, the diaphragm, and the pelvic floor all work really closely together. So often if someone has something going on in the hips, the pelvic floor is somehow involved too. I see that almost every single time someone comes into the office.

[22:58] Dr. Linda Bluestein: So a lot of my patients tend to be younger, and when I mention pelvic floor physical therapy and recommend they try it, they're like, "Oh my gosh, they're gonna do something invasive." Once I explain to them what it is, oftentimes I get a hard no the first time I bring it up. Then I bring it up again and explain — well, they're going to talk to you before they do anything. Is it possible to treat people without doing intravaginal work or that kind of thing?

[23:30] Dr. Emily Bohan: Yeah. Not everyone is comfortable with doing an internal assessment. Many pelvic floor PTs do prefer to do that because we can look directly at the muscle function. But if that's something someone's not comfortable with — or in the case of vaginismus, where we get such a big guarding response that you literally can't get anything in there — that no longer becomes an option anyway. We want people to be comfortable coming into our office.
[23:54] The pelvic floor interacts so closely with other muscle groups that if we can work on those groups and also work on how you're moving — do you breath-hold every single time you pick up your groceries and put pressure on your pelvic floor, so your pelvic floor is just fatigued and tight because it's sick of getting all this pressure on it? — those are things we can work on. Doing some hip stretches, for example, can really help relax the pelvic floor. Research has shown that doing happy baby pose in yoga can be really effective at relaxing the pelvic floor.
[24:33] In a lot of in-office settings, they can also do some external electrodes to look at pelvic floor function externally. But yeah, I really like to focus on how are all the other muscles interacting with the pelvic floor, because that can give us really good insight into what's actually happening to the pelvic floor itself.

[24:54] Dr. Linda Bluestein: What is the happy baby pose?

[24:58] Dr. Emily Bohan: That's where you are lying on your back. The full expression of the pose is where you grab the inside of your feet. But you can always do a modified version where you just bring the legs up, hold on above or underneath the knees, and let the legs drift apart.

[25:14] Dr. Linda Bluestein: Oh, okay. So that's why it's called happy baby pose — the baby's lying on its back holding the inside of its feet, giggling. Fantastic. We are going to take a quick break, and when we come back we are going to talk more about the pelvic floor and how it impacts other things, like low back pain. We will be right back.

[27:17] Dr. Linda Bluestein: Okay, we are back with Emily Bohan — physical therapist, pelvic floor physical therapist, and my physical therapist. Most important. Just kidding, but super important. We've been working together for a couple of years now.

[27:31] Dr. Emily Bohan: Does that sound right? It's been at least two.

[27:32] Dr. Linda Bluestein: Yeah, it's been a while. You've taught me a lot, which is amazing. So the pelvic floor affects a lot of other aspects of the body as we've been discussing, but that's also true of other parts of the body. We get referred pain. Can you explain what referred pain is and also about myofascial pain and how that works?

[27:58] Dr. Emily Bohan: Yeah, so referred pain or myofascial pain — sometimes we get what we call active trigger points. Think of a muscle knot in the body, but where the pain is felt is not exactly where that knot is. For example, we have one of our rotator cuff muscles that sits right above the shoulder blade. When that muscle gets irritated, people often feel it down the arm, sometimes even a little bit past the elbow. So referred and myofascial pain doesn't always mean that the location of pain is the culprit of what is happening.
[28:38] Another good example I really like is the rectus abdominis — your six-pack muscle in the front. That can actually refer pain to the low back, on the other side of the body. That's where treating globally as a physical therapist can be really important, to make sure there aren't other contributing muscles creating pain that feels further away from where the actual problem is.

[29:02] Dr. Linda Bluestein: That can be so confusing, because a person can have pain in a certain part of the body that might not actually be causing the problem.

[29:16] Dr. Emily Bohan: Yeah, exactly. Another one I think is really interesting — for anyone who's experienced sciatica, the gluteus minimus muscle, which sits right in the glutes near the top of the pelvis, can actually mimic a similar referral pain pattern to sciatica. That's where it's really important to see a specialist who is able to rule out a few different pieces and determine whether myofascial or referred trigger point pain is a present part of your presentation.

[29:52] Dr. Linda Bluestein: Okay, I feel like this is super important and we're going to digress just very briefly from pelvic floor physical therapy. Because I think — you know what I'm going to ask. So a person may have sciatica and may have had an MRI of their back. And if they read the report — I mean, they don't even have to be that old to have some little disc bulges and things here and there. You're going to see a lot of things on your report. But that definitely might not be the cause of your sciatica. It might not be coming from the spine at all. It could be coming from someplace else, even if there are some apparent findings on your MRI report.

[30:29] Dr. Emily Bohan: Yeah, correct. Sciatica could also come from compression of that sciatic nerve under the piriformis muscle — so still having to do with the hip. It could be coming from a gluteus minimus trigger point creating sensation down the leg.
And here's something really important: one in four people over the age of 25 have some sort of findings in their low back on imaging. However, there's no correlation between imaging findings and pain findings. There are plenty of people who have something going on in their low back, and they live pain-free. And then they also take imaging of people with severe low back pain, and those people don't have any findings on imaging. So I think that's really important to emphasize, because I do think sometimes we get caught up in this mindset that the body is fragile. But the body is actually really resilient. Even if you do have some structural changes, learning what you can do to work with those structural changes — getting really strong and moving well — can go so far for pain.
[31:33] Low back surgery, the success rate I believe is around 60 to 70%. It's not very good. To me, what that says is: what do people's lifestyles look like? How strong are they? How much are they loading their muscles versus loading some of the other passive structures? I think ruling out if there's anything going on musculoskeletally, and how the body is moving first, is important before doing something like surgery. Because if we don't fix potentially the movement dysfunction that's causing the pain, the low back surgery is not going to help.

[32:11] Dr. Linda Bluestein: And that's so interesting because when people have joint hypermobility, we tend to hang more on our ligaments and tendons because oftentimes our muscles aren't as strong. So that's where we can really get into a lot of trouble, right?

[32:28] Dr. Emily Bohan: Mm-hmm. Yeah, absolutely. The body always likes to pick the most efficient way possible, and that's hanging out on joints and tendons. For someone who's not hypermobile, that doesn't create quite as many issues as for someone who's got really far end ranges. So making sure that the muscles are strong enough to create the support rather than the joints is really important.

[32:54] Dr. Linda Bluestein: So that's where — and there are a lot of reasons why people have limitations in how much they're able to move — but that's why, if at all possible, we want to try to move more, move better, and develop that stabilization and strength in our muscles, whether it's the pelvic floor or anywhere else. Because if we can get our muscles to support our joints, that's the best medicine.

[33:19] Dr. Emily Bohan: Yeah, absolutely. To circle back around to the pelvic floor — the pelvic floor tends to be that missing piece in a lot of athletes and just general people. We think about strengthening our abs and protecting our back, but we don't think about the top and the bottom of our core canister, which is our breathing and then our pelvic floor. And so if there's some dysfunction going on at the top or the bottom, that can also create pain in some of these other areas because now the low back has to work harder because you're not breathing very well, or your pelvic floor isn't able to support.

[34:01] Dr. Linda Bluestein: So if someone is having low back pain, some targets to work on would be both the diaphragm — the top of the canister — and the pelvic floor — the bottom of the canister. Is that correct?

[34:14] Dr. Emily Bohan: Yeah. There's a research study that showed that 95% of people with low back pain also had pelvic floor dysfunction. So treating the pelvic floor can be really helpful for low back pain.
[34:27] There's also another piece of research done in weightlifters — people who are lifting heavy amounts of weight overhead, snatch, clean and jerk. They split the participants into two groups: a group that had chronic low back pain and another group that didn't. They found that the group with chronic low back pain actually had thinner diaphragms and didn't have as good expiratory pressure. And so that shows that part of our stabilization of this area comes from how we breathe — what does the function of the diaphragm look like?

[35:07] Dr. Linda Bluestein: That's fascinating, because in both of those groups you would think they're pretty fit.

[35:12] Dr. Emily Bohan: Yeah. But especially once you start looking at chronic pain conditions too, you have to start asking how has the body started compensating for this pain? Compensation isn't always necessarily a bad thing, but when pain has been going on for a while, we also have to reverse some of those strategies the body is trying to use.

[35:36] Dr. Linda Bluestein: Interesting. And I'm wondering, as you were explaining that weightlifting study, whether there are people who naturally have a less strong and/or thinner diaphragm and therefore get back pain, or whether people who are training differently develop a stronger diaphragm and therefore have less back pain. I'm wondering what the actual sequence might be — I mean, we may not know based on the study.

[36:02] Dr. Emily Bohan: Yeah, I would have to double-check whether they came to that conclusion in the study. Which came first, the chicken or the egg, right?
[36:09] But I do think that working on proper breathing strategies helps with good pelvic floor function and helps regulate the pressure in all areas of our core canister. So breathing is important regardless, especially for pelvic floor function.

[36:27] Dr. Linda Bluestein: And this is where I think your background is so helpful, because you've trained as a yoga instructor, you've worked as a personal trainer, you've done weightlifting, and you're a physical therapist and pelvic floor physical therapist. You've put all of that different education and training together, which I think is really, really helpful for people.

[36:56] Dr. Emily Bohan: Yeah. I'm very passionate about everyone getting as strong as they are capable of. I think the stronger you can be, the more resilient you are in life. You don't want to be living at your one-rep max at all points in time. If your one-rep max for picking something off the ground is 20 pounds, then every time you pick up a 15-pound grocery bag you're pushing the limit of your body, which makes you more prone to injury. So if we can build the strength of your whole body, that can really help with overall quality of life and making sure we don't end up getting injured. Prehab is better than rehab.

[37:38] Dr. Linda Bluestein: Mm-hmm, yeah. And tissues need to be loaded in a certain way in order to get stronger — they respond to load by getting stronger. Now obviously some people really struggle with that more than others, but even in bendy bodies that's what we should be trying to do in order to get our tissues stronger.

[38:00] Dr. Emily Bohan: Yeah, and I especially see in my folks with hypermobility that they're even more sensitive to increases in load, especially if you make big jumps. It doesn't have to be big jumps. I feel like the fitness industry has trained us to do all or nothing — six days a week of intense workouts. It doesn't have to be that. If you haven't been lifting at all, doing one set of an exercise every day is still more than what your body has been doing, and it's still creating good changes in muscle strength and all of that. Knowing where you're starting, and that it doesn't take much to start making good changes — work smarter, not harder. If you're so sore from exercising that you're holding onto the counter to sit down in a chair, we don't need to push the body to that level. Just add one set of something. Slowly start building the resilience of the body.

[39:00] Dr. Linda Bluestein: And you've done a great job of that with me — sometimes having to back off a bit and say, okay, let's modify this exercise and do it in a more gentle way, like just using the weight of the arm. But you have to get especially creative when you're working with people with hypermobility.

[39:18] Dr. Emily Bohan: Absolutely. Those really small incremental changes so that the tissue doesn't overreact — we definitely don't want to create any flare-ups. That gradual increase in tolerance to strength and pressure is really important.
[39:32] And then also taking into account people's stress in life. If your dog just died and you're having family stress and you've been working 12-hour days — maybe now is not the time for that hour-long fitness routine. That doesn't mean you can't do something, but I like to think of it as a stress bucket: all of those stressors go into the same bucket. Account for the other stressors in your life when deciding how much stress you should be adding from exercise.

[40:04] Dr. Linda Bluestein: Getting back to the pelvic floor specifically — people assigned female at birth versus people assigned male at birth, the pelvic floor is going to be different, correct? And I know that you work with people assigned male at birth a lot with pelvic floor physical therapy, which a lot of people might be surprised to hear can be beneficial. Can you tell us about some of those differences, and what pelvic floor physical therapy can help with in different populations?

[40:41] Dr. Emily Bohan: Yeah, absolutely. First of all, men, you also have a pelvic floor. I feel like a lot of guys out there don't even know that. But the pelvic floor in men and women is actually surprisingly similar. Men have a narrower pelvis, which is going to change a few things. I would say the biggest difference is the opening that goes through the pelvic floor for the vaginal canal — men don't have that. And so we tend to not see quite as many pelvic floor issues sometimes in men, just because the integrity of not having the vaginal canal there can be helpful. But otherwise, internally, those deep pelvic floor muscles are all the same. Even some of the external muscles — the muscles that run right under the labia, called the bulbospongiosus — men still have those muscles, right near where the penis is. So pelvic floor PT for men and women actually looks quite similar despite the differences in external genitalia.
[41:50] That being said, men can present with issues like testicular pain, penile pain, urinary urgency, frequency, and incontinence, and we can also treat them for constipation. I have treated quite a few men who were diagnosed with chronic prostatitis, had been on multiple rounds of antibiotics, and nothing seemed to really help. Pelvic floor PT, especially with those guys, can be really, really helpful for addressing some of that pelvic pain.

[42:34] Dr. Linda Bluestein: Do you see that men tend to be less amenable to that, or if they're coming to see you, they've already discussed it with their doctor and they're pretty open?

[42:47] Dr. Emily Bohan: Yeah, I think we have a long ways to go in education of men with pelvic floor issues. A lot of the guys I've seen have had pain or issues for so long that they're willing to do anything at that point — they're like, "Anything that will make me better." And coming back around to internal assessments — not all guys are okay with that, since it is a rectal exam. But working on some of those external muscles can be really helpful.
[43:15] One of the things that can often pop up is testicular pain. And if we have trigger points in some of our abdominal muscles, that actually refers pain to the testicles. I've worked on guys where we hit a good trigger point up in the abdomen and they're like, "That's my pain — I feel that in my scrotum." So there are multiple ways to approach it, even for men who maybe aren't so sure about pelvic floor PT.

[43:46] Dr. Linda Bluestein: Oh my gosh, that's so important. And I know — you know I'm married to a urologist. They call it "ball pain," and sometimes people want to have surgery for that or get referred for surgery. When you were saying that, my head just exploded, because can you imagine having a testicle removed when really what you needed was trigger point work done on your abdomen?

[44:14] Dr. Emily Bohan: Yeah. I've treated guys who have had surgery for that. It doesn't help because it's coming from somewhere else. I've treated a lot of guys with pelvic issues that have been going on for years, especially some of my younger male athletes. That population — it's even less talked about. You're not going to talk to your friend about your ball pain. You feel really isolated. And after you've taken the antibiotics and everything, no one thinks about the musculoskeletal side of it.
[44:52] So yeah, I think the young male athletes — and then my post-prostatectomy guys dealing with urinary incontinence — those two groups really, really benefit from pelvic floor PT.

[45:04] Dr. Linda Bluestein: Okay, I'm going to repeat that last part. My husband is actually a robotic prostatectomy surgeon — well, he's retired now — but you're saying that if you've had a prostatectomy surgery and you have some urinary incontinence after surgery, pelvic floor physical therapy can actually help with that?

[45:30] Dr. Emily Bohan: Yes, absolutely. Some degree of leakage after that surgery is to be expected — everything's really inflamed and irritated. But if you're months past surgery, or I've treated guys who are a year or two out and still having some leakage, that's where pelvic floor can come in.
[45:51] I like to think of it this way for my post-prostatectomy guys: especially if part of your prostate was removed because of overgrowth, you've been pushing to get urine out for a long time — putting a lot of pressure downwards on the pelvic floor, which is what we don't want. But now we take out this natural stopping gate that had been the overgrown prostate. We just went from a dripping faucet to a fire hose. So we have to retrain the pelvic floor on the appropriate timing to be able to stop leakage from happening.

[46:25] Dr. Linda Bluestein: Oh, that's really, really interesting. Okay, that's fantastic. If you're post-op and everybody apparently leaks initially — that's what my husband says — but yeah, if you're a ways out and you're still leaking, it's amazing that pelvic floor physical therapy can help with that. That's wonderful.
[46:47] Are there other things that the pelvic floor — especially in bendy bodies, especially people with joint hypermobility or a connective tissue disorder like EDS — can affect that we haven't covered yet?

[47:00] Dr. Emily Bohan: I think something worth a little more conversation is certain hip pains that can be really tied in with the pelvic floor. A good example is labral tears. The obturator internus — it's not directly a part of the pelvic floor, but it's this big fan-shaped muscle that sits right there with the pelvic floor. The pelvic floor and obturator share some fascial attachments; they work together really closely. If the obturator and pelvic floor are irritated or tight, it can create pain that mimics labral tear pain.
[47:38] Especially in my folks with bendy bodies, I often see some sort of hip pain or hip issues going on. So I think getting that ruled out — if you have some of that wraparound pain or even if you've been diagnosed with a labral tear — look at how your pelvic floor is functioning and rule out whether there's a musculoskeletal piece contributing to your pain.

[48:03] Dr. Linda Bluestein: Yeah, you definitely don't want to have surgery on your hip if you have a problem that is potentially amenable to physical therapy or pelvic floor physical therapy.

[48:14] Dr. Emily Bohan: Yeah, exactly.

[48:16] Dr. Linda Bluestein: Those labral tear surgeries, especially for bendy bodies, are so tricky because afterwards, with non-weight bearing — using crutches or a wheelchair — that's really, really challenging. I want to talk about another specialized population. When women are pregnant, what should we know about the pelvic floor in pregnancy?

[48:37] Dr. Emily Bohan: Yeah, so the pelvic floor, like all other areas of the body, as we progress through pregnancy, the hormone relaxin increases. That makes everything even more loosey-goosey. I see in a lot of my women, as they get later in pregnancy and everything gets even more lax, the pelvic floor really tends to tighten up to try to create stability — because there's so much more pressure going down on the pelvic floor, but it's also trying to compensate for some of that laxity in the system.
[49:05] Also as we go through pregnancy, we end up with that anterior pelvic tilt to help make room in the pelvis, which also opens it up a little to make room for the growing baby. But that also increases the pressure downwards onto the pelvic floor. So the most common thing I tend to see is that the pelvic floor really gets a workout through pregnancy — but that doesn't mean we can't still work on motor control and function.
[49:34] And a lot of women, especially as they get into the later trimesters, start battling some low back pain or pubic symphysis pain. Having the pelvic floor working as well as we can get it can help combat some of that pain.

[49:56] Dr. Linda Bluestein: Yeah, that makes sense. And the pubic symphysis being where the bones connect in the front, just below the bladder. Okay. There was a question from a listener that I want to read. They said: "I'm female, and when I have sex, my hips tend to sublux or sometimes even feel like they dislocate. I lay there for a while to get my hips back in place, and hours later things seem to subside. How can I better support my hips? Do you have any suggestions?"

[50:30] Dr. Emily Bohan: Yeah, that's an interesting question. I would say trying to create some external support would be really important. If you're having intercourse lying on your back, maybe that looks like putting pillows on either side of you to help create some external support for those hips. Or getting into a position that isn't quite as subluxing for the hips. My question for that listener would be: what positions seem to cause the most of that subluxing feeling?
[51:10] But yeah, external support is probably the best way to go. And then I would also wonder if there's a little bit of pain accompanying that. I would want to know if the obturator internus — that muscle that refers pain to the hips — is creating some referral pain that almost feels subluxy, but is actually a trigger point getting irritated during intercourse.

[51:35] Dr. Linda Bluestein: That's really interesting, because hips are really hard to dislocate, correct?

[51:42] Dr. Emily Bohan: Yes. Your hips do not like to dislocate — you're going to be in the hospital for an actual hip dislocation. But that doesn't mean there isn't a little bit of movement. It's more likely coming from pain or position than an actual subluxation.

[51:58] Dr. Linda Bluestein: And a subluxation — I should have said this first — is a partial dislocation, whereas a dislocation is when the bones have completely come out of contact with each other. So the shoulder is a lot more mobile than the hips, and the hips — if we feel like we have a subluxation or dislocation — it's more often snapping hip syndrome, correct?

[52:24] Dr. Emily Bohan: Yeah, it can be snapping hip syndrome, which can be sometimes a tendon rolling around. The way the hip joint moves, we have to get a little bit of forward and backward movement within the hip. And if that movement isn't happening correctly — for example, when we bring our leg up towards us, our femur actually has to move a little bit backwards in the socket — if we're not getting that backwards movement because of, say, a lot of tightness in the glutes, that can make it feel like things are kind of out of place when they aren't actually.
[52:58] The hip joint is very deep, so it is very hard to get the femur out of the hip joint. Unlike the shoulder — I like to think of the shoulder almost like a golf ball sitting on a golf tee, where a lot of stability comes from the muscles. The hip joint, because it's such a weight-bearing joint, already has so much inherent stability just from the deepness of the socket.

[53:18] Dr. Linda Bluestein: Which actually leads me to another question. If somebody has hip dysplasia — meaning a shallow hip socket — would they be more prone to dislocation? Could they actually potentially dislocate their hip?

[53:29] Dr. Emily Bohan: Yeah, someone who has hip dysplasia might actually be more prone to that. But for most people, we all have variations in our anatomy and the angle of that femur within the hip joint, and for most individuals that hip socket is deep enough to create some inherent stability.

[53:47] Dr. Linda Bluestein: Okay. And I know you have training as a personal trainer, in addition to yoga and physical therapy. Could you tell us a little bit — if somebody is listening and trying to figure out whether to work with an athletic trainer, a personal trainer, a physical therapist, or a yoga instructor — do you have suggestions for how a person might find the right person to work with and how they might choose among those different fields?

[54:26] Dr. Emily Bohan: Yeah, that is a great question. Whether it's a physical therapist, a personal trainer, or a yoga teacher, I like to think of us like your hairdresser. Just because you got a bad haircut once doesn't mean you should never get your hair cut again. We all have different treatment styles that fit different specialty populations. So just because physical therapy didn't work for you once doesn't mean it won't work with someone else's style.
[55:00] We all have this amazing training of getting our doctorate in physical therapy. But the human body, to some extent, is an art — figuring out what's going on. Finding someone who can think outside the box is really important, especially for my folks with hypermobility, because there are nuances that make a big difference for anyone who has hypermobility in their joints.
I'm biased toward physical therapists because we've had so much training in movement mechanics. I think personal trainers can be really good too, but the barrier of entry is lower to get into personal training. So really do your research — how long have people been in the field, who do they work with? Don't be afraid to ask a lot of questions to make sure they're a good fit for you and your goals.
Another benefit of seeing a physical therapist is that we're trained in exercise selection to help get you stronger, but we also have hands-on skills that some other professions like athletic training and personal training don't necessarily have. And sometimes getting your hands on someone's body can give us a lot of information.

[56:15] Dr. Linda Bluestein: A lot of information and a lot of relief. I love it when you're going to work on my body and I've been holding a lot of tension in my neck and upper traps. I'm so excited when I get to see Emily — it's really going to help.

[56:34] Dr. Emily Bohan: That's actually a great example. Some of my folks with hypermobility have all this muscular tension, and we've talked about this — I don't always like to dry needle my folks with hypermobility because sometimes if we release everything too much, initially people are like, "I feel great." But then the body goes, "Oh, we have no stability," and there's like this backfire response that happens. So I think it's an important point to bring up: sometimes the body wants a muscle tight for a reason, and we should find out why that's tight rather than just releasing all of it. Especially if you don't have a whole lot of joint stability, it's really important to figure out the underlying reason why that muscle has gotten tight.

[57:25] Dr. Linda Bluestein: I think I told you that another physical therapist once dry needled my shoulders so much that the pain completely went away — which was great. But at the same time, my shoulder felt like it was falling off.

[57:37] Dr. Emily Bohan: Yeah.

[57:38] Dr. Linda Bluestein: So maybe a little too loose. A lot of my patients will literally say to me, "Physical therapy does not work for me." And I always feel like it's a matter of finding the right physical therapist. I love your hairdresser analogy — I think most people have had a bad haircut, so we can really relate to that.
[58:03] Do you have suggestions for people where maybe it's been multiple physical therapists they've worked with and they're really feeling anxious about trying again? How can someone determine if somebody might be a good fit?

[58:22] Dr. Emily Bohan: Yeah, absolutely. I think something really important is communicating with whoever you go to see next about what things you've tried and what hasn't worked, so you don't end up in this rat race of everyone kind of wanting to do the same thing. And especially when it comes to hypermobility — ask that practitioner if they've worked with other people with hypermobility. Do they understand some of the pieces that come along with these hypermobility conditions? Most physical therapists have had experience working with people who have some degree of hypermobility, but as you get to the more extreme levels, that's going to look a lot different.
Asking if they work with dancers is another good question you could ask, because a lot of dancers have hypermobility.
[59:23] And then sometimes it can actually help to not stay within a fast-paced clinical setting where they're seeing patients every half hour. No matter how good that physical therapist is, they sometimes just don't have the time to dive into the nuance of what you might need if you've been dealing with a chronic issue for a long time. Find a clinic that's a little slower paced and make sure it's one-on-one treatment. Unfortunately, physical therapy has moved in the direction of treating more than one patient at a time, so calling ahead and making sure the PT is seeing their patients one-on-one is really important.

[1:00:07] Dr. Linda Bluestein: Those are such great tips. And every time I've gone to see you, I'm the only one working with you at that time, and that's huge. And also having that stability over time — I've been working with you for so long that you know how my body works. I think another mistake a lot of people make is they don't go back. If they get more sore after a session, they feel like it failed and don't give that physical therapist the opportunity to act on that information.

[1:00:45] Dr. Emily Bohan: Yeah, it gives us a lot of information even if things feel a little worse after one session. Now we know your body's threshold or that you didn't respond well to that approach. For a certain diagnosis, maybe 80% of people respond to a set of exercises, but there's 20% that maybe don't or feel worse. If we don't get told that things made you feel worse, we can't switch our mindset and try Plan B. So that information is really, really crucial.

[1:01:22] Dr. Linda Bluestein: Makes perfectly good sense. We are going to wrap up in just a minute. Before we go, I want to hear your key take-home points, and then we're going to jump into our hypermobility hack. So first, if you could distill this down into just a couple of key take-home points, what would you say?

[1:01:44] Dr. Emily Bohan: Yes. My biggest thing is: if you're dealing with any sort of pelvic pain, incontinence, frequency, urgency — even if you get up at night to go to the bathroom, you don't necessarily need to be doing that — go see a pelvic floor physical therapist. You don't have to live with leakage. You don't have to live with urgency that disrupts your daily life. Intercourse or any sort of intimacy doesn't need to have any pain associated with it. I think sometimes we just live with these things happening in the pelvis because we don't know that there's actually someone who can help us work through it.
[1:02:26] And even if there's not a whole lot going on with direct pelvic floor symptoms — if you have low back pain or hip pain — get that pelvic floor screened. See if the pelvic floor is a piece contributing to your low back pain or hip pain. I think that's really important.

[1:02:44] Dr. Linda Bluestein: Okay. And I always like to have a hypermobility hack. Do you have one to share?

[1:02:51] Dr. Emily Bohan: Yeah. My hypermobility hack would be being really mindful of how you increase your exercise. People with hypermobility tend to be really sensitive to increases in load. So start with one set of an exercise, one set of five reps — we're still creating really good changes in the body, slowly starting to strengthen that muscle without flaring up the whole system. Work smarter, not harder.
[1:03:30] Maybe it's taking a walk up and down the street. That's extra load on all your leg muscles, your back muscles, your pelvis. It doesn't have to be super intense to start making some really good positive changes.

[1:03:44] Dr. Linda Bluestein: Excellent. And can you finish out by telling us what you're up to these days and if there's something you want to plug?

[1:03:52] Dr. Emily Bohan: Yeah, absolutely. In the last couple of months I opened my own business, Bohan PT and Training. I do some in-person physical therapy here in Denver, Colorado, and I also do some consulting over Zoom. And I'm doing some personal training as well, diving back into that piece of my background.

[1:04:17] Dr. Linda Bluestein: Fantastic. What's the best way for people to learn more about you and get in touch with you?

[1:04:22] Dr. Emily Bohan: Yeah, absolutely. I have an Instagram, a TikTok, and a Facebook page — Bohan PT Training is where you can find me on all of those. And I also have a website that is linked in the show notes.

[1:04:38] Dr. Linda Bluestein: Okay, BohanPTTraining.netlify.app?

[1:04:40] Dr. Emily Bohan: Yes, it's through a different domain, which is why I'm saying it's linked.

[1:04:48] Dr. Linda Bluestein: We will definitely link that in the show notes. And Bohan is spelled B-O-H-A-N.

[1:04:53] Dr. Emily Bohan: Yes.

[1:04:54] Dr. Linda Bluestein: Fantastic. Well, thank you so much, Emily. I really appreciate all of this incredible information you've shared, and I look forward to seeing you next time.

[1:05:04] Dr. Emily Bohan: Great. Thank you, Linda.

[1:05:38] Dr. Linda Bluestein: Wow, that was such a great conversation with Emily, and I hope you learned as much as I did. I want to thank you for listening to this week's episode of the Bendy Bodies with the Hypermobility MD Podcast. You can help us spread the word about joint hypermobility and related conditions by sharing the podcast and leaving a review. This really helps raise awareness about these complex conditions. If you'd like to meet with me one-on-one, check out the available options on the services page of my website at hypermobilitymd.com.
[1:06:07] You can also find me, Dr. Linda Bluestein, on Instagram, Facebook, TikTok, Twitter, and LinkedIn @hypermobilitymd. You can find Human Content, my producing team, at Human Content Pods on TikTok and Instagram. To learn about the Bendy Bodies Program disclaimer and ethics policy, submission verification and licensing terms, and HIPAA release terms, or to reach out with any questions, please visit bendybodiespodcast.com. Bendy Bodies Podcast is a Human Content production. Thank you so much for being a part of our community, and we'll catch you next time on the Bendy Bodies Podcast.